Q&A: How to Optimize Pediatric Hypertension Diagnosis and Treatment

A recent study from Nemours Children’s Health has highlighted many of the common barriers to pediatric hypertension screening, suggesting a series of actionable strategies for improvement.1

The study took the form of semi-structured, qualitative interviews conducted with 25 clinicians across 10 pediatric primary clinics. The interviews aimed to identify barriers to hypertension detection from the perspective of clinicians actively attempting to diagnose the condition.2

Among the survey responses, 5 major themes were identified – these included a lack of standardized clinical pathways, inadequate training and confidence, EMR design and workflow misalignment, a lack of equipment availability and maintenance, and inefficient communication and referral pathways. The surveys also produced 5 recommendations to improve these issues – these were the implementation of a standardized clinical pathway for blood pressure measurement, competency-based training and educational resources, optimization of EMR integration, ensuring readily available and well-maintained equipment, and strengthening communication between primary care physicians and communications, respectively.2

Abbas Zaidi, MD, assistant professor at Thomas Jefferson University, medical director of outpatient cardiology at Nemours Children’s Health, and lead investigator of the study, spoke with HCPLive in an exclusive interview to discuss the ideal structure for pediatric hypertension diagnosis and treatment, as well as how clinicians can achieve this goal.

Why is pediatric hypertension still missed?

HCPLive: Pediatric hypertension guidelines have been available for years, yet detection rates remain low. Why has this remained such a persistent problem despite increasing awareness?

Abbas Zaidi, MD: That's a great question. So, as you can imagine, we work in pretty complex healthcare ecosystems. As you try to bring change or improve care, what I've realized through years of studying this is that it's a system of interconnected challenges that have to work together. And when one part of that system breaks down, the whole pathway fails, and it becomes really complex, especially when you think about how complex the guidelines are.

For pediatric patients, you have to look at their age, gender, and height specific percentiles to even detect high blood pressure. The measurement itself can be quite demanding; the child has to sit still for 5 minutes, with both feet on the ground, and you have to pick the correct cuff size. And if you do all of those things perfectly, then you have to ask the families to come back for multiple visits to get to a diagnosis, and you need at least three to make a diagnosis for hypertension. This means that the families now are facing real-world challenges that intersect with the healthcare system challenges that we're facing.

Families lose income every time they have to take time off to come to clinic. Kids have to miss school. Insurance doesn't always cover visits, and it can be a challenge. It's not just one thing that makes hypertension detection fail. It's a very complex conglomerate of factors that are intersecting with a complex guideline. And on the health system side of things, if you think about it, there's no clear clinic workflow or EMR-based tools. And if there is no sort of alert system telling physicians exactly what they need to do as next steps, and that leads to this black box of care. So, it's not about awareness or not knowing that the guidelines exist or not knowing that this is a problem in kids. It's not a failure at any one point. It's a failure at multiple points in this complex system.

HCPLive: The study suggests that even motivated clinicians can miss hypertension because of workflow issues. Which step in the diagnostic process is most vulnerable to failure in routine pediatric practice?

Abbas Zaidi, MD: There have been studies on this, and even within our preliminary data that we had, we know that majority of pediatric patients who are coming for volunteer child visits are getting a blood pressure check. It's not that people aren't getting a blood pressure check - 97% of kids get a blood pressure checked in clinic. It's actually the step immediately after they get the blood pressure check, which is where their vulnerability really starts in my mind. Even if it's recorded correctly in the chart, if nothing is flagging it appropriately, or there's no automated trigger or a protocol that starts the chain of events that the physicians need to do to start a conversation with the family about, “Hey, you need to come back,” then that's where the problem starts.

Even if physicians do recognize that it's abnormal, and they tell the family to come back for a repeat measurement, what happens next remains a black box. Once families leave the clinic, they're operating in an environment where we obviously don't have control, and we're intersecting with a lot of social determinants of health factors such as losing money, taking time off, leaving school, and all of that. These are not small inconveniences. If you think about it, they're directly impacting families and their lives. So, in my mind, the critical point is after the initial blood pressure gets measured and what happens next.

HCPLive: Many clinicians assume time pressure is the primary obstacle, but the study suggests inefficient systems may be a bigger issue. How should practices rethink their workflows to improve diagnosis without asking clinicians to do more?

Abbas Zaidi, MD: I think what I really wanted to highlight in this study is that it's a health system problem. Our findings definitely are pushing back on that assumption that a simple fix is telling physicians what to do or telling them to slow down or double check more. Clinicians are already stretched thin, and asking for more vigilance without changing the system is just going to add more friction, and that's going to erode over time. We see that play out in healthcare systems every day.

I think the more sustainable approach is to build that recognition as part of the workflow and support physicians who are already busy. These clinicians also have to navigate not just hypertension guidelines, but a lot of other pediatric-related care in 15-minute clinic visits. So having the right decision support that, for example, automatically flags an abnormal blood pressure and spits out exactly what they need to do next, and for them to easily sign off on that to do their part. The goal isn't to make sure they're putting in more effort. It's to have fewer touch points where the system is going to fall apart, and for everything to be more automated.

What does the study believe should be improved, and how can clinicians approach doing so?

Abbas Zaidi, MD: The clinicians interviewed repeatedly called for simplified clinical pathways instead of expecting providers to navigate lengthy guidelines during a busy clinic session. What would an ideal decision-support pathway actually look like in practice?

Zaidi: We're in the process of developing our own pathway, and I know there's been work nationally and at different various institutions in developing pathways. I think in my mind, an ideal pathway would initially surface an alert when the reading is actually abnormal and is appropriately flagged. So that's the first step to making sure that the blood pressure reading itself is being picked up as abnormal using guideline-appropriate data, and then using that to tell physicians in plain language that “hey, you need to repeat this.” For the front-line staff, one thing we learned in our study is that the guidelines need to be tailored to the end user - they can't just be one guideline that applies to different roles within the healthcare system. You need role-specific pathways and guidelines where the MAs get an alert about repeating the blood pressure and how exactly they need to do that, versus a physician getting all of that data to make that clinical decision, integrating the patient's blood pressures, labs, and other testing in one visual of what those trends look like over time to make that clinical decision. Ideally, they’ll then, with a click of a button, move the patient along in that pathway to the next step. I think they need to be seamless. They need to be role specific, and they need to integrate patient data in a more seamless way for physicians to make decisions quickly.

HCPLive: Looking beyond pediatric hypertension, could these implementation barriers be representative of broader challenges in preventive cardiovascular care? What lessons could adult cardiology or other specialties take from these findings?

Abbas Zaidi, MD: I think this basically represents that science to practice gap, and this is a known phenomenon: it takes about almost two decades for evidence-based practice to get into clinical care, and only a fraction of that actually reaches a patient. What we're unfolding here – or rather, scratching the surface on - is a very complex, larger health system issue, which also, of course, intersects with what happens in adult cardiology. If you take the analogy of hypertension and apply that across preventive cardiovascular care for adults, you can start to see similar patterns of treating detection failures as knowledge or motivation problems. We've been saying, “let's respond to this with more education” when the failure actually is very structural. It's a health system issue, and one purpose for me in doing the study and highlighting these findings is for them to be more generalizable across various healthcare systems, including adult cardiology, because they have their own version of very similar problems. I think the lesson that can transfer over is that closing a gap usually isn't about convincing clinicians to do more. It's about identifying the specific steps in the workflow, and for health systems to really invest in that effort, to then make sure that the systems aren't silently dropping the signals that are clearly there but are working to redesign and make health systems better around the steps, rather than just asking clinicians to work with more diligence.

Editors’ Note: Zaidi reports no relevant disclosures.

References

1. Nemours Children’s Health. Nemours Children’s Health Study Identifies Strategies to Improve Pediatric Hypertension Screening Rates. July 14, 2026. Accessed July 24, 2026. https://nemours.mediaroom.com/PediatricHypertensionScreeningStudyZaidi

2. Zaidi AH, Sood E, De Ferranti S, et al. Clinician Perceptions of Barriers and Strategies to Improve Pediatric Hypertension Detection. JAMA Network Open. 2026;9(2):e2560542. doi:10.1001/jamanetworkopen.2025.60542