Editorial Commentary
New American Academy of Pediatrics Hypertension Guideline
Who Is Up and Who Is Down
Marc B. Lande, Donald L. Batisky
See related article, pp XXX–XXX
T he definition of hypertension in adults is based on the
level of blood pressure (BP) resulting in increased car-
diovascular events and mortality.1 However, because hyper-
tension-associated events, such as myocardial infarction and
stroke, occur in later decades, the definition of hypertension
in children is instead by convention based on comparison to
reference data from the normal distribution of BP in healthy
children and adolescents.2 Such reference range data have
allowed estimates of the prevalence of hypertension in chil-
dren and adolescents and have been essential in the formu-
lation of national consensus guidelines for the identification,
evaluation, and management of elevated BP in youth.
In September 2017, the American Academy of Pediatrics
(AAP) published the new Clinical Practice Guideline (AAP
CPG) for screening and management of high BP in chil-
dren and adolescents,3 an update to the 2004 Fourth Report
on the Diagnosis, Evaluation, and Treatment of High BP in
Children and Adolescents.4 The Fourth Report included nor-
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mative BP tables and defined hypertension as average BP
≥95th percentile for age, sex, and height on ≥3 occasions.
However, the Fourth Report normative BP tables included
data from overweight and obese children, potentially
increasing thresholds for elevated BP and possibly lead-
ing to the underdiagnosis of hypertension. The recent AAP
CPG includes new normative pediatric BP tables based on
normal-weight children only. Among other changes, the
AAP CPG also includes a simplified BP classification in
adolescents ≥13 years of age that aligns with the recently
released American Heart Association and American College
of Cardiology adult BP guidelines.1 In children <13 years of
age, the definition of hypertension remains ≥95th percentile
for age, sex, and height on ≥3 occasions. However, for ado-
lescents ≥13 years of age hypertension is now defined as BP
≥130/80, regardless of age, sex, or height. Therefore, for
many adolescents, and especially boys, the threshold for the
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Department of Pediatrics, University of Rochester, NY
(M.B.L.); and Department of Pediatrics, Emory University, Atlanta,
GA (D.L.B.).
Correspondence to Marc Lande, Department of Pediatrics, University
of Rochester, 601 Elmwood Ave, Box 777, Rochester, NY 14642. Email
marc_lande@urmc.rochester.edu
(Hypertension. 2018;73:00-00.
DOI: 10.1161/HYPERTENSIONAHA.118.11819.)
© 2018 American Heart Association, Inc.
Hypertension is available at https://www.ahajournals.org/journal/
hyp
DOI: 10.1161/HYPERTENSIONAHA.118.11819
1
definition of hypertension has been lowered, leading to the
prediction that more children and adolescents will be diag-
nosed as hypertensive. Some have even expressed concern
that implementation of the AAP CPG will result in overbur-
dening of primary care providers.5
However, the true impact of the new AAP CPG has yet
to be established. In this issue of Hypertension, Bell et al6
make a significant contribution in that direction by reporting
the prevalence of elevated BP and hypertension using AAP
CPG tables and definitions in participants in the Houston-
based school screening program of the Pediatric Hypertension
Program at the University of Texas McGovern Medical
School. The Houston Pediatric Hypertension Program has a
long history of producing seminal research in both the preva-
lence and consequences of elevated BP in youth using data
collected through their well-established school screening pro-
gram. The current report compares the prevalence of elevated
BP (previously termed prehypertension) and hypertension
using both the AAP CPG and previous Fourth Report guide-
lines among >22 000 children aged 10 to 17 years screened at
28 different middle and high schools between 2000 and 2017.
Participants had 2 to 3 oscillometric BP measurements at the
initial assessment. All subjects with BP ≥90th percentile or
≥120/80 mm Hg on the initial screening day subsequently
had repeated BP measurements on up to 2 additional occa-
sions. Therefore, an important strength of the report by Bell
et al6 is that hypertension prevalence estimates are based on
BP measurements on >1 occasion. BPs for all participants at
each screen were classified by both Fourth Report guidelines
and the AAP CPG. The investigators found that overall the
prevalence of elevated BP increased by 1.5% (from 14.8% to
16.3%) using the AAP CPG and that the prevalence of hyper-
tension remained similar to Fourth Report levels, at 2% to 4%.
The authors underscore that the assumption that all AAP CPG
hypertension thresholds are lower than Fourth Report thresh-
olds because of the exclusion of overweight and obese nor-
mative data is incorrect. Instead, the impact of the AAP CPG
on the prevalence of elevated BP and hypertension depends
largely on the child’s age. Youth <13 years old tend to have a
higher prevalence of both elevated BP and hypertension while
older adolescents have a higher prevalence of hypertension.
By contrast younger teens, aged 13 to 15 years, tend to have a
higher prevalence of elevated BP but less hypertension.
Others have also examined the impact of the AAP CPG on
the prevalence of and detection of the consequences of hyper-
tension. Khoury et al7 reported on the clinical impact of using
the AAP CPG in 364 youth participating in a study of the car-
diovascular effects of obesity and type 2 diabetes mellitus. By
 2  Hypertension  January 2019
design 59% of the subjects were obese, and the average age
was 14.9 years. They found that the prevalence of hyperten-
sion was 13% by AAP CPG criteria compared with only 8%
using Fourth Report thresholds. Although BP was measured
on only one occasion, their finding underscores that patients
who are obese and older will be more likely to be categorized
as hypertensive under the newer AAP guideline. They also
found that the new guideline was more sensitive to the iden-
tification of target-organ damage in hypertensive patients. In
particular, the proportion of participants with left ventricular
hypertrophy categorized as hypertensive increased from 20%
to 31% using the AAP CPG rather than the Fourth Report.
Jackson et al8 reported an analysis of the prevalence of
hypertension using AAP CPG and Fourth Report BP thresholds
in US youth participating in the 2001 to 2016 National Health
and Nutrition Examination Survey. Although the prevalence of
hypertension declined in this time period by both the new and
former guidelines, they found that there was a weighted net esti-
mated increase of 795 000 youth being reclassified as having
hypertension employing AAP CPG using 2013 to 2016 data.
Youth who were older, male and those with obesity accounted
for most of the people reclassified as having hypertension. In
a similar report of National Health and Nutrition Examination
Survey participants from 1999 to 2014, Sharma at el9 reported
that applying AAP CPG increased the prevalence of elevated
BP from 11.8% to 14.2% and also increased the number of
children with hypertension or worsening in clinical stage to
5.8%. However, prevalence rates based on National Health
and Nutrition Examination Survey data may be overestimates
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as hypertension categorization is based on BP measured on a
single occasion rather than ≥3 occasions as required for the
clinical diagnosis of hypertension in children.
Taken together, these reports indicate that older adolescent
males who are taller and younger boys who are shorter, and
youth with obesity, are more likely to be classified as hyper-
tensive using the AAP CPG. Similar but attenuated trends are
noted for girls.6 However, the clinical implications of this shift
in the categorization of hypertension remain unclear. Neither
the Fourth Report nor the new AAP CPG defines hyperten-
sion in youth according to associated cardiovascular out-
comes, either long-term cardiovascular events or intermediate
hypertensive target-organ damage as a surrogate for longer-
term outcomes. Therefore, current guidelines for the manage-
ment of hypertension in youth remain more consensus-based
rather than evidence-based. It is now well established that
hypertensive target-organ damage is common during youth
itself. Hopefully current10 and future research to determine
the level of BP elevation that leads to an increased incidence
of target-organ damage, and, therefore, presumably height-
ened long-term cardiovascular risk, will allow future pediat-
ric hypertension management guidelines to be predominantly
outcomes based.
Sources of Funding
None.
Disclosures
M.B. Lande and D.L. Batisky have been coauthors with Dr Joshua
Samuels on previous articles. M.B. Lande and D.L. Samuels are
currently coinvestigators on the SHIP AHOY (Study of High Blood
Pressure in Pediatrics: Adult Hypertension Onset in Youth Study).
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