4 hypertensive kids in 45 minutes. name: anthony age: 6 sex: male place: allergy clinic bp: 145/87

4 Hypertensive Kidsin 45 Minutes

Name: Anthony

Age: 6

Sex: Male

Place: Allergy Clinic

BP: 145/87

Name: Chris

Age: 17

Sex: Male

Place: Inpatient

BP: 180/115

Name: Brittiney

Age: 13

Sex: Female

Place: Clinic

BP: 125/78

Name: Caleb

Age: 3

Sex: Male

Place: Phone Call

BP: 118/75

Caleb

AnthonyBrittiney

Chris

The Fourth Task Force Report on Pediatric High Blood Pressure

6 Questions

• Does the child really have high blood pressure?

• Do I have time to ask any more questions?• Why does the child have high blood

pressure? • Does the child have other risk factors? • What has high blood pressure already

done to the child's body? • What should we do about it?

6 Questions

• Does the child really have high blood pressure?

• Do I have time to ask any more questions?• Why does the child have high blood

pressure? • Does the child have other risk factors? • What has high blood pressure already

done to the child's body? • What should we do about it?

Blood Pressure Measurement Technology is in the Dark Ages.

Confirm all blood pressure readings before acting.

It’s a Pain in the A** to Detect HTN

Equipment is inherently flawed, hard to findOr gives inaccurate readings if not used right.

It’s a Pain in the A** to Detect HTN

Spurious elevations are common

It’s a Pain in the A** to Detect HTN

Not everyone has a BP reading.

It’s a Pain in the A** to Detect HTN

Mild Hypertension takes weeks to confirm

It’s a Pain in the A** to Detect HTN

Norms for Pediatric BP are found in a 4-D table

It’s a Pain, But you Got to Do it

http://www.statcoder.com/growthcharts.htm

Normal

< 90% le

Pre-Hypertension

90-95% le

Stage 1 Hypertension95% to 5 mm above 99%le

Stage 2 Hypertension> 5 mm above 99%le

Hypertension is Common

02468

101214161820

Hypertension Asthma

%

Caleb118/75

Anthony145/87

Brittiney125/78

Chris180/115

161 cm (72%le)

95% BP = 126/8290% BP = 122/78

114 cm (75%le)

168 cm (16%le)

98 cm (64%le)

95% BP = 113/7499% BP = 120/82

95% BP = 133/8599% BP = 141/93

95% BP = 110/6799% BP = 118/75

Recognizing or ruling out a hypertensive emergency is the 1st

order of business in any hypertension evaluation.

6 Questions

• Does the child really have high blood pressure?

• Do I have time to ask any more questions?• Why does the child have high blood

pressure? • Does the child have other risk factors? • What has high blood pressure already

done to the child's body? • What should we do about it?

Is this an Emergency?

Hypertensive Emergency

Elevated Blood Pressure with symptoms of end-organ damage

Hypertensive Urgency

A high BP that makes you uncomfortable

Hypertensive Emergencies

• Drop the Blood Pressure no more than 10%

• Use short acting IV medications– IV Labetolol– IV Hydralazine– IV Nicardipine drip

• Start small and then escalate your dose

• Get the patient to a PICU

Chris

Chest Pain and a splitting headache

Labetolol and hydralazine given on the floor – no effect. Nicardipine drip in PICU. BP 150s/80s by noon.

6 Questions

• Does the child really have high blood pressure?

• Do I have time to ask any more questions?• Why does the child have high blood

pressure? • Does the child have other risk factors? • What has high blood pressure already

done to the child's body? • What should we do about it?

School Age Teenager

Chronic UTIs

GlomerularDisease

RenovascularDisease

Aortic Coarctation

Essential Hypertension

Essential Hypertension

GlomerularDisease

RenovascularDisease

Other Causes of Pediatric Hypertension that you still think about• Inpatients

– Increased ICP– Pain– Iatrogenic steroid-induced

• Uncommon outpatient causes– Endocrine causes (Cushing, Pheo)– Pre-eclampsia

The Younger the Patient with Hypertension,

the More Likely you’ll find a Cause

Rule of Thumb #1

The Higher the Blood Pressure,

the more likely there’s a cause

Rule of Thumb #2

Symptoms to Ask About

History

UAC as a newborn

UTIs or febrile illnesses

Medications

Supplements

Family History

Physical

Arm & Leg BPs

A

B

C

What’s Normal?

1. A = B = C

2. A = B > C

3. A = B < C

4. A > B > C

What’s Normal?

1. A = B = C

2. A = B > C

3. A = B < C

4. A > B > C

Eye Grounds

Heart Findings

Listen for a Bruit

Skin

CALMs of NF-1Acanthosis Nigricans

Skin

Labs & Imaging

Pre-Hypertension

Lipids Fasting Glucose Echocardiogram Retinal Exam

Young Stage 1 or Stage 2

Renin CatecholaminesAngiogram Urine Steroids

+

Teenager Stage 1

RFP Urinalysis Renal Ultrasound+

Pre-Hypertension

Lipids Fasting Glucose Echocardiogram Retinal Exam

LVH on an echocardiogram is the most common end-organ manifestation in pediatric hypertension

Essential hypertension almost always occurs with other risk factors

Teenager Stage 1

RFP Urinalysis Renal Ultrasound

Quantitate any abnormal urine protein

There’s no normal creatinine in pediatrics, but there is a normal GFR.

Renal vessel doppler are of questionable value.

Young Stage 1 or Stage 2

Renin CatecholaminesAngiogram Urine Steroids

Plasma renin is usually uninterpretable.

Elevated urine catecholamines are usually transient and not subtle.

Don’t bother with MRAs or nuclear scans; the gold standard is an angiogram.

Caleb

Category of HTN: Young Stage 1History & Symptoms: NonePhysical: NormalLabs: NormalImaging:

Echo: Mild LVHU/S: Left kidney < RightAngio: Normal

Brittiney

Category of HTN: Pre-HypertensionHistory & Symptoms: SnoresPhysical: Elevated BMI ~ 98%le

Labs: Fasting BG 121Imaging:

Echo: NormalU/S: Normal

Life-style changes

Give a TV target of 2 hours per day or less

Write a prescription for PE

DASH diet (http://www.nhlbi.nih.gov/)

Surveillance

Lipids, Blood Sugars, Weight, Urine Protein

Ambulatory Blood Pressure Monitor (ABPM)

Ambulatory Blood Pressure Monitor

Anthony

Category of HTN: Young Stage 2History & Symptoms: Intermittent headaches

Physical: Single Café au LaitLabs: NormalImaging:

Echo: Moderate LVHU/S: NormalAngio:

Chris

Category of HTN: Teenager Stage 2History & Symptoms: Transplant;

On a dripPhysical: TachycardicLabs: Creatinine 1.7Imaging:

U/S:

Chris

Hydronephrosis, Ureteral obstruction

Blood pressure dramatically better (off drips) after nephrostomy

6 Questions

• Does the child really have high blood pressure?

• Do I have time to ask any more questions?• Why does the child have high blood

pressure? • Does the child have other risk factors? • What has high blood pressure already

done to the child's body? • What should we do about it?

7 Classes of Anti-hypertensives

• Diuretics• Beta-blockers IV labetolol• Central Alpha-Blockers• Calcium Channel Blockers nicardipine

drip• ACE Inhibitors• Direct Vasodilators IV hydralazine• Angiotensin Receptor Blockers• Peripheral Blockers

Take Home Points

• Report the percentile of Blood Pressure on Any BP you get

• Recognize a hypertensive emergency

• Refer to the 4th Task Force Report or your local pediatric nephrologist once you recognize a high blood pressure