‘There is so much we can change’ to recognize, prevent primary hypertension in children
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Key takeaways:
- Primary hypertension in children is a risk factor for CVD in adulthood.
- Clinicians must emphasize prevention efforts, including a healthy diet and exercise.
Primary hypertension in children is a predictor of hypertension and other CVD in adulthood, yet the condition is often unrecognized and undertreated.
In a new American Heart Association scientific statement published in Hypertension in March, researchers highlighted risk factors for primary hypertension, which is now the leading type of hypertension, particularly for adolescents. Those risk factors include but are not limited to excess adiposity, suboptimal lifestyles, environmental stressors, low birth weight and genetic factors, according to Carissa M. Baker-Smith, MD, MPH, FAHA, director of pediatric preventive cardiology, Nemours Children’s Health, and a co-author of the scientific statement.
Baker-Smith spoke with Healio about what high BP in children means for CV risk in adulthood, what factors contribute to hypertension burden and changes at the community level that could improve health. Baker-Smith is also immediate past chair of the AHA’s Young Hearts – Atherosclerosis, Hypertension and Obesity in the Young Committee.
Healio: Why was a new scientific statement on primary hypertension in children needed now?
Baker-Smith: Our understanding of primary hypertension in children has evolved, particularly our understanding of the relationship between primary hypertension as it presents in childhood and what that means in terms of long-term CV health risk and CV events during adulthood.
Defining hypertension has historically been challenging. That is still evolving. We are better able now to say your BP at age 7 years does matter in terms of your BP at age 28 years. It matters in terms of your risk for premature HF and MI, in adulthood. That has led to ongoing revisions in how we define hypertension in kids. In this new scientific statement, we provide that historical backdrop for how this evolved. Initially, we used adult cutoffs for everyone. We later recognized that there may be a bell curve to this, with the median being the 90th to 95th percentile for children.
We then reevaluated what was considered “normal” BP. As children transition to adulthood, we want to make that more seamless in how we define hypertension, with updated cutoff values around adolescence. That will continue to change as more data becomes available.
Healio: What is driving the rate of pediatric hypertension that we see today?
Baker-Smith: There are two types of pediatric hypertension, primary and secondary. The guideline is about primary, meaning it is not secondary to kidney disease or an endocrine abnormality. There are three things that determine your BP: stroke volume, heart rate and systemic vascular resistance. For younger people, that cardiac output, your stroke volume and heart rate, really determine BP. The most common way that plays out is in so-called white coat hypertension — when a child gets nervous, their BP will rise. When it is a sustained effect it is hypertension, and what may be driving it has everything to do with the sustained factors that cause a sustained elevation in heart rate. Namely, obesity. Then there are other things such as the impact of environmental factors and stressors in the development of hypertension. For those social stressors, neighborhood deprivation may play a role.
Can you explain how primary hypertension in children is a predictor of CV events?
Baker-Smith: Hypertension alone is a primary driver of CV events in adulthood for all-comers; data on this are clear. Additionally, new data from the International Childhood Cardiovascular Cohort (i3C) Consortium, published in 2022 in The New England Journal of Medicine, found that childhood risk factors, including hypertension, and the change in the combined-risk z score between childhood and adulthood were associated with CV events in midlife.
We also know that your BP is part of your AHA Life’s Essential 8 score. If someone has more health factors like high cholesterol, obesity and diabetes, and has hypertension, the greater the risk for poor CV health in adulthood. It is important for people to know that. This may seem novel to some, but we now have many studies suggesting these associations. As a child ages, what their CV health status looks like as they turn age 18 years influences their CVD rates and prevalence as an adult.
Healio: How do pediatricians and other providers begin to tackle this issue? What needs to be happening on the screening front?
Baker-Smith: I spend a lot of time educating general pediatricians about Life’s Essential 8, health status, and why it is so important that we do things like check a child’s BP and counsel the family on unexpected weight gain and check lipid levels. Yet, there is a lot of hesitancy to do those things. Some providers ask, “Well, what do I do with these numbers?” In busy practices, pediatricians have many patients, staff turnover, and question whether the tools used to measure BP are accurate. So many parents have concerns, including psychosocial concerns. You want a child to have positive self-esteem, and talking about weight, lifestyle and a healthy diet can be very challenging, especially if resources are limited. We should know that only about 20% of children get the recommended amount of physical activity. This is where parents can play a role. There are intergenerational components as well.
Healio: Any other takeaways from the scientific statement you would like to highlight?
Baker-Smith: We have to think really hard about what risk factors are modifiable and which risk factors are not modifiable. We focus a lot on genetics, but I would tell you that is the least strong association. A lot of this comes down to policy. If we create safe places to exercise and emphasize a healthy diet — a “food is medicine” approach — as a priority, and parental education, we have an opportunity to improve outcomes. If we do not, this will forever be an issue. It really is these environmental, community-level factors that are most important in terms of disease prevalence. It is easier to chalk this problem up to things you cannot change. Yet, there is so much we can change about pediatric hypertension.
References:
- Falkner B, et al. Hypertension. 2023;doi:10.1161/HYP.0000000000000228.
- Jacobs DR, et al. N Engl J Med. 2022;doi:10.1056/NEJMoa2109191.
For more information:
Carissa M. Baker-Smith, MD, MPH, FAHA, can be reached at carissa.baker-smith@nemours.org.
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