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    Easier pediatric blood pressure screening

    Dr. Andrew Schuman recently sat down with Dr. David Kaelber to discuss the implications of his vastly simplified screening tool for pediatric hypertension

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    Q: Can you comment on the technique of obtaining BP measurements in children, specifically which cuff sizes are appropriate for use with children?

    a: Cuff size is very important in taking a BP measurement in children. Details of the technique are clearly discussed in the Fourth Report, as follows:


    Table 2: Recommended dimensions for BP cuff bladders
    By convention, an appropriate cuff size is a cuff with an inflatable bladder width that is at least 40% of the arm circumference at a point midway between the olecranon and the acromion (see http://www.americanheart.org/presenter.jhtml?identifier=576). For such a cuff to be optimal for an arm, the cuff bladder length should cover 80% to 100% of the circumference of the arm. Such a requirement demands that the bladder width-to-length ratio be at least 1:2.2 The Fourth Report also includes a nice table outlining typical sizes based on age range (TABLE 2).

    Q: Many pediatric practices use automated sphygmomanometers. Are automated BP measurements reliable?

    a: As per the Fourth Report, "An elevated BP reading obtained with an oscillometric device should be repeated by using auscultation." The difference between automatic and manual BP measurements is further discussed in my article.3

    Q: What is the current utility and accuracy of continuous, or ambulatory, BP monitoring in diagnosing hypertension in children?

    a: Per the Fourth Report, ambulatory BP monitoring (ABPM) is especially helpful in the evaluation of "white-coat hypertension" as well as the risk for hypertensive organ injury, apparent drug resistance, and hypotensive symptoms with antihypertensive drugs. ABPM is also useful for evaluating patients for whom more information on BP patterns is needed, such as those with episodic hypertension, chronic kidney disease, diabetes, and autonomic dysfunction. Conducting ABPM requires specific equipment and trained staff. Therefore, ABPM in children and adolescents should be used by experts in the field of pediatric hypertension who are experienced in its use and interpretation.2


    Summary of the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
    In my own experience, for a number of reasons, including lack of insurance reimbursement and difficulty obtaining ambulatory BP measurement, among other issues, it is not practical to order ABPM routinely on every patient with an elevated BP and/or suspected hypertension or prehypertension.

    Q: Is there any role for pediatricians to evaluate and manage patients with prehypertension or hypertension, or should all such patients be referred to pediatric cardiologists or nephrologists?

    a: My own view is that general pediatricians could take care of "simple" prehypertension and hypertension without referral to a pediatric cardiologist or nephrologist. Most adults with prehypertension and hypertension are cared for by their primary care physicians, not by an adult cardiologist or nephrologist. However, like managing any other medical condition, the pediatrician doing so should feel comfortable with their knowledge of evaluating and managing the disease. If they do not feel comfortable then referral to a specialist, typically a pediatric cardiologist or nephrologist, is warranted.

    DR. SCHUMAN is an adjunct assistant professor of pediatrics at Dartmouth Medical School, Lebanon, N.H., and a contributing editor for Contemporary Pediatrics. DR. KAELBER is a practicing internist and pediatrician and the Chief Medical Informatics Officer of the MetroHealth System, Cleveland. He is also an Assistant Professor of Internal Medicine and Pediatrics at Case Western Reserve University, Assistant Program Director of the Case Western Reserve University (MetroHealth) Internal Medicine and Pediatrics (Med-Peds) Program, and Fellowship Director of MetroHealth's EPIC Clinical Informatics Fellowship. The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

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    Andrew J Schuman, MD, FAAP
    Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, ...

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