A new Australian guideline for the management and identification of hypertension in children and adolescents was released last month, and experts warn that early intervention is crucial to reduce the risk for heart attacks and stroke.

The guideline, a national collaboration between organizations including BPOzKids, Hypertension Australia, Murdoch Children’s Research Institute (MCRI), and Edith Cowan University, recommends blood pressure checks at ages 7-9 and at ages 13-15. The guidelines call for screening at all healthcare visits for children aged 3 years or older who have risk factors and recommend that most children with hypertension undergo a 6-month trial of nonpharmacologic, team-based management.

As many as 40,000 kids across Australia have stage 2 hypertension, most of which is undetected, Nicholas Larkins, MBBS, PhD, consultant in nephrology and metabolic medicine at Perth Children’s Hospital, senior research fellow at the Nutrition and Health Innovation Research Institute at Edith Cowan University, and lead author of the guidelines, told Medscape News Australia.

“Obesity is the biggest single risk factor for this, but it’s not the whole story: Salt intake, energy drink consumption, and exercise all contribute,” he said. “The risk is that it’s silent and doesn’t wait until adulthood…. The good news is that these changes are reversible with early intervention.”

It is crucial that children be checked at least twice throughout their childhood, Jonathan Glenning, an MD/PhD candidate at the University of Melbourne and the MCRI, told Medscape News Australia. Glenning, who contributed to the guideline, also is an honorary researcher in the Department of Cardiology at the Royal Children’s Hospital in Melbourne.

“For the longest time, high blood pressure and cardiovascular disease have been seen as adult problems, but high blood pressure starts in childhood,” he said. “The problem is that most won’t know it — it’s a silent disease in kids. The damage is silently occurring without physical symptoms yet. The length of time you have high blood pressure is directly linked to your damage and risk. It’s about knowing about it and getting it checked. We can intervene and can reduce kids’ lifetime risk for heart attack and stroke.”

The guidelines assert that general practitioners are best placed to undertake the checks — which take less than a minute to perform — and provide individualized, whole-of-life care, yet they emphasize that the recommendations “need to be implementable in the context of current general practice workflows, time demands, and billing constraints in the Australian system.”

Hurdles to Overcome

There are several hurdles to implementing the guidelines, given the limited existing structures for preventive healthcare for school-age children, said Larkins. The hurdles relate to access to the right-sized cuff, validated sphygmomanometers for children, and knowing what to do with the resulting blood pressure value. “That last one is what the guideline fixes,” he added.

The guidelines state that at the time of diagnosis of elevated blood pressure, clinicians should provide advice on the Dietary Approaches to Stop Hypertension diet and recommend moderate-to-vigorous physical activity at least 3-5 d/wk to help lower blood pressure. They acknowledge, however, “that most children with hypertension will continue to be referred to specialist clinics initially,” stressing the importance of providing educational opportunities and outreach for general pediatricians and practitioners that facilitate the decentralized care of less complex patients.

Glenning agreed with the guidelines, adding that other barriers to general practitioner-based screening include access to healthcare, especially in rural and remote areas, and financial considerations. School-based blood pressure checks, which can be carried out by trained school nurses, hold huge promise in his opinion.

“Most kids go to school, so we’re thinking, ‘Could this work well at schools? Does it work effectively?’ In our research, we found it works well. We got fantastic acceptability numbers from staff, kids, and parents,” he said.

In 2023, the MCRI ran the Healthy Hearts @ School Study, which checked blood pressure among students in grades 3-6 (with parental or carer consent) at a school in South Yarra. The study, which Glenning coordinated, also ran a heart health education session that taught how the heart and arteries work and what children can do to promote heart health. The children with high blood pressure readings received letters to give to their general practitioners.

Today, GenPRESSURE is a primary school blood pressure screening trial led by the MCRI in partnership with Australian universities and other research centers. It’s part of GenHEART, a 10-year strategy designed to combat rising childhood obesity and related health conditions. Research predicts that half of the children and adolescents in Australia will have overweight or obesity by 2050. GenPRESSURE is investigating whether blood pressure checks at primary school reduce the risk for stroke and heart disease. The trial is due to begin next year.

Infrastructure Needs Development

While school-based checks have potential, the infrastructure must be developed, and its scalability must be confirmed before implementation can become widespread, said Larkins. For now, he encourages parents to lead by example.

“For parents, the most common modifiable risk factors are overweight, obesity, and hidden salt in processed and packaged goods,” he said. “Importantly, hypertension is a strongly inherited trait, and associated risk factors cluster within families. Children will follow our lead, and positive changes are far more likely to stick if made at a family level.”

Glenning is hoping to see school-based blood pressure checks become a nationally funded program. “We have lots of work to do. It’s just hard when events are 40 years down the track. It’s hard to show benefit in the ways that policymakers like to see,” he said. “But this is a significant issue, and we have an opportunity to not only treat it in childhood but [also] prevent it in the first place. Prevention is the best cure.”

Larkins and Glenning reported having no relevant financial relationships.