Reply

To the Editors:Flynn and Faulkner clearly point out the alarming increase

in hypertension in children and the problem we face in con-fronting this situation. Early detection and adequate inter-vention in those who have hypertension is likely to benefitthe patients, and perhaps society, by reducing long-termmedical costs. The issue is not whether we should try to detecthypertension as early as possible, but how to do this effec-tively. The high rate of false positivity in a screening test isvery costly. There is the cost of unnecessary follow-up testing

The importance of blood pressure screeningin children

To the Editor:The value of routine blood pressure (BP) measurement as

a screening test for hypertension in children has recently beenquestioned.1 To be effective a screening test must fulfilla number of criteria, including accuracy, reproducibility,acceptability to the individual, and cost-effectiveness. Thecondition screened should have both important health impli-cations and effective treatments.2 Routine BP measurementwas judged to be inaccurate, not reproducible, and of uncer-tain cost, and therefore of uncertain value. However, beforewe stop measuring BP in children, it is important to analyzethe context in which these questions were raised and to con-sider carefully the health implications of abandoning currentpractice.

The study in question was a single-center study conductedin an urban, tertiary care children’s hospital emergency de-partment.3 Although the Fourth Report recommends thatchildren should have their BP measured ‘‘.at least once dur-ing every health care episode,’’4 it is unlikely that a hospitalemergency department can be conducive to accurate BPmeasurement, even by trained personnel in the context ofa research study. This is supported by the data from thestudy, which report an extraordinarily high percentage—34%—of children with an initially elevated BP measure-ment.3 This figure is substantially higher than that recentlyreported from a large school screening study with similarBP measurement methodology5 and calls into questionwhether those children identified in the study for follow-upBP measurements actually had elevated initial measurementsin the first place.

The second issue to consider is the increasing prevalenceof hypertension in childhood and the potential increase incardiovascular disease in young adults. In a recent reviewof BP data in 8- to –17-year-old children from the USNational Health and Nutrition Survey (NHANES) and otherrelated population-based studies, Din-Dzietham et al6 founda recent increase in the prevalence of high BP in children,with the prevalence of pre-hypertension now reaching10% and the prevalence of hypertension nearly 4%. Theiranalysis demonstrated that this increase in high BP waslargely attributable to the increase in childhood obesityand that the recent trends in both obesity and high BPhave had a much greater effect on non-Hispanic black andMexican-American children than on white children. The in-creases in both childhood obesity and high BP will have sig-nificant effects on cardiovascular risk in childhood, which inturn may lead to an epidemic of cardiovascular disease inyoung adults.7,8

We agree that improved methods of detecting childhoodhypertension should be developed and that the study of Stew-art et al suggests that the emergency department is not theproper place to screen for disease. However, now is not the

time to abandon routine BP measurement in children or sus-pend it while examining its risk/benefit ratio.1 Prevention isa key tenet of pediatric medicine. There is an epidemic onthe horizon, and we must use all the tools in our armamen-tarium to head it off.

Joseph T. Flynn, MD, MSSeattle Children’s Hospital

Division of NephrologySeattle, Washington

Bonita E. Falkner, MDThomas Jefferson University

Department of Medicine and PediatricsPhiladelphia, Pennsylvania

10.1016/j.jpeds.2009.03.037

References

1. Friedman A. Blood pressure screening in children: do we have this right?

J Pediatr 2008;153:452-3.

2. UK National Screening Committee. Criteria for appraising the viability,

effectiveness and appropriateness of a screening programme, 2003.

Available at: http://www.nsc.nhs.uk/pdfs/criteria.pdf. Accessed: Jan 2,

2009.

3. Stewart JN, McGillivary D, Sussman J, Foster B. The value of routine

blood pressure measurement in children presenting to the emergency de-

partment with nonurgent problems. J Pediatr 2008;153:478-83.

4. National High Blood Pressure Education Program Working Group on

High Blood Pressure in Children and Adolescents. The fourth report

on the diagnosis, evaluation, and treatment of high blood pressure

in children and adolescents pediatrics. Pediatrics 2004;114(Suppl):

555-76.

5. McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM,

Portman RJ. Prevalence of hypertension and pre-hypertension among

adolescents. J Pediatr 2007;150:640-4. 644.e1.

6. Din-Dzietham R, Liu Y, Bielo M-V, Shamsa F. High blood pressure trends

in children and adolescents in national surveys, 1963 to 2002. Circulation

2007;116:1488-96.

7. Bibbins-Domingo K, Coxson P, Pletcher MJ, Lightwood J, Goldman L.

Adolescent overweight and future adult coronary heart disease. N Engl

J Med 2007;357:2371-9.

8. Falkner B. What exactly do the trends mean? Circulation 2007;116:

1437-9.

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