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Practice Change Needed for the Identification of Pediatric Hypertension in Marginalized Populations: An Example From
Patricia Arnaiz1, Ivan Müller1, Harald Seelig1
1Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland.
Insights
International hypertension guidelines may overestimate pediatric hypertension in South Africa. Developing local reference data is crucial for accurate diagnosis in disadvantaged children, ensuring better cardiovascular disease management.
Area of Science:
- Pediatric Hypertension
- Public Health
- Cardiovascular Disease Epidemiology
Background:
- Childhood hypertension is a growing global concern, particularly in low- and middle-income countries.
- International age-, sex-, and height-adjusted normative tables are standard for diagnosing pediatric hypertension.
- The applicability of international standards to diverse populations, like South African children from disadvantaged communities, remains uncertain.
Purpose of the Study:
- To evaluate and compare different international blood pressure references for identifying hypertension in South African school-aged children.
- To assess the appropriateness of global, American, and German hypertension guidelines in a specific disadvantaged population.
Main Methods:
- A cohort of 897 children (aged 8-16 years) from peri-urban South African schools had their blood pressure, weight, and height measured.
- Hypertension prevalence was calculated using American, German, global, and study-specific (pseudo-normative) data.
- Multinomial logistic regression analyzed the association between blood pressure categories, body mass index (BMI), and cardiovascular disease risk markers.
Main Results:
- Hypertension prevalence varied significantly, from 11.4% (study data) to 28.8% (German reference).
- Global and American guidelines showed higher systolic than diastolic hypertension rates.
- The American guidelines indicated the highest increased risk for hypertension stage 2 with rising BMI (OR, 1.72).
Conclusions:
- Blood pressure estimates in South African children show significant heterogeneity, influenced by the reference standards used.
- International guidelines may not accurately represent African children, potentially leading to misdiagnosis.
- There is a critical need for South African-specific pediatric normative data to ensure accurate hypertension identification and management.
Introduction:
Hypertension in children has increased globally over the past 20 years; yet, little is known about this issue among disadvantaged communities from low- and middle-income countries. Age-, sex-, and height-adjusted normative tables are the "gold" standard for the diagnosis and estimation of pediatric hypertension worldwide, but it is unclear whether the use of international standards is appropriate for all contexts. The purpose of this study was to evaluate and compare different international references to identify hypertension among South African school-aged children from disadvantaged communities.
Methods:
Blood pressure, weight, and height were measured in a cohort of 897 children aged 8-16 years from eight peri-urban schools in the Eastern Cape of South Africa. Cross-sectional prevalence of hypertension was calculated according to American, German, and global normative tables, as well as pseudo-normative data from the own study population. Isolated systolic hypertension and body mass index (BMI) were considered markers for cardiovascular disease. Multinomial logistic regression was used to compare the likelihood of blood pressure categorization with increasing BMI levels.
Results:
Hypertension prevalence ranged from 11.4% with the pseudo-normative study tables to 28.8% based on the German reference. Global guidelines showed the highest agreement both among international standards (92.5% with American guidelines) and with the study reference (72.5%). While the global and the American references presented higher systolic over diastolic hypertension rates (23.6 vs. 10.6% and 24.2 vs. 14.7%, respectively), the American guidelines predicted the highest increased risk for hypertension stage 2 [odds ratio, 1.72 (95% confidence interval: 1.43-2.07)] with raising levels of BMI.
Conclusion:
Our results support the heterogeneity of blood pressure estimates found in the South African literature, and highlight the underrepresentation of African children in international guidelines. We call for caution in the use of international standards in different contexts and advocate for the development of normative tables that are representative of the South African pediatric population necessary to ensure an accurate identification of hypertension both from the clinical and epidemiological perspective.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.