LAUSR

Untreated hypertension in children and adolescents can lead to disastrous consequences in the short and long term [1]. Acute rise of blood pressure by more than 30 mmHg in children may lead to brain involvement (e.g., cognitive abnormalities, hypertensive encephalopathy), left ventricular insufficiency, visual disturbances due to damage of the retina, and epistaxis [2]. While a hypertensive crisis is rarely overlooked, milder hypertension is asymptomatic and may not be recognized, remaining untreated for years. This is despite the fact that patients may develop irreversible end-organ damage, major cardiovascular morbidity, and mortality later in life [3]. There is evidence of underdiagnosis of hypertension in children and adolescents [4]. This is especially true in the emergency department, as elevated blood pressures are noted but remain unreferred, even for adults [5]. Barriers to referral for elevated blood pressure include education about reference intervals, hesitancy if patients are asymptomatic, required financial compensation to refer, and a perception that blood pressure was influenced by the medical doctor [5]. While the referral hesitancy applies equally to nurses, physician assistants, and emergency physicians, the latter group also cites lack of time as a barrier, doubts about their concern for the blood pressure, and feeling emotionally uncomfortable when referring [5]. Children and adolescents with elevated blood pressure are often referred to subspecialists, namely pediatric nephrologists or pediatric cardiologists, owing to the need for a detailed work-up for underlying causes [6], whereas adults most often have essential hypertension; secondary etiologies are more common in the pediatric setting. Owing to the obesity pandemic, hypertension is on the rise among children [7] around the globe. Obesity is a major predictor of childhood hypertension, and in younger children more so than other known risk factors such as low birth weight [8]. Unfortunately, there is a paucity of data in the literature about recognition of hypertension in children and time to referral to specialists or subspecialists who treat hypertension. This is in spite of published access targets for the diagnosis and management of hypertension [9, 10]. In this context, we are pleased to read in this edition of Pediatric Nephrology Hamby’s study of 120 children and adolescents from a single pediatric nephrology practice in Fort Worth, North Texas. Their cohort was analyzed in depth about the time to referral to the pediatric nephrology team from the first documented elevated blood pressure [11].