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How to diagnose it.

And how to fix it.

Clark Crane, MD
Noon Conference, 3/20/19

 Understand the epidemiology and etiology of childhood/adolescent hypertension

 Identify age-specific blood pressure cut-offs and diagnostic criteria for elevated blood
pressure and hypertension
 Take a blood pressure the correct way
 Start the basic HTN evaluation
 Don’t miss secondary hypertension
 Counsel on lifestyle changes
 Challenge yourself to get comfortable prescribing meds in the appropriate circumstances
 Know when to refer

 An 11 year old boy presents for a routine well child check. While
reviewing the chart, you note that Epic flags his BP of 122/82 as
>95%ile for his age and height. What do you do next?
A. Have the MA recheck the blood pressure
B. Confirm the BP with auscultation
C. Follow-up in 6 months for BP check
D. Start amlodipine
E. Ignore it; he was upset
 Prevalence depends on definition
 Increase of “elevated blood pressure” when using
new guidelines
 ~14-16% prevalence of elevated blood pressure, 2-4%
with hypertension
 Interestingly, prevalence decreased from 2001 to 2016
looking at NHANES data

Epidemiology  More common in obese and overweight…and this

prevalence is clearly increasing
 Other risk factors include family history (more likely in
primary than secondary), male gender, OSA, sleep
duration, IUGR, extreme prematurity, cigarette
smoke exposure, hypertension in pregnancy
Hypertension. 2019 Jan;73(1):148-152
MMWR Morb Mortal Wkly Rep. 2018 Jul 13;67(27):758-762
MMWR Morb Mortal Wkly Rep. 2018 Jul 13;67(27):758-762
Why it matters

It is well established that HTN and elevated BP in childhood increases risk of adult HTN
and metabolic syndrome

Some studies suggest correlation between childhood SBP and adult CAD

Presence of intermediate markers of CVD (increased LV mass, cIMT, and pulse

wave velocity) seen in pediatric patients with HTN are known to predict CV events
in adults

J Pediatr. 2011 Oct;159(4):584-90—Pediatr Nephrol Feb;25(2):323-8—

Circulation. 2010 Feb 2;121(4):505-11
Etiology: Primary Hypertension

Diagnosis of exclusion;
Multifactorial; renal salt
more likely in school-
retention, increased
aged children and
RAAS, endothelial
adolescents who have a
family history of HTN, and
are overweight or obese
Etiology: Secondary Hypertension

Identifiable cause: See UpToDate for list

Potentially curable

Potentially accounting for 55-67% of HTN in

children, although these are older studies
Per AAP guidelines, BP should be checked
annually in all children ≥ 3 years old

Screening At every healthcare encounter if obesity, BP

raising medications, renal disease, history of
coarctation or DM

2017 Sep;140(3).
pii: e20171904.
Oscillometric devices are sufficient for screening
but any elevated values should be confirmed by
Consider ABPM for confirmation if elevated
BP category for over 1 year or stage I HTN
for more than 3 clinic visits
History of prematurity <32 week’s gestation or small for gestational age, very low birth weight, other neonatal
complications requiring intensive care, umbilical artery line
Congenital heart disease (repaired or unrepaired)
Recurrent urinary tract infections, hematuria, or proteinuria
Known renal disease or urologic malformations
Family history of congenital renal disease
Solid-organ transplant
Malignancy or bone marrow transplant
Treatment with drugs known to raise BP
Other systemic illnesses associated with HTN (neurofibromatosis, tuberous sclerosis, sickle cell disease,114 etc)
Evidence of elevated intracranial pressure

Screen under three years of age in specific populations

Pediatrics. 2017 Sep;140(3). pii: 20171904.
How to take a blood pressure

 Seated in a quiet room for 3–5 min before measurement, with the back supported and feet uncrossed
on the floor.
 BP should be measured in the right arm. The arm should be at heart level, supported, and uncovered
above the cuff. The patient and observer should not speak while the measurement is being taken.
 The correct cuff size should be used. The bladder length should be 80%–100% of the circumference of
the arm, and the width should be at least 40%.
 Auscultatory BP:
 Bell of the stethoscope should be placed over the brachial artery in the antecubital fossa, and
the lower end of the cuff should be 2–3 cm above the antecubital fossa. The cuff should be
inflated to 20–30 mm Hg above the point at which the radial pulse disappears.
 Deflate at a rate of 2–3 mm Hg per second. The first (phase I Korotkoff) and last (phase V
Korotkoff) audible sounds should be taken as SBP and DBP.
Pediatrics. 2017 Sep;140(3). pii: e20171904.
Auscultation vs Oscillometric

 Oscillometric devices derive SBP and DBP by measuring MAP based upon pressure
oscillations of the brachial artery wall as the cuff is deflated
 Appropriate to use for screening (assuming the device is validated in a pediatric age
 Measurements > 90th percentile need to be repeated by auscultation
 Oscillometric BP generally higher (~2.53mmHg), worse in non-validated devices and younger ages

Pediatrics. 2017 Sep;140(3). pii: e20171904.

J Hypertens. 2017 Feb;35(2):213-224.

 You confirm a blood pressure of 115/75 by auscultation. Checking

the tables, this is just above the 90%ile for his age and height. Since
you are very interested in optimizing billing, what diagnosis do you
add to the problem list?
A. Elevated blood pressure
B. Essential hypertension
C. Stage 1 hypertension
D. Stage 2 hypertension
For Children Aged 1–<13 y For Children Aged ≥13 y
Normal BP: <90th percentile Normal BP: <120/<80 mm Hg
Elevated BP: ≥90th percentile to <95th Elevated BP: 120/<80 to
percentile or 120/80 mm Hg to <95th 129/<80 mm Hg
percentile (whichever is lower)
Stage 1 HTN: ≥95th percentile to <95th Stage 1 HTN: 130/80 to 139/89
percentile + 12 mmHg, or 130/80 to 139/89 mm Hg
mm Hg (whichever is lower)
Stage 2 HTN: ≥95th percentile + 12 mm Hg, or Stage 2 HTN: ≥140/90 mm Hg
≥140/90 mm Hg (whichever is lower)

Use BP tables or app

 “Pediatric Blood Pressure Guide” ($0.99)
 “Pediatric Blood Pressure 2017” (free)
Pediatrics. 2017 Sep;140(3). pii: e20171904.

 Hypertension is diagnosed when

the the auscultatory-confirmed
average systolic and/or diastolic
blood pressure ≥ 95th percentile
for gender, age, and height
percentile on ≥ 3 occasions
 Secondary HTN is diagnosed
when an underlying cause is
 Primary (”Essential”) HTN is a
diagnosis of exclusion

 Your 11 year old patient has a confirmed single elevated blood

pressure reading. In addition to discussing diet and activity, how
will you proceed with follow-up?
A. Follow-up in 1 week for blood pressure check
B. Follow-up in 1 month
C. Follow-up in 6 months
D. Order ambulatory blood pressure monitoring (ABPM)
E. Recommend buying a BP cuff and recording home measurements to
discuss at follow-up
Approach: Elevated Blood Pressure

≥90th percentile to <95th percentile

 Discuss lifestyle
 Low sodium diet and/or DASH diet, more physical activity
and minimize screen time
 Recheck in 6 months
 If remains elevated, check upper and lower extremity BP (to
rule out coarctation) and recheck in 6 months
 If remains elevated, continue to counsel on lifestyle and
consider additional workup
 Consider ABPM

 Ambulatory blood pressure monitoring

 Cuff and box that records BP every 20-30 minutes throughout the day and night
 Can be helpful to confirm diagnosis and has been shown to be more accurate than clinic-
measured BP
 Likely needs Nephrology referral given limited access to devices and need for interpretation
 Can also be quite annoying for the patient

J Hypertens. 2010;28:e423–e424
≥95th percentile to <95th percentile + 12 mmHg
 Discuss lifestyle

Approach:  Recheck in 1-2 weeks

 If remains elevated, check upper and lower extremity
Stage I HTN BP (to rule out coarctation) and recheck in within 3
 If remains elevated, needs further workup and
continued emphasis on lifestyle
≥95th percentile + 12 mmHg
 If symptomatic (headache, vision changes, chest pain,
abdominal pain, poor feeding, confusion, seizures),
proceed to ED
Stage II HTN  If asymptomatic, check upper and lower extremity BP,
discuss lifestyle, and repeat in 1 week
 Depending on the situation, initiate additional workup,
offer pharmacotherapy, or refer

 At follow-up, your patient’s blood pressure is worse. It is now slightly over the 95%ile
and, after confirming this on 3 separate occasions, you have diagnosed him with
stage I hypertension. Physical exam is only notable for BMI 90%ile for age. Both his
parents are being treated for essential hypertension. How do you proceed?
A. Continue to emphasize lifestyle interventions without additional workup
B. Obtain BMP, UA, CBC, lipids, A1c
C. Obtain the above plus additional labs and imaging to evaluate the most common causes
of secondary hypertension
D. Refer to Nephrology

 Children ≥ 6 years of age do not require extensive

evaluation for secondary HTN if there is a positive family
history, are overweight/obese and/or do not have
concerning physical exam findings
Evaluation: Labs

 Goal is to identify possible secondary cause of hypertension and to evaluate for target organ damage
 Stage I HTN
 Renal Function Panel
 UA (protein), urine culture
 Urine protein/creatinine ratio
 TSH, fT4
 Lipid panel, A1c
 Stage II
 Renin and aldosterone
 If proteinuria, consider C3 and C4, ANA, dsDNA
Evaluation: Imaging

 Renal ultrasound with doppler

 Identify presence of both kidneys, presence of any congenital anomaly, or disparate renal size,
which may suggest renal scarring
 Echocardiogram
 To assess for coarctation and cardiac target organ damage
 LVH is defined as LV mass >51 g/m or LV mass >115 g per body surface area (BSA) for boys and LV
mass >95 g/BSA for girls
 Grade C, moderate recommendation
 As an aside, is this really helpful?
 CTA or MRA if concern for renal artery stenosis
 Probably leave this to specialist; try to minimize radiation and contrast exposure
Pediatrics. 2017 Sep;140(3). pii: e20171904.

 Which of the following dietary interventions is most effective for

reducing blood pressure?
A. Sodium restriction alone
B. DASH diet
C. Mediterranean diet
D. MIND diet
E. Flexitarian diet
Recommended for all
 Sodium restriction, DASH diet
 Limited pediatric data for
sodium restriction, well
established adult outcomes
with DASH
 Handouts available in iCentra
 Google “DASH diet for kids
pdf” or “DASH diet pdf”
 Dietitian referral, talk about
paying attention to nutrition

Pediatrics. 2017 Sep;140(3). pii: e20171904.

Management: Lifestyle

 Vigorous activity (30-60 minute session) at

least 3 to 5 days per week
 Limit unnecessary screen time
 Just decrease sedentary time!
 Involve the family

 Weight loss has only been shown to reduce blood pressure in adults; like many others,
the pediatric recommendations are extrapolated from adult data.
A. True
B. False
Weight loss!

 2014 systematic review showed obesity intervention regimens reduced BP with a mean
decrease of 1.64 mmHg (95% CI -2.56 to -0.71) in systolic BP (SBP) and 1.44 mmHg (95% CI -
2.28 to -0.60) in diastolic BP (DBP).
 Similar to results seen in adults (~1 mmHg for every 1 kg lost)
 Combined diet and physical activity interventions led to a significantly greater reduction
in both systolic BP and diastolic BP than the diet-only or physical activity-only intervention

Circulation. 2014 May;129(18):1832-9.


 What is your patient’s goal blood pressure?

A. BP below the 95th percentile or <140/90 if over 13 years old
B. BP below the 90th percentile or <130/80 if over 13 years old
C. Not sure; there’s no good data
D. Until they have positive orthostatics

 Your patient has made moderate progress adhering adhering to

lifestyle modifications. His additional workup revealed normal labs
with exception of Hgb A1c of 6.5%. Unfortunately he continues to
have blood pressures >95%ile. What is your next step?
A. Continue to emphasize diet and activity only
B. Start antihypertensive meds
C. Start Metformin
D. Refer to Endocrine
E. Refer to Nephrology
Management: Indications for meds

 Stage 2 HTN (without a clearly modifiable risk factor)

 Stage 1 HTN
 No improvement after 3-6 months of lifestyle changes
 Secondary hypertension
 LVH or target-organ damage
 Symptomatic
 Diabetes, hyperlipidemia, or other CV risk factors
 Kidney disease

 Due to lack of improvement after 3-6 months of lifestyle changes,

you decide medications are now indicated. Your patient weighs
45 kg. What do you start?
A. Amlodipine 2.5 mg daily
B. Lisinopril 5 mg daily
C. Chlorthalidone 12.5 mg daily
D. I wouldn’t feel comfortable prescribing these meds
Calcium channel blockers

 Long-acting dihydropyridine agents; good all around

 Safe and effective
 Class example: amlodipine
 Start 0.1 mg/kg/dose daily to BID
 Increase up to 0.6 mg/kg/day (max 20 mg per day)
 For > 6 years old, 2.5 to 5 mg daily is an effective dose
 Likely safe to go up to 10 mg in larger adolescents
 Side effects: edema, orthostasis, fatigue

 Best for use in proteinuric renal disease, diabetes, heart failure, high renin activity
 Avoid in bilateral renal artery stenosis, solitary kidney, hyperkalemia, pregnancy
 Class example: Lisinopril
 Start 0.07-0.1 mg/kg/dose daily
 Can increase up to 0.6 mg/kg/day, max 40 mg/day
 Typical starting adolescent/adult dose is 5 or 10 mg
 Counsel about fluid intake; kidneys (SCr) can be very sensitive to volume depletion
 Side effects: dizziness, increased SCr (less than 30% acceptable), hyperkalemia,
cough, teratogenicity (protect the kidneys at the cost of kidneyless babies)

 You decide to start an ACEI due to concern for developing

comorbid diabetes. What is your next step?
A. Follow-up in 4 weeks for repeat blood pressure
B. Obtain BMP in 1-2 weeks
C. Obtain urine microalbumin/creatinine ratio in 1-2 weeks
D. Obtain a random fasting glucose

 Useful with concomitant heart failure or tachyarrhythmias

 Concerns in setting of impaired glucose tolerance, interference in lipid metabolism,
and airway reactivity in children with asthma. Don’t use in athletes.
 Class example: Labetalol
 Start at 1 – 3 mg/kg/day divided BID
 Increase to max of 12 mg/kg/day with max of 1200 mg/day
 Reasonable to start adolescents/adults at 100 mg BID
 Side effects: bradycardia, orthostatic hypotension, edema, weight gain,
hyperglycemia, fatigue

 Typically thiazide class used in setting of normal renal function

 Good for an initial or second agent
 Concerns include potassium losses, hyperglycemia and
potential for volume depletion
 Class example: HCTZ
 Start 0.5 to 1 mg/kg daily
 Can increase to 3 mg/kg daily, max of 50 mg/day
 Typically start adolescent/adults on 12.5 mg daily
 Side effects: Hypokalemia, hyperglycemia, volume depletion,

 Your patient is tolerating lisinopril well at a 6 week follow-up. The follow-up chemistry was
normal. Blood pressures are improved but still remain elevated above your goal. What do
you do next?
A. Be content with the progress made
B. Increase the dose
C. Add a second agent
D. Refer to Nephrology
 Begin with lowest dose of a single agent
 Limited evidence to guide best initial agent
 Provider comfort level and guided by
 All are likely equally effective and safe

Management:  Check labs in 1-2 weeks (particularly

important for ACEI and diuretics)
Meds  Close follow-up with repeat blood pressure
in 2-4 weeks
 Increase dose if not at goal BP (<90%ile) by
4-8 weeks
 If at goal, continue to follow closely, at
least every 3 months
 Screen! And ensure blood pressures are taken correctly
 Make the diagnosis
 Start the initial workup (labs, renal ultrasound)
 Lifestyle counseling
 Dietitian referral

What you can  Regular and close follow-up; motivational


do as a PCP  If overweight/obese, refractory to lifestyle measures and

in the absence of concerning features, don’t be afraid
to start meds
 Pick one, understand it well
 Close follow-up and titration
 Refer if uncomfortable
When to refer

If uncomfortable

Stage 2 HTN or evidence of end organ damage

Concern for secondary cause of hypertension

Concern for underlying renal disease (abnormal SCr, proteinuria, etc)

HTN refractory to lifestyle changes and initial medication