A new AAP technical report can help clinicians gain further clarity regarding the
methods and approach used to generate the 2017AAPClinical Practice Guideline for Screening and Management of High Blood Pressure in
Children and Adolescents.
The report details the systematic review process utilized for identifying and characterizing
(e.g., level of evidence) the literature used to generate the 30 key action statements
and 27 additional recommendations in the practice guidelines.
The report, Diagnosis, Evaluation, and Management of High Blood Pressure in Children and Adolescents from the Subcommittee on Screening and Management of High Blood Pressure in Children,
is available at https://doi.org/10.1542/peds.2018-2096 and will be published in the September issue of Pediatrics.
To generate the 2017 clinical practice guideline (CPG), a broader content outline
of 100 topics related to the diagnosis and management of hypertension in youths was
condensed into four primary “PICOT” (Patient, Intervention, Comparison, Outcome, Time) questions. Additional topics were searched separately, such as defining hypertension
(HTN) in youths, defining left ventricular hypertrophy, the economic impact of HTN
screening, patient/child perspectives, evidence gaps and proposed future directions.
Key questions addressed in the technical report and ultimately in the guideline include
PICOT 1: How should systemic HTN (primary HTN, renovascular HTN) be diagnosed in neonates,
infants and children (0 to 18 years of age)? How should white coat HTN and masked
HTN be diagnosed in children and adolescents? What is the optimal approach for diagnosing
HTN in children and adolescents?
PICOT 2: What is the recommended workup for evaluating children and adolescents with suspected
or confirmed systemic HTN? How do we best identify the underlying etiologies of secondary
HTN in children and adolescents, including renal-, endocrine-, environment-, medication-
and obesity-related causes? When should providers suspect a monogenic form of systemic
HTN among children and adolescents?
PICOT 3: What is the optimal goal systolic blood pressure and/or diastolic blood pressure
for children and adolescents? What nonpharmacologic and pharmacologic therapies are
available to treat high blood pressure (HBP) in children and adolescents?
PICOT 4: In children and adolescents 1 to 18 years of age, how do the presence and severity
of systemic HTN influence indirect markers of cardiovascular disease and vascular
dysfunction (e.g., flow-mediated dilation, carotid intima media thickness), and how
does HTN in children impact long-term risk of HTN into adulthood? Among children and
adolescents with systemic HTN, how do the presence and the severity of systemic HTN
influence comorbidities such as dyslipidemia, obstructive sleep apnea syndrome and
Compared with prior pediatric HTN guidelines, the 2017 guideline combined clinical
expertise with a detailed, systematic review process and an evidence scoring method.
Of the nearly 15,000 references identified, 570 were selected for inclusion. Most
references were level of evidence C, and the majority of key action statements were
of “moderate recommendation.”
Highlights from the technical report include:
a process flow map detailing the approach used to generate the 2017 guideline;
a description of the PICOT questions used;
a detailed description in the appendix of the search terms used to identify key references
(including the date and time the search was conducted); and
strategies for implementing the 2017 guideline blood pressure definitions into the
electronic health record.
Overall, the technical report details a comprehensive approach to updating the pediatric
Dr. Baker-Smith, a lead author of the technical report, is a pediatric cardiologist
who served as epidemiologist and methodologist for the clinical practice guideline.
She is a member of the AAP Subcommittee on Screening and Management of High Blood
Pressure in Children.