1. Pediatric Hypertension Elizabeth Burrows

2. Introduction Hypertension in American children is a growing epidemic Hypertension in American children is a growing epidemic High blood pressure is estimated to be prevalent in 4.5% of children 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 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

3. Why the rise in childhood hypertension? Increasing epidemic of childhood obesity Increasing epidemic of childhood obesity Sedentary lifestyles Sedentary lifestyles Epidemiologic studies indicate that about 30% of obese children have hypertension Epidemiologic studies indicate that about 30% of obese children have hypertension Hypertension and obesity are two common preventable disorders facing pediatric clinicians 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 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

4. Why are health care providers failing to make the diagnosis? Blood pressure in children is a function of age, sex, and height percentile 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 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 Clinicians usually cannot remember normal blood pressures for the wide range of children observed in their typical primary care setting

5. Factors making diagnosis more likely in children Older age Older age Taller height Taller height Obesity 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 Younger children and adolescents who are not overweight and generally appear healthy are typically the patients where hypertension is not suspected and often missed

6. Hansen’s 2007 Study Analyzed the medical records of 507 hypertensive and pre-hypertensive children and adolescents over a span of seven years 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 All the children visited an outpatient clinic at least three times 376 patients (74%) had undiagnosed hypertension 376 patients (74%) had undiagnosed hypertension 80 patients (15.8%) had a true hypertension diagnosis 80 patients (15.8%) had a true hypertension diagnosis 7 participants had undiagnosed stage 2 hypertension 7 participants had undiagnosed stage 2 hypertension Data to make the diagnosis of hypertension or prehypertension was present in the patients' records Data to make the diagnosis of hypertension or prehypertension was present in the patients' records

7. Hansen’s 2007 Study There is a much needed modification for identifying pediatric hypertension There is a much needed modification for identifying pediatric hypertension Current discussion is centered on the development of a computer program Current discussion is centered on the development of a computer program 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 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

8. Why is it important to diagnose and treat hypertension in childhood? Prevent progression and target organ damage of the brain, eyes, heart, and kidneys 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 A study by Hanevoid demonstrated that severe target organ damage occurs in hypertensive children 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 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 If caught early, preventative measures can be taken to reduce risks for other comorbidities in childhood and adulthood

9. Pediatric Classifications The Fourth Report 2004 includes new classifications for hypertension The Fourth Report 2004 includes new classifications for hypertension Prehypertension Prehypertension Stage 1 Stage 1 Stage 2 Stage 2

10. Pediatric Classifications Pre-hypertension- average systolic and/or diastolic blood pressure between the 90th and 95th percentile for gender, age, and height 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 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 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 Elevated blood pressure must be confirmed on three repeated visits before diagnosing a child as having hypertension

11. Pediatric Classifications 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 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 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 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 symptomatic give immediate treatment and refer to hypertension specialist If asymptomatic refer to specialist within one week If asymptomatic refer to specialist within one week

12. Measurement of BP in Pediatrics The Fourth Report recommends that children 3 years and older have their blood pressure measured regularly 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 The preferred method of blood pressure measurement is auscultation In order to correctly diagnose hypertension blood pressure must be measured accurately In order to correctly diagnose hypertension blood pressure must be measured accurately

13. Measurement of BP in Pediatrics Main source of error – Using wrong cuff size Main source of error – Using wrong cuff size Small cuff- overestimates BP Small cuff- overestimates BP Large cuff- underestimates BP Large cuff- underestimates BP

14. Appropriate Cuff Size Inflatable bladder width that covers at least 40% of the arm circumference midway between the olecranon process and the acromion process 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 length should cover 80-100% of the circumference of the arm The bladder width-to-length ratio should be at least 1:2 The bladder width-to-length ratio should be at least 1:2

15. Measurement of BP in Pediatrics Preparing the child for blood pressure measurements 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 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 If a patient has a reading that is >90th percentile BP should be repeated twice at the same office visit BP should be repeated twice at the same office visit Document average systolic and diastolic BP Document average systolic and diastolic BP

16. ABPM Ambulatory Blood Pressure Monitoring allows clinicians to observe the patients BP 2-4 times per hour over at least 24 hours 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 Patients are encouraged to continue normal everyday 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 missed Make diagnosis that would otherwise be missed

17. Nocturnal Blood Pressure Nocturnal BP Dip- Typically individuals have 10-15% drop in their mean day and night blood pressure readings Nocturnal BP Dip- Typically individuals have 10-15% drop in their mean day and night blood pressure readings ABPM can detect ABPM can detect An abnormality nocturnal BP dip An abnormality nocturnal BP dip Elevations of nocturnal blood pressure Elevations of nocturnal blood pressure Both usually indicative of secondary hypertension

18. Masked Hypertension A condition where a patient’s office blood pressure is normal but ABPM classify the patient as hypertensive 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 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 Showed these children with have an elevated left ventricular mass index equivalent to truly hypertensive patients

19. White Coat Hypertension A patient with blood pressure levels >95th percentile in a physician’s office or clinic and who is normotensive outside a clinical setting 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 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 Counsel patient about therapeutic lifestyle changes and monitor for development of true hypertension

20. Pediatric Symptoms Hypertension is often thought of as a silent disease because typically there have not been any classic symptoms 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 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 3 most common symptoms headache headache difficulty initiating sleep difficulty initiating sleep daytime tiredness daytime tiredness These were all reduced with treatment

21. After Hypertension is Diagnosed Want to rule out secondary causes Want to rule out secondary causes BP should be measured in both arms and a leg to rule out coarctation of the aorta 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 Fasting lipid, Fasting glucose, standard chemistry panel, serum urea nitrogen (BUN), CBC, creatine, urinalysis and urine culture Echocardiogram, renal ultrasound Echocardiogram, renal ultrasound Screen for major sleep disorders using BEARS: Screen for major sleep disorders using BEARS: Bedtime problems Bedtime problems Excessive daytime sleepiness Excessive daytime sleepiness Awakenings during the night Awakenings during the night Regularity and duration of sleep Regularity and duration of sleep Snoring Snoring

22. Treatment Lifestyle modifications are typically the initial treatment of choice Lifestyle modifications are typically the initial treatment of choice Indications for antihypertensive drug therapy in children Indications for antihypertensive drug therapy in children Secondary hypertension Secondary hypertension Insufficient response to lifestyle modifications Insufficient response to lifestyle modifications Stage 2 hypertension Stage 2 hypertension

23. Pharmacologic Therapy of Childhood Hypertension 2002 Best Pharmaceuticals for Children Act has led to recent study and FDA approval of several antihypertensive medications for use in pediatrics 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 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 ACE-I and calcium channel blockers are the most commonly used antihypertensive medications in children

24. Conclusion Hypertension and obesity in children are increasing in an upward trend Hypertension and obesity in children are increasing in an upward trend It is imperative that pediatric hypertension is recognized and treated 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 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 It is important to encourage healthy lifestyles in all children and adolescents and help institute lifestyle changes for weight reduction in overweight children

25. References Childs, Dan. "Kids' High Blood Pressure Often Missed." ABC News 21 Aug. 2007.. Childs, Dan. "Kids' High Blood Pressure Often Missed." ABC News 21 Aug. 2007.. Couch, Sarah C., Stephen Daniels. "Diet and Blood Pressure in Children." Current Opinion in Pediatrics Oct. 2005: 648-652. 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. 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. 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.. Falker, Bonita. "Hypertension in Children." Audio-Digest Family Practice. Current Issues in Pediatrics. Mar. 2007.. 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. 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. 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. 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. Masters, Coco. "High Blood Pressure Affects Kids Too." Time 21 Aug. 2007. 12 Sept. 2007.

26. References 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. 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. 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. “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. 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. 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. 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. 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. 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. 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.