Our data were generated from a pediatric subspecialty clinic that follows patients with diagnoses that carry an in- creased risk for hypertension. Private and ...
Table I. Results of screening for pre-hypertension/hypertension over 6 months in an outpatient pediatric endocrinology clinic
Total scheduled visits Total actual visits Total number meeting inclusion criteria Number meeting NHBPEP criteria for “hypertension” Number meeting NHBPEP criteria for “pre-hypertension”
Number of visits
F/M
Number of patients
F/M
F/M age, years (mean ⴞ standard deviation)
989 881 782 200 83
— — 414/368 116/84 45/38
— — 642 181* 80
— — 345/297 106/75 43/37
— — 11 ⫾ 4.4/11.9 ⫾ 4.8 11.6 ⫾ 4.7/11.7 ⫾ 4.9 12.2 ⫾ 3.6/11.3 ⫾ 4.9
*30 patients had normal BP on another visit, 17 were diagnosed previously with hypertension, and 5 were noted as agitated or upset during BP measurement. 2. Henderson PR, Schwartz ID. Retrospective screening for hypertension/prehypertension in a pediatric subspecialty clinic [abstract]. Pediatr Res 2005;58:818.
Table II. Reasons for visits* Type I diabetes Type II diabetes Obesity/dysmetabolic syndrome Thyroid disorders Adrenal/CAH Precocious puberty Growth disorders Other
298 21 45 94 27 23 177 98
*Primary diagnoses (patients could overlap or have multiple diagnoses).
Of our 642 patients, 80 (12.5%) fulfilled NHBPEP criteria for prehypertension, similar to the findings of McNiece et al. However, an additional 164 (25.5%) of previously “normotensive” eligible patients screened positive for hypertension on 1 or more occasions during the 6-month study period. Some patients had multiple diagnoses; the various diagnoses found in our study group are listed in Table II. Our data were generated from a pediatric subspecialty clinic that follows patients with diagnoses that carry an increased risk for hypertension. Private and academic general pediatric clinics likely would be busier, but those patients would be expected to be “healthier,” without extra risks for hypertension. Our patients had a wider age range than those of McNiece et al, but the mean age was similar. Nevertheless, the report of McNiece et al supports our findings. We agree with them that such identified patients should be monitored closely for persistent hypertension. This material was presented in part at the 46th Annual Midwest Society for Pediatric Research, St Louis, MO, October 20 –21, 2005.
I. David Schwartz, MD Patrick R. Henderson, BS, MS IV Division of Endocrinology Department of Pediatrics University of South Carolina School of Medicine Columbia, South Carolina 10.1016/j.jpeds.2007.08.004
REFERENCES 1. McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and prehypertension among adolescents. J Pediatr 2007;150:640-4.
Letters to the Editor
The egg or the chicken? Further data on whether good compliance to multi-injection insulin therapy should be a criterion for insulin pump therapy, or does insulin pump therapy improve compliance? To the Editor: In a previous commentary to DiMeglio et al1 about factors predicting success of continuous subcutaneous insulin infusion (CSII), we reported the results of the introduction of pump therapy in two Italian Centers for Pediatric Diabetology, where patients were enrolled with somewhat different entrance criteria.2 The introduction of CSII in patients with poor compliance to the multi-injection therapy and higher HbA1c levels (so called “chicken” patients from Naples, group B) was followed by a reduction of HbA1c to the same levels of the patients with previous good compliance (so called “egg” patients from Messina, group A). In their response, DiMeglio et al recommended duration of the improvement of HbA1c by pump be determined before considering CSII therapy as a standard option for adolescents in poor control. Since our first description, CSII has been implanted in the two centers in other several patients chosen with almost the same criteria (“chicken” in Naples and “egg” in Messina). At present, 139 subcutaneous insulin pumps have been implanted (48 in Naples, mean HbA1c, 9.4 ⫾ 1.4, and 91 in Messina, mean HbA1c, 7.9 ⫾ 1.2; P ⬍ .0001) in patients ranging between 5.9 and 33.2 years of age (average, 15.6 ⫾ 3.9). We evaluated the prevalence of dropouts from the CSII to multi-injection therapy. Eighteen (12.9%) patients (9 males and 9 females) dropped out from CSII. There was no statistically significant difference between Naples (14.6%) and Messina (12%; P ⫽ .9). The percentage of dropouts was statistically higher in the first year than in the second year (7.3% vs 4%; P ⬍ .001) and in the first 6 months than in the following 6 months (4.6% vs 2.79%; P ⬍ .001). Our data demonstrate that the enrolment criteria on the basis of metabolic control do not predict the dropout rate. Pump therapy compliance should be assessed at least 6 months after implantation. e23
Fortunato Lombardo, MD Department of Paediatric Sciences University of Messina Dario Iafusco, MD Department of Paediatrics Second University of Naples Guiseppina Salzano, MD Department of Paediatric Sciences University of Messina Alessia Piscopo, MD Department of Paediatrics Second University of Naples Giuseppe Saitta, MD Department of Paediatric Sciences University of Messina Francesca Pisani, MD Department of Paediatrics Second University of Naples Filippo De Luca, MD Department of Paediatric Sciences University of Messina Messina, Italy Francesco Prisco, MD Department of Paediatrics Second University of Naples Naples, Italy 10.1016/j.jpeds.2007.08.035
Pre-hypertension and hypertension among adolescents of Switzerland To the Editor: McNiece et al1 showed a high prevalence of pre-hypertension and hypertension in American adolescents aged 11 to 17 years. To provide insight on this issue in another population, we provide similar analysis from a recent school-based survey in Switzerland.2 We examined 5207 schoolchildren in the 6th grade of the canton of Vaud in 2005/2006 (2621 boys, 2586 girls; mean ⫾ SD age: 12.3 ⫾ 0.5 years). The prevalence of excess body weight (“at risk of overweight” or “overweight”) was 14.3%. At visit 1, blood pressure (BP) was measured 3 times with a clinically validated oscillometric device, and the average of the final 2 of 3 readings was considered. BP was assessed on up to 2 additional visits if age-, sex-, and height-specific BP was ⱖ95th percentile.3 We defined prehypertension and hypertension in the same way as McNiece et al.1 Figures from the latter study are provided for comparison (n ⫽ 6790, in Houston area; mean ⫾ SD age: 12.7 ⫾ 1.2 years). The prevalence of pre-hypertension and hypertension are presented in the Table. By visit 3, 2.2% had hypertension. A major limitation in both surveys1,2 is that repeated BP measurements were performed only among participants with BP in the hypertensive range at visit 1. Had we also measured BP on several visits in the other children, it is possible that a proportion of children with pre-hypertension on visit 1 would have shifted into the normal BP category on visit 3, as shown in adults.4 Hence, prevalence of pre-hypertension is probably overestimated in both surveys. Our findings in a different population of children confirm that BP decreases over subsequent visits, which stresses the need for measuring BP over several visits to detect falsepositive cases of hypertension.5 Further studies should examine the predictive value of pre-hypertension in children. Arnaud Chiolero, MD, MSc Fred Paccaud, MD, MSc Pascal Bovet, MD, MPH Institute of Social and Preventive Medicine (IUMSP) University Hospital Center University of Lausanne Lausanne, Switzerland
REFERENCE 1. DiMeglio LA, Pottorff TM, Boyd SR, France L, Fineberg N, Eugester EA. A randomized, controlled study of insulin pump therapy in diabetic preschoolers. J Pediatr 2004;145:380-4. 2. Iafusco D, Confetto S, Prisco F, Lombardo F, Salzano G, De Luca F. The egg or the chicken? Should good compliance to multi-injection insulin therapy be a criterion for insulin pump therapy, or does insulin pump therapy improve compliance? J Pediatr 2006;148:421; reply 421-2.
10.1016/j.jpeds.2007.08.043
Table. Prevalence (%) of pre-hypertension and hypertension in adolescents in Switzerland (Vaud Canton) and in America (Houston area1) Visit 1
Normal blood pressure Pre-hypertension Hypertension Stage 1 Stage 2
Visit 2
Visit 3
Switzerland
USA
Switzerland
USA
Switzerland
USA
75.3 13.3 11.4 10.1 1.3
81.1 9.5 9.4 8.4 1
— — 3.8 3.3 0.5
— — — — —
— — 2.2 1.7 0.4
— — 3.2 2.6 0.6
BP is based on mean of final 2 of 3 readings (Vaud) and final 3 of 4 readings (Houston). BP categories: (1) Normal blood pressure: BP ⬍90th percentile for age, height and sex; (2) Pre-hypertension: BP ⱖ90th but ⬍95th percentile or BP ⱖ120/80 mm Hg; (3) Stage 1 hypertension: BP ⱖ95th but ⱕ99th percentile ⫹ 5 mm Hg; (4) Stage 2 hypertension: BP ⬎99th percentile ⫹ 5 mm Hg.
e24 Letters to the Editor
The Journal of Pediatrics • December 2007
