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CONFUSED DOCTORS

困惑的醫(yī)生

The problem, according to Dr. Carissa Baker-Smith, an epidemiologist at the University of Maryland and the lead data scientist on the new American Academy of Pediatrics guidelines,^[1]  is that many of these issues go undetected until disaster strikes. 

根據(jù)馬里蘭大學(xué)流行病學(xué)家和新成立的美國(guó)兒科學(xué)會(huì)指南的首席數(shù)據(jù)科學(xué)家卡麗莎·貝克-史密斯說(shuō)法，關(guān)鍵的一點(diǎn)在于許多這樣的問(wèn)題直到疾病發(fā)生時(shí)才被會(huì)被發(fā)現(xiàn)。

She points to several studies that provided the definitive evidence that although heart disease often may not become apparent until adulthood, its seeds are planted in childhood. 

她指出有多項(xiàng)研究提供了明確的證據(jù)證明，盡管心臟病在成年前通常可能會(huì)不明顯，但是它的種子在童年期就種下了。

A study called Pathobiological Determinants of Atherosclerosis in Youth in the 1990’s and the ongoing Bogalusa Heart Study have measured the prevalence of narrowed and hardened arteries (atherosclerosis) in adolescents and young adults who died accidentally. 

90年代一項(xiàng)叫做關(guān)于青少年動(dòng)脈粥樣硬化病理決定因素的研究和如今正在進(jìn)行中的博加盧薩研究所研究發(fā)現(xiàn)，在意外死亡的青少年和年輕的成年人中研究發(fā)現(xiàn)動(dòng)脈狹窄硬化（動(dòng)脈粥樣硬化）普遍存在。

Both studies show strong associations between atherosclerosis - a leading predictor of heart disease - and smoking, cholesterol levels and hypertension. "I really want people, especially parents, to understand that high blood pressure does occur in kids. We\\\\\\'re seeing adult disease in children," Baker-Smith says.

這兩項(xiàng)研究表明動(dòng)脈粥樣硬化-心臟病的主要預(yù)測(cè)因子-與吸煙、膽固醇水平和高血壓之間的存在緊密聯(lián)系。貝克-史密斯說(shuō)：“我真的希望人們明白，尤其是父母，高血壓的的確確發(fā)生在孩子身上，我們?cè)趦和砩峡吹搅顺赡耆说募膊??！?/p>

These results challenge the now-outdated notion that hypertension in kids was primarily the result of congenital conditions that affected the kidney and heart. Although genetics accounts for one-fifth of all high blood pressure cases in kids under 18, the remainder are "adult-style" hypertension issues, caused by a convergence of biological and environmental factors. 

這些結(jié)果挑戰(zhàn)了現(xiàn)在一種過(guò)時(shí)的觀念，即小兒高血壓主要是先天性疾病影響腎臟和心臟的結(jié)果。在18歲以下所有的小兒高血壓病例中，盡管遺傳因素占了1/5，余者全是“成人型”高血壓?jiǎn)栴}，這種“成人型”高血壓是由生物和環(huán)境因素綜合作用的結(jié)果。

Large epidemiological studies by the Centers for Disease Control and Prevention have documented a rise in systolic blood pressure and in diastolic blood pressure in children between 1988 and 2000, which suggests the increase in pediatric hypertension isn\\\\\\'t just the result of heightened awareness. Although adults have a single cutoff^[2]  for potential blood pressure problems, determining that point is more complex for pediatricians because blood pressure in growing children varies by age, height and sex. 

由疾病控制預(yù)防中心的大型流行病學(xué)研究證實(shí)，早在1988至2000年就有兒童收縮壓和舒張壓增高的現(xiàn)象，這表明兒童高血壓現(xiàn)象的增加不僅僅是現(xiàn)在才意識(shí)到的結(jié)果。雖然對(duì)于成年人來(lái)說(shuō)潛在高血壓?jiǎn)栴}存在一個(gè)界限值，但是對(duì)兒科醫(yī)生來(lái)說(shuō)，由于在兒童成長(zhǎng)中血壓會(huì)因年齡、身高和性別的不同而不同，因此確定這一界限值更加困難.^[3]

Even when doctors were vigilant about screening for blood pressure issues in children, they struggled to interpret those results. "A lot of doctors were very confused," says Dr. Suzanne Lazorick, a pediatrician and preventive medicine physician at Eastern Carolina University.

即使醫(yī)生在對(duì)兒童高血壓?jiǎn)栴}篩查時(shí)保持如此警惕，也很難解釋這些結(jié)果。東卡羅來(lái)納大學(xué)的兒科醫(yī)師和預(yù)防醫(yī)學(xué)醫(yī)師蘇珊妮·拉佐里克說(shuō)：“很多醫(yī)生也很困惑啊”。  

Kaelber puts it more starkly. "If you reviewed electronic medical records [for children], you could see blood pressures recorded, but the pediatrician never diagnosed hypertension," he says. Physicians were unclear about what blood pressure level was too high,^[4]  so the condition in children went unnoticed.

卡爾伯博士對(duì)此所述更加了當(dāng)。她說(shuō)：“如果你回顧那些電子病歷（指兒童的），你可以看到血壓值被記錄下來(lái)，但是兒科醫(yī)師從來(lái)不診斷高血壓?！贬t(yī)生并不清楚什么水平的血壓才算是血壓過(guò)高，所以兒童的病情就沒(méi)有得到注意。

REVERSE ANY DAMAGE

逆轉(zhuǎn)傷害

These challenges led Kaelber and Dr. Joseph Flynn, a nephrologist at the University of Washington, to call for a revision of the 2004 guidelines they had authored. 

這些挑戰(zhàn)使得卡爾伯和華盛頓大學(xué)的腎病學(xué)家約瑟夫·弗林博士呼吁修訂他們?cè)帉?xiě)過(guò)的2004版指南。

Baker-Smith led a review of the 15,000-plus studies published since 2004 to create a rigorous base from which to distill findings. From there, they reviewed how well the current standards were working and what scientists were learning about high blood pressure in children and adolescents. 

貝克-史密斯?fàn)款^審閱了自2004年以來(lái)發(fā)表的15000多篇綜述，以建立一個(gè)能從中提煉精華的嚴(yán)謹(jǐn)?shù)馁Y料庫(kù)。他們從審閱中回顧了當(dāng)前標(biāo)準(zhǔn)發(fā)揮作用之好以及科學(xué)家們對(duì)兒童和青少年高血壓的研究情況。

The finaldocument contains several major changes from previous recommendations, including how to measure blood pressure and how doctors diagnose hypertension, as well as the terminology to use.

最后修改出來(lái)的指南有不同于先前指南的幾個(gè)重要內(nèi)容的變更，包括如何測(cè)量血壓和醫(yī)生們?nèi)绾卧\斷高血壓，以及相關(guān)術(shù)語(yǔ)的使用。

Instead of screening for high blood pressure at every health care visit, the new guidelines say to screen only at annual well-child visits beginning at age 3. Many transient factors can affect blood pressure, including stress and caffeine, which could lead to inaccurate data and unnecessary testing. And doctors need several blood pressure readings to make a diagnosis of hypertension.

新的指南指出，高血壓的篩查要從兒童3歲開(kāi)始的年度隨訪中進(jìn)行，而不是每一次的健康隨訪。許多暫時(shí)性的因素可能會(huì)影響血壓，包括壓力和咖啡因等，這些都可能導(dǎo)致數(shù)據(jù)的不準(zhǔn)確或不必要的測(cè)量。這時(shí)醫(yī)生就需要多次測(cè)量血壓以做出高血壓的診斷。

The panel also altered the transition from pediatric blood pressure tables to the 120/80 mmHg cutoff used for adults. The transition used to come at age 18, so a child could have abnormal blood pressure at the age of 17 years and 364 days and then be fine the next day, Kaelber says. The new tables begin transitioning children to adult markers at age 13, depending on height and weight. This provides more consistency and will ease the transition to adult blood pressure standards.

指南還改變了兒童血壓標(biāo)準(zhǔn)向成年人血壓標(biāo)準(zhǔn)120/80mmHg的年齡過(guò)渡?？柌f(shuō)，過(guò)去這一年齡過(guò)渡是18歲，所以一個(gè)小孩可能17歲時(shí)364天的血壓值不正常，但是到了第二天就好了。新標(biāo)準(zhǔn)根據(jù)兒童的身高體重，將兒童到成人年齡過(guò)渡標(biāo)定在了13歲。這使得判定標(biāo)準(zhǔn)更加一致，并使得兒童血壓標(biāo)準(zhǔn)在向成人的轉(zhuǎn)變中能緩慢過(guò)渡。

To de Jesus, the importance of the new guidelines in ensuring adequate diagnosis and treatment of childhood hypertension can\\\\\\'t be overstated.^[5] When kids are young, they can completely  reverse  cardiovascular  damage  from hypertension or high cholesterol. By the time they reach adulthood, however, this ability diminishes.

新指南對(duì)兒童高血壓的診斷和治療制定了標(biāo)準(zhǔn)，對(duì)德熱蘇來(lái)說(shuō)，這一點(diǎn)很重要，再怎么強(qiáng)調(diào)都不為過(guò)。在孩子們小的時(shí)候，他們就可以完全逆轉(zhuǎn)由高血壓或高膽固醇所致的心血管損傷。但是等到他們成年的時(shí)候，這種能力就降低了。

Kaelber, Flynn, Baker-Smith and colleagues also recalibrated the blood pressure tables to include only children with normal weights. Pediatricians decide if^[6]  a child\\\\\\'s blood pressure is high by comparing it with those of a group of healthy children. 

卡爾伯、弗林、貝克和同事們也重新標(biāo)定了血壓基準(zhǔn)，該基準(zhǔn)是從正常體重的兒童人群調(diào)查得出。兒科醫(yī)師判斷一個(gè)小孩的血壓是不是高，需要通過(guò)與基準(zhǔn)組的健康兒童作比較。

But the growing numbers of children who are overweight and obese, two traits strongly linked to increased blood pressure, have skewed that benchmark data^[7] . Using only normal-weight children provides a better definition for a healthy blood pressure, Baker-Smith says. 

但是現(xiàn)在超重和肥胖的兒童越來(lái)越多，而這兩點(diǎn)特征是與血壓升高密切關(guān)聯(lián)的，這就影響的基準(zhǔn)數(shù)據(jù)的準(zhǔn)確性。

The team also eliminated the need for echocardiograms (an ultrasound of the heart) unless the child requires medication, a change that reflects the growing number of hypertensive children without underlying congenital heart issues. 

貝克-史密斯說(shuō)，只有采用正常體重兒童的血壓數(shù)據(jù)，才能更好的定義健康血壓值。要是小孩在接受藥物治療，該小組還會(huì)給他做超聲心動(dòng)圖（一種心臟超聲）檢查，這一方法的改變揭示出數(shù)目攀升的高血壓兒童并沒(méi)有隱匿的先天性心臟問(wèn)題。

For those with more severe hypertension in need of medication, echo-cardiograms have revealed cardiac complications more usually seen in adults, such as left ventricular hypertrophy, a thickening of the heart muscle.

對(duì)于這些高血壓更為嚴(yán)重、需要藥物治療的孩子，超聲心動(dòng)圖檢查出在成年人身上才更多見(jiàn)的心臟并發(fā)癥，如左心室肥大、心肌增厚。

Lastly, the guideline revision group changed the term "pre-hypertension," used to indicate children whose blood pressure was a concern but who didn\\\\\\'t meet clinical definitions of hypertension, to "elevated blood pressure." 

最后，指南修訂小組還將“高血壓前期”的說(shuō)法改為“血壓升高”?！案哐獕呵捌凇卑凳疽粋€(gè)小孩的血壓該引起注意了，但是并沒(méi)有達(dá)到臨床高血壓水平。

The new language is intended to sound an alarm. "Parents tend to hear pre-hypertension and think it\\\\\\'s not a problem because it\\\\\\'s before a disease, but that\\\\\\'s not what we\\\\\\'re trying to say," Lazorick says.

“血壓升高”是為了聽(tīng)上去能給人以警報(bào)。拉佐里克說(shuō)：“父母傾向于聽(tīng)到高血壓前期，認(rèn)為這不是病，因?yàn)檫€在疾病之前，但那并不是我們要表達(dá)的意思?！?/p>

The increasing reliance on ambulatory blood pressure monitoring devices could pose a challenge. Although these monitors provide increased accuracy, not all pediatricians have access to them. Ramping up^[8]  the availability of ambulatory monitoring will be key to putting the recommendations into practice, Lazorick says.

對(duì)動(dòng)態(tài)血壓檢測(cè)設(shè)備的日益依賴可能會(huì)帶來(lái)挑戰(zhàn)。盡管這些檢測(cè)儀器測(cè)得的準(zhǔn)確性更高，但并非所有的兒科醫(yī)師都能掌握使用。拉佐里克說(shuō)，普及動(dòng)態(tài)血壓檢測(cè)儀的使用是將上述建議轉(zhuǎn)化為實(shí)踐的關(guān)鍵。

Although some of these guidelines may seem more conservative-hypertension screening only at regular preventive care visits, reduced recommendations for echocardiogram - they actually decrease the potential for over-diagnosis of pediatric hypertension. "No one wants to give kids a diagnosis they don\\\\\\'t have or a treatment they don\\\\\\'t need," Baker-Smith says.

盡管指南中的一些內(nèi)容可能看起來(lái)比較保守-只會(huì)在定期的預(yù)防保健時(shí)篩查高血壓，建議減少做超聲心動(dòng)圖-但這些實(shí)際上減少了對(duì)兒童高血壓過(guò)度診斷的可能性。貝克-史密斯說(shuō)：“沒(méi)有人會(huì)想給孩子診斷出他們實(shí)際上并沒(méi)有得的疾病，或者是給他們根本就不需要的治療?！?/p>

No standards can eliminate the risk of overdiagnosis. But given that first-line treatment for children with high blood pressure is dietary and physical activity changes, Baker-Smith says this advice is low-risk and can benefit many children, even those without hypertension. Making these changes isn\\\\\\'t easy, especially in a culture awash in salty, fatty foods. 

沒(méi)有標(biāo)準(zhǔn)可以消除過(guò)度診斷的危險(xiǎn)。但是鑒于兒童高血壓的一線治療是飲食習(xí)慣和運(yùn)動(dòng)行為的改變，貝克-史密斯說(shuō)這個(gè)建議的風(fēng)險(xiǎn)就很低，并且對(duì)很多孩子都有好處，甚至是那些沒(méi)有患高血壓的孩子。做出這些改變并不容易，尤其是在一個(gè)高鹽高脂的飲食文化中。

By starting early and modeling healthy behaviors, de Jesus says, parents can teach their kids to make good decisions about food and exercise as they get older and have more autonomy. "Even adults struggle to choose water over soda or juice. How can we expect a 10-year-old to do that?" Lazorick asks.

德熱蘇斯說(shuō)，父母可以讓孩子在早期就開(kāi)始養(yǎng)成健康的行為習(xí)慣，這樣在長(zhǎng)大后就能教他們能在食物和鍛煉方面做出好的決定，并能更加獨(dú)立。拉佐里克說(shuō)：“甚至大人們都會(huì)糾結(jié)是喝水還是蘇打還是果汁。我們?cè)趺茨苤竿粋€(gè)10歲的孩子那樣做呢？”

But for children diagnosed with high blood pressure, having an adult disease requires growing up fast.  

但是對(duì)于診斷出高血壓的兒童來(lái)說(shuō)，患成人疾病就需要盡快長(zhǎng)大。