hypertension in children - university of arkansas for ... docs 2/news/kidney 2012/hypertension...

Hypertension in ChildrenHypertension in ChildrenHypertension in ChildrenHypertension in Children

M h d Il M DMohammad Ilyas, M.D.

Associate Professor of Pediatrics

f h l fDivision of Nephrology, Department of Pediatrics. UAMS Little Rock

archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

OutlineOutlineOutlineOutline

• Prevalence.Prevalence.

• AAP recommendations for BP measurement.

• Case StudyCase Study

– BP measurement.

Definition of hypertension– Definition of hypertension.

– Workup of hypertensive patient.

• Fourth Task Force treatment recommendations• Fourth Task Force treatment recommendations.

• Athletic participation.


HypertensionHypertension in Childrenin ChildrenHypertension Hypertension in Childrenin Children

Prevalence of Overweight in Children

16%

Prevalence of Hypertension in School Children

4.50%

5.00%

6%

8%

10%

12%

14%

eval

ence

1971-19741999-2000 2.50%

3.00%

3.50%

4.00%

4.50%

vale

nce

19892004

0%

2%

4%

6%

6 to 11 years 12 to 19 years

Pre

0.50%

1.00%

1.50%

2.00%

Prev 2004

Ogden CL et al. JAMA 2002 Sorof JM et al. Pediatrics 2004

Age Group0.00%

Year

g

PrevalencePrevalencePrevalencePrevalence

4%10%0

Children

0

Adults

10%

Htn

Pre‐htn31%

44% Htn

86% Normal

25%

Pre‐htn

Normal

5%

Sorof JM et al. Pediatrics 2004CDC Hypertension Facts


Significance of Pediatric HypertensionSignificance of Pediatric HypertensionSignificance of Pediatric HypertensionSignificance of Pediatric Hypertension

• For children in the upper quartile of BP on any single examination, the likelihood of remaining in the upper quartile in adulthood ranged from 41 to 52 percent for systolic BP and from 35 to 44 percent for diastolic BP (B l St d ) Shear et al Pediatrics 1986;77(6):862 9BP . (Bogalusa Study)

• Association of elevated BP and cardiovascular changes like carotid intimal medial thickness LVH

Shear et.al Pediatrics. 1986;77(6):862‐9

changes like; carotid intimal medial thickness, LVH, and arterial stiffness is reported.

Sorof JM et al. Pediatrics. 2003;111(1):


AAP Recommendations for Blood AAP Recommendations for Blood Pressure MeasurementPressure Measurement

• Every child 3 years or more should have, as a part of their routine continuing medical

l bl dcare, a yearly blood pressure measurement• All acutely ill children, regardless of age, h ld h bl d dishould have a blood pressure reading performed at the time of evaluation


Conditions Under Which Children <3 Years Conditions Under Which Children <3 Years Old Sh ld H BP M dOld Sh ld H BP M dOld Should Have BP MeasuredOld Should Have BP Measured

• History of prematurity, very low birthweight, or other neonatal complication requiring intensive carep q g

• Congenital heart disease, whether repaired or non‐repaired

• Recurrent urinary tract infections, hematuria, or proteinuria

• Known renal disease or urologic malformations

Fourth report on BP. Pediatrics August 2004



Role of Adult PCP in Pediatric Role of Adult PCP in Pediatric HypertensionHypertension

• 4296 adolescents4296 adolescents – 73% 11‐14 yrs

66% boys– 66% boys

– 53% Black

48% i ht– 48% overweight

– 23% received antihypertensive treatment

f f• 60 % of patients received prescriptions from adult primary care physicians.


Yoon EY et al. Yoon EY et al. Pediatrics Pediatrics 2012;129:12012;129:1––88

CASE STUDYCASE STUDYCASE STUDYCASE STUDY


14 yrs old asymptomatic WF had a blood pressure of 14 yrs old asymptomatic WF had a blood pressure of 142/82 mm Hg on a sports physical Referred to PCP142/82 mm Hg on a sports physical Referred to PCP142/82 mm Hg on a sports physical. Referred to PCP 142/82 mm Hg on a sports physical. Referred to PCP officeofficeExam: NormalExam: Normal

10

BP: 156/80 &150/79 mm HgBP: 156/80 &150/79 mm HgWeight: 58 kg (50Weight: 58 kg (50thth %)%)Height: 174 cm (50Height: 174 cm (50thth %)%)Choose ONE best answerChoose ONE best answer1 She is hypertensive

0% 0%0%0%

1. She is hypertensive

2. She has normal BP

3 I don’t know1 2 3 4

0% 0%0%0%3. I don’t know

4. Need more information


Definition of HypertensionDefinition of HypertensionDefinition of HypertensionDefinition of Hypertension

HTN Classification 2004 Working Group (percentiles) JNC VII (mmHg)

Children Adults

Normotensive <90th <120/80

Pre‐hypertension 90th to <95th or if BP > 120/80 even <90th 120‐139/80‐89Pre hypertension 90 to <95 or if BP > 120/80 even <90 120 139/80 89

Stage I HTN 95th‐99th +5mmHg (three separate visits) 140‐159/90‐99

hStage 2 HTN >99th+5 mmHg (three separate visits) > 160/100



Blood Pressure Cuff sizeBlood Pressure Cuff sizeBlood Pressure Cuff sizeBlood Pressure Cuff size

Images MD


g

Blood Pressure Cuff SizeBlood Pressure Cuff SizeBlood Pressure Cuff SizeBlood Pressure Cuff Size

Index line Cuff length = 80% of MACIndex line

Bladder length (80%) 20%

Cuff length 80% of MAC

g ( )

Cuff width = 40% of MAC

Largest allowable mid arm circumference for bladder (100%)

Cuff width = 40% of MACMAC


circumference for bladder (100%)

Case HistoryCase HistoryCase HistoryCase History

• 12 years old boy

• Admitted for cellulitis of left lower leg• Admitted for cellulitis of left lower leg

• BP= 210/110 mm Hg

• Blood pressure rechecked

• Physical examination, Wt. 587 poundsy , p


Blood Pressure Cuff sizeBlood Pressure Cuff sizeBlood Pressure Cuff sizeBlood Pressure Cuff size



HTN Classification JNC VII (mmHg)

Adults

Normotensive <120/80

Pre‐hypertension 120‐139/80‐89Pre hypertension 120 139/80 89

Stage I HTN 140‐159/90‐99

Stage 2 HTN > 160/100



Pediatric BP StandardsPediatric BP StandardsPediatric BP StandardsPediatric BP Standards

• Blood pressure correlates with:pAge

GenderGender

Height percentile

St d d• StandardsAges 1‐12 months: 1987 task force

Ages 1‐17 years: Fourth BP report



p g

5 yrs old Girl

BP 121/80BP 121/80Height 90th

percentile90th :

Normal

95th :/

109/69Pre-HTN

112/73

HTN


Fourth Report on BP. Pediatrics August 2004

5 yrs old Girl

BP 121/80Height 90th

percentile 90th :percentile

95th :112/73

109/69

112/73

99th :120/81120/81

Stage I

>125/86

Stage II




HTN Classification 2004 Working Group (percentiles) JNC VII (mmHg)

Children Adults

Normotensive <90th <120/80

Pre‐hypertension 90th to <95th or if BP > 120/80 even <90th 120‐139/80‐89Pre hypertension 90 to <95 or if BP > 120/80 even <90 120 139/80 89

Stage I HTN 95th‐99th +5mmHg (three separate visits) 140‐159/90‐99

hStage 2 HTN >99th+5 mmHg (three separate visits) > 160/100



Following study will most likely be helpful in the Following study will most likely be helpful in the 10g y y pg y y pdiagnosisdiagnosis

10

Choose ONE best answer

1. Echocardiogram

2 Chest X ray and EKG2. Chest X‐ray and EKG

3. Ambulatory BP monitoring

4. Arteriogram of renal vessels

0% 0% 0%0%0%

g

5. Chest X‐ray and echocardiogram


1 2 3 4 5

0% 0% 0%0%0%

Case Study Case Study



ClassificationClinic BP

(percentiles)Mean ambulatory SBP (percentiles)

SBP Load (%)

Normal BP <95th <95th <25Normal BP 95 95th 25

White coat HTN >95th <95th <25

Masked HTN <95th >95th >25

P h i 95 95th 25 50Pre‐hypertension >95 <95th 25‐50

Ambulatory HTN >95th >95th 25‐50

Severe ambulatory >95th >95th >50HTN

Urbina et al. Hypertension. 2008


Clinical Evaluation of Confirmed Clinical Evaluation of Confirmed H iH i **HypertensionHypertension**

Study or Procedure PurposeStudy or Procedure Purpose

History, including sleep, family, risk Helps focus subsequent factors, diet, smoking, drinking and physical examination

evaluation

BUN creatinine electrolytes R/O renal diseaseBUN, creatinine, electrolytes, urinalysis, and urine culture CBC

R/O renal disease, pyelonephritis anemia

Renal ultrasound R/O renal scar, congenital anomaly

* * All children with persistent BP > 95All children with persistent BP > 95thth percentilepercentile


* * All children with persistent BP > 95All children with persistent BP > 95thth percentilepercentile



Fasting lipid panel, fasting glucose**

Identify hyperlipidemia and metabolic abnormalitiesglucose metabolic abnormalities

Drug screen *** Identify substances causing hypertension

Polysomnography *** Identify sleep disorder associated with HTN

thth* * All children with persistent BP > 95All children with persistent BP > 95thth percentilepercentile

** Overweight children with BP 90** Overweight children with BP 90thth --9494thth percentilepercentile*** History of drugs or snoring*** History of drugs or snoring Fourth Report on BP. Pediatrics August 2004


p g



Echocardiography** Identify LVH or other cardiac involvement

Retinal examination* Identify retinal vascular changes

ABPM *** Identify white coat hypertension

* * All children with persistent BP > 95All children with persistent BP > 95thth percentilepercentile** Children with co morbid risk factors with BP 90** Children with co morbid risk factors with BP 90thth --9494thth percentilepercentile*** When white coat hypertension suspected*** When white coat hypertension suspected

Fourth report on BP Pediatrics August 200



Clinical Evaluation of Confirmed Clinical Evaluation of Confirmed HypertensionHypertension**HypertensionHypertension

Study or Procedure Purposey

Plasma renin level Identify low renin, suggesting mineralocoticoid related HTNmineralocoticoid related HTN

Renovascular imaging Identify renovascular disease

Plasma and urine steroid levels

Identify steroid mediated HTN

Plasma and urine Identify catecholamine mediatedPlasma and urine catecholamines

Identify catecholamine mediated hypertension

* * Young children with stage 1 and any child with stage 2 HTNYoung children with stage 1 and any child with stage 2 HTN



Most Common Causes by AgeMost Common Causes by Agey gy g

< 1 th 1 th t < 6

Renal arterial thrombosis Coarctation of aorta

Renal parenchymal diseaseCoarctation of aorta

< 1 month 1 month to < 6 yr

Coarctation of aortaCongenital renal diseaseBPD

Coarctation of aortaRenal arterial stenosis

Renal parenchymal disease Essential hypertension6 to < 10 yr 10 to < 18 yr

Renal parenchymal diseaseRenal arterial stenosisEssential hypertension

Essential hypertensionEssential hypertensionRenal parenchymal disease


Classification of Hypertension in ChildrenClassification of Hypertension in Childrenand Adolescents With Therapy Recommendationsand Adolescents With Therapy Recommendationsand Adolescents, With Therapy Recommendationsand Adolescents, With Therapy Recommendations

Therapeutic Lifestyle ChangesTherapeutic Lifestyle Changes

N lN l E h lth di t l dNormalNormal Encourage healthy diet, sleep, and physical activity.

PrePre--hypertensionhypertension Recommend weight management counseling if overweight; introduce physical activity and diet management.

Stage 1 hypertensionStage 1 hypertension Recommend weight managementStage 1 hypertensionStage 1 hypertension Recommend weight management counseling if overweight; introduce physical activity and diet management.

Stage 2 hypertensionStage 2 hypertension Recommend weight management counseling if overweight; introduce physical activity and diet management.



What is the antihypertensive group of your first What is the antihypertensive group of your first h i i 14 ld l ith fi dh i i 14 ld l ith fi dchoice in a 14 years old male with confirmed choice in a 14 years old male with confirmed hypertension?hypertension?Choose ONE BEST AnswerChoose ONE BEST AnswerChoose ONE BEST AnswerChoose ONE BEST Answer

A. Thiazide diuretic

B CCBB. CCB

C. Beta blocker

D. ACEi/ARB

E. Benzodiazepine


p

Choosing an AntihypertensiveChoosing an AntihypertensiveChoosing an AntihypertensiveChoosing an AntihypertensiveNo evidence that HCTZ should be first line agent No evidence that HCTZ should be first line agent in children and adolescentsin children and adolescentsRacial differences in response to various drug Racial differences in response to various drug classes have yet to be shown in children and classes have yet to be shown in children and adolescentsadolescentsD h i t i ll b d b fit/ idD h i t i ll b d b fit/ idDrug choice typically based on benefit/side Drug choice typically based on benefit/side effect profile, availability, and ease of effect profile, availability, and ease of administrationadministrationadministrationadministrationMaximizing dose of single agent is Maximizing dose of single agent is recommended before adding an additional agentrecommended before adding an additional agentrecommended before adding an additional agentrecommended before adding an additional agent

Calcium Channel BlockersCalcium Channel BlockersCalcium Channel BlockersCalcium Channel BlockersDihydropyridine CCBsDihydropyridine CCBs

Inhibit Ca influx into vascular smooth muscle whichInhibit Ca influx into vascular smooth muscle which–– Inhibit Ca influx into vascular smooth muscle which Inhibit Ca influx into vascular smooth muscle which decreases peripheral vascular resistancedecreases peripheral vascular resistance

–– Common first line agent when etiology of HTN is unknownCommon first line agent when etiology of HTN is unknown–– Side effectsSide effects

Flushing, Headache, peripheral edema, fatigueFlushing, Headache, peripheral edema, fatigue–– ExamplesExamplesExamplesExamples

Amlodipine (0.1 Amlodipine (0.1 -- 0.6 mg/kg/day q day)0.6 mg/kg/day q day)–– Infants may need BID dosingInfants may need BID dosing–– Can be compounded in a 1 mg/mL suspensionCan be compounded in a 1 mg/mL suspensionp g pp g p

Nifedipine XR (0.25 mg/kg/day Nifedipine XR (0.25 mg/kg/day –– no max dose established q day no max dose established q day or BID)or BID)

–– Capsule must be swallowed wholeCapsule must be swallowed whole

–– The use of short acting CCBs (e.g. Nifedipine) is not The use of short acting CCBs (e.g. Nifedipine) is not recommended for chronic treatment of HTNrecommended for chronic treatment of HTN

ACE Inhibitors/ARBsACE Inhibitors/ARBsACE Inhibitors/ARBsACE Inhibitors/ARBsTypically well tolerated although concern for inducing Typically well tolerated although concern for inducing renal failure limits use prior to evaluationrenal failure limits use prior to evaluationrenal failure limits use prior to evaluationrenal failure limits use prior to evaluationFirst line agents in diabetics and patients with proteinuriaFirst line agents in diabetics and patients with proteinuriaSide effectsSide effects

Cough (ACEi) angioedema decline in renal functionCough (ACEi) angioedema decline in renal function–– Cough (ACEi), angioedema, decline in renal function, Cough (ACEi), angioedema, decline in renal function, hyperkalemiahyperkalemia

–– ACE fetopathy during 2ACE fetopathy during 2ndnd and 3and 3rdrd trimestertrimesterExamplesExamplesExamplesExamples–– Lisinopril (0.07 Lisinopril (0.07 -- 0.6 mg/kg/day q day)0.6 mg/kg/day q day)

May need BID dosing in infantsMay need BID dosing in infantsCan be compounded as a 1 mg/mL suspensionCan be compounded as a 1 mg/mL suspension20 20 –– 30 mg is typically max dose at which BP response is observed30 mg is typically max dose at which BP response is observed

–– Enalapril (0.08 Enalapril (0.08 -- 0.6 mg/kg/day q day or BID)0.6 mg/kg/day q day or BID)Can be compounded as a 1 mg/mL suspensionCan be compounded as a 1 mg/mL suspension

Losartan (0 7Losartan (0 7 1 4 mg/kg/day q day)1 4 mg/kg/day q day)–– Losartan (0.7 Losartan (0.7 -- 1.4 mg/kg/day q day)1.4 mg/kg/day q day)Can be compounded as a 2.5 mg/mLCan be compounded as a 2.5 mg/mL

Management AlgorithmManagement AlgorithmF th R t BP P di t i A t 2004

Measure BP and Height and Calculate BMIDetermine BP category for sex, age, and height

g gg gFourth Report on BP. Pediatrics August 2004

Educate on Heart Healthy

Prehypertensive

90–<95% <90%

Normotensive

TherapeuticLifestyle

Stage 2 Hypertension Stage 1 Hypertension

Repeat BPLifestyle

For the family

Diagnostic Workup Includes

>95%

LifestyleChanges

Repeat BPIn 6 months

Over 3 visits

90–<95% or 120/80 mmHg

or 120/80 mmHg

Diagnostic Workup Includes

Rx Specific

Evaluation for Target-Organ Damage

SecondaryHypertension

In 6 months

Consider Diagnostic Workup and

PrimaryHypertension

Consider Referral

Evaluation for Target-Organ Damage

Therapeutic

SecondaryHypertension

or PrimaryHypertension

Rx Specificfor Cause

>95% OverweightNormal BMI Overweight

Consider Diagnostic Workup and Evaluation for Target-Organ Damage

If overweight or comorbidity exists

Normal BMI

Consider ReferralTo provider with expertisein pediatric hypertension

Overweight Normal BMI

Therapeutic LifestyleChanges

Drug Rx‡ MonitorQ 6 Mo

BMI

Weight Reduction

BMI

Drug Rx Weight Reductionand Drug Rx

Weight Reduction

Still >95%

BMI

Athletic ParticipationAthletic ParticipationAthletic ParticipationAthletic Participation

• Regular, non‐competitive physical activity should be g p p y yencouraged because it reduces hypertension.

• Dynamic exercise– Increase SBP

– Moderate increase in MAP

– Decrease in DBP, and TPR

• Static exercise– SBP, DBP, MAP all increase significantly

– TPR unchanged


Athletic ParticipationAthletic ParticipationAthletic ParticipationAthletic Participation


IIIABobsledding/lugeField events

IIIBBody buildingDownhill skiing

IIICBoxingCanoeing/kayaking

GymnasticsMartial artsSailing, water skiingWeight liftingWindsurfing

gSnowboardingSkateboardingWrestling

g/ y gCyclingDecathlonRowingSpeed skatingTriathlonWindsurfing Triathlon

IIAArcheryAuto racingDiving

IIBAmerican football, jumpingFigure skating, RodeoRugby

IICBasketballIce hockeyCross country skiingDiving

EquestrianMotorcycling

RugbyRunning (sprint)SurfingSynchronized swimming

Cross‐country skiingLacrosseRunningTeam handball

IABilliardsBowlingCricket

IBBaseball/softballFencingTable tennis

ICBadmintonField hockey, TennisOrienteering

CurlingGolfRiflery

Volleyball Race walkingRacquetball/squashRunning (long distance)Soccer


RecommendationsRecommendationsRecommendationsRecommendations

• Lifestyle modification.y

• Pre‐hypertension , no restriction.

• Stage I hypertension: In absence of TOD including g yp gLVH or concomitant heart disease , no restriction. Recheck BP in 1‐2 weeks to confirm hypertension

• Stage 2 hypertension: in the absence of TOD, restrict high static sport until BP in normal range.

• HTN and other CV disease– Participation is based on type and severity of CVS disease


RecommendationsRecommendationsRecommendationsRecommendations

• Salt intake in athletes.

• Care should be taken to appropriately diagnose and monitor the overweight athletes and athletes with spinal cord injuries


SummarySummarySummarySummary

• Prevalence of hypertension is much lower in childrenPrevalence of hypertension is much lower in children compared to adults but has increased significantly in last 15 years.

• Adult hypertension may have roots in pediatric age, so it is important to identify these children.

• Accurate BP measurement is the key for diagnosis.

• ABPM study may be helpful before initiating pharmacologic treatment.


hypertension in children - university of arkansas for ... docs 2/news/kidney 2012/hypertension...

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