PEDIATRIC HYPERTENSION CLINICAL PRACTICE GUIDELINES

Milena Archuleta, MSN, MBA, FNP-BC, CPHON University of New Mexico Hospital

Disclosures • None

Hypertension: Why so Important? • Occurs in 3.5% of all pediatric patients •  Top 5 chronic diseases in children and adolescents • Missed in up to 75% of pediatric primary care visits • Higher blood pressure in childhood correlates with higher BP in

adulthood • More likely to develop metabolic syndrome • More likely to have accelerated vascular aging and cerebral

vascular accident in adulthood

(Flynn et.al., 2017)

Prevalence • Greater among Hispanic and Non-Hispanic African

American Children

• Higher rates amongst males • Higher rates among adolescents vs. younger children • More prevalent in adolescents who are overweight or obese • Higher rates in children with chronic conditions

•  Obesity, sleep disordered breathing, chronic kidney disease, pre-term birth, endocrine disorders, chronic steroid use (i.e malignancies)

(Flynn et. al, 2017)

AAP Guidelines •  American Academy of Pediatrics updated clinical practice guidelines

•  Replaces the 2004 Guidelines •  Updated tables are based on normal weight children •  Simplified screening table to identify BPs needing further evaluation •  Simplified BP classification in adolescents, ≥ 13 years of age

•  Consistent with American Heart Association Guidelines and American College of Cardiology adult guidelines

•  Term “pre-hypertension” has been replaced with “elevated blood

pressure”

(Flynn et. al, 2017; Mattoo, 2017)

AAP Guidelines •  Limited recommendation on when to perform BP screening

•  Expanded role for ambulatory BP monitoring

• Revised recommendations on when to perform echocardiograms

(Flynn et. al, 2017; Mattoo, 2017)

New BP Tables • Based on normal-weight children

•  Do not include children and adolescents with overweight and obesity •  BMI ≥85th percentile)

•  Several millimeters of mercury lower than tables in the Fourth Report

•  Include SBP and DBP values arranged by age, sex, and height • Categorized as normal (50th percentile), elevated BP (>90th

percentile), stage 1 HTN (≥95th percentile), and stage 2 HTN (≥95th percentile + 12 mm Hg)

• Heights in centimeters and inches

(Flynn et.al, 2017)

Simplified BP Tables • Designed as a screening tool only to identify children and

adolescents who need further evaluation of their BP • Based on the 90th percentile BP for age and sex for children at

the 5th percentile of height

•  Should not be used as single measure to diagnose elevated BP or HTN •  Actual cut offs should be used for diagnosis

•  For adolescents ≥13 years of age, a threshold of 120/80 mm Hg is used in the simplified table regardless of sex to align with adult guidelines

(Flynn et.al, 2017)

Simplified BP Tables

Staging of Hypertension in the Adolescent

Normal Blood Pressure < 120/80 Elevated Blood Pressure 120/80 to 129/<80 Stage 1 Hypertension 130/80 to 139/89 Stage 2 Hypertension ≥ 140/90

For adolescents ≥ 13 years of age

(Flynn et. al, 2017)

Measurement of Blood Pressure •  Measure beginning at 3 years of age

•  If they are identified as high risk for HTN you can check prior to < 3 yrs old

•  Annual measurement during routine well-child check •  At every health visit ONLY if adolescent has obesity, taking

medications known to increase blood pressure, renal disease, diabetes, h/o of aortic arch obstruction or coarctation of the aorta

•  If BP is elevated, perform 2 additional readings at the same visit and average them •  Auscultation or Oscillometric device

•  If repeat readings are still elevated, and if using a oscillometric device, repeat auscultation 2 times and average the readings

(Flynn et.al, 2017)

Primary Hypertension • Older age ≥ 6 years old • Positive family history

• Parent and/or grandparent • Overweight or obese • Typically asymptomatic • Elevated systolic blood pressure

• In children ≥ 6 years old and a positive family history and overweight or obese, adolescents do NOT require extensive work-up for secondary causes of hypertension

(Flynn et.al, 2017; Mattoo, 2017)

Secondary Hypertension • Younger children, pre-puberty •  Elevated diastolic blood pressure reading •  Typically symptomatic with symptoms related to underlying

cause •  Renal disease/ Renovascular disease •  Coarctation of the aorta •  Endocrine Disorders •  Environmental exposures •  Neurofibromatosis •  Supplements •  Medications

•  Steroids, decongestants, cold medications, OCPs, Stimulants, anti-depressants, Erythropoietin, Cyclosporin/Tacrolimus, Asthma medication

(Flynn et. al, 2017; Mattoo, 2017)

Goals of Evaluation • Distinguish between primary and secondary hypertension •  For children with secondary hypertension, identify and treat

underlying cause

•  Identify other comorbid risk factors for coronary vascular disease •  Obesity, dyslipidemia, diabetes mellitus

(Mattoo, 2017)

Initial Work-Up •  Focused History

• ROS: fatigue, weight loss/weight gain, fevers, flushing, chest pain, palpitations, edema, SOB, snoring, orthopnea

•  Family History

• HTN, Early CV disease, CVA, End Stage Renal Disease, DM

•  Past Medical History

• Prematurity, neonatal course, OSA, frequent UTIs

Initial Work-Up •  Social History

•  Tobacco Use, illicit drugs, alcohol, diet, exercise, school/work •  Feelings of depression, anxiety, bullying and body image perceptions

•  Nutritional History •  Salt content, sugars, processed foods

•  Medications •  Steroids, decongestants, cold medications, OCPs, stimulants, anti-depressants,

Erythropoietin, Cyclosporin/Tacrolimus, asthma medication, supplements

Initial Work-Up •  Focused Physical Exam

•  Vitals: Repeat BP manually (using appropriate cuff size) •  Gen: Moon facies, truncal obesity, buffalo hump •  Skin: Hirsutism, butterfly rash, neurofibromas, café au lait spots •  HEENT: Retinopathy, crowded oropharynx, enlarged tonsils, thyromegaly •  CV: Pulses in all 4 extremities, heart sounds (laying, sitting, standing), edema, carotid bruits •  Resp: crackles, rhonci, wheezing •  ABD: abdominal mass, pregnancy, abdominal bruits •  MSK: Pain with ROM, Joint swelling •  PSYCH: Anxiety

Diagnostic Work-Up •  Initial Diagnostic Work-Up on All Patients:

•  Basic Metabolic Panel •  Quick assessment of renal function and electrolyte abnormalities

•  Urinalysis •  Lipid Panel •  Renal U/S

•  For any adolescent with an abnormal U/A or renal function

•  **Echocardiogram •  To be done when pharmacologic measures are considered and should be done

prior to initiating medications

(Flynn, et.al, 2017)

Additional Diagnostic Work-Up •  Overweight/obese (BMI > 95th percentile): Hemoglobin A1c, Liver

Enzymes

•  Concern for OSA: Sleep Study •  Concern for pregnancy: Urine Pregnancy Test •  Concern for illicit drug use: UDM

(Flynn et.al, 2017)

Treatment • Goal of treatment is to reduce risk for end-organ damage

• Reduce risk of coronary vascular disease in adulthood

• Reduction of BP < 130/80 in adolescents

• Reduction of BP < 90th percentile in children

Lifestyle Modifications • Counsel regarding weight management and nutrition

•  DASH Diet •  Limit fast food/processed foods, limit sugar, limit sodium •  Increase servings of fruits and vegetables and low fat dairy •  Moderate amounts of whole grains, fish, poultry, and nuts

• Regular daily exercise •  Goal of 1 hour of physical activity at least 3-5 days per week •  Encourage participation in a sport

•  Limit screen time and social media to 1-2 hours per day

•  Stress Reduction/Meditation

(Flynn et.al, 2017; Mattoo, 2017)

Pharmacologic Management •  Stage I hypertension when there is no response to non-pharmacologic

management after 6 months

•  Stage 1 hypertension IF symptomatic and/or with end organ disease •  Stage II hypertension without a modifiable risk factor •  Hypertension associated with chronic kidney disease and diabetes •  Initial treatment recommended by the American Academy of Pediatrics:

•  ACE Inhibitor •  Angiotensin Receptor Blocker •  Long-Acting Calcium Channel Blocker •  Thiazide diuretics

(Mattoo, 2017)

Pharmacologic Management •  Avoid beta-blockers and potassium sparing diuretics as initial treatment

•  If not controlled with single agent, may consider adding a second agent of different class

•  Starting doses should be the lowest known dose

•  Medication can be increased every 2-4 weeks until BP is controlled

•  Should be seen in clinic every 4-6 weeks until BP is well controlled •  Once blood pressure is well controlled, may extend follow-up to every 3-6

months •  Continue counseling on lifestyle modifications

(Flynn et. al, 2017)

ACE Inhibitors •  Mechanism of Action: Prevents conversion of Angiotensin I to

Angiotensin II, resulting in increased renin activity and reduction in aldosterone secretion

•  Contraindicated in pregnancy

•  Discontinue immediately if pregnancy is suspected. Can cause injury or death to the fetus

•  Side Effects

•  Common: Cough, headache, dizziness •  Severe: Hyperkalemia, AKI, angioedema

•  Monitor BUN/Cr and baseline electrolytes prior to starting •  Periodically check throughout treatment

(Up to Date, 2017)

ACE Inhibitors •  Lisinopril

•  Initial Dose: 0.07-0.1 mg/kg/dose once daily •  Max Initial Dose = 5mg/DAY

•  May increase in 1-2 week intervals •  Max daily dose= 40mg/DAY

•  Fosinopril •  < 50 kg: 0.1mg/kg/dose once daily •  > 50 kg: 5-10mg once daily •  Max daily dose = 40mg/DAY

•  Other: Benazapril, Captopril, Quinapril

•  Typically very well tolerated

•  When to Consider: Typically used as first line medication; diabetes, Proteinuria, Chronic Kidney Disease

(Up to Date, 2017)

Angiotensin Receptor Blockers • Mechanism of Action: Blocks the vasoconstriction and

aldosterone secreting effects of angiotensin II • Contraindicated in pregnancy

•  Discontinue immediately if pregnancy is suspected. Can cause injury or death to the fetus

•  Side Effects

•  Common: headache, dizziness •  Severe: Hyperkalemia, AKI, angioedema

• Monitor BUN/Cr and baseline electrolytes prior to starting. •  Periodically check throughout treatment

(Up to Date, 2017)

Angiotensin Receptor Blockers •  Losartan

•  0.7 mg – 1.4mg/kg/dose once daily •  Max Dose = 100 mg/DAY

•  Valsartan •  1.3mg – 2.7mg/kg/dose once daily

•  Max Dose = 160mg/DAY

•  Other: Candesartan, Olmesartan, Irbesartan (not indicated in children)

•  Typically well tolerated •  When to Consider: Could not tolerate ACE due to cough, Diabetes,

Proteinuria, Chronic Kidney Disease

Calcium Channel Blockers • Mechanism of Action: Inhibits Calcium from entering the slow

channels of vascular smooth muscle and myocardium during depolarization, producing relaxation of coronary vascular smooth muscle and coronary vasodilation

• Contraindication: Hypersensitivity to calcium channel blockers; Sick Sinus Syndrome

•  Side Effects

•  Common: flushing, peripheral edema, dizziness •  Severe: angioedema

• Monitor heart rate and baseline liver enzymes (Up to Date, 2017)

Calcium Channel Blockers • Amlodipine

•  Initial dose: 2.5mg-5mg once daily •  Max Dose= 10mg/DAY

•  Isradapine •  Initial dose: 0.15 mg- 0.2mg/kg/day divided 3-4 times daily

•  Max dose = 20 mg/day •  Most adult patients do not show an improvement with doses > 10mg/day

• Other: Felodipine, Nifedepine

• When to consider: Diminished renal function, hyperkalemia, and sexually active females who are unable to take or non- adherent to contraception

(Up to Date, 2017)

Thiazide Diuretics •  Mechanism of Action: Inhibits sodium reabsorption in the distal

tubules causing increased excretion of sodium and water as well as potassium

•  Contraindications: Anuria, hypersensitivity to thiazide diuretics or

sulfonamide derived drugs •  Side Effects

•  Common: Dizziness, hypokalemia •  Severe: Cardiac dysrhythmia, hyperglycemia, jaundice, pancreatitis

•  Monitor BUN/Cr, glucose, electrolytes. Obtain baseline basic metabolic panel and repeat at least 4 weeks after starting and continue to monitor periodically throughout treatment

(Up to Date, 2017)

Thiazide Diuretics • Hydrochlorothiazide

•  1mg-2mg/kg/day in 1-2 divided doses •  Max dose = 100mg/DAY

• Chlorthalidone •  0.3mg/kg/dose once daily •  Max dose = 50 mg/DAY

• When to Consider: Often preferred second agent

(Up to Date, 2017)

Beta-Blockers • Mechanism of Action: Selective inhibitor of beta 1 adrenergic

receptors • Contraindications: asthma, heart block •  Side-Effects

•  Common: Bradycardia, dizziness, fatigue, headache, blurred vision •  Severe: Bronchospasm, dyspnea, heart block

• Monitor heart rate throughout treatment

(Up to Date, 2017)

Beta Blockers •  Metoprolol

•  0.5mg- 1mg/kg/dose divided BID •  Max Initial Dose = 25mg/dose •  Max Daily Dose = 200 mg/DAY

•  Atenolol

•  0.5mg- 1mg/kg/dose divided BID or once daily •  Max Daily Dose = 100 mg/DAY

•  Other: Propranolol, Carvedilol

•  When to Consider: Adolescents of childbearing potential; children not responsive to ACE, ARB, Thiazides, or Calcium Channel Blockers; Typically 3rd line agent

(Up to Date, 2017)

Elevated Blood Pressure

• Children (1-13): •  Elevated BP: ≥90th percentile

• Adolescents (≥13 years of age): •  120/80 to 129/ <80

(Flynn et. al, 2017)

Elevated Blood Pressure •  Lifestyle modifications •  Weight management •  Initial labs: Basic Metabolic Panel, Urinalysis, and Lipid Panel •  Follow-up in 6 months

•  Repeat BP •  Lifestyle modifications, weight management counseling •  F/U again in 6 months •  If BP still elevated after 12 months consider:

•  Ambulatory blood pressure monitoring •  Full Diagnostic work-up •  Consider referral to subspecialty

•  If BP normalizes at any point. Return to annual screening

Stage 1 Hypertension • Children (1-13):

•  ≥95th percentile

• Adolescents (≥13 years of age): •  130/80 to 139/89

Stage 1 Hypertension •  Lifestyle modifications •  Weight management •  Initial Labs: Initial labs: Basic Metabolic Panel, Urinalysis, and Lipid

Panel •  Repeat BP in 1-2 weeks, if BP still at Stage 1, follow-up in 3 months •  3 Month Follow-Up

•  Repeat blood pressure •  Lifestyle and weight management counseling •  If still elevated after 3 months consider

•  Ambulatory blood pressure monitoring •  Diagnostic evaluation •  Initiate treatment •  Consider referral to subspecialty

(Flynn et. al, 2017)

Stage 2 Hypertension • Children (1-13):

•  ≥95th percentile + 12 mm Hg

• Adolescents (≥13 years of age): •  ≥ 140/90

Stage 2 Hypertension •  Lifestyle modifications and weight management counseling •  Initial Labs: Basic Metabolic Panel, Urinalysis, Lipid Panel

•  If asymptomatic, repeat BP in 1 week •  Alternatively may refer to specialty within 1 week

•  If BP remains elevated: •  Ambulatory BP monitoring •  Echocardiogram •  Initiate pharmacologic treatment •  Refer to subspecialty

•  If symptomatic or BP > 180/120 refer to immediate care

(Flynn et.al, 2017)

Hypertensive Emergency

•  Symptoms consistent with hypertensive emergency •  Severe headache, seizures, mental status changes, vomiting, focal

neurologic complaints, visual disturbances, chest pain, SOB, palpitations

• Require immediate pharmacologic management and typically hospitalization for evaluation of ongoing care

(Mattoo, 2017)

Sports Participation •  Elevated Blood Pressure (120/80 to 129/<80)

•  May participate in sports without restriction

•  Stage 1 Hypertension (130/80 to 139/89) •  May participate in sports without restriction if there is no evidence of end

organ damage •  Repeat blood pressure 1-2 weeks after starting sport •  Stage 2 Hypertension (≥ 140/90) •  Restricted from high static sports •  Once treated and normotensive, may participate in sports without restriction

•  No data linking the presence of HTN to sudden death related to sports participation

(Mattoo, 2017)

Prevention • Lifestyle modifications • Dietary Intervention • Exercise

AJ •  15 year old Hispanic male here for routine sports physical •  Past Medical Hx:

•  Born at term, vaginal delivery, no complications •  Broken right wrist after a fall

•  Family Medical Hx:

•  Maternal Grandmother: Controlled Type 2 DM, HTN, Hypothyroid •  Mother: GERD •  Father: Controlled Type 2 DM, HTN •  Sister: Healthy

•  Social History:

•  Exercise: Football games/practice daily for at least 60 min; Weight training 3 days per week •  Diet: Protein shakes prior to each practice, 2 Dr. Pepper’s per day, eats fast food approx 4 d/wk, 3

Bottles of Gatorade per day •  Tobacco/Drugs/ETOH: Denies use, however does have secondary exposure. Father does smoke •  Works 20 hours per week at local grocery store

•  Medications: NONE

AJ •  ROS: Tired during the day, headaches after football practice •  Vital Signs:

•  T: 36.7; HR: 85; RR: 18; O2: 98% RA •  Wt: 160 lbs (90%); HT: 5’8” (50%); BMI: 24 (90%) •  BP: 139/88 (automated cuff); 135/80 (1st manual repeat) ; 138/85 (2nd manual repeat) •  Average BP reading: 136/84

•  Physical Exam •  Unremarkable

•  Labs: •  Urinalysis: + for trace protein

•  Review of chart shows BP of 130/80 and 132/82 on 2 separate visits over the last year

AJ

• Diagnosis: • Stage 1 Hypertension • Proteinuria • Overweight

AJ •  Stage 1 Hypertension

•  BMP, urinalysis, lipid panel •  Lifestyle modifications, weight management counseling •  Ok to participate in football •  RTC in 3 months to follow-up BP and lifestyle modifications

•  Proteinuria •  Renal U/S

• Overweight •  Lifestyle modifications, weight management counseling

AJ, 3 month Follow-Up •  Social: Stopped part-time job to focus on sports and school, stopped Dr. Pepper and now

only drinking 1 bottle of Gatorade per day, mother packing lunch and cooking dinner daily. Father stopped smoking

•  T: 36.7; HR: 85; RR: 18; O2: 98% RA; Wt:160 lbs (90%); HT: 5’8” (50%); BMI: 24

(90%) •  BP: 130/80, repeat auscultated measure: 132/85 •  Physical Exam

•  Unremarkable

•  Labs: •  BMP-Normal •  Lipid Panel- Normal

•  Renal U/S: •  Unremarkable

AJ, 3 month Follow-Up •  Stage 1 Hypertension

•  No response with lifestyle modifications •  Continue weight management and lifestyle modifications •  Ambulatory blood pressure monitoring •  Diagnostic evaluation

•  Considering Treatment: Echocardiogram

•  Consider referral to subspecialty

•  F/U in 1 month to review echocardiogram results

AJ, FU Echo Results •  Echocardiogram is normal

• Review of Ambulatory BP shows an average reading of 135/80

• After a total of 6 months and continued stage 1 hypertension, you decide to initiate medications

What Medication to Choose? •  Lisinopril

• Metoprolol

•  Losartan

• Hydrochlorothiazide

What Did I Choose?

• Lisinopril • 5mg PO q day

What Medication to Choose? •  Lisinopril

•  Typically well tolerated •  Low side-effect profile

•  Metoprolol •  Not generally used as first line medication •  Would not choose in active teen, due to side-effects particularly fatigue

•  Losartan •  Also well tolerated •  Would like to have as a second choice if ACE is not tolerated due to cough

•  Hydrochlorothiazide

•  Often preferred as a second agent •  Would try to avoid in active teen due to side effects

References •  Flynn, J., Kaelber, D., Baker-Smith, C., Blowey, D. Carroll, A., Daniels, S., De

Ferranti, S., …Uribina, E. (2017). Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. American Academy of Pediatrics. Retrieved from http://pediatrics.aappublications.org/content/140/3/e20171904

•  Mattoo, T., Stapleton, F., & Kim, M. (2017). Nonemergent Treatment of Hypertension in Children and Adolescents. Up to Date. Retrieved from https://www.uptodate.com/contents/nonemergent-treatment-of-hypertension-in-children-and-adolescents?source=search_result&search=Nonemergent%20managment%20hypertension%20adolescents&selectedTitle=1~150

•  Mattoo, T., Stapleton, F., & Kim, M. (2017). Evaluation and Management of Hypertension in Children and Adolescents. https://www.uptodate.com/contents/evaluation-of-hypertension-in-children-and-adolescents?source=search_result&search=adolescent%20hypertension&selectedTitle=1~150

References •  Up to Date (2017). Pediatric Drug Information: Amlodipine. Retrieved from

https://www.uptodate.com/contents/amlodipine-pediatric-drug-information?source=search_result&search=Amlodipine&selectedTitle=2~121

•  Up to Date (2017). Pediatric Drug Information: Hydrochlorothiazide. Retrieved from https://www.uptodate.com/contents/hydrochlorothiazide-pediatric-drug-information?source=search_result&search=hydrochlorothiazide&selectedTitle=2~150

•  Up to Date (2017). Pediatric Drug Information: Lisinopril. Retrieved from https://www.uptodate.com/contents/lisinopril-pediatric-drug-information?source=search_result&search=Lisinopril&selectedTitle=2~83

•  Up to Date (2017). Pediatric Drug Information: Metoprolol. Retrieved from https://www.uptodate.com/contents/metoprolol-pediatric-drug-information?source=search_result&search=metoprolol&selectedTitle=2~150