Transcript Pediatric Hypertension - University of Kentucky

Pediatric Hypertension
Elizabeth Burrows
Introduction
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Hypertension in American children is a growing
epidemic
High blood pressure is estimated to be prevalent
in 4.5% of children
A recent study by Hansen found that in the
United States health care providers fail to
diagnose high blood pressure in more than 75%
of children
Why the rise in childhood
hypertension?
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Increasing epidemic of childhood obesity
Sedentary lifestyles
Epidemiologic studies indicate that about 30% of
obese children have hypertension
Hypertension and obesity are two common preventable
disorders facing pediatric clinicians
Study by Couch in which obese patients achieved a
reduction in BMI of 8-10% showed a decline in blood
pressures that were in the range of 8 to 16 mm Hg
Why are health care providers failing
to make the diagnosis?
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Blood pressure in children is a function of age,
sex, and height percentile
What is normal for one child may be considered
hypertensive in another child of the same age
Clinicians usually cannot remember normal
blood pressures for the wide range of children
observed in their typical primary care setting
Factors making diagnosis more
likely in children
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Older age
Taller height
Obesity
Younger children and
adolescents who are not
overweight and generally
appear healthy are typically
the patients where
hypertension is not suspected
and often missed
Hansen’s 2007 Study
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Analyzed the medical records of 507 hypertensive and
pre-hypertensive children and adolescents over a span
of seven years
All the children visited an outpatient clinic at least three
times
376 patients (74%) had undiagnosed hypertension
80 patients (15.8%) had a true hypertension diagnosis
7 participants had undiagnosed stage 2 hypertension
Data to make the diagnosis of hypertension or
prehypertension was present in the patients' records
Hansen’s 2007 Study
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There is a much needed modification for
identifying pediatric hypertension
Current discussion is centered on the
development of a computer program
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Through electronic record keeping - send a red flag
alerting the provider when a patient’s blood pressure
is in the pre-hypertensive to hypertensive state
Why is it important to diagnose and
treat hypertension in childhood?
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Prevent progression and target organ damage of the
brain, eyes, heart, and kidneys
A study by Hanevoid demonstrated that severe target
organ damage occurs in hypertensive children
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41% of the 129 hypertensive children and adolescents
studied had left ventricular hypertrophy (LVH) by pediatric
criteria, and 16% had LVH even when using adult criteria
If caught early, preventative measures can be taken to
reduce risks for other comorbidities in childhood and
adulthood
Pediatric Classifications
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The Fourth Report 2004 includes new
classifications for hypertension
Prehypertension
Stage 1
Stage 2
Pediatric Classifications
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Pre-hypertension- average systolic and/or diastolic
blood pressure between the 90th and 95th percentile
for gender, age, and height
Lifestyle modifications and reevaluation every six
months are recommended to help prevent progression
to hypertension
Hypertension- average systolic and/or diastolic blood
pressure that is ≥95th percentile for gender, age, and
height
Elevated blood pressure must be confirmed on three
repeated visits before diagnosing a child as having
hypertension
Pediatric Classifications
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Stage 1- average systolic and/or diastolic blood pressure levels
that range from the 95th percentile to 5 mm Hg above the 99th
percentile for gender, age, and height
Initially patients in stage 1 should be reevaluated within one to
two weeks
Stage 2- average systolic and/or diastolic blood pressure levels
that are >5 mm Hg above the 99th percentile for gender, age,
and height
If symptomatic give immediate treatment and refer to
hypertension specialist
If asymptomatic refer to specialist within one week
Measurement of BP in Pediatrics
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The Fourth Report recommends that children 3
years and older have their blood pressure
measured regularly
The preferred method of blood pressure
measurement is auscultation
In order to correctly diagnose hypertension
blood pressure must be measured accurately
Measurement of BP in Pediatrics
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Main source of error – Using wrong cuff size
Small cuff- overestimates BP
Large cuff- underestimates BP
Appropriate Cuff Size
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Inflatable bladder width that covers at least 40%
of the arm circumference midway between the
olecranon process and the acromion process
The bladder length should cover 80-100% of
the circumference of the arm
The bladder width-to-length ratio should be at
least 1:2
Measurement of BP in Pediatrics
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Preparing the child for blood pressure
measurements
Sit quietly for five minutes with their back and
right arm supported at heart level and feet flat
on the floor
If a patient has a reading that is >90th
percentile
BP should be repeated twice at the same office visit
 Document average systolic and diastolic BP
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ABPM
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Ambulatory Blood Pressure Monitoring allows clinicians to
observe the patients BP 2-4 times per hour over at least 24 hours
Patients are encouraged to continue normal everyday activities
while being monitored
Successful in children even as young as 2 months
Make diagnosis that would otherwise be missed
Nocturnal Blood Pressure
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Nocturnal BP Dip- Typically individuals have
10-15% drop in their mean day and night blood
pressure readings
ABPM can detect
An abnormality nocturnal BP dip
 Elevations of nocturnal blood pressure
Both usually indicative of secondary hypertension
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Masked Hypertension
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A condition where a patient’s office blood
pressure is normal but ABPM classify the
patient as hypertensive
Study of masked hypertension reviewed by
McNiece showed a prevalence of 7.6% among
592 children aged 6–18 years
Showed these children with have an elevated left
ventricular mass index equivalent to truly
hypertensive patients
White Coat Hypertension
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A patient with blood pressure levels >95th
percentile in a physician’s office or clinic and
who is normotensive outside a clinical setting
Several studies suggest that in some children this
may be a prehypertensive state that eventually
may progress to hypertension
Counsel patient about therapeutic lifestyle
changes and monitor for development of true
hypertension
Pediatric Symptoms
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Hypertension is often thought of as a silent disease
because typically there have not been any classic
symptoms
A recent study by Croix found that 51% of untreated
hypertensive children when surveyed reported 1-4
Symptoms, and 14% reported more than four
symptoms
3 most common symptoms
headache
 difficulty initiating sleep
 daytime tiredness
These were all reduced with treatment
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After Hypertension is Diagnosed
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Want to rule out secondary causes
BP should be measured in both arms and a leg to rule out
coarctation of the aorta
Fasting lipid, Fasting glucose, standard chemistry panel, serum
urea nitrogen (BUN), CBC, creatine, urinalysis and urine culture
Echocardiogram, renal ultrasound
Screen for major sleep disorders using BEARS:
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Bedtime problems
Excessive daytime sleepiness
Awakenings during the night
Regularity and duration of sleep
Snoring
Treatment
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Lifestyle modifications are typically the initial
treatment of choice
Indications for antihypertensive drug therapy in
children
Secondary hypertension
 Insufficient response to lifestyle modifications
 Stage 2 hypertension
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Pharmacologic Therapy of
Childhood Hypertension
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2002 Best Pharmaceuticals for Children Act has led to
recent study and FDA approval of several
antihypertensive medications for use in pediatrics
Unknown long-term effects of antihypertensive therapy
in children- especially with regard to growth and
development
ACE-I and calcium channel blockers are the most
commonly used antihypertensive medications in
children
Conclusion
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Hypertension and obesity in children
are increasing in an upward trend
It is imperative that pediatric
hypertension is recognized and treated
It is advisable to measure blood
pressure at every visit with the
appropriate technique, use the gender,
age, and height specific blood pressure
table, and to follow the
recommendations of the Fourth
Report
It is important to encourage healthy
lifestyles in all children and adolescents
and help institute lifestyle changes for
weight reduction in overweight children
References
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Childs, Dan. "Kids' High Blood Pressure Often Missed." ABC News 21 Aug. 2007.
<http://www.abcnews.go.com/Health/CardiacHealth/>.
Couch, Sarah C., Stephen Daniels. "Diet and Blood Pressure in Children." Current Opinion in Pediatrics Oct.
2005: 648-652.
Croix, Beth, and Daniel I. Feig. "Childhood Hypertension is Not a Silent Disease." Pediatric Nephrology 21
(2006): 527-532. Medline. University of Kentucky. 2 Oct. 2007.
Din-Dzietham, Rebecca, Yong Liu, Marie-Vero Bielo, and Falah Shamsa. "High Blood Pressure Trends in
Children and Adolescents in National Surveys, 1963-2002." Circulation Journal of the American Heart
Association (2007): 1392-1400. PubMed. University of Kentucky. 12 Sept. 2007.
Falker, Bonita. "Hypertension in Children." Audio-Digest Family Practice. Current Issues in Pediatrics. Mar.
2007. <http://www.audiodigest.org/pages/htmlos/02130.5.111 25619159917457817/FP5526>.
Hanevoid, Coral, Jennifer Waller, Stephen Daniels, Ronald Portman, and Jonathan Sorof. "The Effects of
Obesity, Gender, and Ethnic Group on Left Ventricular Hypertrophy and Geometry in Hypertensive Children:
a Collaborative Study of the International Pediatric Hypertension Association." Pediatrics 113 (2004): 328-333.
University of Kentucky. 2 Oct. 2007.
Hansen, Matthew L., Paul W. Gunn, and David C. Kaelber. "Underdiagnosis of Hypertension in Children and
Adolescents." JAMA 298.8 (2007): 874-879. University of Kentucky. 28 Oct. 2007.
Kavey, Rae-Ellen W., Daniel A. Kveselis, Nader Atallah, and Frank C. Smith. "White Coat Hypertension in
Childhood: Evidence for End-Organ Effect." The Journal of Pediatrics 150.5 (2007): 491-497. Science Direct.
University of Kentucky. 2 Oct. 2007.
Masters, Coco. "High Blood Pressure Affects Kids Too." Time 21 Aug. 2007. 12 Sept. 2007
<http://www.time.com/time/health/article/0,8599,1654856,00.html>.
References
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McGavock, Jonathan M., Brian Torrance, Karen A. McGuire, Paul Wozny, and Richard Z. Lewanczuk. "The
Relationship Between Weight Gain and Blood Pressure in Children and Adolescents." American Journal of
Hypertension 20 (2007): 1038-1043. PubMed. University of Kentucky. 1 Nov. 2007.
McNiece, Karen L., Ronald J. Portman. "Ambulatory Blood Pressure Monitoring: What a Pediatrician Should
Know." Current Opinion in Pediatrics 2007: 178-182.
“The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and
Adolescents.” Pediatrics 114 (2004): 555-576. University of Kentucky. 2 Oct. 2007.
Nguyen, Mai, Mark Mitsnefes. "Evaluation of Hypertension by the General Pediatrician." Current Opinion in
Pediatrics 2007: 165-169.
Podoll, Amber, Michelle Grenier, Beth Croix, and Daniel I. Feig. "Inaccuracy in Pediatric Outpatient Blood
Pressure Measurement." Pediatrics 119.3 (2007): 538-543. University of Kentucky. 2 Oct. 2007.
Robinsona, Renee F., Donald L. Batisky, John R. Hayes, Milap C. Nahata, and John D. Mahan. "Significance of
Heritability in Primary and Secondary Pediatric Hypertension." American Journal of Hypertension 18 (2005):
917-921. PubMed. University of Kentucky. 1 Nov. 2007.
Robinsonb, Renee F., Milap C. Nahata, Donald L. Batisky, and John D. Mahan. "Pharmacologic Treatment of
Chronic Pediatric Hypertension." Pediatric Drugs 7 (2005): 27-40. MedLine. University of Kentucky. 2 Oct.
2007.
Seikaly, Mouin G. "Hypertension in Children: an Update on Treatment Strategies." Current Opinion in
Pediatrics 2007: 170-177.
Sun, Shumei S., Gilman D. Grave, Roger M. Siervogel, Arthur A. Pickoff, Silva S. Arsianian, and Stephen R.
Daniels. "Systolic Blood Pressure in Childhood Predicts Hypertension and Metabolic Syndrome Later in Life."
Pediatrics 119 (2007): 237-246. University of Kentucky. 2 Oct. 2007.