Pediatric Hypertension - Home | AAP Point-of-Care-Solutions...Image courtesy of Wikimedia Commons. Treat with confidence. Trusted answers from the American Academy of Pediatrics. Additional

Treat with confidence. Trusted answers from the American Academy of Pediatrics.Treat with confidence. Trusted answers from the American Academy of Pediatrics.

Pediatric Hypertension

Brian Stotter, MD, FAAPAssistant Professor of PediatricsWashington University School of MedicineSt. Louis, MO


Disclaimer Statements and opinions expressed are those of the author and not

necessarily those of the American Academy of Pediatrics (AAP).

Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter’s comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.


Learning Objectives Define and confirm elevated blood pressure and hypertension

in children.

List common causes of hypertension in children across different age ranges.

Describe the diagnostic evaluation of a child presenting with suspected hypertension based on history and physical exam findings.

*Figures for this presentation, unless otherwise noted, were created by Brian Stotter, MD, FAAP on behalf of the AAP Section on Nephrology (SONp) Executive Committee.


A 14-year-old girl is referred to you for elevated blood pressure first noted at her well adolescent visit. She complains of intermittent headaches but otherwise has been well.

Vital signs: HR 56, RR 18, BP 165/94 (automated), Ht 163.4 cm, Wt 56.7 kg (BMI 21.2)

You obtain a right arm manual BP of 156/88. Four extremity BPs are 158/92 (left arm), 156/88 (right arm), 166/100 (left leg), 168/98 (right leg).

What other information do you want to know?

Caremate Sphygmomanometer [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]https://upload.wikimedia.org/wikipedia/commons/1/1c/CM-3411-3421.jpg


What is blood pressure?Generally refers to the arterial pressure in systemic circulation

Diastolic BP pressure in the blood vessels during heart relaxation

Systolic BP pressure in the blood vessels during heart contraction

Mean arterial pressure (MAP) average pressure during a single cardiac cycle

• MAP = DBP + (SBP – DBP)/3


Definitions

Reproduced with permission from the American Academy of Pediatrics. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.

Children ages 1 to <13 years Children ≥13 years

Normal BP: <90th percentile Normal BP: <120/<80 mmHg

Elevated BP: ≥90th percentile to <95th percentile or 120/80 mmHg to <95th percentile (whichever is lower)

Elevated BP: 120/<80 to 129/<80 mmHg

Stage 1 HTN: ≥95th percentile to <95th percentile + 12 mmHg or 130/80 to 139/89 mmHg (whichever is lower)

Stage 1 HTN: 130/80 to 139/89 mmHg

Stage 2 HTN: ≥95th percentile + 12 mmHg or ≥140/90 (whichever is lower)

Stage 2 HTN: ≥140/90 mmHg


Is my patient’s blood pressure elevated? Where are these percentiles? From the 2017 AAP Clinical Practice Guideline for Pediatric

Hypertension• Update from the “Fourth Report” (Pediatrics. 2004) with new

HTN definitions and normative BP values‒ Unlike the “Fourth Report,” new BP tables exclude measurements

from overweight and obese children

• Systolic and diastolic blood pressure values for age, gender, and height based on manual BPs

• Data provided for 50th, 90th, 95th, and 95th + 12 mmHg percentiles


How common is hypertension in children? Variable prevalence in epidemiologic studies, commonly due

to different BP measurement techniques and populations studied

1.6% prevalence of “high BP” (≥95th percentile) in children ages 8–17 years using NHANES 2011–2012 data, “borderline high BP” prevalence of 9.4% (90th–95th percentile)

Likely underestimated with increase in obesity in children

“White coat hypertension” estimated prevalence of 30%–40% from office BP readings

Kit BK, Kuklina E, Carroll MD, Ostchega Y, Freedman DS, Ogden CL. Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999-2012. JAMA Pediatr. 2015;169(3):272–279.


Classification of Hypertension Primary or essential hypertension No definable secondary

cause• May be familial or related to obesity/metabolic syndrome• Traditionally more common in older children and adults, but has

become more common in younger children

Secondary hypertension Attributable to a specific disease process• More common in infants or young children presenting with

hypertension• More commonly encountered when hypertension is particularly

severe


Secondary Hypertension: ExamplesRenal Vascular Endocrine CNS Drugs

Glomerulonephritis Coarctation of aorta Cushing syndrome Dysautonomia Oral contraceptives

Obstructive uropathy

Renal artery stenosis Adrenal tumors• Pheochromocytoma

Seizures Exogenous steroids

Renal scarring Midaortic syndrome Hypo/hyperthyroidism Intracranial hypertension

Cocaine and other illicit substances

Cystic kidney diseases

• ADPKD• ARPKD

Vasculitis• Takayasu arteritis• Polyarteritis

nodosa

Monogenic disorders (associated with low renin)

• AME• GRA• Liddle syndrome

Drug withdrawal• Clonidine


Sample Case

You are consulting on a 3-year-old boy hospitalized with Henoch-Schönlein purpura nephritis/IgA vasculitis. He is 95 cm tall (50th percentile). His blood pressures have been elevated the past 48 hours and you consider starting him on an anti-hypertensive agent. What is his 95th + 12 mmHg BP percentile?


Sample Case

Reprinted with permission from the American Academy of Pediatrics. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.


Reprinted with permission from the American Academy of Pediatrics. Flynn JT, Kaelber DC, Baker-Smith CM, et al. clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.


Obesity as a Risk Factor for Hypertension Bogalusa Heart Study

• 4.5x increased risk of systolic hypertension• 2.4x increased risk of diastolic hypertension

Houston school-based screening program• Prevalence of elevated BP after three measurements was 4.5% in study group.• Prevalence increased progressively with BMI percentile (2% for BMI ≤5th

percentile, 11% for BMI ≥95th percentile).

National Health and Nutrition Examination Survey (NHANES)• Impact of body weight on blood pressure isn’t linear, with prevalence

dramatically increasing once BMI crosses into the 85th percentile.

Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. 2004;113(3 Pt 1):475–482; Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics. 1999;103(6 Pt 1):1175–1182; and Tu W, Eckert GJ, DiMeglio LA, Yu Z, Jung J, Pratt JH. Intensified effect of adiposity on blood pressure in overweight and obese children. Hypertension. 2011;58(5):818–824.


Approach to the Hypertensive Child Confirmation of hypertension

• Manual BP measurements in 3 separate visits using appropriately-sized cuff.

• Bottom edge of the cuff should be 2–3 cm above the antecubital fossa.

• Patient should be sitting upright, back supported, with feet on the ground, for at least 5 minutes before obtaining BP.

• Listen for Korotkoff sounds using the bell of the stethoscope.

Cuff Width: >40% of arm circumference

Cuff Length: bladder length >80% of arm circumference

Reprinted with permission from the American Academy of Pediatrics. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: A working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Pediatrics. 1996;98(4 Pt 1):649–658.


Important History/Physical Exam Findings Was the child born preterm or at low

birth weight?

Any abnormal prenatal ultrasound findings (kidney appearance, cysts, urinary tract dilation)?

Were there any prior febrile UTIs (possible renal scarring)?

Any family history of hypertension, MI, stroke, kidney disease, or endocrinopathies?• Metabolic syndrome risk factors

Image courtesy of Wikimedia Commons.


Additional History to Obtain What potential nephrotoxic medications or illicit substances are being used?

• NSAIDs, antibiotics• Caffeine, energy drinks

What is the child’s salt intake? Sugar intake?

Does the child have any abnormal urinary findings or lower urinary tract symptoms?• Gross hematuria, oliguria• Flank pain

Are hypertensive symptoms present? • Frequent headaches, vision changes, tinnitus, epistaxis, chest pain, dyspnea• If hypertensive emergency, requires prompt treatment to carefully lower blood

pressure


Physical Exam Clues For Secondary Hypertension

Physical Findings Conditions

Tachycardia and hypertension Amphetamines, substance abuse, hyperthyroidism, catecholamine-producing tumors

Asymmetric 4-extremity BPs Vascular disorders

Swelling or unintentional weight gain Glomerulonephritis, hypothyroidism

Skin rash, myalgias, or arthralgias SLE, vasculitis

Hypo/hyperpigmented skin lesions, other birth marks

Neurofibromatosis, tuberous sclerosis


Diagnostic Evaluation

Ambulatory blood pressure monitoring (ABPM) • Confirm true hypertension, rule out white coat hypertension

Screening tests • Urinalysis (with microscopy if proteinuria or hematuria are

present)• Electrolytes, BUN, creatinine• Lipid profile• Renal ultrasound (for children <6 years, or any child with

abnormal urinary findings or renal function)


Secondary Evaluation Obesity-related hypertension

• Hemoglobin A1C• Fasting lipid profile• AST/ALT (for fatty liver disease screening)

Additional tests (based on history, exam, and initial labs)• Fasting glucose (if at risk for diabetes mellitus)• Thyroid function tests• Other endocrine studies (renin, aldosterone, plasma metanephrines,

urine catecholamines)• Drug screen• Sleep study• Other imaging (e.g. CTA, MRA, DMSA)


Non-Pharmacologic Treatment of Hypertension

Lifestyle modification, especially if obesity-related hypertension or metabolic syndrome is a concern• Low-sodium/DASH diet

• Weight loss if overweight or obese‒ Intervention with a dietitian at outpatient visits

• Increased physical activity/exercise


Pharmacologic Treatment of Hypertension Select most effective treatment while minimizing side

effects.

Pathophysiology of an individual disease process can be used to tailor therapy.• Volume overload and sodium retaining states: Diuretics,

vasodilators (e.g. calcium channel blockers)• Renin-mediated hypertension: ACE inhibitor or ARB

‒ Exception: Bilateral renal artery stenosis (can precipitate AKI)• Proteinuria and CKD: ACE inhibitor or ARB• Coarctation of aorta: Beta blocker


Back to our case…


A 14-year-old girl is referred to you for elevated blood pressure first noted at her well adolescent visit. She complains of intermittent headaches but otherwise has been well.

Vital signs: HR 56, RR 18, BP 165/94 (automated), Ht 163.4 cm, Wt 56.7 kg (BMI 21.2)

You obtain a right arm manual BP of 156/88 (stage 2 hypertension). Four extremity BPs are 158/92 (left arm), 156/88 (right arm), 166/100 (left leg), 168/98 (right leg).

What other information do you want to know?

Caremate Sphygmomanometer [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]https://upload.wikimedia.org/wikipedia/commons/1/1c/CM-3411-3421.jpg


The patient likely does not have aortic coarctation. Her BMI is normal, making obesity-related hypertension unlikely.

Things to consider:• Was she born preterm? (lower nephron endowment with preterm

birth increases the risk of hypertension long-term)• Any history of recurrent UTIs (possible renal scarring)?• Dietary history, including caffeine/energy drinks• Current medications (prescribed and non-prescribed) and illicit

substances• Family history• Are there other symptoms/physical findings to suggest secondary

hypertension (e.g. urinary symptoms, endocrine dysfunction)?Caremate Sphygmomanometer [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]https://upload.wikimedia.org/wikipedia/commons/1/1c/CM-3411-3421.jpg


Further ReadingDionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol. 2012;27(1):17–32.

Feld LG, Corey H. Hypertension in childhood. Pediatr Rev. 2007;28(8):283–298.

Ferguson MA, Flynn JT. Rational use of antihypertensive medications in children. Pediatr Nephrol.2014;29(6):979–988.

Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.

Ingelfinger JR. The child or adolescent with elevated blood pressure. N Engl J Med.2014;370(24):2316–2325.

Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: A working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Pediatrics. 1996;98(4 Pt 1):649–658.


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Pediatric Hypertension - Home | AAP Point-of-Care-Solutions...Image courtesy of Wikimedia Commons. Treat with confidence. Trusted answers from the American Academy of Pediatrics. Additional