Evaluation and Management of Hypertension in Children

1
Evaluation and Management of Hypertension in
Children

• John Brandt, MD MPH
• Division of Nephrology
• Dept Pediatrics, UNMSOM

2
Objectives

• Why Hypertension is important in Pediatrics.
• The Association Between Childhood Obesity and
  Hypertension.
• How to Evaluate and Manage Hypertension in Your
  Practice

3
Hypertension Definitions

• Normal BP Both systolic and diastolic BP lt 90th
  for age, gender, and height
• Pre-HTN BP 90 but lt 95
• In adolescents if BP gt120/80 mmHg (even if lt 90th
  by the tables)
• HTN Systolic and/or Diastolic BP 95 measured
  upon 3 separate occasions
• Stage 1 HTN
• Systolic and/or diastolic BP between the 95 and
  the 99 5 mmHg.
• Stage 2 HTN
• Systolic and/or diastolic BP 99 5 mmHg
• Masked HTN Normal office BP, with HTN on ABPM
• White Coat HTN
• Office BP readings 95 but with normal BP
  outside on ABPM

4
HTN Definitions

• Primary (Essential)
• No underlying etiology identified.
• Secondary
• An underlying disorder identified.

5
Hypertension Prevalence

• 1989 2002
• Adults 25 30
• Children 1.1 4.5

Sorof J, et al. Pediatrics. 2004 Mar113(3 Pt
1)475-82. (n5102, Age 10-19 yrs)
6
Prevalence of Hypertensionin the United States
by Age Group
Hypertension Prevalence

Age
Based on data from the 1999?2000 National Health
and Nutrition Examination Survey. Hypertension
is defined as blood pressure ?140/90 mm Hg or as
receiving antihypertensive treatment. Low
reliability due to large relative error.
Hypertension Online www.hypertension.org
Fields LE, et al. Hypertension. 200444398-404.
7
Cardiovascular Mortality RiskIncreases as Blood
Pressure Rises
8x
8
7
6
5
4x
CardiovascularMortality Risk
4
3
2x
2
1
0
115/75
135/85
155/95
175/105
Systolic/Diastolic Blood Pressure (mm Hg)
Measurements taken in individuals aged 4069
years, beginning with a blood pressure of
115/75 mm Hg.
Lewington S, et al. Lancet. 20023601903-1913 Ch
obanian AV, et al. JAMA. 20032892560-2572.
Hypertension Online www.hypertension.org
8
Hypertension
9
Complications of HypertensionEnd-Organ Damage
LVH, CHD, CHF
Hemorrhage, Stroke
Peripheral Vascular Disease
Renal Failure, Proteinuria
Retinopathy
CHD coronary heart disease CHF congestive
heart failure LVH left ventricular hypertrophy
Hypertension Online www.hypertension.org
Chobanian AV, et al. JAMA. 20032892560-2572.
10
The Effects of Hypertension Start in Childhood
Left Ventricular Hypertrophy
Carotid Intimal Thickness
Pediatr Nephrol (2009) 2415451551
Hypertension (2006) 4840-48
11
What are the Characteristics of Hypertension in
Kids?

• Is it Primary or Secondary?
• Does it vary with Age, Body size or Ethnicity?

12
Kids have mostly Secondary HTN, Right?
Feld L, (1988) Curr Probl Pediatr 18317373 Arar
MY, (1994) Pediatr Nephrol 8186189 Flynn JT,
Pediatr Nephrol (2005) 20961966.

• All in pediatric nephrology practices referral
  bias may lead to an overestimate of the
  prevalence of severe (secondary) disease.

13
HTN Etiology by Age

• Acta Paediatr 1992 81(3)244-6

14
HTN Etiology in Children

• In children with Pre-HTN, 2/3rd progresses to
  overt HTN within 3 years.

• N1025, age 1 mo.18 yrs, referred to Pediatric
  Nephrologist for HTN,
• may over-estimate secondary disease.

Acta Paediatr 1992 Mar81(3)244-6
15
Is HTN Accurately Identified in Children?

• In a study of gt14,000 children seen for
  well-child care with at least 3 visits.
• 0.9 had a diagnosis of HTN
• 3.6 met BP criteria for diagnosis of HTN.
• Only 1 out of 4 children with HTN were identified
  in the medical record as having HTN.

Underdiagnosis of Hypertension in Children and
Adolescents Hansen ML, JAMA. 2007298(8)874-879
16
Does Obesity contribute to HTN in Children?
Average SBP and DBP at first screening for each
BMI percentile category
Sorof, J. M. et al. Pediatrics 2004113475-482
17
Overweight (BMIgt85) by Age
Flynn JT. Amer J Hypertension. 21(6) 605-12
18
Weight in NM Children
Child and Adolescent Health Initiative.
CAHMIhttp//www.cahmi.org
19
Obesity and HTN in Children

• HTN in children has increased 3-fold since the
  1980s.
• Obesity prevalence has tripled in the last 30
  years.
• Obesity brings with it glucose intolerance,
  dyslipidemia, hepatic disease, orthopedic
  problems, psychological disorders and future
  cardiovascular disease.

20
Hypertension Prevalence by BMI
Brown C., et al. Body Mass Index and the
Prevalence of Risk Factors for Cardiovascular
Disease
21
BMI and Cardiovascular Disease Risk in Children
Harris CV, Pediatrics 2008
22
HTN and Ethnicity
23
What Does it all Mean?

• HTN is increasing in children.
• HTN is under-diagnosed in children.
• Identification and treatment of HTN in childhood
  can decrease adult CV morbidity.
• Although Children with HTN have a high incidence
  of Secondary disease compared to
  adults,Essential HTN is increasing rapidly in
  childhood.
• This increase is largely due to adolescents (gt 14
  yrs) with Obesity.

24
What should we be doing now?Clinical Guidelines

• PEDIATRICS 2004, 1142555

Journal of Hypertension 2009, 2717191742
25
Who should have their BP Checked?

• Children gt 3 years old who are seen in a medical
  setting should have their BP measured, at least
  yearly.
• Correct measurement requires an appropriately
  size cuff.
• Current commercial cuff designations (infant,
  child, adult) are often inappropriate.
• Confirm high BP x 3 before diagnosing
  hypertension.
• 3 measures separated by gt 1 week , unless severe
  (gt99) or symptomatic.

PEDIATRICS 2004, 1142555
26
When should Children lt 3 years old have a BP
check?

• Prematurity, LBW, or NBICU grad.
• Chronic illness especially renal, cardiac,
  neurologic or endocrine.
• Treatment with drugs known to raise BP.
• Systemic conditions associated with hypertension
  (Neurofibromatosis, Tuberous Sclerosis,
  Hyperthyroid, etc).

PEDIATRICS 2004, 1142555
27
Measuring BP in Children

• Choose appropriate cuff for body size (not just
  age).
• Child should be quiet and calm for 3-5 minutes
  prior to measurement.
• Measures taken when child is moving or obviously
  anxious are suspect.
• Cuff or stethoscope bell should be at heart
  level.
• Record BP 2-3 times and take the average for the
  best estimate.
• Normal values are based on auscultative measures.
  
• If possible, confirm elevated BP obtained by
  machine with manual measure.

28
Problems with Traditional Child BP Cuff Sizing

• Prineas J, et al. 2007, Blood Press Monit
  127580
• Mid Arm Circumference (MAC) measured in gt 5000
  children in the 1999-20004 NHANES increased
  compared to 1988-1994 survey.
• In children 7-12 years
• 40 need a adult cuff
• In children aged 13-17 years
• 52 of boys and 42 of girls need an adult cuff.
• The need for a large adult cuff increased 6 fold
  in boys and 2 fold in girls from the 1994 to 2004
  survey.

29
Measuring the BP Determining proper cuff size
by patient arm size

• The cuff bladder width should be 40 of the
  circumference of the arm measured at mid arm.

www.uptodate.com
30
Measuring the BP Determining proper cuff size

• The cuff bladder length should cover 80 to 100
  of the circumference of the arm.

31
Auscultative BP Measurement

• Blood pressure should be measured with cubital
  fossa at heart level.
• The arm should be supported.
• The stethoscope bell is placed over the brachial
  artery pulse, proximal and medial to the cubital
  fossa, below the bottom edge of the cuff.
• If the leg is used in children, the same size and
  position criteria apply.

32
Confirming High BPs

• To confirm HTN, BP should be measured in both
  arms and in one leg.
• Normally, BP is 10 to 20 mm Hg higher in the legs
  than the arms.
• If the leg BP is lower than the arm BP or if
  femoral pulses are weak or absent, coarctation of
  the aorta may be present.
• Obesity alone is an insufficient explanation for
  diminished femoral pulses in the presence of high
  BP.

33
Automated BP machines

• Common in many Hospital and office settings
• Measure mean arterial pressure (MAP) and
  calculate SBP and DBP.
• Concerns
• The algorithms used by companies are proprietary
  and not standardized.
• These machines must be calibrated regularly
• High BPs with machines should be confirmed with
  manual BP.

34
New 2004 BP tables

• Includes 50, 90, in addition to 95 and 99 BP
  data.
• BP grouped by age, gender and height
• Height data based on new CDC growth charts
  www.cdc.gov/growthcharts

PEDIATRICS 2004, 1142555
35
Using BP Tables

• Example 1
• Age 5 years
• BP 107/65 mmHg
• Gender Male
• Height 105 cm (25)

36
Using the New BP Tables
5 y.o. Boy BP 107/65 Height 25 BP mmHg
95 110/71 99 118/79 995
123/84 Dx No HTN
37

• Infants Use Systolic BP
• 90 SBP 95SBP
• lt 7 days 90 mmHg 95 mmHg
• 8-30 days 100 105
• 1-12 months 105 110

Task Force on Blood Pressure Control in
Children. Report of the Second Task Force on
Blood Pressure Control in Children1987. Pediatric
s.198779125(PR)
38
Hypertension Staging

• SBP or DBP (x 3) Classification
• lt 90 Normal BP
• 90 to lt 95 Pre-HTN
• gt120/80 mmHg in adolescent
• 95 to 99 5 mmHg Stage 1 HTN
• gt 99 5 mmHg Stage 2 HTN

The difference between 95 and 99 is only 7-10
mmHg. The 4th report recommends a little leeway
before starting evaluation or meds.
39
Hypertension Staging. Why?

• Guides the pace of diagnostic and therapeutic
  approach.
• Helps determine
• Who needs Observation?
• Who needs Evaluation?
• Who needs Therapy?

40
Clinical Evaluation of Child with Pre-HTN (90
to lt95 or gt120/80 in adolescent)

• Complete H P
• If History indicates a risk
• Sleep study or Drug screen
• If co-morbid risk factors present
• Retinal exam
• Echocardiogram
• Fasting lipids and glucose

Diabetes or Chronic kidney dis., Fmhx of HTN or
CVD, or Diabetes
41
Clinical Evaluation of Stage 1 and 2 HTN

• In all kids rule out common secondary causes of
  HTN
• Renal Ultrasound, BUN, Creatinine, UA, Renin
• Cardiac Femoral pulses, CBC, Echocardiogram
• Endocrine Electrolytes
• In all kids screen for metabolic syndrome and CVD
  risk
• Fasting lipids, triglycerides and glucose
• In selected patients look for rare causes of HTN
• Severe HTN (gtgt99), very young (lt10 years) or
  patients with targeted symptoms to suggest a rare
  cause
• Malignancy, neurologic, drugs, pregnancy,
  Reno-vascular disease, Thyroid disease, etc.

42
Clinical Evaluation of HTN

• 4. Consider Essential HTN if
• Child is gt 14 years with mild-moderate BP
  elevation
• Family history of HTN
• Elevated BMI
• 24 hour Ambulatory BP monitoring (ABPM) is good
  first step in these patients.
• If elevated BMI coexists, assess co-morbid risks
• Fasting Glucose, lipids and insulin

Flynn J, et al. Pediatrics 2002110899
43
24 hour ABPM

• Records BP q 15-30 minutes for 24 hrs
• Diagnosis of White coat HTN or Pre-HTN.
• Diagnosis of Masked HTN.
• Tracking kids with Pre-HTN.
• Adjusting medication dosing.

44
Which kids with high BP should you treat?

• Treat everyone with Therapeutic Lifestyle Changes
  (TLC)
• Healthy diet, weight loss if indicated, exercise.
• Treat with medication if the child has
• Secondary HTN or Stage 2 HTN
• Stage 1 or Pre-HTN if
• Their is co-existing co-morbid disease.
• Stage 1 HTN with evidence of end organ effect
• Symptomatic HTN, LVH, Hypertensive Retinal
  changes
• Stage 1 HTN with failure to improve after of 6-12
  mo. trial of TLCs
• BP goal lt 90 , lt 75 if co-morbid disease

Co-morbidity Renal or Cardiac disease or
diabetes mellitus
45
Therapeutic Lifestyle Changes

• If obese, make a goal to gradually get BMI lt 85
• Set realistic, achievable, pace of weight loss.
• Exercise
• Moderate to vigorous aerobic activity for 40 min,
  3-5 days/week
• Avoid sedentary activity gt 2 hrs / day
• Diet
• Avoid sugary foods/drinks and saturated fats.
  Less salt.
• Eat fruit, vegetables, lean meats and whole
  grains.
• 50/50 plate
• Involve the whole family as partners.
• Develop a health promoting reward system.
• Set achievable goals!

46
http//www.envisionnm.org/tools_resources.html
47
Does obesity intervention really help with BP
reduction or CV risk factors in Children?

• 2 yr Obesity intervention study (N240)
• 1yr intervention program of physical exercise,
  nutrition education, and behavior therapy,
  followed by 1 year of observation.
• 174 children finished study
• 72 achieved a reduction in BMI
• In those who reduced their BMI
• Systolic and Diastolic BP was reduced
• Lipid panel improved
• Fasting Insulin and glucose improved
• Improvements were sustained at 2 year follow-up.

Am J Clin Nutr 2006844906.
48
Pre-Hypertension

• BP at 90-95 for age, height and gender.
• Many have other risk factors for CV Disease.
• Many of these kids progress to stage 1 HTN.
• 67 progress within 3 years.
• If co-morbid disease present (renal, cardiac,
  diabetes) treat with medications (goal BP lt 75).
• Otherwise follow yearly, encourage TLC.

Acta Paediatr 1992 Mar81(3)244-6
49
White coat HTN

• Elevated BP at clinical setting, but normal BP at
  home or on 24 hr ABPM.
• Many of these kids have BP in pre-hypertensive
  range or risk factors for HTN or CV disease.
• They need ongoing follow-up like pre-HTN
• If random BP is always high, a yearly ABPM is
  helpful.

50
Sports Participation for Hypertensive Children

• Stage 1 HTN (95-99)
• If no end organ damage and no coexisting heart
  disease
• May play all sports, monitor BP every 2 months.
• 2) Stage 2 HTN (gt995)
• Restricted from competitive sports and highly
  static (isometric) activities especially static
  sports, until BP controlled and they have no
  evidence of end organ damage.
• Since cardiovascular conditioning may be less
  strenuous than competitive athletics, complete
  restriction of exercise may not be necessary for
  those with severe hypertension.
• 3) HTN and CV disease
• Restricted participation dependent on nature of
  CV disease.

AAP Committe on Sports Medicine and Fitness, 1995
51
Summary Diagnosis of HTN
Journal of Hypertension 2009, Vol 27 No 9
52
Drug Treatment for Pediatric HTN

• Children needing medication should see a provider
  with experience in treating pediatric HTN.
• 1st choice meds for Pediatric HTN
• Calcium channel blockers- Amlodipine
• Angiotensin converting enzyme inhibitors -
  Lisinopril
• Caution with renovascular disease and adolescent
  girls (teratogenic)
• 2nd line
• Beta blockers- Labetolol, Metoprolol
• Diuretics- Thiazides
• Angiotensin receptor blockers- Losartan
• Avoid combination agents

53
Summary

• Children gt 3 yrs old should be screened for HTN
  yearly
• Secondary HTN is more common in Children
• Essential HTN is increasing in Children due to
  increasing levels of Obesity.
• Treatment of mild-moderate HTN in children should
  involve lifestyle changes before using
  medications.

54
Summary BP Management in Children
PEDIATRICS 2004, 1142555
55
Resource for Obesity, HTN, Metabolic syndrome
Management
http//www.envisionnm.org/index.html
56
(No Transcript)
57
Resources

• National High Blood Pressure Education Program
  Working Group on High Blood Pressure in Children
  and Adolescents. The fourth report on the
  diagnosis, evaluation, and treatment of high
  blood pressure in children and adolescents.
  National Heart, Lung, and Blood Institute,
  Bethesda, Maryland. Pediatrics 2004 114555576.
• Management of high blood pressure in children and
  adolescents recommendations of the European
  Society of Hypertension. Lurbe et al. J
  Hypertension 2009, 271719-1742.
• International Society for Pediatric Hypertension
  (www.pediatrichypertension.org).
• Envision New Mexico (www.envisionnm.org).

58

• BP load gt 25 is suggestive of HTN
• BP loads gt 50 predict the presence of LVH

59
Rough Guide to HTN by Height
Journal of Hypertension 2009, Vol 27 No 9
60
Rough Guide to Elevated BP by Age

• Age 90 gt 95
  gt99
• lt 1 week - SBP gt100 SBP gt110
• 8-30 days - SBP gt110 SBP gt115
• 1-2 yr - 110 / 65 115 / 70
• 2-5 yr 105/65 115 / 70 120 / 75
• 5-10 yr 110/70 120 / 75 125 / 80
• 10-12 yr 115/75 125 / 80 130 / 85
• gt13 yr 120/80 130 / 85 140 / 90
• General estimates based on 50 height in boys
  and girls BP charts in 4th NHBPEP

61
Appropriate BP Cuff Size

• Bladder width gt 40 of mid-arm circumference.
• Bladder length 80-100 of mid-arm circumference.
• Bladder widthlength 12

A. Ideal arm circumference B. Range of acceptable
arm circumferences C. Bladder length D.
Midline of bladder E. Bladder width F. Cuff
width.
Perloff D, Grim C, Flack J, Frohlich ED, Hill M,
McDonald M, Morgenstern BZ Human blood pressure
determination by sphygmomanometry. Circulation
882460-2470, 1993
62
Thank You!