Skip to main content
NCBI home page
The Journal of Clinical Hypertension logoLink to The Journal of Clinical Hypertension
. 2020 Apr 13;22(5):876–878. doi: 10.1111/jch.13858

The challenge of simplifying blood pressure screening in children and adolescents

Stella Stabouli 1,✉, Christina Antza 2, Katerina Chrysaidou 1, Vasilios Kotsis 2
PMCID: PMC8029806  PMID: 32282118

Abstract

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.

Keywords: adolescents, blood pressure screening, blood‐pressure‐to‐height ratio, children

The quest for simplifying blood pressure (BP) screening in childhood and adolescence has started several years ago as reports for inadequate BP screening and underdiagnosis of hypertension in childhood 1 , 2 , 3 , 4 proved to be the achilles heel of implementation of pediatric hypertension guidelines for routine BP screening. 5 The complexity of normative BP data, which include numerous different BP thresholds according to age, sex, and height, may have contributed to underdiagnosis of hypertension in children and adolescents. Simplified methods of screening could facilitate the clinical routine of the primary care physicians and may increase adherence to pediatric hypertension guidelines.

In the current issue of the Journal of Clinical Hypertension Yazdi et al, 6 investigated the performance of three different formulas for blood‐pressure‐to‐height ratio in identifying hypertensive children and suggested that modified ratios may be superior to initial simple blood‐pressure‐to‐height ratio. The main advantage of these formulas is the simplicity of data needed to evaluate a child's BP status, including only office BP values and height. Although the initial blood‐pressure‐to‐height ratio was appealing in terms of ease to use, the newer modified blood‐pressure‐to‐height ratios [BP/(height (cm) + 7 (13‐age), and BP/(height + 3 (13‐age)] 7 , 8 may further compel the physician to familiarize and memorize more complex mathematical formulas. This could be a first limitation for their use in clinical practice beyond epidemiological studies, in which statistical formulas facilitate the calculation of the modified ratios.

The application of blood‐pressure‐to‐height ratios in population screening studies has been examined by several investigators around the world. Since the first study in 2011 reporting the performance of blood‐pressure‐to‐height ratio in Chinese Han children and adolescents, 9 a number of studies used different large pediatric population samples including children and adolescents in the United States NHANES 1999‐2012, as well as Iranian, Brazilian, Nigerian, and Italian pediatric populations to test the effectiveness of the blood‐pressure‐to‐height ratios in hypertension screening. 10 , 11 All ratios showed good predictive power in terms of area under the curve and sensitivity compared to the gold standard National High Blood Pressure Education Program (NHBPEP) BP tables, 12 but resulted in low positive predictive values (PPV) meaning a high rate of false‐positive cases and possibly increased subsequent work load for primary physicians, which is another important limitation for their use in routine BP screening. In this issue Yazdi et al, 6 confirming the results of a previous study by Zhang et al, 13 also found good performance of the blood‐pressure‐to‐height ratios for hypertension screening using the modified NHBPEP normative tables and definitions by the American Academy Pediatrics (AAP) 2017 guideline, but the PPV was low as in previous reports. The blood‐pressure‐to‐height ratios have been previously reported to have good performance against the NHBPEP BP tables. Thus, these results were expected as the new normative tables are in general 2‐3 mmHg lower for each hypertension stage according to age, sex, and height category compared to the initial NHBPEP tables included in the Fourth Report and the European Society Hypertension (ESH) 2016 guidelines. 14

Another important finding of the two aforementioned studies was the different performance of blood‐pressure‐to‐height ratios depending on the participants’ ethnicity. This is different than the results of a previous meta‐analysis showing that blood‐pressure‐to‐height ratio as screening tool for high BP pressure performed well independent of age, sex, and ethnicity. 10 However, sex is well‐known to be a major determinant of BP levels starting from adolescence, 15 and male gender may carry an increased risk for future hypertension. 16 , 17 The study by Yazdi et al, 6 has also showed that these formulas are age, sex, and weight status dependent. The latter finding highlights the need to validate the blood‐pressure‐to‐height ratios in high‐risk populations for hypertension such as overweight and obese children. 18 Of note, if optimal thresholds of blood‐pressure‐to‐height ratios for identification of pediatric hypertension are different by age, sex, and weight status the promising simplicity and main advantage of the ratios would be lost.

The validation of any BP screening tool in children and adolescents is currently performed against the traditional NHBPEP BP tables by age, sex, and height, which are based on the statistical distribution of BP in healthy children and adolescents. It is well‐known that these tables are not validated against cardiovascular outcomes. 19 Possibly the next step to validate any simple BP screening tool would be testing its performance to identify children who may have out of office hypertension 20 or hypertension‐related target organ damage. 14 , 21 Finally, simple, user‐friendly, web‐based applications may also facilitate their use, but again validation of any model is crucial before applying in routine pediatric clinical practice.

CONFLICT OF INTEREST

None.

AUTHOR CONTRIBUTIONS

SS and CA drafted the manuscript. KC and VK critically revised the manuscript for important intellectual content.

Stabouli S, Antza C, Chrysaidou K, Kotsis V. The challenge of simplifying blood pressure screening in children and adolescents. J Clin Hypertens. 2020;22:876–878. 10.1111/jch.13858

REFERENCES

  • 1. Stabouli S, Sideras L, Vareta G, et al. Hypertension screening during healthcare pediatric visits. J Hypertens. 2015;33(5):1064‐1068. [DOI] [PubMed] [Google Scholar]
  • 2. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874‐879. [DOI] [PubMed] [Google Scholar]
  • 3. Bijlsma MW, Blufpand HN, Kaspers GJ, Bokenkamp A. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Ped. 2014;164(1):173‐177.e177. [DOI] [PubMed] [Google Scholar]
  • 4. Patel ND, Newburn A, Brier ME, Chand DH. Pediatric hypertension: are pediatricians following guidelines? J Clin Hyperten. 2016;18(12):1230‐1234. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. Lurbe E, Agabiti‐Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016;34(10):1887‐1920. [DOI] [PubMed] [Google Scholar]
  • 6. Yardi MAF, Daniali S, Heshmat R, et al. Perfomance of modified blood‐pressure‐to‐height ratio for diagnosis of hypertension in children: the CASPIAN‐V study. J Clin Hyperten. 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Dong B, Wang Z, Wang HJ, Ma J. Improving hypertension screening in childhood using modified blood pressure to height ratio. J Clin Hyperten. 2016;18(6):557‐564. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8. Ma C, Lu Q, Wang R, Liu X, Lou D, Yin F. A new modified blood pressure‐to‐height ratio simplifies the screening of hypertension in Han Chinese children. Hyperten Res. 2016;39(12):893‐898. [DOI] [PubMed] [Google Scholar]
  • 9. Lu Q, Ma CM, Yin FZ, Liu BW, Lou DH, Liu XL. How to simplify the diagnostic criteria of hypertension in adolescents. J Hum Hypertens. 2011;25(3):159‐163. [DOI] [PubMed] [Google Scholar]
  • 10. Yin X, Liu Q, Bovet P, Ma C, Xi B. Performance of blood pressure‐to‐height ratio as a screening tool for elevated blood pressure in pediatric population: a systematic meta‐analysis. J Hum Hypertens. 2016;30(11):697‐702. [DOI] [PubMed] [Google Scholar]
  • 11. Xi B, Zhang M, Zhang T, Li S, Steffen LM. Simplification of childhood hypertension definition using blood pressure to height ratio among US youths aged 8–17years, NHANES 1999–2012. Int J Cardiol. 2015;180:210‐213. [DOI] [PubMed] [Google Scholar]
  • 12. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl 4th Report):555‐576. [PubMed] [Google Scholar]
  • 13. Zhang Y, Ma C, Yang L, Bovet P, Xi B. Performance of modified blood pressure‐to‐height ratio for identifying hypertension in Chinese and American children. J Hum Hypertens. 2018;32(6):408‐414. [DOI] [PubMed] [Google Scholar]
  • 14. Lurbe E, Litwin M, Pall D, et al. Insights and implications of new blood pressure guidelines in children and adolescents. J Hypertens. 2018;36(7):1456‐1459. [DOI] [PubMed] [Google Scholar]
  • 15. Kotsis V, Stabouli S, Pitiriga V, Toumanidis S, Papamichael C, Zakopoulos N. Ambulatory blood pressure monitoring and target organ damage: effects of age and sex. Blood pressure monitoring. 2006;11(1):9‐15. [DOI] [PubMed] [Google Scholar]
  • 16. Kotsis V, Stabouli S, Pitiriga V, Papamichael C, Toumanidis S, Zakopoulos N. Impact of gender on 24‐h ambulatory blood pressure and target organ damage. J Hum Hypertens. 2006;20(9):658‐665. [DOI] [PubMed] [Google Scholar]
  • 17. Lurbe E, Thijs L, Torro MI, Alvarez J, Staessen JA, Redon J. Sexual dimorphism in the transition from masked to sustained hypertension in healthy youths. Hypertension. 2013;62(2):410‐414. [DOI] [PubMed] [Google Scholar]
  • 18. Stabouli S, Nika T, Kollios K, Antza C, Doundoulakis I, Kotsis V. Performance of simplified tables for high blood pressure screening in a European pediatric population. J Hypertens. 2019;37(5):917‐922. [DOI] [PubMed] [Google Scholar]
  • 19. Stabouli S, Redon J, Lurbe E. Redefining hypertension in children and adolescents: A review of the evidence considered by the European Society of Hypertension and American Academy of Pediatrics guidelines. J Hypertens. 2020;38(2):196‐200. [DOI] [PubMed] [Google Scholar]
  • 20. Kollios K, Nika T, Kotsis V, Chrysaidou K, Antza C, Stabouli S. Arterial stiffness in children and adolescents with masked and sustained hypertension. J Hum Hypertens. 2020. [DOI] [PubMed] [Google Scholar]
  • 21. Antza C, Doundoulakis I, Stabouli S, Tziomalos K, Kotsis V. Masked hypertensives: a disguised arterial stiffness population. J Clin Hyperten. 2019;21(10):1473‐1480. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from The Journal of Clinical Hypertension are provided here courtesy of Wiley

RESOURCES