On 2014 Jul 20, Johan van Schalkwyk commented:

Within Ingelfinger’s thorough review[1] of elevated blood pressure (EBP) in adolescents and children lies a paradox that will likely increase costs and diminish putative benefits of diagnosis and treatment of EBP. If EBP is defined as a sustained increase in pressure over the 90th percentile, why should teen rates be 12.3–19%,1 and not the expected 10%?

The answer must lie in the diagnostic criteria used. With diagnosis based on elevated levels on three or more occasions[1,2] rather than an average of all values taken on many occasions, random variation in blood pressure predisposes to spurious identification of EBP.[3] More lax criteria, as commonly used,[4] will cause higher error rates.

Without application of consistent, appropriate diagnostic criteria, many completely normal teens will be subjected to basic laboratory tests, renal ultrasonography, left ventricular mass assessment, eye examination and other tests,[1] and even unnecessary treatment.

[1] Ingelfinger JR. The Child or Adolescent with Elevated Blood Pressure. N Engl J Med. 2014; 370:2316-2325.

[2] National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114:Suppl:555-76.

[3] van Schalkwyk JM, Turner MJ. Diagnosing hypertension in children and adolescents. JAMA. 2008;299:168.

[4] Feber J, Ahmed M. Hypertension in children: new trends and challenges. Clin Sci (Lond) 2010;119:151-61.

(Note: Publication of the above comment was declined by the NEJM editors)

On 2014 Jul 20, Johan van Schalkwyk commented:

Within Ingelfinger’s thorough review[1] of elevated blood pressure (EBP) in adolescents and children lies a paradox that will likely increase costs and diminish putative benefits of diagnosis and treatment of EBP. If EBP is defined as a sustained increase in pressure over the 90th percentile, why should teen rates be 12.3–19%,1 and not the expected 10%?

The answer must lie in the diagnostic criteria used. With diagnosis based on elevated levels on three or more occasions[1,2] rather than an average of all values taken on many occasions, random variation in blood pressure predisposes to spurious identification of EBP.[3] More lax criteria, as commonly used,[4] will cause higher error rates.

Without application of consistent, appropriate diagnostic criteria, many completely normal teens will be subjected to basic laboratory tests, renal ultrasonography, left ventricular mass assessment, eye examination and other tests,[1] and even unnecessary treatment.

[1] Ingelfinger JR. The Child or Adolescent with Elevated Blood Pressure. N Engl J Med. 2014; 370:2316-2325.

[2] National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114:Suppl:555-76.

[3] van Schalkwyk JM, Turner MJ. Diagnosing hypertension in children and adolescents. JAMA. 2008;299:168.

[4] Feber J, Ahmed M. Hypertension in children: new trends and challenges. Clin Sci (Lond) 2010;119:151-61.

(Note: Publication of the above comment was declined by the NEJM editors)