1. Pediatric Hypertension
Michele Mills, RN, MS, CPNP
Pediatric Nephrology & Dialysis
April 15, 2016

2. Objectives Correct measurements Correct Diagnosis When to refer
How to treat

3. Introduction Prevalence of pediatric hypertension
Has been increasing in children since the 1990’s
14% who have pre-hypertension develop hypertension within 2 years

4. Introduction Why we care
In children with hypertension as many as 1 in 3 has end organ damage
Health People 2020 objective 5.2
To reduce the prevalence of hypertension among children and adolescents by 10%
Adult outcomes start in childhood

5. Current recommendations:
National High Blood Pressure Education Program (NHBPEP)-2004
Measure blood pressure in children age >3yo who are seen in a medical setting
Bright Futures Guidelines by AAP 2007
Children age 3-17 receive BP screening at their annual preventative care visit
Current practice:
In 2006 only 85% of those kids had preventative health care visits

6. Who should get their BP taken?
All children >3 yo
Children <3 yo :
Are NICU ‘graduates’
Have congenital heart disease
With history of UTI’s, hematuria or proteinuria
With known renal or urologic malformations
Family history of congenital renal disease
Solid organ transplant
Malignancy or bone marrow transplant
Exposure to drugs known to increase blood pressure
Other systemic illness associated with hypertension
Evidence of elevated intracranial pressure
Heart disease- self explanatory
Kidney disease…………………transplants
“Other diseases” Neurofibromatosis; tuberous sclerosis; diabetes;

7. Adult definitions of hypertension- AHA
his blood pressure chart reflects categories defined by the American Heart Association.
Adult definitions of hypertension- AHA
Blood Pressure Category
Systolic mm Hg (upper #)
Diastolic mm Hg (lower #)
Normal
less than 120
and
less than 80
Prehypertension
120 – 139 or
80 – 89
High Blood Pressure (Hypertension) Stage 1
140 – 159
90 – 99
High Blood Pressure (Hypertension) Stage 2
160 or higher
100 or higher
Hypertensive Crisis (Emergency care needed)
Higher than 180
Higher than 110
Adult hypertension guidelines from the American Heart Association, and are pretty straight forward…..
But – using the age old quote “kids are not little adults”, and it makes sense that they shouldn’t have blood pressures as high as adults

8. History of Pediatric Hypertension
1977, the first age related norms for children were developed.
1987, a revision of the standards, data from > 70,000 Caucasians, African-Americans, Hispanic kids from 0-18 years. Standards for measurement techniques were revised.
1996, age and heights were considered. Diastolic BP was redefined as the 5th rather than 4th Korotkoff sound.
2004, the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents.

9. 2004 the High blood pressure education program released comprehensive guidelines.

10. BP Tables Here are the tables-
You can see they can be a bit overwhelming at first so we’ll walk through one….

11. Adult definitions of hypertension- AHA
his blood pressure chart reflects categories defined by the American Heart Association.
Adult definitions of hypertension- AHA
Blood Pressure Category
Systolic mm Hg (upper #)
Diastolic mm Hg (lower #)
Normal
less than 120
and
less than 80
Prehypertension
120 – 139 or
80 – 89
High Blood Pressure (Hypertension) Stage 1
140 – 159
90 – 99
High Blood Pressure (Hypertension) Stage 2
160 or higher
100 or higher
Hypertensive Crisis (Emergency care needed)
Higher than 180
Higher than 110
Adult hypertension guidelines from the American Heart Association, and are pretty straight forward…..
But – using the age old quote “kids are not little adults”, and it makes sense that they shouldn’t have blood pressures as high as adults

12. Proper blood pressure measurements
Equipment
Technique
Repeat measurements

13. Proper cuff size
Cuff size can cause a lot of erroroneous readings

14. Cuff Size Cuffs come in a variety of sizes….
Don’t be fooled by the ‘names’ on the cuffs

15. Measurement of blood pressure
Sitting at least five minutes
Taken in upper arm with arm at heart level
Bladder width at least 40% of mid-arm circumference
Bladder length at least 80% of circumference of arm without overlapping

16. BP tables Take a 3 yo male with height at the 50th percentile….
Plot the height and get the 95%ile as a starting point. If BP is greater than that, will need the 99%ile also

17. Classification of hypertension
SBP or DBP percentile*
Normal
<90th
Pre-hypertension
90th – <95th or if BP exceeds 120/80 even if <90th up to <95th
Hypertension
≥95th
Stage 1 hypertension
95-99th plus 5mmHg
Stage 2 hypertension
>99th plus 5mmHg
Tables are based on auscultatory – not oscillimetric.
*For gender, age and height
*Measured on at least 3 separate occasions
*Preferred auscultatory method

18. Prehypertension Blood pressure between the 90-95%ile
In adolescents BP ≥ 120/80 *
Lifestyle modification
Diet
Exercise
Best outcomes with whole family changes
On charts SBP>120 at about 12 yo & DBP at about 16yo
Whole family ex…..

19. Nutrition….Diet
My personal favorite reference…….amazing responses from kids

20. Diet - sodium
The 2015–2020 Dietary Guidelines for Americans recommend that Americans consume less than 2,300 milligrams (mg) of sodium per day as part of a healthy eating pattern.
Based on these guidelines, the vast majority of adults eat more sodium than they should—an average of more than 3,400 mg each day.
First think to explore is daily sodium intake
Most people don’t think they have a high sodium intake. Walk them through a day….

21. Age 1200 mg /day in 4-8 year olds 1500 mg/day 8-16 year olds
2300 mg/day for adults
Goldfish:

22. Diet- Sodium
No added salt
Sea salt
Garlic “salt”

23. The obvious culprits

24. Fast food and even restaurant foods
- red lobster 400/biscuit – shrimp fetuccini 4090

25. Lunchmeats, canned foods, frozen foods
Much of preservatives contain sodium

26. Teaching proper label reading; serving size
Start with educating themselves

27. Diet - Caffeine

28. “It’ll stunt your growth”
Caffeine
“It’ll stunt your growth”
Remember when……

29. Caffeine
Not only the caffeine but the calories…….

30. Weight Management Which leads us to the next topic
One that is often difficult to discuss with families

31. Obesity
Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years. It alone triples the risk of hypertension
In 2012, more than one third of children and adolescents were overweight or obese.1
CDC reports

32. Public Messages - Excercise
Lets Move – Michelle Obama
Healthy Kids – Nationwide initiative
Play 60 – NFL
WHO- Healthy People 2020
WHO___School-aged children and adolescents should:
limit energy intake from total fats and sugars;
increase consumption of fruit and vegetables, as well as legumes, whole grains and nuts;
engage in regular physical activity (60 minutes a day).

33. TLC Summary Increased activity/less screen time Sodium restriction
NAS + Fruits and vegetables + lowfat dairy and protein (similar to DASH diet)
Increased potassium and calcium
Family centered approach vs patient oriented is more effective
Dietary Approaches to Stop Hypertension

34. Home Monitoring ? Home monitoring can be difficult
Not usually a recommendation by primary care
If willing to do is very helpful in evaluation
Equipment is not standard
Manual blood pressure monitoring is easy and cheap to acquire
Young children hard
Not usually required for pre-hypertension
If very motivated then sure!!

35. Home Monitoring
Pretty hard to manual until patient is somewhat cooperative
Is more accurate – but user error comes into play
All of the data is based on this.
Probs: skill, hearing probs, hard to do yourself, young children

36. Home Monitoring This is what every one wants…
Pros: Consistent, no user error (push a button), can do yourself
Cons: COST, not all products are good/reliable OMRON (Reli-ON)
Need to ensure home BP cuffs are properly sized- providing ideal cuff size or arm measurements are helpful- don’t just say adult, small adult, etc as different companies have different measurements.
Please do not use wrist cuffs, as these have not been standardized in children

37. “Home” Monitoring Return to the office for repeat measurements
Although seems easiest……..
To accurately diagnose = 3 diff measurements
Most do this….
Loading them up, finding the time, stress to get there,
remember to sit for 5 min, first, sitting – if high on machine should be repeated manually
White Coat Hypertension***

38. Ambulatory BP Monitor Requires AT LEAST 1 successful reading/hr
Worn for 24 hours
Takes BP every 20 minutes during day and every minutes at night
Patients must log vigorous activity and when they eat and sleep
Requires AT LEAST 1 successful reading/hr
Difficult in young children
Reimbursement only for WCH

39. ABPM report Computer calculates means for day, night and 24 hours
These are compared to age/height standards
BP load calculated = # of measurements over the 95th %ile >25% is significant
And dipping status 10% decline in means – can differentiate 1 Vs 2ndary
NOT REIMBURSED WELL (cost of monitor and maintenance- retuning-)

40. 24 hour blood pressure monitoring
24 hour mean ABP more closely related to end organ damage than clinic BP
Evaluate morning BP rise
Nocturnal BP: dippers vs non-dippers
BP variability- among hypertensive patients, increased variability had a greater score for end-organ damage
Comparing clinic BP and ABPM-
Literature Review by Guiseppe Mancia and Gianfranco Parati demonstrated benefits of 24 hour monitoring over clinic bp’s:
Long known association with early morning waking and increased incidence of MI, sudden death and stroke. Not clear if rise in BP is cause or not. Unclear how we should treat this time frame- should we decrease the slope of BP or leave alone and change overall mean vales?
Known that subjects drop their BP at night. Arbitrary value of 10% drop in BP is ‘normal’. Non dippers have increased end organ damage
BP variability – among hypertensive patients, increased BP variability has a greater score for organ damage. Not clear if this is cause or result of organ damage
Mancia & Parati. Hypertension. 2000;36:894.

41. Nocturnal Dip
Long been known BP drops when asleep and as part of waking period it increases
Speculation that the rate of rise of BP may be less significant than the degree of rise
Waning of anti-hypertensives may increase risk of CV events
Dippers - those whose nighttime average BP drops more than 10% of daytime average BP
Non-dippers have greater organ damage and higher incidence of cardiovascular disease
As mentioned earlier we can evaluate the nocturnal dip with ABPM and the AM rise
10% is an arbitrary number
Is this reproducible

42. Causes of hypertension by age group
Infants
School-age
Adolescents
Primary/essential
<1%
15-30%
85-95%
Secondary
99%
70-95%
5-15%
Renal parenchymal disease
20%
60-70%
Renovascular
25%
5-10%
Endocrine 1%
3-5%
Aortic coarctation
35%
10-20%
Reflux nephropathy 0%
Neoplastic 4%
1-5%
Miscellaneous
Back it up a bit….
When you get htn (keeping in mind- infants rarely are checked…) most cardiac defects are diagnosed early, murmur, or color not BP
Take home is the flip in causes – and it is moving backwards
The 5-15% 2ndary are usually GN
Flynn, 2001

43. Miscellaneous causes of hypertension
Vasculitides
Congenital or inherited parenchymal disease (dysplasia, AD/RPKD)
Renal transplant artery stenosis
Congenital adrenal hyperplasia
Hyperthyroidism
Renal tumors (Wilms)
Cathecholamine-secreting tumors
Pheochromocytoma
Neuroblastoma
Increased ICP
Dysautonomia
Drug-induced
Corticosteroids
NSAIDs
OCPs
Erythropoietin
Sympathomimetic drugs
Nasal decongestants
Street drugs
Diet-mediated
Alcohol
Caffeine

44. History-taking Past medical history Family history Prenatal history
Prematurity, IUGR or SGA
NICU course (if any) including umbilical line placement
Recent and chronic illnesses
Recurrent UTIs or unexplained fevers
Family history
Hypertension
Renal disease
Cardiovascular disease (hyperlipidemia, stroke)
Diabetes

45. History-taking Medication use Sleep history Physical activity Diet
Prescription meds
ADHD: Ritalin, Streterra, adderall, Intuniv**
OTC, illicit drug use including smoking
Sleep history
Physical activity
Diet
Symptoms
Smoking cigs & marijuana
Sleep for OSA – snoring, frequent waking, waking feeling tired
Symptoms leads to next slide

46. History-taking (Specialist)
Headache, dizziness, diplopia, vomiting, epistaxis
Abdominal pain, dysuria, frequency, urgency, nocturia, enuresis
Hematuria, edema, fatigue
Joint pains/swelling, edema, rashes
Weight loss, sweating, flushing, palpitations
Muscle cramps, weakness, constipation
Delayed puberty
Snoring
Symptoms suggestive of hypertension
Urinary tract infections
Underlying renal disease
Auto-immune mediated
Pheochromocytoma or hyperthyroidism
Hypokalemia with hyperaldosteronism
CAH
Sleep apnea
When concerned about hypertension; start with a good thorough H&P; there are keys in the questioning
h/a- time of day, relationship to eating

47. Physical examination Vitals signs: Tachycardia, 4-limb BPs, MANUAL BP
General: Growth parameters, Ht/Wt/BMI
HEENT: Moon faces, proptosis/goiter, webbed neck, adenotonsillar hypertrophy, papilledema
Lungs: Crackles or rales
CV: Murmur
Tachycardia hyperthyroidism, pheo, neuroblastoma, primary HTN, coarctation
Growth retardation CKD, obesity essential HTN
Moon facies Cushing
Crackles heart failure

48. Physical examination Abdomen: Masses, hepatomegaly, bruits
Genitalia: Ambiguous, precocious puberty
Extrem: Edema, joint swelling, rickettsial changes
Dermatologic: Neurofibromas, tubers, acanthosis nigricans, striae, acne, rashes, needle tracks
Neuro: Encephalopathy, cranial nerve palsy
Mass obstructive nephropathy, Wilms, neuroblastoma, pheo, PKD
Bruit – RAS, abd coarctation
Genitalia – CAH
Tuberous sclerosis, excess ACTH, insulin resistance, Cusihgn disease

49. Diagnostic Testing
Serum chemistries, BUN, creatinine, complete blood count, urinalysis
Fasting lipid panel, glucose *
Renal ultrasound with Doppler imaging
Echocardiogram – usually determined by specialist
Sleep study- based on history
+/- drug screen
Retinal exam
Lipids in overweight >90-95th %ile and all stage 2 htn & CKD
Sleep screening with BEARS (bedtime problems/excessive sleepiness/awakenings at night/regularity and duration of sleep/snoring-SDB)…approx 15% kids snore. 1-3% have SDB/OSA
Drug screen based on suspicion after screening

50. When to treat Symptomatic hypertension
End organ damage (LVH, retinopathy, proteinuria)
Stage 1 hypertension that does not respond to lifestyle modifications
Stage 2 Hypertension BP > 99th%ile
Decision to teat is life altering for many families
Will discuss end organ issues later

51. Treatment Goals
Goal is to bring BP to < 95th%ile, for age, gender, and sex
If there are co-morbidities, or end organ damage the goal is lowered to < 90th%ile for age, gender, and sex

52. Stage 1 & Stage 2 Hypertension
Referrals
Cardiology & Nephrology are primary referrals
Historically children with hypertension likely had a renal source for it; now a great deal of the referrals are obese children and adolescents

53. Sub-Specialists Cardiology Nephrology Other
Echo/EKG- structural heart defects
Nephrology
Structural
Renal hormone mediated
Glomerulonephritis
Other
Thyroid
Behavioral
Structural: OU, RAS, tumor, Pheo, neuroblastoma
Hormonal: RAAS, metanephrines
GN: PIGN – lupus
Behavioral (ADD/anxiety)

54. Sub-specialists Endocrinology Plasma metanephrine and normetanephrine
Elevated in 80% of children with pheochromocystoma even when asymptomatic (Eisenhofer et al, 1999)
Thryoid function tests
Plasma and urine steroid level
Infrequently a first line referral- often after these are identified by someone else

55. Treatment If a source is identified, may be able to be corrected
Thyroid
Cardiac
RAS

56. Treatment Very hard for many parents…..and kids
A lot, and this is increasing
Non adherence
adolescents

57. End Organ Damage Kidney filter damage Retinal changes
Left ventricular hypertrophy (LVH)

58. Proteinuria Urinalysis Spot urine protein to creatinine ratio
Screening
Should be repeated
Spot urine protein to creatinine ratio
Normal <0.2
First morning specimen
Accompanied by hematuria
Glomerulonephritis- referral

59. Stages of hypertensive retinopathy
Recovers if found early and treated aggressively
Can screen but suspicion should go to opthalmologist

60. LVH Most prominent evidence of end organ damage as a result of htn
Echos done at diagnosis and periodically after
+LVH is an indication to treat or intensify treatment
It is reversible

61. Choosing medications
More drugs have been tested and approved for pediatric use
Should be initiated with a single drug
TLC always reinforced even with treatment
FDAMA – FDA modernization Act provided incentives to the pharmaceutical companies to study drugs in kids
irony of old drugs no data
Just because it isnt studied- doesn’t mean you cant use it.
No studies to date on comparing the effects of drugs- just effects on BP for each drug

62. Anti-hypertensives
The 4th report is a little vague on this questions saying “the choice of drug for initial anti-hypertensive therapy resides in the preference of the responsible physician”.
That being said they do mention that single therapy should be chosen and the dose increased to response or highest recommended dose achieved. Then a drug from a second class can be added.
They also admit that specific clases of anti-hypertensive drugs should be used preferentially in certain hypertensive children: eg; ACEi in pts with diabetes or microalbuminuria, Bblockers in pts with migraines.

63. Anti-hypertensives
The 4th report is a little vague on medication choices:
“Choice of the drug for initial anti hypertensive therapy resides in the preference of the responsible physician (provider)”
Often based on comfort level of individual medication
There are some specific indications:
ACE Inhibitors/ARB’s in diabetes; microalbuminuria, and or proteinuria.
Beta blockers; with migraines

64. Anti-hypertensives And contraindications:
Thiazide diuretics and Beta blockers are on Anti- Doping list (athletes)
Beta blockers ≠ Asthma
Beta blockers can impede athletic function
Suspensions can be difficult, very few commercial

65. Angiotensin Converting Enzyme inhibitors (ACEi)
Antagonist of the angiotensin converting enzyme
Angiotensin II is a powerful vasoconstrictor
Stimulates secretion of aldosterone
Multiple pathways

66. ACE Inhibitor’s The “PRILS”
Enalapril, Lisinopril, benazepril…
The most commonly prescribed medication for both primary and secondary pediatric hypertension
Can be renoprotective also
Antiproteinuric effects are beneficial in chronic kidney disease and diabetes
Many are FDA approved for children >6yo and with eGFR >30 ml/min
Angiotensin
Approved: enalapril* First ped htn med FDA approved/fosinipril/benazepril and Lisinopril
Vasocnstriction may cause increased creat

67. ACEi
Pros:
Cheap, very effective, commercially prepared compounds, renoprotective, antiproteinuric
Cons:
Bloodwork monitoring
Cough/angioedema possible side effects
Teratogenic; decreased GFR
Many 4$ drug lists
Long acting
Labs for creatinine and potassium
Dehydration and pregnancy avoidance.

68. Angiotensin receptor blockers – ARB’s

69. ARB’s The “ARTAN” meds Similar indications as ACEi
Candesartan, losartan, olmesartan, valsartan
FDA approved in children >6yo and eGFR>30 ml/min
Similar indications as ACEi
Decreased side effect profile
Side effects – often used when cough occurs with acei

70. Calcium Channel Blockers
Decreases contractility of the heart
Vasodilation of the arterial system

71. Calcium Channel Blockers
The “IPINE” medicines
Amlodipine, isradipine, nifedipine….
Amlodipine is the only FDA approved CCB in children
There is a lot of pediatric experience with isradipine, felodipine and nifedipine ER

72. CCB’s Pros: Cons: Both short and long acting preparations
Easily compounded
Cons:
Peripheral angioedema, gingival hyperplasia
Flushing, headache with immediate response formulas (isradipine)

73. Beta Blockers
‘block’ the beta adrenergic receptors located on the myocardium to reduce the heart rate and decrease contractility
Cardioselective (beta-1)and non cardioselective (block beta 1 & 2)

74. Beta Blockers The “OLOL” medicines
Atenolol, propranolol, metoprolol…..
Metoprolol ER is the only FDA approved BB for children
Atenolol & propranolol have extensive pediatric experience.

75. Beta Blockers Pro’s Cons Helps with migraines Many long acting
Contraindicated in asthma
Bradycardia is the dose limiting factor
Decreased sports performance
Some weight gain
Sports- blunts tachycardia

76. Central alpha agonist Clonidine is FDA approved in children >12 yo
Acts in the brainstem (central) and reduces sympathetic tone
Increases parasympathetic tone by block alpha 2 receptors decreasing norepinephrine and decreasing vascular tone
Pros:
Sedating effect
Tablet, liquid, patch
Cons:
Sedative effect, dry mouth,
Rebound hypertension
Rebound htn= non adherence

77. Diuretics

78. Diuretics
Thiazide diuretics: work in the distal tubule preventing salt and water reabsorption and promoting diuresis
Hydrochlorothiazide is the only FDA approved diuretic in children
Contraindicated in sulfa allergies
Loop diuretics: work in loop of Henle interfering with the na-k-cl cotransporter. Not for use alone for htn, revs up the RAAS system to compensate for lost volume
Furosemide is approved for edema, but can be used for hypertension
Potassium sparing diuretics:
Spironolactone, triamterene, amiloride
ALL decrease extracellular volume= lowers BP
Thiazide diuretics are first line antihypertensive for adult htn (ACEi, ARB, CCB) – hctz very erratic chlorthalidone long acting. In children often a second line
Least available clinical trial data (off patent)

79. Loop of Henle…..diuretics

80. Peripheral alpha antagonists
The “ZOSIN” medications
Doxazosin, prazosin, and terazosin: None are approved in pediatrics
Induces relaxation of both arterial and venous smooth muscle (vasodilation)
Rarely used in pediatrics
Can sometimes cause syncope or hypotension when started.

81. Vasodilators Hydralazine & Minoxidil are FDA approved in children
Typically used in acute settings

82. Ongoing monitoring End organ damage monitoring
Home blood pressure monitoring
Drug side effect monitoring
Laboratory monitoring
Ongoing TLC

83. In summary
Everyone should have for reference.

84. Q