USPSTF Final Recommendation Statement
Evidence Lacking on HBP Screening in Children, Adolescents
November 19, 2020, 8:44 am News Staff -- On Nov. 10, the U.S. Preventive Services Task Force issued a final recommendation statement, final evidence review and evidence summary on screening for high blood pressure in children and adolescents.
Based on its review of the available evidence, the task force concluded that it is insufficient to assess the balance of benefits and harms of screening for HBP in this population, and therefore insufficient to recommend for or against screening. This is an “I” recommendation statement, and it applies to children and adolescents who are not known to have hypertension.
“Although high blood pressure is a serious health issue, there is not enough evidence on whether or not screening children and teens leads to better long-term health,” said task force member Michael Silverstein, M.D., M.P.H., in a press release. “Clinicians should use their best judgment about whether or not to screen youth who do not have signs or symptoms.”
Although the exact number remains unclear, the CDC, using clinical practice guidelines from the American Academy of Pediatrics, has estimated that about 4% of American youth ages 12 to 19 have hypertension, while about 10% have elevated blood pressure. This is an important consideration because individuals who have hypertension early in life are more likely to have hypertension in adulthood, which puts them at increased risk for conditions such as heart disease and stroke.
Comparison With Other Recommendations
It should be noted that the USPSTF’s recommendation on screening for HBP in children and adolescents differs from recommendations from other health care organizations.
Story Highlights
The AAP recommends screening all patients for hypertension annually, and screening high-risk patients at each visit, beginning at age 3 years. The AAP also recommends using ambulatory blood pressure monitoring to confirm the presence of hypertension. The AAFP gave the AAP guideline its affirmation of value designation in February 2018.
Other organizations, such as the American Heart Association and the National Heart, Lung and Blood Institute, recommend routine screening for HBP in patients beginning at age 3 years.
Update of Previous Recommendation
The final recommendation statement is in agreement with the task force’s April draft recommendation, which also concluded that the current evidence was insufficient to assess the balance of benefits and harms of screening for HBP in children and adolescents (an “I” recommendation).
The final recommendation statement is also consistent with the task force’s October 2013 recommendation on the topic. At that time, the USPSTF concluded that the available evidence was insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood. The AAFP supported the 2013 recommendation.
To update the previous recommendation, the USPSTF conducted a systematic literature review of English-language articles published between June 1, 2012, and Sept. 3, 2019, with additional surveillance of the literature conducted through Oct. 6, 2020. The review focused on the benefits of screening, test accuracy, effectiveness and harms of treatment, and association between hypertension and markers of cardiovascular disease in childhood and adulthood, with the study population of interest extended to include children and adolescents with secondary hypertension. A total of 42 studies were included in the evidence review.
Findings
The task force found no direct evidence that compared screening with no screening in asymptomatic children and adolescents.
While results from some epidemiological studies reported an association between hypertension in childhood and adolescence and HBP in adulthood, and results from longitudinal studies found an association between HBP in adolescents and young adults and end-stage renal disease and death from cerebrovascular events in adulthood, the task force stated that “the evidence on other parts of the evidence chain supporting screening in unselected populations is weak.”
The task force also found inconclusive evidence regarding whether the diagnostic accuracy of blood pressure measurements was adequate for screening asymptomatic children and adolescents in primary care. In addition, the task force found no evidence that determined whether screening for HBP is effective in identifying children with secondary hypertension who are asymptomatic.
In response to the lack of evidence, the task force called for additional studies to provide more information on HBP screening in children and adolescents in a number of areas, including
- benefits and harms of long-term pharmacologic treatment;
- benefits and harms of screening and treatment in children at increased risk;
- the long-term natural history of hypertension in children and spontaneous resolution of hypertension; and
- harms of medications, long-term adherence with treatment and the effect of individual components of multifactorial interventions.
“Children and teens who have high blood pressure are more likely to have it as adults,” commented task force member Martha Kubik, Ph.D., R.N. “But we need better evidence to help us understand whether lowering blood pressure in youth leads to better cardiovascular health.”
Response to Public Comment
Following publication of the draft recommendation, the task force received several comments requesting clarification on secondary hypertension. In response, the task force added clarifying language to the Supporting Evidence section. The task force also provided additional language on the harms associated with screening in the Supporting Evidence and Research Needs and Gaps sections. Finally, in response to a comment on the lack of attention given to health inequities, the task force added language to the Research Needs and Gaps section.
What’s Next
The AAFP’s Commission on Health of the Public and Science plans to review the USPSTF’s final recommendation statement and evidence summary and will then determine the Academy’s stance on the recommendation.