Pediatric Pediatric HypertensionHypertension

Elizabeth BurrowsElizabeth Burrows

IntroductionIntroduction

Hypertension in American children Hypertension in American children is a growing epidemic is a growing epidemic

High blood pressure is estimated to High blood pressure is estimated to be prevalent in 4.5% of children be prevalent in 4.5% of children

A recent study by Hansen found that A recent study by Hansen found that in the United States health care in the United States health care providers fail to diagnose high blood providers fail to diagnose high blood pressure in more than 75% of pressure in more than 75% of childrenchildren

Why the rise in childhood Why the rise in childhood hypertension?hypertension?

Increasing epidemic of childhood obesityIncreasing epidemic of childhood obesity Sedentary lifestylesSedentary lifestyles Epidemiologic studies indicate that about 30% Epidemiologic studies indicate that about 30%

of obese children have hypertensionof obese children have hypertension Hypertension and obesity are two common Hypertension and obesity are two common

preventable disorders facing pediatric preventable disorders facing pediatric cliniciansclinicians

Study by Couch in which obese patients Study by Couch in which obese patients achieved a reduction in BMI of 8-10% showed achieved a reduction in BMI of 8-10% showed a decline in blood pressures that were in the a decline in blood pressures that were in the range of 8 to 16 mm Hgrange of 8 to 16 mm Hg

Why are health care Why are health care providers failing to make providers failing to make

the diagnosis?the diagnosis? Blood pressure in children is a function Blood pressure in children is a function

of age, sex, and height percentile of age, sex, and height percentile What is normal for one child may be What is normal for one child may be

considered hypertensive in another considered hypertensive in another child of the same agechild of the same age

Clinicians usually cannot remember Clinicians usually cannot remember normal blood pressures for the wide normal blood pressures for the wide range of children observed in their range of children observed in their typical primary care settingtypical primary care setting

Factors making diagnosis Factors making diagnosis more likely in childrenmore likely in children

Older ageOlder age Taller height Taller height Obesity Obesity Younger children and Younger children and

adolescents who are adolescents who are not overweight and not overweight and generally appear generally appear healthy are typically healthy are typically the patients where the patients where hypertension is not hypertension is not suspected and often suspected and often missedmissed

Hansen’s 2007 StudyHansen’s 2007 Study Analyzed the medical records of 507 hypertensive Analyzed the medical records of 507 hypertensive

and pre-hypertensive children and adolescents and pre-hypertensive children and adolescents over a span of seven yearsover a span of seven years

All the children visited an outpatient clinic at least All the children visited an outpatient clinic at least three times three times

376 patients (74%) had undiagnosed hypertension 376 patients (74%) had undiagnosed hypertension 80 patients (15.8%) had a true hypertension 80 patients (15.8%) had a true hypertension

diagnosis diagnosis 7 participants had undiagnosed stage 2 7 participants had undiagnosed stage 2

hypertensionhypertension Data to make the diagnosis of hypertension or Data to make the diagnosis of hypertension or

prehypertension was present in the patients' prehypertension was present in the patients' recordsrecords

Hansen’s 2007 StudyHansen’s 2007 Study

There is a much needed modification for There is a much needed modification for identifying pediatric hypertension identifying pediatric hypertension

Current discussion is centered on the Current discussion is centered on the development of a computer programdevelopment of a computer program Through electronic record keeping - send a Through electronic record keeping - send a

red flag alerting the provider when a red flag alerting the provider when a patient’s blood pressure is in the pre-patient’s blood pressure is in the pre-hypertensive to hypertensive statehypertensive to hypertensive state

Why is it important to Why is it important to diagnose and treat diagnose and treat

hypertension in childhood?hypertension in childhood? Prevent progression and target organ damage Prevent progression and target organ damage

of the brain, eyes, heart, and kidneys of the brain, eyes, heart, and kidneys A study by Hanevoid demonstrated that severe A study by Hanevoid demonstrated that severe

target organ damage occurs in hypertensive target organ damage occurs in hypertensive childrenchildren 41% of the 129 hypertensive children and 41% of the 129 hypertensive children and

adolescents studied had left ventricular hypertrophy adolescents studied had left ventricular hypertrophy (LVH) by pediatric criteria, and 16% had LVH even (LVH) by pediatric criteria, and 16% had LVH even when using adult criteria when using adult criteria

If caught early, preventative measures can be If caught early, preventative measures can be taken to reduce risks for other comorbidities in taken to reduce risks for other comorbidities in childhood and adulthoodchildhood and adulthood

Pediatric ClassificationsPediatric Classifications

The Fourth Report 2004 includes The Fourth Report 2004 includes new classifications for hypertension new classifications for hypertension

PrehypertensionPrehypertension Stage 1Stage 1 Stage 2Stage 2

Pediatric ClassificationsPediatric Classifications Pre-hypertensionPre-hypertension- average systolic and/or - average systolic and/or

diastolic blood pressure between the 90th diastolic blood pressure between the 90th and 95th percentile for gender, age, and and 95th percentile for gender, age, and heightheight

Lifestyle modifications and reevaluation Lifestyle modifications and reevaluation every six months are recommended to help every six months are recommended to help prevent progression to hypertensionprevent progression to hypertension

HypertensionHypertension- average systolic and/or - average systolic and/or diastolic blood pressure that is ≥95th diastolic blood pressure that is ≥95th percentile for gender, age, and heightpercentile for gender, age, and height

Elevated blood pressure must be confirmed Elevated blood pressure must be confirmed on three repeated visits before diagnosing on three repeated visits before diagnosing a child as having hypertensiona child as having hypertension

Pediatric ClassificationsPediatric Classifications Stage 1-Stage 1- average systolic and/or diastolic blood average systolic and/or diastolic blood

pressure levels that range from the 95th pressure levels that range from the 95th percentile to 5 mm Hg above the 99th percentile percentile to 5 mm Hg above the 99th percentile for gender, age, and heightfor gender, age, and height

Initially patients in stage 1 should be reevaluated Initially patients in stage 1 should be reevaluated within one to two weekswithin one to two weeks

Stage 2-Stage 2- average systolic and/or diastolic blood average systolic and/or diastolic blood pressure levels that are >5 mm Hg above the pressure levels that are >5 mm Hg above the 99th percentile for gender, age, and height99th percentile for gender, age, and height

If symptomatic give immediate treatment and If symptomatic give immediate treatment and refer to hypertension specialistrefer to hypertension specialist

If asymptomatic refer to specialist within one If asymptomatic refer to specialist within one weekweek

Measurement of BP in Measurement of BP in PediatricsPediatrics

The Fourth Report recommends that The Fourth Report recommends that children 3 years and older have their children 3 years and older have their blood pressure measured regularlyblood pressure measured regularly

The preferred method of blood The preferred method of blood pressure measurement is pressure measurement is auscultationauscultation

In order to correctly diagnose In order to correctly diagnose hypertension blood pressure must be hypertension blood pressure must be measured accuratelymeasured accurately

Measurement of BP in Measurement of BP in PediatricsPediatrics

Main source of error – Using wrong Main source of error – Using wrong cuff sizecuff size

Small cuff- overestimates BP Small cuff- overestimates BP Large cuff- underestimates BP Large cuff- underestimates BP

Appropriate Cuff SizeAppropriate Cuff Size

Inflatable bladder width that covers at Inflatable bladder width that covers at least 40% of the arm circumference least 40% of the arm circumference midway between the olecranon process midway between the olecranon process and the acromion processand the acromion process

The bladder length should cover 80-The bladder length should cover 80-100% of the circumference of the arm 100% of the circumference of the arm

The bladder width-to-length ratio The bladder width-to-length ratio should be at least 1:2should be at least 1:2

Measurement of BP in Measurement of BP in PediatricsPediatrics

Preparing the child for blood pressure Preparing the child for blood pressure measurements measurements

Sit quietly for five minutes with their Sit quietly for five minutes with their back and right arm supported at heart back and right arm supported at heart level and feet flat on the floor level and feet flat on the floor

If a patient has a reading that is >90th If a patient has a reading that is >90th percentilepercentile BP should be repeated twice at the same BP should be repeated twice at the same

office visitoffice visit Document average systolic and diastolic BPDocument average systolic and diastolic BP

ABPM ABPM Ambulatory Blood Pressure Monitoring allows Ambulatory Blood Pressure Monitoring allows

clinicians to observe the patients BP 2-4 times per clinicians to observe the patients BP 2-4 times per hour over at least 24 hourshour over at least 24 hours

Patients are encouraged to continue normal everyday Patients are encouraged to continue normal everyday activities while being monitored activities while being monitored

Successful in children even as young as 2 months Successful in children even as young as 2 months Make diagnosis that would otherwise be missedMake diagnosis that would otherwise be missed

Nocturnal Blood Nocturnal Blood Pressure Pressure

Nocturnal BP Dip- Typically Nocturnal BP Dip- Typically individuals have 10-15% drop in individuals have 10-15% drop in their mean day and night blood their mean day and night blood pressure readings pressure readings

ABPM can detect ABPM can detect An abnormality nocturnal BP dipAn abnormality nocturnal BP dip Elevations of nocturnal blood pressure Elevations of nocturnal blood pressure

Both usually indicative of secondary Both usually indicative of secondary hypertension hypertension

Masked HypertensionMasked Hypertension A condition where a patient’s office A condition where a patient’s office

blood pressure is normal but ABPM blood pressure is normal but ABPM classify the patient as hypertensiveclassify the patient as hypertensive

Study of masked hypertension reviewed Study of masked hypertension reviewed by McNiece showed a prevalence of by McNiece showed a prevalence of 7.6% among 592 children aged 6–18 7.6% among 592 children aged 6–18 yearsyears

Showed these children with have an Showed these children with have an elevated left ventricular mass index elevated left ventricular mass index equivalent to truly hypertensive patients equivalent to truly hypertensive patients

White Coat HypertensionWhite Coat Hypertension A patient with blood pressure levels A patient with blood pressure levels

>95th percentile in a physician’s office or >95th percentile in a physician’s office or clinic and who is normotensive outside a clinic and who is normotensive outside a clinical settingclinical setting

Several studies suggest that in some Several studies suggest that in some children this may be a prehypertensive children this may be a prehypertensive state that eventually may progress to state that eventually may progress to hypertensionhypertension

Counsel patient about therapeutic Counsel patient about therapeutic lifestyle changes and monitor for lifestyle changes and monitor for development of true hypertensiondevelopment of true hypertension

Pediatric SymptomsPediatric Symptoms Hypertension is often thought of as a Hypertension is often thought of as a

silent disease because typically there have silent disease because typically there have not been any classic symptomsnot been any classic symptoms

A recent study by Croix found that 51% of A recent study by Croix found that 51% of untreated hypertensive children when untreated hypertensive children when surveyed reported 1-4 Symptoms, and surveyed reported 1-4 Symptoms, and 14% reported more than four symptoms14% reported more than four symptoms

3 most common symptoms3 most common symptoms headache headache difficulty initiating sleep difficulty initiating sleep daytime tiredness daytime tiredness These were all reduced with treatment These were all reduced with treatment

After Hypertension is After Hypertension is DiagnosedDiagnosed

Want to rule out secondary causesWant to rule out secondary causes BP should be measured in both arms and a leg to BP should be measured in both arms and a leg to

rule out coarctation of the aortarule out coarctation of the aorta Fasting lipid, Fasting glucose, standard chemistry Fasting lipid, Fasting glucose, standard chemistry

panel, serum urea nitrogen (BUN), CBC, creatine, panel, serum urea nitrogen (BUN), CBC, creatine, urinalysis and urine culture urinalysis and urine culture

Echocardiogram, renal ultrasoundEchocardiogram, renal ultrasound Screen for major sleep disorders using BEARS: Screen for major sleep disorders using BEARS:

Bedtime problemsBedtime problems Excessive daytime sleepinessExcessive daytime sleepiness Awakenings during the nightAwakenings during the night Regularity and duration of sleep Regularity and duration of sleep SnoringSnoring

TreatmentTreatment

Lifestyle modifications are typically Lifestyle modifications are typically the initial treatment of choice the initial treatment of choice

Indications for antihypertensive Indications for antihypertensive drug therapy in children drug therapy in children Secondary hypertensionSecondary hypertension Insufficient response to lifestyle Insufficient response to lifestyle

modificationsmodifications Stage 2 hypertension Stage 2 hypertension

Pharmacologic Therapy of Pharmacologic Therapy of Childhood Hypertension Childhood Hypertension

2002 Best Pharmaceuticals for Children Act 2002 Best Pharmaceuticals for Children Act has led to recent study and FDA approval of has led to recent study and FDA approval of several antihypertensive medications for use several antihypertensive medications for use in pediatricsin pediatrics

Unknown long-term effects of Unknown long-term effects of antihypertensive therapy in children- antihypertensive therapy in children- especially with regard to growth and especially with regard to growth and development development

ACE-I and calcium channel blockers are the ACE-I and calcium channel blockers are the most commonly used antihypertensive most commonly used antihypertensive medications in childrenmedications in children

ConclusionConclusion Hypertension and obesity in Hypertension and obesity in

children are increasing in an children are increasing in an upward trendupward trend

It is imperative that pediatric It is imperative that pediatric hypertension is recognized hypertension is recognized and treated and treated

It is advisable to measure It is advisable to measure blood pressure at every visit blood pressure at every visit with the appropriate with the appropriate technique, use the gender, technique, use the gender, age, and height specific blood age, and height specific blood pressure table, and to follow pressure table, and to follow the recommendations of the the recommendations of the Fourth ReportFourth Report

It is important to encourage It is important to encourage healthy lifestyles in all healthy lifestyles in all children and adolescents and children and adolescents and help institute lifestyle help institute lifestyle changes for weight reduction changes for weight reduction in overweight childrenin overweight children

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