Cate, Bradley, Chris, and Nate Ewing
By Joe Kita
March 28, 2024
Chris and Bradley Ewing were vacationing near Lake Michigan in July 2023 when their 15-year-old son, Nate, started telling them that his heart was racing and that he was "not feeling right." Nate, who had been adopted from Ethiopia with his twin sister, Cate, when they were infants, was about to start high school and try out for the football team. One of his idols, 18-year-old LeBron "Bronny" James Jr., had just had a cardiac arrest and collapsed during basketball practice. The news was all over social media.
Chris and Bradley, who live in Cincinnati, attributed their son's symptoms to anxiety. After all, Nate was thin and fit, and although he'd been diagnosed with ADHD in second grade, he'd had normal wellness exams ever since. But when he continued to report lightheadedness and unusual feelings in his chest, they sought help. Yet visits to the school nurse, then their pediatrician, and a cardiologist all ended with assurances that Nate’s heart was normal and healthy.
To be certain, the cardiologist had Nate wear an ambulatory blood pressure (ABP) monitor for 24 hours. But the device malfunctioned and its subsequent alarms stressed Nate out even more, to the point where he refused to repeat the process. Chris tried testing his blood pressure manually at home. The results were inconclusive. It wasn't until January 2024 when a second cardiologist convinced Nate to try the ABP monitor again. It showed clear evidence of high blood pressure (hypertension).
"The biggest challenge was just figuring out what was wrong. It took so long to get a diagnosis."
-Chris Ewing
"Doctors and nurses just assume you know what blood pressure numbers mean," Bradley Ewing says. "They'd send us home with a monitor and explain what to do, but we still didn't really know what we were looking for. Is this high? Is this low? We were flying blind."
Nate is now on blood pressure medication and doing better.
"The biggest challenge was just figuring out what was wrong," says Chris Ewing, who's thankful that nothing serious happened to Nate during those intervening months. "It took so long to get a diagnosis. I wish someone had educated us more about hypertension and how it presents in children."
Alarming Statistics
As many as 5% of U.S. children and teens under age 18 may have hypertension, according to the American Academy of Pediatrics (AAP). That's up to 3.6 million kids with a serious condition that used to be found mainly in older adults. And 10% more, or 7.3 million, may have elevated blood pressure, putting them in danger of developing hypertension later. (Elevated blood pressure is above normal but below hypertension.) These statistics are four times higher than they were 30 to 40 years ago.
The causes are clear. Childhood obesity rates rose from 5% in the late 1970s to 19.7% in 2020, according to the CDC. This is a major risk factor for hypertension, as are poor nutrition, a sedentary lifestyle, too much sodium, poor sleep, energy drinks packed with sugar and caffeine, and (as is likely in Nate's case) genetics. All can chronically raise blood pressure.
In March 2023, the American Heart Association (AHA) published a scientific statement calling pediatric hypertension an "unrecognized condition" and alerting medical personnel (and parents) about how common it is and how to accurately diagnose and treat it.
Bonita Falkner, MD, who led the team of experts who wrote the AHA statement, sees cause for concern. "Essentially, many of these children have a medical profile that's already similar to their grandparents," says Falkner, a professor emeritus of medicine and pediatrics at Thomas Jefferson University who has studied pediatric hypertension for 20 years.
Blood Vessels Aging Too Soon
"The problem with children having unmanaged hypertension or elevated blood pressure is that it adds a pressure burden to their cardiovascular systems and kidneys for a much longer time," Falkner says. "These children are already showing signs of vascular aging, meaning their blood vessels are a little stiffer and their heart muscles are a bit bigger. Fortunately, hypertension can be managed and even reversed with lifestyle changes (including better nutrition, more exercise, and weight loss) and, if necessary, medication. This first requires awareness of the problem and then early and accurate detection — two things that the AAP says are lacking.
"The diagnosis is missed in up to 75% of pediatric patients in primary care settings," the AAP stated in its 2017 guidelines on pediatric hypertension. The AHA's more recent statement shows that progress has been slow.
A Routine Check That's Often Skipped
Before the mid-1970s, doctors typically didn't measure blood pressure in children without symptoms. "It was assumed children did not have hypertension," Falkner says. Since 2017, the AAP has recommended making it a routine part of annual wellness checks from age 3.
But this procedure isn't as routine as it may sound.
Margaret Solomon, MD, is a pediatrician and internal medicine doctor at the Redwood Health Center in Salt Lake City, UT. Since 2005, she has been attending to an ethnically diverse and often economically disadvantaged patient population. Despite her best efforts to make everyone more aware of this "silent illness" through accurate diagnosis, education, and management, "a lot of these kids with blood pressure issues are becoming adults with hypertension," she says. "I've been here long enough to see the evolution."
Getting an accurate reading from youngsters is challenging. Solomon says, "They rush in from school, they're here to get shots, they're nervous, they can't sit still ... so we're often dealing with measurement issues." This is the first obstacle. Some busy doctors, who can see up to 25 patients a day with their families, may attribute a high reading to anxiety (so-called "white coat hypertension") and dismiss it, or just make a note to check it at the child's next wellness visit.
"At our center we always do an initial automated blood pressure measurement," Solomon says. "If that's abnormal, we wait for a while until the child is less anxious and do two manual measurements. Then we average the three."
The second obstacle is determining what that number means. Because kids' blood vessels are smaller overall, the blood pressure levels used to separate normal from abnormal in adults don't apply to those under 13 years of age. Doctors must figure out what percentile the child is in based on age, sex, and height, then consult a standardized table to determine their blood pressure category. For teens, the benchmarks are the same as for adults.
This process isn't simple. "Kids are dynamic organisms," says Solomon. "They're growing and changing, so you have to look at different charts to assess their blood pressures. I've always found it a bit overwhelming." Even Falkner, with decades of expertise, admits it can be time-consuming and confusing for doctors, not to mention parents.
Using Tech to Simplify Diagnosis
To make things more efficient, Solomon helped develop and implement a "best practice alert" at her health center. Created with the support of the IT department at the University of Utah Health system, it automates this entire process. Here's how it works:
When an initial blood pressure is abnormal, an alert pops up on the computer screen telling the medical assistant to take two more manual readings (one with a stethoscope and one with a blood pressure cuff) later in the visit. Once that's done, the program automatically averages the three readings and analyzes the result based on the child's age, sex, and height. When further action is needed, a diagram pops up on screen showing AAP recommendations for treatment. The program will even automatically schedule a follow-up visit in a few weeks or months with either the attending pediatrician or a specialist.
"It helps make sure nothing sneaks through the cracks," Solomon says.
The best practice alert system was built using Epic Software — an electronic health records system common in hospitals, medical offices, and health clinics — according to AAP guidelines. Solomon says it could probably be easily replicated elsewhere.
What Parents Can Do
Until programs like the best practice alert system become more widespread, Solomon and Falkner recommend that parents become advocates for their child's well-being on this important issue. Their advice: Don't hesitate to ask that your child's blood pressure be taken, especially if hypertension runs in your family. And if the nurse or medical assistant just recites the reading with no explanation, ask for clarification.
"Don't accept, 'It's OK," Falkner says. "Ask for the number and where that stands given the child's percentile or age. If it's a little high, ask the doctor if more tests are needed or what else can be done."
"Simple lifestyle changes like becoming more active as a family and making healthier food choices can make a huge difference."
-Margaret Solomon, MD
It works the other way, too. When Jennifer Bright of Hellertown, PA, took her 12-year-old son, Austin, for his annual wellness check, his initial blood pressure was 130/90.
"The nurse looked at me, alarmed, and launched into a speech about the dangers of high blood pressure," Bright says. "I calmly asked if she could take it again. Then I turned to Austin and explained that blood pressure can read high if you're talking or under stress. So I asked him to relax, rest his feet on the floor, close his eyes, and take some deep breaths. When the nurse took it again, it was normal. He was just nervous."
Bright now reminds Austin to do breathing exercises at every doctor's visit or whenever he's feeling stressed, even at school. "It turned out to be a great teaching opportunity," she says, "and his blood pressure has been normal ever since."
If your child is diagnosed with elevated blood pressure or hypertension, Solomon encourages parents to stay positive. "Don't [say], 'Oh my gosh, my kid has high blood pressure, and he's going to be sick for the rest of his life,'" she says. "Yes, this is a chronic illness, but we know a lot about it, and it can be successfully managed. Simple lifestyle changes like becoming more active as a family and making healthier food choices can make a huge difference," not only for their blood pressure but also for every other aspect of their health — now and for years to come.