2017 AAP CPG

1. WELCOME
TO
JOURNAL CLUB PRESENTATION
Maj Jahangir Alam
Classified Specialist in Paediatrics
CMH Dhaka

2. REVIEW ON NEW CLINICAL PRACTICE GUIDELINE FOR
THE MANAGEMENT OF HIGH BLOOD PRESSURE IN
CHILDREN AND ADOLESCENTS
Authors : Joseph T. Flynn, Bonita E. Falkner
Oct 2017
Volume : 70
P : 683-86

3. Introduction
 Before 1977, there was no consistent
definition of hypertension in
childhood.
 Childhood hypertension had been
considered rare and, if detected, the
assumption was that it would be
secondary to an underlying disorder.

4.  In the mid-1970s, National Heart Lung and
Blood Institute (NHLBI) convened a task force
to examine available BP data on healthy
children.
 The recommendations of this task force on
detection, evaluation, and management of
hypertension in children and adolescents
were published in 1977 (1st report).
Introduction cont…

5.  Major updates were published in
1987(2nd), 1996(3rd), and
2004(4th).
 Interest in childhood hypertension
(HTN) has increased since the
2004 publication (forth report).
Introduction cont…

7.  Clinical Practice Guideline for Screening and
Management of High Blood Pressure in Children and
Adolescents are an update to the 2004 “Fourth
Report".
 It is known as "2017 AAP CPG“
Introduction cont….

8. Understand the changes in the new AAP childhood
hypertension guideline and how these changes will
affect the management of hypertension.
objectives

9. Definition of Hypertension in children & Adolescents
Categories For children aged 1-13 yr For children aged > 13 yr
Normal BP < 90th percentile <120/<80 mm Hg
Elevated BP > 90th percentile to < 95th
percentile 0r 120/80 mm Hg to
< 95th percentile (whichever is
lower)
120/<80 to 129/<80
mm Hg
Stage 1 HTN > 95th percentile to < 95th
percentile +12 mm Hg or
130/80 to 139/89 mm Hg (
Whichever is lower)
130/80 to 139/89 mm
Hg
Stage 2 HTN > 95th percentile + 12 mm Hg or
>140/90 mm Hg (whichever is
lower)
> 140/90 mm Hg

10.  BP >90th percentile is now termed
‘elevated BP’
 BP cut-points for Stage 1 and 2 HTN
simplified
 BP cut-points for adolescents ≥13
years of age are the same as in new
AHA/ACC adult HTN guideline
changes in CPG 2017 compared to forth report

11.  4th Report BP tables generated from BP values in
~70,000 healthy children where many of the children
had overweight or obesity
 New normative BP tables commissioned for this
clinical practice guideline, based only on BP readings
from ~50,000 normal-weight children
New normative blood pressure table

12. New blood pressure table

13. New blood pressure table

14. New blood pressure table

15.  Simplified BP table created
for use in initial screening
of BP values
 Based on 90th percentile
BP values for children at
5th height percentile
Simplified Blood Pressure Table

16.  NHBPEP guidelines recommended routine
measurement of BP in children and adolescents for
screening purposes at every healthcare encounter.
 The 2017 AAP CPG recommends that routine BP
screening be performed only at annual preventive
care visits unless any predisposing condition such as
obesity, diabetes mellitus, heart disease, or kidney
disease.
Routine BP Screening

17.  Confirmation of the diagnosis of
hypertension
suspected white-coat
hypertension;
 Evaluation for masked hypertension
with a history of repaired
coarctation of the aorta;
 Evaluation of BP pattern and risk for
hypertensive TOD in high-risk
conditions, such as CKD;
Ambulatory BP monitoring (ABPM)

18.  Evaluation for possible hypertension in
obstructive sleep apnea syndrome.
 Evaluation of BP in pediatric heart and
kidney transplant recipients;
 Assessment & monitoring of
treatment efficacy.
Ambulatory BP monitoring (ABPM)

19.  2004 Fourth Report recommended that
echocardiograms be obtained in all hypertensive
children and adolescents at the time of diagnosis of
hypertension.
 But 2017 CPG recommended that echocardiograms
be obtained to assess for cardiac TOD at the time
initiation of pharmacological treatment.
Echocardiography

20.  Additional time points for consideration of
echocardiography include
 monitoring of known TOD and
 when concentric LVH or reduced LV ejection
fraction is present on the initial
echocardiogram.
Echocardiography

21. Indications for antihypertensive medications is found
in the 2017 AAP CPG
I. Persistent hypertension despite lifestyle
modification, especially with an abnormal
echocardiogram; Symptomatic hypertension;
II. Stage 2 hypertension without a modifiable risk
factor; or
III. Any stage of hypertension in patients with
diabetes mellitus or CKD.
Antihypertensive medication

22.  The replacement of the term “prehypertension” with the
term “elevated blood pressure,”
 New normative pediatric blood pressure (BP) tables
 A simplified screening table for identifying BPs.
 A simplified BP classification in adolescents ≥13 years.
 Limited recommendation for screening BP.
 Expanded role for ambulatory BP monitoring.
 Revised recommendations for echocardiography.
Significant changes in these guidelines

23.  The 2017 AAP CPG is a comprehensive document that
addresses numerous aspects of the evaluation and
management of high BP in children and adolescents.
 It is the first pediatric hypertension guideline to be
developed from a strict evidence-based approach and
 First to be aligned as much as possible with a new
hypertension guideline for adults.
 However, further studies are required to confirm the
impact of new guidelines on the prevalence of
hypertension in children.
Conclusion

24. THANK YOU