Scribd Logo
Upload

Welcome to Scribd!

  • 2K views

    Pediatric Hypertension Noon Conference 03.20.2019

    Uploaded by

    Emily Eresuma
    The document provides guidance on diagnosing and managing pediatric hypertension, including defining diagnostic criteria based on age and blood pressure thresholds, screening recommendations, lifestyle counseling, evaluating for secondary causes, and outlining follow-up plans including additional testing and medication management for elevated or high blood pressure readings. Proper blood pressure measurement technique and use of tables or apps to determine blood pressure percentiles for age, gender and height are also reviewed.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Pediatric Hypertension Noon Conference 03.20.2019

    Uploaded by

    Emily Eresuma
    2K views44 pages
    The document provides guidance on diagnosing and managing pediatric hypertension, including defining diagnostic criteria based on age and blood pressure thresholds, screening recommendations, lifestyle counseling, evaluating for secondary causes, and outlining follow-up plans including additional testing and medication management for elevated or high blood pressure readings. Proper blood pressure measurement technique and use of tables or apps to determine blood pressure percentiles for age, gender and height are also reviewed.

    Original Description:

    Pediatric Morning Report

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document provides guidance on diagnosing and managing pediatric hypertension, including defining diagnostic criteria based on age and blood pressure thresholds, screening recommendations, lifestyle counseling, evaluating for secondary causes, and outlining follow-up plans including additional testing and medication management for elevated or high blood pressure readings. Proper blood pressure measurement technique and use of tables or apps to determine blood pressure percentiles for age, gender and height are also reviewed.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    2K views44 pages

    Pediatric Hypertension Noon Conference 03.20.2019

    Uploaded by

    Emily Eresuma
    The document provides guidance on diagnosing and managing pediatric hypertension, including defining diagnostic criteria based on age and blood pressure thresholds, screening recommendations, lifestyle counseling, evaluating for secondary causes, and outlining follow-up plans including additional testing and medication management for elevated or high blood pressure readings. Proper blood pressure measurement technique and use of tables or apps to determine blood pressure percentiles for age, gender and height are also reviewed.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 44

    How to diagnose it.

    Pediatric
    Hypertension
    And how to fix it.

    Clark Crane, MD
    Noon Conference, 3/20/19
    Objectives

     Understand the epidemiology and etiology of childhood/adolescent hypertension


     Identify age-specific blood pressure cut-offs and diagnostic criteria for elevated blood
    pressure and hypertension
     Take a blood pressure the correct way
     Start the basic HTN evaluation
     Don’t miss secondary hypertension
     Counsel on lifestyle changes
     Challenge yourself to get comfortable prescribing meds in the appropriate circumstances
     Know when to refer
    Case

     An 11 year old boy presents for a routine well child check. While
    reviewing the chart, you note that Epic flags his BP of 122/82 as
    >95%ile for his age and height. What do you do next?
    A. Have the MA recheck the blood pressure
    B. Confirm the BP with auscultation
    C. Follow-up in 6 months for BP check
    D. Start amlodipine
    E. Ignore it; he was upset
     Prevalence depends on definition
     Increase of “elevated blood pressure” when using
    new guidelines
     ~14-16% prevalence of elevated blood pressure, 2-4%
    with hypertension
     Interestingly, prevalence decreased from 2001 to 2016
    looking at NHANES data

    Epidemiology  More common in obese and overweight…and this


    prevalence is clearly increasing
     Other risk factors include family history (more likely in
    primary than secondary), male gender, OSA, sleep
    duration, IUGR, extreme prematurity, cigarette
    smoke exposure, hypertension in pregnancy
    Hypertension. 2019 Jan;73(1):148-152
    MMWR Morb Mortal Wkly Rep. 2018 Jul 13;67(27):758-762
    MMWR Morb Mortal Wkly Rep. 2018 Jul 13;67(27):758-762
    Why it matters

    It is well established that HTN and elevated BP in childhood increases risk of adult HTN
    and metabolic syndrome

    Some studies suggest correlation between childhood SBP and adult CAD

    Presence of intermediate markers of CVD (increased LV mass, cIMT, and pulse


    wave velocity) seen in pediatric patients with HTN are known to predict CV events
    in adults

    J Pediatr. 2011 Oct;159(4):584-90—Pediatr Nephrol Feb;25(2):323-8—


    Circulation. 2010 Feb 2;121(4):505-11
    Etiology: Primary Hypertension

    Diagnosis of exclusion;
    Multifactorial; renal salt
    more likely in school-
    retention, increased
    aged children and
    RAAS, endothelial
    adolescents who have a
    dysfunction,
    family history of HTN, and
    catecholamines
    are overweight or obese
    Etiology: Secondary Hypertension

    Identifiable cause: See UpToDate for list

    Potentially curable

    Potentially accounting for 55-67% of HTN in


    children, although these are older studies
    Per AAP guidelines, BP should be checked
    annually in all children ≥ 3 years old

    Screening At every healthcare encounter if obesity, BP


    raising medications, renal disease, history of
    coarctation or DM

    Pediatrics.
    2017 Sep;140(3).
    pii: e20171904.
    Oscillometric devices are sufficient for screening
    but any elevated values should be confirmed by
    auscultation
    Consider ABPM for confirmation if elevated
    BP category for over 1 year or stage I HTN
    for more than 3 clinic visits
    History of prematurity <32 week’s gestation or small for gestational age, very low birth weight, other neonatal
    complications requiring intensive care, umbilical artery line
    Congenital heart disease (repaired or unrepaired)
    Recurrent urinary tract infections, hematuria, or proteinuria
    Known renal disease or urologic malformations
    Family history of congenital renal disease
    Solid-organ transplant
    Malignancy or bone marrow transplant
    Treatment with drugs known to raise BP
    Other systemic illnesses associated with HTN (neurofibromatosis, tuberous sclerosis, sickle cell disease,114 etc)
    Evidence of elevated intracranial pressure

    Screen under three years of age in specific populations


    Pediatrics. 2017 Sep;140(3). pii: 20171904.
    How to take a blood pressure

     Seated in a quiet room for 3–5 min before measurement, with the back supported and feet uncrossed
    on the floor.
     BP should be measured in the right arm. The arm should be at heart level, supported, and uncovered
    above the cuff. The patient and observer should not speak while the measurement is being taken.
     The correct cuff size should be used. The bladder length should be 80%–100% of the circumference of
    the arm, and the width should be at least 40%.
     Auscultatory BP:
     Bell of the stethoscope should be placed over the brachial artery in the antecubital fossa, and
    the lower end of the cuff should be 2–3 cm above the antecubital fossa. The cuff should be
    inflated to 20–30 mm Hg above the point at which the radial pulse disappears.
     Deflate at a rate of 2–3 mm Hg per second. The first (phase I Korotkoff) and last (phase V
    Korotkoff) audible sounds should be taken as SBP and DBP.
    Pediatrics. 2017 Sep;140(3). pii: e20171904.
    Auscultation vs Oscillometric

     Oscillometric devices derive SBP and DBP by measuring MAP based upon pressure
    oscillations of the brachial artery wall as the cuff is deflated
     Appropriate to use for screening (assuming the device is validated in a pediatric age
    group)
     Measurements > 90th percentile need to be repeated by auscultation
     Oscillometric BP generally higher (~2.53mmHg), worse in non-validated devices and younger ages

    Pediatrics. 2017 Sep;140(3). pii: e20171904.


    J Hypertens. 2017 Feb;35(2):213-224.
    Case

     You confirm a blood pressure of 115/75 by auscultation. Checking


    the tables, this is just above the 90%ile for his age and height. Since
    you are very interested in optimizing billing, what diagnosis do you
    add to the problem list?
    A. Elevated blood pressure
    B. Essential hypertension
    C. Stage 1 hypertension
    D. Stage 2 hypertension
    For Children Aged 1–<13 y For Children Aged ≥13 y
    Normal BP: <90th percentile Normal BP: <120/<80 mm Hg
    Elevated BP: ≥90th percentile to <95th Elevated BP: 120/<80 to
    percentile or 120/80 mm Hg to <95th 129/<80 mm Hg
    percentile (whichever is lower)
    Stage 1 HTN: ≥95th percentile to <95th Stage 1 HTN: 130/80 to 139/89
    percentile + 12 mmHg, or 130/80 to 139/89 mm Hg
    mm Hg (whichever is lower)
    Stage 2 HTN: ≥95th percentile + 12 mm Hg, or Stage 2 HTN: ≥140/90 mm Hg
    ≥140/90 mm Hg (whichever is lower)

    Use BP tables or app


     “Pediatric Blood Pressure Guide” ($0.99)
     “Pediatric Blood Pressure 2017” (free)
    Pediatrics. 2017 Sep;140(3). pii: e20171904.
    Diagnosis

     Hypertension is diagnosed when


    the the auscultatory-confirmed
    average systolic and/or diastolic
    blood pressure ≥ 95th percentile
    for gender, age, and height
    percentile on ≥ 3 occasions
     Secondary HTN is diagnosed
    when an underlying cause is
    identified
     Primary (”Essential”) HTN is a
    diagnosis of exclusion
    Case

     Your 11 year old patient has a confirmed single elevated blood


    pressure reading. In addition to discussing diet and activity, how
    will you proceed with follow-up?
    A. Follow-up in 1 week for blood pressure check
    B. Follow-up in 1 month
    C. Follow-up in 6 months
    D. Order ambulatory blood pressure monitoring (ABPM)
    E. Recommend buying a BP cuff and recording home measurements to
    discuss at follow-up
    Approach: Elevated Blood Pressure

    ≥90th percentile to <95th percentile


     Discuss lifestyle
     Low sodium diet and/or DASH diet, more physical activity
    and minimize screen time
     Recheck in 6 months
     If remains elevated, check upper and lower extremity BP (to
    rule out coarctation) and recheck in 6 months
     If remains elevated, continue to counsel on lifestyle and
    consider additional workup
     Consider ABPM
    ABPM

     Ambulatory blood pressure monitoring


     Cuff and box that records BP every 20-30 minutes throughout the day and night
     Can be helpful to confirm diagnosis and has been shown to be more accurate than clinic-
    measured BP
     Likely needs Nephrology referral given limited access to devices and need for interpretation
     Can also be quite annoying for the patient

    J Hypertens. 2010;28:e423–e424
    ≥95th percentile to <95th percentile + 12 mmHg
     Discuss lifestyle

    Approach:  Recheck in 1-2 weeks


     If remains elevated, check upper and lower extremity
    Stage I HTN BP (to rule out coarctation) and recheck in within 3
    months
     If remains elevated, needs further workup and
    continued emphasis on lifestyle
    ≥95th percentile + 12 mmHg
     If symptomatic (headache, vision changes, chest pain,
    abdominal pain, poor feeding, confusion, seizures),
    proceed to ED
    Stage II HTN  If asymptomatic, check upper and lower extremity BP,
    discuss lifestyle, and repeat in 1 week
     Depending on the situation, initiate additional workup,
    offer pharmacotherapy, or refer
    Case

     At follow-up, your patient’s blood pressure is worse. It is now slightly over the 95%ile
    and, after confirming this on 3 separate occasions, you have diagnosed him with
    stage I hypertension. Physical exam is only notable for BMI 90%ile for age. Both his
    parents are being treated for essential hypertension. How do you proceed?
    A. Continue to emphasize lifestyle interventions without additional workup
    B. Obtain BMP, UA, CBC, lipids, A1c
    C. Obtain the above plus additional labs and imaging to evaluate the most common causes
    of secondary hypertension
    D. Refer to Nephrology
    Evaluation

     Children ≥ 6 years of age do not require extensive


    evaluation for secondary HTN if there is a positive family
    history, are overweight/obese and/or do not have
    concerning physical exam findings
    Evaluation: Labs

     Goal is to identify possible secondary cause of hypertension and to evaluate for target organ damage
     Stage I HTN
     Renal Function Panel
     UA (protein), urine culture
     Urine protein/creatinine ratio
     CBC
     TSH, fT4
     Lipid panel, A1c
     Stage II
     Renin and aldosterone
     If proteinuria, consider C3 and C4, ANA, dsDNA
    Evaluation: Imaging

     Renal ultrasound with doppler


     Identify presence of both kidneys, presence of any congenital anomaly, or disparate renal size,
    which may suggest renal scarring
     Echocardiogram
     To assess for coarctation and cardiac target organ damage
     LVH is defined as LV mass >51 g/m or LV mass >115 g per body surface area (BSA) for boys and LV
    mass >95 g/BSA for girls
     Grade C, moderate recommendation
     As an aside, is this really helpful?
     CTA or MRA if concern for renal artery stenosis
     Probably leave this to specialist; try to minimize radiation and contrast exposure
    Pediatrics. 2017 Sep;140(3). pii: e20171904.
    Case

     Which of the following dietary interventions is most effective for


    reducing blood pressure?
    A. Sodium restriction alone
    B. DASH diet
    C. Mediterranean diet
    D. MIND diet
    E. Flexitarian diet
    Management:
    Lifestyle
    Recommended for all
     Sodium restriction, DASH diet
     Limited pediatric data for
    sodium restriction, well
    established adult outcomes
    with DASH
     Handouts available in iCentra
     Google “DASH diet for kids
    pdf” or “DASH diet pdf”
     Dietitian referral, talk about
    paying attention to nutrition
    labels

    Pediatrics. 2017 Sep;140(3). pii: e20171904.


    Management: Lifestyle

     Vigorous activity (30-60 minute session) at


    least 3 to 5 days per week
     Limit unnecessary screen time
     Just decrease sedentary time!
     Involve the family
    Case

     Weight loss has only been shown to reduce blood pressure in adults; like many others,
    the pediatric recommendations are extrapolated from adult data.
    A. True
    B. False
    Weight loss!

     2014 systematic review showed obesity intervention regimens reduced BP with a mean
    decrease of 1.64 mmHg (95% CI -2.56 to -0.71) in systolic BP (SBP) and 1.44 mmHg (95% CI -
    2.28 to -0.60) in diastolic BP (DBP).
     Similar to results seen in adults (~1 mmHg for every 1 kg lost)
     Combined diet and physical activity interventions led to a significantly greater reduction
    in both systolic BP and diastolic BP than the diet-only or physical activity-only intervention

    Circulation. 2014 May;129(18):1832-9.


    Case

     What is your patient’s goal blood pressure?


    A. BP below the 95th percentile or <140/90 if over 13 years old
    B. BP below the 90th percentile or <130/80 if over 13 years old
    C. Not sure; there’s no good data
    D. Until they have positive orthostatics
    Case

     Your patient has made moderate progress adhering adhering to


    lifestyle modifications. His additional workup revealed normal labs
    with exception of Hgb A1c of 6.5%. Unfortunately he continues to
    have blood pressures >95%ile. What is your next step?
    A. Continue to emphasize diet and activity only
    B. Start antihypertensive meds
    C. Start Metformin
    D. Refer to Endocrine
    E. Refer to Nephrology
    Management: Indications for meds

     Stage 2 HTN (without a clearly modifiable risk factor)


     Stage 1 HTN
     No improvement after 3-6 months of lifestyle changes
     Secondary hypertension
     LVH or target-organ damage
     Symptomatic
     Diabetes, hyperlipidemia, or other CV risk factors
     Kidney disease
    Case

     Due to lack of improvement after 3-6 months of lifestyle changes,


    you decide medications are now indicated. Your patient weighs
    45 kg. What do you start?
    A. Amlodipine 2.5 mg daily
    B. Lisinopril 5 mg daily
    C. Chlorthalidone 12.5 mg daily
    D. I wouldn’t feel comfortable prescribing these meds
    Calcium channel blockers

     Long-acting dihydropyridine agents; good all around


     Safe and effective
     Class example: amlodipine
     Start 0.1 mg/kg/dose daily to BID
     Increase up to 0.6 mg/kg/day (max 20 mg per day)
     For > 6 years old, 2.5 to 5 mg daily is an effective dose
     Likely safe to go up to 10 mg in larger adolescents
     Side effects: edema, orthostasis, fatigue
    ACE-Inhibitors/ARBs

     Best for use in proteinuric renal disease, diabetes, heart failure, high renin activity
     Avoid in bilateral renal artery stenosis, solitary kidney, hyperkalemia, pregnancy
     Class example: Lisinopril
     Start 0.07-0.1 mg/kg/dose daily
     Can increase up to 0.6 mg/kg/day, max 40 mg/day
     Typical starting adolescent/adult dose is 5 or 10 mg
     Counsel about fluid intake; kidneys (SCr) can be very sensitive to volume depletion
     Side effects: dizziness, increased SCr (less than 30% acceptable), hyperkalemia,
    cough, teratogenicity (protect the kidneys at the cost of kidneyless babies)
    Case

     You decide to start an ACEI due to concern for developing


    comorbid diabetes. What is your next step?
    A. Follow-up in 4 weeks for repeat blood pressure
    B. Obtain BMP in 1-2 weeks
    C. Obtain urine microalbumin/creatinine ratio in 1-2 weeks
    D. Obtain a random fasting glucose
    Beta-Blockers

     Useful with concomitant heart failure or tachyarrhythmias


     Concerns in setting of impaired glucose tolerance, interference in lipid metabolism,
    and airway reactivity in children with asthma. Don’t use in athletes.
     Class example: Labetalol
     Start at 1 – 3 mg/kg/day divided BID
     Increase to max of 12 mg/kg/day with max of 1200 mg/day
     Reasonable to start adolescents/adults at 100 mg BID
     Side effects: bradycardia, orthostatic hypotension, edema, weight gain,
    hyperglycemia, fatigue
    Diuretics

     Typically thiazide class used in setting of normal renal function


     Good for an initial or second agent
     Concerns include potassium losses, hyperglycemia and
    potential for volume depletion
     Class example: HCTZ
     Start 0.5 to 1 mg/kg daily
     Can increase to 3 mg/kg daily, max of 50 mg/day
     Typically start adolescent/adults on 12.5 mg daily
     Side effects: Hypokalemia, hyperglycemia, volume depletion,
    orthostasis
    Case

     Your patient is tolerating lisinopril well at a 6 week follow-up. The follow-up chemistry was
    normal. Blood pressures are improved but still remain elevated above your goal. What do
    you do next?
    A. Be content with the progress made
    B. Increase the dose
    C. Add a second agent
    D. Refer to Nephrology
     Begin with lowest dose of a single agent
     Limited evidence to guide best initial agent
     Provider comfort level and guided by
    comorbidities
     All are likely equally effective and safe

    Management:  Check labs in 1-2 weeks (particularly


    important for ACEI and diuretics)
    Meds  Close follow-up with repeat blood pressure
    in 2-4 weeks
     Increase dose if not at goal BP (<90%ile) by
    4-8 weeks
     If at goal, continue to follow closely, at
    least every 3 months
     Screen! And ensure blood pressures are taken correctly
     Make the diagnosis
     Start the initial workup (labs, renal ultrasound)
     Lifestyle counseling
     Dietitian referral

    What you can  Regular and close follow-up; motivational


    interviewing

    do as a PCP  If overweight/obese, refractory to lifestyle measures and


    in the absence of concerning features, don’t be afraid
    to start meds
     Pick one, understand it well
     Close follow-up and titration
     Refer if uncomfortable
    When to refer

    If uncomfortable

    Stage 2 HTN or evidence of end organ damage

    Concern for secondary cause of hypertension

    Concern for underlying renal disease (abnormal SCr, proteinuria, etc)

    HTN refractory to lifestyle changes and initial medication


    Thanks.

    You might also like