is

apirgm

12Fh3

415H6RU7t829ac1Ee21v21a2121d21

Teoommeghft

idip

mpnvbb

4

nto an algorithmic approach should further improve the preci-ion of classification.

The long-term goals in CP are to improve preventionnd to develop neuroprotective strategies in the neonataleriod and effective interventions during childhood. Find-ngs from the ELGAN study will continue to focus theesearch on improving classification and will encourageeneral pediatricians to examine children with CP fromultiple perspectives.

Pasquale J. Accardo, MDDivision of General Pediatrics

Virginia Commonwealth University School of MedicineRichmond, Virginia

Alexander H. Hoon, Jr, MD, MPHJohns Hopkins University School of Medicine

Phelps Center for Cerebral Palsy and Neurodevelopmental MedicineKennedy Krieger Institute

Baltimore, Maryland

REFERENCES. Jainism and Buddhism. Udana 68-69: Parable of the Blind Men and the Elephant.. Sanger TD, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW, for the Taskorce on Childhood Motor Disorders. Classification and definition of disorders causing

Blood Pressure Screening in Child

ased on a number of well described criteria.2,3 The goal of

sufsofott

bbwshtcpshtitmt

52 Editorials

. Nelson NB, Ellenberg JH. Children who “outgrew” cerebral palsy. Pediatrics982;69:529-36.. Crothers B, Paine RS. The Natural History of Cerebral Palsy. Cambridge, MA:arvard University Press; 1959.

. Yeargin-Allsopp M, Van Naarden Braun K, Doernberg NS, Benedict RE, KirbyS, Durkin MS. Prevalence of cerebral palsy in 8-year-old children in three areas of thenited States in 2002: a multisite collaboration. Pediatrics 2008;121:547-54.

. Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates of cerebral palsy:he European Cerebral Palsy Study. JAMA 2006;296:1602-8.. Keogh JM, Badawi N. The origins of cerebral palsy. Curr Opin Neurol006;19:129-34.. Kuban KC, O’Shea M, Allred E, Leviton A, Gilmore H, DuPlessis A, et al. Videond CD-ROM as a training tool for performing neurologic examinations of 1-year-oldhildren in a multicenter epidemiologic study. J Child Neurol 2005;20:829-31.0. Laughon M, Bose C, Allred E, O’Shea TM, Van Marter LJ, Bednarek F, for theLGAN Study Investigators. Factors associated with treatment for hypotension in

xtremely low gestational age newborns during the first postnatal week. Pediatrics007;119:396-7.1. Kuban K, Adler I, Allred EN, Batton D, Bezinque S, Betz BW, et al. Observerariability assessing US scans of the preterm brain: the ELGAN study. Pediatr Radiol007;37:1201-8.2. Kuban KCK, Allred EN, O’Shea M, Paneth N, Pagano M, Leviton A. Anlgorithm for identifying and classifying cerebral palsy in young children. J Pediatr008;153:466-72.3. Accardo J, Kammann H, Hoon AH Jr. Neuroimaging in cerebral palsy. J Pediatr004;145:S19-27.4. Krägeloh-Mann I, Horber V. The role of magnetic resonance imaging in eluci-ating the pathogenesis of cerebral palsy: a systematic review. Dev Med Child Neurol007;49:144-51.5. Nagae LM, Hoon AH Jr, Stashinko E, Lin D, Zhang W, Levey E, et al. Diffusion

ypertonia in childhood. Pediatrics 2003;111,e89-97.. Education of the Handicapped Act Amendments. Pubic Law no. 99-457 (1986).)

tensor imaging in children with periventricular leukomalacia: variability of injuries towhite matter tracts. AJNR Am J Neuroradiol 2007;28:1213-22.

ren: Do We Have This Right?

he manuscript by Stewart et al,1 published in thisissue of The Journal, reports that although bloodpressure measurements in children at the time of

mergency department visits for a nonurgent condition wereften elevated (26%), follow-up did not uncover a single casef “true” hypertension. The authors conclude, “The yield ofeasuring blood pressure at triage to the emergency depart-ent in children with nonurgent problems appears to be

xtremely low.” Hypotension, certainly a concern in the emer-ency department, is predicted by other findings, and trueypertension was not diagnosed in the population studied. Inact, a large number of false-positive results resulted from theriage measurements performed.

The report actually may draw attention to an even moremportant question, which goes to the heart of screening forisease. Is screening for hypertension in childhood, the way it

s recommended today, a useful individual health (or evenublic health) strategy?

Provocative? Perhaps, but let’s explore why the questionay be worthy of debate. Pediatricians, as much as any

hysician group, are familiar with screening. Almost everyewborn in the United States undergoes screening for aariety of conditions with a drop of blood obtained soon afterirth. The decision to include screening for a condition is

creening should be to (1) identify a previously unknown orndiagnosed condition in an apparently healthy or symptom-ree patient; (2) offer presymptomatic intervention becauseuch intervention will reduce the likelihood of disease devel-pment, progression, morbidity, or death; (3) offer counselingor risk; or (4) perform research. Perhaps with the exceptionf research, the reason to screen also involves the principlehat with presymptomatic diagnosis there is indeed an effec-ive treatment or option available to the patient.

The consideration of whether a screening test shoulde used is based on a number of principles. The test shoulde able to distinguish those with the condition from thoseho do not have it. The

ensitivity should beigh, thereby detectinghose who truly have theondition (high positiveredictive value). Thepecificity should beigh, thereby excludinghose who do not havet (high negative predic-ive value). Further-ore, a good screening

See related article, p 478

Reprint requests: Aaron Friedman, MD,Department of Pediatrics, University ofMinnesota, 420 Delaware St SE, MMC 319,Minneapolis, MN 55455.

J Pediatr 2008;153:452-3

0022-3476/$ - see front matter

Copyright © 2008 Mosby Inc. All rightsreserved.

est is accurate, repro-

Th

10.1016/j.jpeds.2008.05.014

e Journal of Pediatrics • October 2008

dNbt

(byTgmtcwcNt

tsiciitlsatendawmaAatppriIieinpithmm

th(

cmrnarbaa

hatttsNOuecaearssc

1pu2Ad3mW4Pa25p6p7c8

E

ucible, easy to perform in the field, and preferably inexpensive.ot every screening test meets all these criteria, but the risk

enefit ratio of performing a screening test should undergo thisype of evaluation.

The 2004 National Blood Pressure Education ProgramNHBPEP) Working Group 4th Report recommends thatlood pressure measurements be performed in all children over 3ears of age when these children are seen in a medical setting.4

he fundamental tenet of such a recommendation is that emer-ency departments or outpatient clinics represent the chance toeasure blood pressure and thus find children who are presymp-

omatic patients with a treatable condition. Furthermore, there islear evidence that the risk to health of hypertension increasesith time leading to known sequelae of hypertension such as

ardiac, renal, and central nervous system injury. Does theHBPEP Working Group 4th Report recommendation meet

he criteria for a good screening test?Using the criteria above, measuring blood pressure is

he way we use to determine whether a patient has hyperten-ion. It must be recognized that, unlike may other conditions,t may be necessary to keep measuring because the earlyhanges in blood pressure may occur at almost any age. Thiss distinctly different from many conditions where the screen-ng test, when it is performed, can immediately be followed byhe definitive test. If a test result is negative, further testingater in life is not necessary. In this regard, hypertensioncreening is more like colon cancer or breast cancer screeningnd not like cystic fibrosis or metabolic disease screening. Also,here are interventions that can be used that are effective. How-ver, the prevalence of hypertension in the pediatric population isot high when screening the whole population is the recommen-ation. This makes a high positive predictive value difficult tochieve. In the study by Stewart et al, the positive predictive valueas 0! What about the test method itself? Are blood pressureeasurements as we do them routinely accurate? Increasingly,

utomated blood pressure machines are employed in all settings.lthough difficult to assess, reports have demonstrated that

utomated blood pressure measurements overestimate both sys-olic and diastolic blood pressures.5,6 This will further reduce theositive predictive value, but it is assumed to assure that allatients with true hypertension will have a positive screeningesult. While, as Stewart et al point out, this “assumption ismplicit in the NHBPEP guidelines,” this remains unstudied.s the method of screening reproducible? This too is unstud-ed. Will the blood pressure measurement performed at anmergency department or an outpatient department be similarf performed at a different site on the same patient? We doot know. We do know that blood pressures in the sameatient do vary depending on time of day and a variety ofnfluences on the patient. Concepts such as white coat hyper-ension or masked hypertension (findings consistent withypertension when using ambulatory blood pressure measure-ents which are not measured by a single random measure-

ent) further put the screening approach in doubt by poten- t

ditorials

ially further reducing the positive predictive value (white coatypertension) or by reducing the negative predictive valuemasked hypertension).7,8

Well, at least the cost of the screening test is not high,orrect? A single blood pressure measurement with an auto-ated machine especially in a patient being seen for other

easons probably does not add much cost. The exact cost isot well studied and the cost of further screening and evalu-tion should be factored into the cost of screening. This tooemains unstudied. Indeed, the increasing use of ambulatorylood pressure measurement because of accuracy may becomen important factor when considering screening, diagnosisnd follow up for hypertension.

Do we have a good strategy for screening children forypertension? Maybe because blood pressure measurementsre common and “easy” to perform, it seemed a good strategyo screen in the outpatient or emergency department. Fur-hermore, the recommendations were predicated on the no-ion that the approach was the best chance at being able tocreen children. But is this good policy? Not necessarily. TheHBPEP guidelines should undergo more thorough testing.ther approaches should be analyzed such as screening pop-

lations as risk (mother and father with hypertension, forxample). The Stewart et al study is “a single center study,onducted over a brief interval. The results should be gener-lized with caution.” But recommending screening of anntire population is large undertaking and deserves carefulnalysis including a careful determination of the risk/benefitatio. There are costs to undiagnosed hypertension but wehould be very certain of the costs of screening for hyperten-ion as well. Such an analysis might help us do what is best forhildren. It is time to reconsider this screening approach.

Aaron Friedman, MDDepartment of Pediatrics

University of MinnesotaMinneapolis, Minnesota

REFERENCES. Stewart JN, McGillivary D, Sussman J, Foster B. The value of routine bloodressure measurement in children presenting to the emergency department with non-rgent problems. J Pediatr 2008;153:478-83.. North AF Jr. Principles of health screening. In: Wallace HM, Gould EM, OglesbyC, editors. Maternal and child health practices: problems, resources and methods ofelivery. 2nd ed. New York: John Wiley and Sons. 1975:569-76.. Presidents Commission for the Study of Ethical Problems in Medicine and Bio-edical and Behavioral Research, 1983, screening and counseling for genetic conditions.ashington DC. Government Printing Office.

. National High Blood Pressure Education Program Working Group on High Bloodressure in Children and Adolescents. The fourth report on the diagnosis, evaluation,nd treatment of high blood pressure in children and adolescents pediatrics. Pediatrics004;114(Suppl):555-76.. Park M, Menard S, Yuan C. Comparison of auscultatory and oscillometric bloodressures. Arch Pediatr Adolesc Med 2001;155:50-3.. Podoll A, Grenier M, Croix B, Feig D. Inaccuracy in pediatric outpatient bloodressures measurements. Pediatrics 2007;119:E538-43.. Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. Howommon is white coat hypertension? JAMA 1988;259:225-8.. Pickering TG, Davidson K, Gerin W, Schwartz JE. Masked hypertension. Hyper-

ension 2002;40:795-6.

453