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November 10, 2020

An Alternative View of Childhood Blood Pressure Screening: Reframing the Question

Author Affiliations
  • 1Department of Pediatrics, University of Washington School of Medicine, Seattle
  • 2Division of Nephrology, Seattle Children’s Hospital, Seattle, Washington
JAMA Netw Open. 2020;3(11):e2027964. doi:10.1001/jamanetworkopen.2020.27964

The United States Preventive Services Task Force (USPSTF) has issued an I statement (insufficient evidence) regarding the benefits and harms of childhood blood pressure (BP) screening.1,2 This outcome, which is the same conclusion as their analysis of childhood BP screening in 2013,3 is expected given how the key questions were framed and the analysis performed. However, what is the best approach to assess whether childhood BP measurement is associated with adult cardiovascular disease (CVD) or whether treatment of high BP in childhood is associated with reducing the burden of adult CVD? The best evidence to address these questions would be randomized clinical trials comparing screening vs no screening and treatment vs no treatment. Given the recommendations of the American Academy of Pediatrics (AAP),4 European Society of Hypertension,5 and other organizations that screening BP measurement should be performed and persistent hypertension treated in children and adolescents, clinical trials that directly address these questions are likely infeasible. The required length of follow-up, likely 5 or 6 decades, is an additional barrier. The questions must be reframed.

Perhaps the appropriate question to ask is: does BP measurement in childhood identify children and adolescents who already have markers of CVD or who are at risk of developing them as adults? Such youth so identified would then be candidates for measures designed to prevent progression of their cardiovascular risk factors to established CVD. Reframing the question in this way maintains a focus on prevention while avoiding the requirement that the only acceptable outcome is prevention of CVD events in adulthood, such as stroke, myocardial infarction, or death. What then are the available data that would address the reframed question?

Cross-sectional studies can establish the association between BP levels and markers of cardiovascular risk that are already present. The body of such evidence has been recently strengthened by several publications from the multicenter Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth (SHIP-AHOY), which enrolled approximately 400 adolescents with office BP values ranging from below the 75th percentile to stage 1 hypertension and then carefully performed additional assessments to examine potential cardiovascular risk, including 24-hour ambulatory BP monitoring, metabolic testing, and examinations of cardiac structure and function, vascular function, and cognition.6 The SHIP-AHOY results have demonstrated that increased left ventricular mass can be demonstrated at BP levels currently classified as normotensive and that abnormal left ventricular function can be seen at similar BP levels.7,8 Furthermore, they have established a substantial association between an abnormal metabolic phenotype and several forms of target-organ damage associated with high BP.9 These multicenter data reinforce prior single-center studies that demonstrated the adverse consequences associated with high BP in children and adolescents10 and set the stage for the institution of measures designed to reverse target-organ damage and reduce cardiovascular risk in youth.4,5

Given the lack of prospective clinical trials, analysis of longitudinal cohort studies is the best available method for examining the potential association between current BP levels and future CVD.11,12 A recent publication from the International Childhood Cardiovascular Cohort Consortium13 showed that specific systolic BP levels in childhood were associated with increased adult carotid intima-media thickness, which is accepted as a surrogate marker of atherosclerosis. Other longitudinal cohort studies have demonstrated meaningful associations between childhood BP levels and other intermediate markers associated with CVD, including stiffer blood vessels, narrowed retinal arteries, and left ventricular hypertrophy and remodeling.11 Additionally, longitudinal BP trajectories within cohorts, such as the Bogalusa Heart Study, have been associated with development of adult CVD, with individuals having persistently high lifetime BP starting in adolescence more likely to have left ventricular hypertrophy in adulthood than those with normal lifetime BP.14

Longitudinal cohort studies also provide data that address an important point raised in the USPSTF statement,1,2 namely whether the pediatric percentile-based BP cut points, such as those in the 2017 AAP guideline,4 are associated with adult hypertension and CVD. In the International Childhood Cardiovascular Cohort Consortium study,13 the specific childhood BP levels that were associated with increased adult carotid intima-medial thickness were remarkably similar to the BP percentile cut points in the AAP guideline for children of similar ages.12 Additional evidence in support of the current childhood BP cut points comes from another analysis of data from the Bogalusa Heart Study.15 The Bogalusa investigators looked at children categorized as having high BP by both the 2017 AAP guideline4 and the 2004 fourth report guideline issued by the National High Blood Pressure Education Program.16 The 2017 AAP guideline classified more children as having high BP than the 2004 fourth report, and those children whose BP category was classified upward had increased relative risks of having hypertension, left ventricular hypertrophy, or metabolic syndrome as adults 36 years later.15 Thus, it would appear that the percentile-based BP cut points currently in use do estimate development of intermediate markers associated with adult CVD, and that they perform better than the cut points in use at the time of the prior USPSTF statement on childhood BP screening.3

The conclusions of the USPSTF statement1,2 underscore the need for additional research on childhood high BP and its association with adult CVD. The starting points for such research can be deduced from currently available cross-sectional and longitudinal data, which demonstrate the detrimental outcomes associated with high BP in youth. Using these data to reframe and answer the questions raised by the USPSTF should point the way toward effective prevention of adult CVD.

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Article Information

Published: November 10, 2020. doi:10.1001/jamanetworkopen.2020.27964

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Flynn JT. JAMA Network Open.

Corresponding Author: Joseph T. Flynn, MD, MS, Division of Nephrology, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 (

Conflict of Interest Disclosures: Dr Flynn reported receving grants from the National Institutes of Health and royalties from UpToDate and Springer outside the submitted work.

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