The challenge of simplifying blood pressure screening in children and adolescents.

Simplified methods of blood pressure screening could facilitate the clinical routine of the primary care physicians and may increase adherence to pediatric hypertension guidelines. Blood-pressure-to-height ratios are appealing for the simplicity of data needed to evaluate a child's blood pressure status, including only office blood pressure values and height. In several epidemiological studies around the world blood-pressure-to-height ratios showed good predictive power in identifying children with high blood pressure in terms of area under the curve and sensitivity compared to the gold standard National High Blood Pressure Education Program blood pressure tables, but low positive predictive values meaning a high rate of false-positive cases and possibly increased subsequent work load for primary physicians. Finally, blood-pressure-to height ratios seem to be dependent to age, sex, and weight status. In conclusion, blood-pressure-to-height ratios need to be further improved and validated in different pediatric populations before routine clinical use.

Performance of modified blood pressure-to-height ratio for diagnosis of hypertension in children: The CASPIAN-V study.

This study aimed to evaluate the accuracy and performance of modified blood pressure-to-height ratio (MBPHR) for identifying high blood pressure (HBP) in a large population of children. This multicentric cross-sectional study was conducted on a nationally representative sample of 7349 Iranian students aged 7-12 years living in 30 provinces in Iran. High systolic blood pressure and diastolic blood pressure were defined according to the 2017 American Academy of Pediatrics (AAP) guidelines. The BP-to height ratio (BPHR) was calculated as BP (mmHg)/height (cm), MBPHR3 as BP (mmHg)/(height (cm) + 3 (13-age)), and MBPHR7 as BP (mmHg)/(height (cm) + 7 (13-age). The receiver-operating characteristic curve analysis was used to evaluate the performance of these three ratios for identification of HBP in children compared to the 2017 AAP guidelines as the gold standard. Mean age of participants was 12.29 ± 3.15 years and 3736 (50.8%) were girls. The prevalence of HBP was 11.9% (11.5% in boys, 12.3% in girls). The area under the curve (AUC) was higher for MSBPHR3/MDBPHR3 (0.97/0.98) than MSBPHR7/MDBPHR7 (0.96/0.97) and SBPHR/DBPHR (0.96/0.95) for identifying high Systolic and diastolic BP. The optimal cut-off points for MSBPHR3/MDBPH, MSBPHR7/MDBPHR7, and SBPHR/DBPHR were 0.76/0.50, 0.69/0.46, and 0.81/0.52 respectively. Negative predictive value was nearly perfect for three ratios (≥98%). Positive predictive value was higher for MBPHR3 (52.7%) than MBPHR7 (51.0%) and BPHR (39.8%). Overall, MBPHR3 had better performance than MBPHR7 and BPHR for identification of HBP in Iranian children and it may improve early hypertension recognition and control in primary screening.

Increased prevalence of hypertensive-level blood pressure using the American Academy of Pediatrics 2017 guidelines: a cross-sectional study in a primary school in Thailand.

Background: In 2017, the American Academy of Pediatrics (AAP) launched a new clinical practice guideline for diagnosis of hypertension in children and adolescents. The new cut-off values were 2-3 mmHg lower than those of the previous 2004 guidelines. Aims: This study was conducted to evaluate the effects of the new cut-off values on the prevalence of hypertensive-level blood pressure (BP) in children in a primary school in Bangkok, Thailand. Subjects and methods: BP, weight, height and waist circumference were recorded in 536 school children aged 8-13 years (270 boys, 50.3%) in grades 4-6. For analysis, BP was classified by the two different cut-off values (the 2004 AAP and the 2017 AAP guidelines). Demographic data for the children whose BP was hypertensive according to the 2017 guidelines but not the 2004 guidelines were compared with those of the children with normal BP according to both guidelines. Logistic regression analysis was performed to evaluate the factors associated with hypertensive-level BP. Results: Fifty-eight children (10.8%) had hypertensive-level BP according to the 2017 guidelines but only 37 (6.9%) with the 2004 guidelines. Twenty-one children who would not have had hypertensive-level BP with the 2004 AAP guidelines had greater Z-scores for body mass index and a greater proportion had obesity than the normotensive children. Body mass index was the only independent factor associated with hypertensive-level BP. Conclusions: The prevalence of hypertensive-level BP in children was increased using the 2017 guidelines. Children with hypertensive-level BP using the 2017 AAP guidelines but not the 2004 AAP guidelines had greater BMI Z-scores and a greater proportion were obese than the in the normotensive children. Body mass index was the only independent factor associated with hypertensive-level BP. Abbreviations: AAP: American Academy of Pediatrics; BMI: body mass index; BP: blood pressure; cm: centimeter; DBP: diastolic blood pressure; HT: hypertension; kg: kilograms; m: meter; NHANES: National Health and Nutrition Examination Survey; ROC: receiver operating characteristic curve; SBP: systolic blood pressure; SBPHR: systolic blood pressure-to-height ratio; SD: standard deviation; WC: waist circumference; WHR: waist-to-height ratio.

A new index to simplify the screening of hypertension in overweight or obese youth.

BACKGROUND AND AIMS: Hypertension (HTH) is a frequent complication in pediatric obesity. To simplify the screening of HTH in overweight/obese (Ow/Ob) youth, we compared the performance of a new index (High Blood Pressure index, HBPi) with respect to the standard criteria of the IV Report [systolic BP (SBP) and/or diastolic BP (DBP) ≥95th percentile for age, gender and height]. We also compared the performance of HBPi with other simplified indices such as the BP/height ratio and the absolute height-specific BP thresholds. Ten pediatrics' outpatient centers participating in the "CARdiometabolic risk factors in ITALY study" provided medical records of 4225 Ow/Ob children and adolescents (age 6-16 years). METHODS AND RESULTS: Centers were divided into two groups: training set (TS) (n = 2204 participants) and validation set (VS) (n = 2021 participants). The simplified HBPi (mmHg) was: (SBP/2 + DBP/10) - age + (1 × female gender). In the TS, a HBPi value ≥57 mmHg in both children and adolescents had high sensitivity (0.89), specificity (0.97), positive (0.89) and negative (0.97) predictive values in classifying youth at high risk of HTN compared with the IV Report. In the VS, the HBPi showed a better performance than high levels of BP/height ratio and height-specific BP thresholds in classifying individuals at risk of HTN: area under curves 0.95 (0.93-0.96), 0.80 (0.78-0.82), 0.76 (0.74-0.79), respectively; specificities 0.95 (0.94-0.96), 0.69 (0.67-0.72), 0.60 (0.57-0.62), respectively. CONCLUSIONS: HBPi, combining SBP and DBP, gender and age, may help pediatricians to implement HTN screening in Ow/Ob youth.

How to Simplify the Diagnostic Criteria of Metabolic Syndrome in Adolescents.

BACKGROUND: This study evaluated the feasibility and accuracy of the height-corrected definition for identifying metabolic syndrome (MS). METHODS: In 2006, anthropometric and biochemical measurements were assessed in a cross-sectional population-based study of 3136 Han adolescents, aged 13-17 years. MS was defined according to the definitions of Cook et al, International Diabetes Federation, and the Society of Pediatrics, Chinese Medical Association. Waist-to-height and blood pressure-to-height ratios were alternatives to waist circumference and blood pressure in the height-corrected definition. RESULTS: According to the MS definition and the height-corrected MS definition, this agreement would be classified as "very good" (National Cholesterol Education Program kappa coefficients: 0.850 in boys and 0.816 in girls; International Diabetes Federation kappa coefficients: 0.953 in boys and 0.807 in girls; Society of Pediatrics, Chinese Medical Association kappa coefficients: 0.932 in boys; p < 0.001) and "good" (Society of Pediatrics, Chinese Medical Association kappa coefficients: 0.737 in girls; p < 0.001). CONCLUSION: The present study demonstrates that the height-corrected definition of MS is a simple, inexpensive, and accurate tool for identifying MS in Han adolescents.

Suitability of blood-pressure-to-height ratio as the criterion for high blood pressure in children in an environmental study.

BACKGROUND: Blood-pressure-to-height ratio is considered a simple, accurate, inexpensive and non-age-dependent index for screening high blood pressure in a clinical setting, but its suitability in epidemiological surveys was not taken into consideration. The aim of this study was to test the suitability of blood-pressure-to-height ratio against blood pressure for age percentiles for the identification of high blood pressure in an environmental study. METHODS: The sample consisted of 2195 children, aged 3 to 15 years, whose blood pressure was measured as part of an environmental study in Belgrade, Serbia. High blood pressure was estimated using percentiles (gold standard) and blood-pressure-to-height ratios for systolic and diastolic pressures separately (proposed criterion). The optimal cut-offs of the blood-pressure-to-height ratio (BPHR) were selected based on Youden's index (sensitivity + specificity - 1) calculated from the receiver operator characteristic curve analysis. RESULTS: The proposed criterion identified five times more cases of high blood pressure in the investigated children of all age groups in comparison to the gold standard. The optimal cut-off values were selected based on the sensitivity and specificity values by age groups and gender. CONCLUSION: Blood-pressure-to-height ratio can be a reliable criterion for the estimation of high blood pressure in epidemiological studies. This is the first study on the applicability of blood-pressure-to-height ratio in Serbian children, but it may not be easily generalized to other populations due to small sample size across the examined age groups and potential diversities in risk factors for high blood pressure. Applied in epidemiological studies, BPHR would help researchers estimate the role of certain environmental factors on blood pressure in children.

Comparison of Different Screening Methods for Hypertension in Han Adolescents.

The aim of this study was to compare different methods of screening for hypertension in Han adolescents. We analyzed data on 3136 Han adolescents (1601 boys and 1535 girls) aged 13 to 17 years from the adolescents hypertension survey of Qinhuangdao in 2006. The blood pressure was classified as without hypertension and with hypertension, consistent with the 2004 Working Group on High Blood Pressure in Children and Adolescents guidelines and the selected screening methods. Sensitivity and specificity were then calculated according to gender range. Somu's formulas and the table proposed by Chiolero had low sensitivities (58.4% to 83.1%), despite good specificities (99.0% to 100.0%). The tables proposed by Mitchell and Kaelber had high sensitivities (100%), but their specificities were low (62.0% to 73.8%). Blood pressure-to-height ratio (BPHR) was a good compromise between sensitivities (boys 99.1% and girls 98.9%) and specificities (boys 91.0% and girls 94.9%). As screening tools, the table proposed by Mitchell and Kaelber and BPHR have high sensitivities. However, BPHR demonstrated specific advantages, and it does not require tables.

The performance of modified blood pressure-to-height ratio as a screening measure for identifying children with hypertension.

OBJECTIVES: This study evaluated the accuracy of modified blood pressure-to-height ratio (MBPHR) for identifying hypertension in Han children aged 7-12 years. METHODS: In 2011, anthropometric measurements were assessed in a cross-sectional population-based study of 1352 Han children aged 7-12 years. Elevated blood pressure was defined according to the 2004 National High Blood Pressure Education Program Working Group definition (as gold standard). The following equations for MBPHR were used: modified systolic blood pressure to height ratio(MSBPHR) = SBP(mmHg)/(height(cm) + 7 × (13 - age(years))), modified diastolic blood pressure to height ratio (MDBPHR) = DBP(mmHg)/(height(cm) + 7 × (13 - age(years))). Receiver operating characteristic curve analyses were performed to assess the accuracy of MSBPHR and MDBPHR as diagnostic tests for elevated SBP and DBP, respectively. RESULTS: The accuracy of MSBPHR and MDBPHR (assessed by area under the curve) for identifying elevated SBP and DBP were over 0.85 (0.953-1.000). When elevated blood pressure was defined by MBPHR (age-dependent cut-off point), the sensitivities were 99.1% in boys and 97.0% in girls and the specificities were 89.0% in boys and 92.3% in girls. When elevated blood pressure was defined by MBPHR (non-age-dependent cut-off point), the sensitivities were 96.4% in boys and 99.2% in girls and the specificities were 81.2% in boys and 75.5% in girls. CONCLUSIONS: MBPHR is an accurate index for screening hypertension in children, but is not superior to BPHR. Compared with age-dependent BPHR cutoff points, non-age-dependent MBPHR cut-off point is simple but increase the proportion of reexamination.

Simplification of childhood hypertension definition using blood pressure to height ratio among US youths aged 8-17years, NHANES 1999-2012.

BACKGROUND: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure (BP) established high BP diagnostic criteria using age-, sex-, and height-specific BP percentiles. However, these BP criteria are quite difficult for use by professionals in the clinic or children and their parents. We aimed to simplify the hypertension diagnostic criteria using BP to height ratio (BP/height) in US children and adolescents aged 8-17years. METHODS: Data were obtained from a national representative sample of 14,624 US children and adolescents aged 8-17years enrolled in the continuous National Health and Nutrition Examination Survey 1999-2012. SBP to height ratio (SBPHR) was calculated as SBP (mmHg)/height (cm) and DBP to height ratio (DBPHR) was calculated as DBP (mmHg)/height (cm). The BP diagnostic criteria recommended by the fourth report were used as the "gold standard". Receive operator characteristic curve analysis was used to choose the optimal thresholds of SBPHR and DBPHR. RESULTS: The optimal thresholds for identifying pre-hypertension and hypertension among children aged 8-12years and adolescents aged 13-17years were determined. The negative predictive value (NPV) for identifying hypertension was nearly 100% for both children and adolescents, although the positive predictive value (PPV) ranged from 19% to 35%. The NPV for identifying pre-hypertension ranged from 95% to 99% for children and adolescents, and the PPV ranged from 11% to 52%. CONCLUSIONS: The optimal thresholds of SBPHR and DBPHR are simple and accurate for screening elevated BP, although PPV is relatively low because of the low prevalence of childhood hypertension.

Hypertension screening using blood pressure to height ratio.

OBJECTIVES: The definition of hypertension in children is too complex to be used by medical professionals and children and their parents because of the age-, gender-, and height-specific blood pressure (BP) algorithm. The aim of this study was to simplify the pediatric BP percentile references using BP to height ratio (BPHR, equal to BP/height) for screening for prehypertension and hypertension in Chinese children. METHODS: Data were obtained from the China Health and Nutrition Survey, which was conducted from 1991 to 2009 and included 11 661 children aged 6 to 17 years with complete data on age, gender, height, and BP values. Receiver operating characteristic curve analysis was performed to assess the performance of systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) for screening for pediatric prehypertension and hypertension. RESULTS: The optimal thresholds for defining prehypertension were 0.81 in children aged 6 to 11 years and 0.70 in adolescents aged 12 to 17 years for SBPHR and 0.52 in children and 0.46 in adolescents for DBPHR, respectively. The corresponding values for hypertension were 0.84, 0.78, 0.55, and 0.50, respectively. The negative predictive values were much higher (all ≥99%) for prehypertension and hypertension, although the positive predictive values were relatively lower, ranging from 13% to 75%. CONCLUSIONS: BPHR index is simple and accurate for screening for prehypertension and hypertension in Chinese children aged 6 to 17 years and can be used for early screening or treating Chinese children with hypertension.

Blood pressure to height ratio: A novel method for detecting hypertension in paediatric age groups.

BACKGROUND: A novel method for detecting hypertension in paediatric age groups has recently been formulated using ratios of systolic blood pressure to height (SBPHR) and diastolic blood pressure to height (DBPHR). AIM: To validate this approach and assess its applicability to children. METHODS: A cross-sectional study of 6837 children and adolescents five to 18 years of age was conducted. Blood pressure (BP) readings obtained were stratified using population-based percentiles from the United States. RESULTS: For SBPHR and DBPHR, areas under the ROC curve were >0.9 for BP at or above the 95th percentile. Performance of the cut-off points for detecting elevated BP in adolescents 13 to 18 years of age compared favourably with previous studies, showing high sensitivity and specificity (>95%). SBPHR and DBPHR also proved satisfactory when applied to children five to 12 years of age. Nevertheless, performance was lower for BP between the 90th and 95th percentiles. CONCLUSIONS: BP to height ratios are a practical means for detecting elevated BP in adolescents and children.

HISTORIQUE: Une nouvelle méthode pour dépister l'hypertension dans les groupes d'âge pédiatrique a récemment été formulée au moyen du ratio entre la tension artérielle systolique et la taille (RTAST) et du ratio entre la tension artérielle diastolique et la taille (RTADT). OBJECTIF: Valider cette méthode et en évaluer l'applicabilité chez les enfants. MÉTHODOLOGIE: Les chercheurs ont procédé à une étude transversale auprès de 6 837 enfants et adolescents de cinq à 18 ans. Ils ont stratifié les lectures de tension artérielle (TA) obtenues au moyen de percentiles en population provenant des États-Unis. RÉSULTATS: Pour ce qui est du RTAST et du RTADT, les aires sous la courbe ROC étaient supérieures à 0,9 lorsque la TA se situait au moins au 95e percentile. Le rendement des seuils pour déceler une TA élevée chez les adolescents de 13 à 18 ans se comparait favorablement à celui d'études antérieures, démontrant une sensibilité et une spécificité élevées (supérieures à 95 %). Le RTAST et le RTADT se sont également révélés satisfaisants lorsqu'on les appliquait aux enfants de cinq à 12 ans, mais le rendement était moins élevé lorsque la TA se situait entre le 90e et le 95e percentile. CONCLUSIONS: Les ratios entre la TA et la taille représentent un moyen pratique de dépister une TA élevée chez les adolescents et les enfants.