Alisa A. Acosta, MD, MPHAsst. Professor, Renal Section

April 5, 2019

Pediatric Hypertension

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Objectives

• Recognize the importance of accurate blood pressure measurement in pediatric patients

• Define pediatric hypertension (HTN) according to the 2017 AAP Clinical Practice Guidelines

• Evaluate a pediatric patient with HTN

• Manage basic pediatric HTN

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Absolute Risk for Ischemic Heart Disease Mortality –Systolic BP

(Graph looks similar for stroke risk)

Adult Data

Lancet 2002; 360: 1903-13

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HTN in Adults• Almost one in three adults has HTN (32.6%)

- Almost half don’t know it (17.2%)- Almost 46% are under-treated

• Lowering BP in adults with Stage 1 HTN leads to a reduction in the incidence of:- Myocardial infarctions (20-25%)- Stroke (35-40%)- Heart Failure (>50%) - AND overall mortality (~10% at 10 years)

Mozaffarian D et al, Circulation 2016;133:447-454

Chobanian, Hypertension 2003;42:1206-52

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Pediatric Hypertension

• Generally healthy children with primary HTN do not suffer from CV end points seen in adults

• Children with elevated BP are likely to become adults with hypertension

• Prevention, early detection, and appropriate treatment for those at risk is the way to eliminate the burden of this disease

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History of Hypertension in Pediatrics• Before 1977: no accepted normative data

• 1977: 1st Task Force Report (3 sources)

- Normative data for children

- Defined HTN >95th percentile for age & gender

• 1987: 2nd Task Force Report (9 sources)

- Additional data for over 60,000 children

- Improved racial mix

• 1996: Task Force Update

- Incorporated height in the BP norms

• 2004: Fourth Working Group Report

• 2017: AAP Clinical Practice Guidelines (CPG)

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http://pediatrics.aappublications.org/content/early/2017/08/21/peds.2017-1904

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Table 1Summary of KAS for Screening and Management of High BP in Children and Adolescents

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Table 11Patient Evaluation & Management According to BP Level

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Classification of BP – Children

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-2 -1 0 1 2

5%

z = +1.65

95%

Epidemiologic Definition

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Who should have BP measured

• Children ≥3 years old should have BP measured annually

• Children ≥3 yrs at every health care encounter if meds/conditions increase risk for HTN

• Children < 3 years should have BP measured under special circumstances

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Special Circumstances for Children < 3 years old

- Prematurity <32 wks or SGA, VLBW, other

- Congenital heart disease

- Renal disease or urologic malformation

• Recurrent UTI, hematuria, proteinuria

• FH of congenital renal disease

- Solid-organ transplant

- Malignancy or BMT

- Tx with meds known to raise BP

- Other systemic illnesses a/w HTN (NF, TS)

- Evidence of elevated intracranial pressure

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Four Clinical Questions

1. Does my patient have hypertension?2. Why does my patient have hypertension?3. Is there any evidence of target organ

damage?4. Are there any other modifiable risk

factors for CVD?

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Case 1

• A 7 year old boy comes to your office for a well child check. Ht is 25th% and wt is >95th%. In triage using a machine and a child cuff, his blood pressure measures 117/78. His history and exam are normal.

• Does he have an elevated blood pressure?

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50th%ile - 94/56

90th%ile - 107/6895th%ile - 110/7195th+12 - 122/83

Pt’s BP: 117/78

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Dilemma of BP Measurement

• Norms based on auscultatory measurements with mercury manometers

• Oscillometric monitors are largely used- Poor correlation with auscultatory methods- Measure the MAP, calculates SBP & DBP using

proprietary, unpublished algorithms• BP > 90th percentile by oscillometric devices

should be repeated by auscultation

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BP Measurement

•Properly positioned-Seated-Back Supported-Feet on the floor-Arm resting at heart level

•After 5 mins of rest

•Empty bladder

•Avoidance of stimulant drugs or foods 30 mins prior

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Proper Cuff Size

•Small cuffs over-

estimate BP more

than large cuffs

under-estimate BP

•Between sizes,

choose the larger

cuff

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Case 1

• You re-measure the blood pressure by auscultation after at least 5 minutes of rest. You measure the arm circumference to be 32 cm.

• Child cuff 15-29 cm• Adult cuff 29-42 cm

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After changing to an adult cuff, his blood pressure was recorded as 105/67

50th%ile - 94/56

90th%ile - 107/6895th%ile - 110/71

95th+12 - 122/83

Pt’s Original BP: 117/78

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Does this patient have hypertension?

no

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Case 2

• A 14 yr old boy has multiple visits with an elevated blood pressure ranging from the 130s-143/ 70s-90 measured by auscultation with an appropriate sized cuff

• Height and weight =95th percentile• Remainder of his history and physical exam is

benign, and there is no family history of hypertension

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Does this patient have hypertension?

Patient’s BP = 130s-143/ 70s-90s

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Is clinic BP the best measure?

• 24 hr Ambulatory Blood Pressure Monitoring

• Useful in the evaluation of- White coat hypertension- Apparent drug resistant hypertension

- Evaluation of drug-induced hypotension

• Provides an overall BP pattern- BP load- Nocturnal BP

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24 hr Ambulatory BP Monitoring• White-Coat Hypertension

- Clinic BP is high but ambulatory BP (ABP) is normal- Prevalence in children is up to 62%, probably 20%- “Pre-hypertensive state?”

• Masked Hypertension- Clinic BP is normal but the ABP is elevated- Occurs in ~10% of youth- Same risk for CVD as those with sustained HTN

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Case 2: 24 hr ABPMSystolic BPMean Arterial PressureDiastolic BP

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130 mmHg77 mmHg

95th %ile

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Does this patient have hypertension?technically, no – white

coat HTN

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Case 3

• An 8 yr old boy had an elevated mean BP by auscultation with an appropriate sized cuff on 3 separate occasions: 148/78, 154/90, 142/81

• Asymptomatic, no significant PMH. MGM has HTN• Wt 34.5kg (75%), Ht 131.5cm (25%), BMI 20.6 (90%)

• BP in RLE 103/72

• Exam is benign but difficult to palpate LE pulses

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Does this patient have hypertension?148/78, 154/90, 142/81

90th%ile – 110/72

95th%ile – 114/77

99th%ile – 122/85

Yes,Stage II

Why does he have hypertension?

Case 3

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Evaluation for Secondary HTN

• Secondary hypertension is more common in children

• The younger the child and /or the more severe the hypertension, the more likely there is a secondary cause

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Causes of Hypertension• Renal parenchymal disease

- Congenital anomalies of the urinary tract- Glomerulonephritis- Polycystic kidney disease- Sequelae of acute kidney injury, i.e. HUS- Chronic kidney disease- Systemic vasculitis with renal involvement

• Renovascular defect- Fibromuscular dysplasia- Midaortic syndrome- Renal vein thrombosis

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Causes of Hypertension

• Coarctation of the aorta• Pulmonary

- Chronic lung disease of the newborn

• Monogenic forms- AME- Liddle’s syndrome- Gordon’s syndrome- GRA

• Renal Tumors

• Endocrine- Catecholamine excess

• Pheochromocytoma• Paraganglioma• Neuroblastoma

- Cushing syndrome- Hyperaldosteronism- Thyroid disorders- Congenital adrenal

hyperplasia- Hypercalcemia

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Initial Evaluation

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Initial Evaluation• Thorough history and physical exam

• Electrolytes, BUN, creatinine• CBC

• +/- Thyroid function studies

• Urinalysis +/- urine cx• Renal ultrasound

- Scars

- Congenital anomaly

- Discordant kidney size

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Further Evaluation• Renovascular imaging• Plasma renin• Plasma and urine steroid levels• Plasma and urine catecholamines

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Case 3• Normal renal ultrasound

• Normal urinalysis• Normal electrolytes, BUN, Cr

• Normal thyroid function tests

• Echocardiogram- Functional bicuspid aortic valve

- Distal aortic arch appeared narrowed

- Abdominal Doppler suggested mild obstruction

- Mild concentric left ventricular hypertrophy

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Four Clinical Questions

1. Does my patient have hypertension?

2. Why does my patient have hypertension?

Yes

Coarctation of the aorta

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Case 4

• 11 yr old female, elevated BP by auscultation on multiple occasions, 126-130/78-89, confirmed by ABPM

• She is asymptomatic. Mom and maternal grandparents have hypertension.

• Negative PMH• Wt 91.4kg (>97%), Ht 160.9cm (>97%), BMI 35.3kg/m2 (>95%)• Exam is unremarkable including 4 extremity BP

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Four Clinical Questions

1. Does my patient have hypertension?

2. Why does she have hypertension?

Yes, stage I

90th%ile – 120/77

95th%ile – 124/8199th%ile – 131/89

126-130/78-89

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Case 4

• Normal urinalysis• Normal electrolytes, BUN, Cr• Normal thyroid function tests• Normal renal ultrasound (not indicated)

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Four Clinical Questions

1. Does my patient have hypertension?

2. Why does my patient have hypertension?

Yes

Primary hypertension, likely obesity-related, family history, etc.

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The Obesity Epidemic

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Prevalence of Obesity* Among US Children and Adolescents (aged 2 – 19 years)

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

NHANES II 1976-1980 NHANES III 1988-1994 NHANES 1999-2002 NHANES 2003-2006

Ages 2 - 5 Ages 6 - 11 Ages 12 - 19 www.cdc.gov

*age and sex-specific BMI ≥ 95th percentile

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Hypertension follows Obesity

Distribution of BMI percentiles and the prevalence of HTN within each BMI percentile category

Sorof et al, J Pediatr 2002;140:660-6

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Four Clinical Questions

1. Does my patient have hypertension?

2. Why does my patient have hypertension?

3. Is there any evidence of target organ damage?

Yes

Likely obesity-related, family history

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Target Organ Damage•Measurable abnormalities attributed to HTN that occur before significant cardiovascular events

-Microalbuminuria or overt proteinuria

-Hypertensive retinopathy

-Left ventricular hypertrophy

-Increased carotid artery intima media thickness

-Decreased vascular compliance

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Left Ventricular Hypertrophy

•Most prominent evidence of target organ damage- Echocardiography should be performed at the

time of consideration of pharmacologic therapy

- Monitored every 6 -12 months

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Four Clinical Questions1. Does my patient have hypertension?

2. Why does my patient have hypertension?

3. Is there any evidence of target organ damage?

4. Are there any other modifiable risk factors for CVD?

Yes

Likely obesity-related, family history

Yes, LVH on echocardiogram

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Evaluation for Co-morbidities•Fasting labs

-Lipid panel

-Hgb A1c

-AST, ALT

•If indicated:-Drug Screen

-TSH

-CBC

-Polysomnography•Snoring or other symptoms of sleep disorded breathing

•Nocturnal hypertension

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Case 4

• Fasting labs- Normal lipid panel - Normal Hgb A1c

• Sleep Study- Obstructive sleep apnea- Treated with CPAP

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Four Clinical Questions1. Does my patient have hypertension?

2. Why does my patient have hypertension?

3. Is there any evidence of target organ damage?

4. Are there any other modifiable risk factors for CVD?

Yes

Likely obesity-related, family history

Yes, LVH on echocardiogram

Several: wt management, insulin resistance, sleep apnea

How should I treat my patient’s hypertension?

Now what?

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Meds or no meds?

• Therapeutic lifestyle changes initiated in all patients- Healthy eating- Regular cardiovascular exercise - Good sleeping habits

• Family-based intervention improves success• Avoid stimulant medications when possible

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Weight Loss

• Indicated in obesity-related HTN• Weight loss improves

- BP in overweight adolescents- Salt sensitivity of BP - Decreases other cardiovascular risk factors

• Dyslipidemia• Insulin resistance

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Sodium Restriction

• Increased sodium intake is associated with

higher BP at all ages

• Current Recommendations

- 4-8 year olds – 1.2 g/day

- > 8 years – 1.5 g/day

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Physical Activity

• Regular physical activity is beneficial for preventing and treating HTN in adults

• In children- Inverse relationship between fitness and SBP- Improved fitness slows the progression of

elevated BP at one year- Studies suggest an effect of exercise on BP

reduction independent of weight loss

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Indications for Pharmacotherapy

• Symptomatic hypertension• Secondary hypertension• Stage 2 hypertension • Target organ damage• Diabetes (types 1 and 2), CKD• Persistent hypertension despite

nonpharmacologic measures

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Pharmacotherapy

• Clinical trials have expanded the number of drugs with pediatric dosing

• Pharmacotherapy should be initiated with a single drug

• Goal is a reduction of BP to <95th percentile- Goal of <90th percentile if concurrent conditions

are present

PharmacotherapyACE inhibitor Benazepril, Captopril, Enalapril,

Fosinopril, Lisinopril, Quinapril

Angiotensin-receptor blocker Irbesartan, Losartan, Valsaratan,Telmisartan

α- and β-antagonist Labetalol

β-antagonist Atenolol, Bisoprolol/HCTZ, Metoprolol, Propranolol

Calcium channel blocker Amlodipine, Felodipine, IsradipineExtended-release nifedipine

Central α- agonist Clonidine

Diuretic Furosemide, HCTZ, Amiloride Spironolactone, TriamtereneChlorthalidone

Peripheral α- antagonist Doxazosin, Prazosin, Terazosin

Vasodilator Hydralazine, Minoxidil

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Choosing a Medication• Based on benefit/side effect profile, availability,

and ease of administration • No evidence HCTZ should be first line agent• Racial differences in response to various drug

classes have yet to be shown• Maximize the dose of single agent before adding

additional agents

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Choosing a Medication

• Calcium channel blockers are generally safe first line agents while awaiting evaluation

• Beta blockers- Avoid the use in asthma patients- Preferred drug if history of migraine HA

• Avoid ACEi and ARB until renal evaluation is complete

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