With hypertension increasingly common in young children and adolescents, PCPs need to know how to assess the numbers and reach diagnoses with confidence – as well as how to explain to families the long-term importance of bringing blood pressure under control. This guide from pediatric nephrologist Sanober Sadiq, MBBS, offers clarity on best practices for measuring BP, distinguishing secondary hypertension from primary, and starting drug therapy. She also discusses valuable lifestyle modifications and how to help kids set goals and comply with treatment plans. Bonus: Find out when to consider ambulatory monitoring.
So, yeah, so as Amy said, I'm soo um Sadiq. Um I'm one of the pediatric nephrologist um that works at U CS F. Um um and I recently started working. Um and so my talk today is on pediatric hypertension. Um I'm going to go through the objectives of this talk, which is firstly to define what is pediatric hypertension and then use the current hypertension guidelines to make diagnostic decisions and to apply diagnostic and treatment strategies for um hypertension management. So, firstly, what is hypertension? So that is defined as the systolic blood pressure, greater than equal to 95th percentile and the diastolic blood pressure um uh greater than equal to 95th percentile. Um That also defines hypertension. So it's just not the systolic blood pressure, but also the diastolic blood pressure are having both the systolic and the diastolic blood pressure greater than equal to 95th percentile. Um There can be a lot of variability in blood pressure measurements. It depends a lot on the technique. It depends a lot on the patients. So blood pressure levels, if they are greater than equal to 95th percentile should be found on three separate visits. Um And that is how we diagnose someone with hypertension. Now, I do want to point out an exception over here, which I'm going to talk about in the upcoming slides too. Uh But um of course, if someone has a very severe hypertension or stage two hypertension, um or um you know, there's concern that, you know, their hypertension is very um high, then sometimes, you know, maybe just um measuring it once and then, you know, thinking about or measuring it multiple times during a similar visit and then coming in with um you know, basically judgment as to um if they should have some intervention done right now versus like waiting for a separate visit. Um and then um getting a blood pressure checked. Um So again, um normal blood pressure values for Children, 1 to 18 years of age is based on the age um sex and height. Um Unfortunately, we do not have any cardiovascular outcome data in Children yet. Um So how we came up with this normative blood pressure values was um based on uh 50,000 Children that were in, that were enrolled in the National Health um and nutrition um examination survey or Nhanes study in the US population. And that is how um the values were based. So they were taken, uh they were um measured based on the auscultatory methods and then they were based on um normal weight Children for um Children greater than 13 years of age. Um the staging aligns with adult hypertension guidelines. And now the pre hypertension um uh has been replaced by the term elevated blood pressure. And I'm uh this is what I was talking about. So, um the normal blood pressure, um firstly, um I want to go back. So it is um now um categorized based on the age. So it's, if age is less than 13 years versus age, greater than equal to 13 years, the normal blood pressure is less than 90th percentile for age sex and height and then greater than equal to 30 years is less than 120 over less than 80. That's considered a normal blood pressure. The elevated blood pressure, uh which previously was known as pre hypertension. Um that is 98 to less than 95th percentile for eight sex in height and then greater than equal to 13 years is greater than equal to 120 over less than 80 to 129 over less than 80. So the diastolic blood pressure is still less than 80. It's the systolic blood pressure that is between 120 to 129. And then stage one hypertension is greater than equal to 95th percentile to 95th percentile plus 11 millimeter mercury and then greater than equal to 13 years is 130 to 1 39/80 to 89. So this is where um the dito hypertension comes in and then stage two hypertension is greater than equal to 95th percentile plus 12 minute meter, mercury and then greater than equal to um uh 140 over greater than equal to 90 millimeter mercury. Um And this is um so this is how it's defined. Um And uh this is how we go with um the categories. So, the epidemiology um so overall uh blood pressure, hypertension itself, the prevalence of that is between 2 to 5% hypertension and then patients with elevated blood pressure, that's closer to 13 to 18%. Um and the general pediatric population in the United States and other countries. And this is based on the fourth report and the clinical practice guidelines 2017, which we very frequently use um uh for hypertension um uh hypertension classification, um management and then primary hypertension is the most common cause of hypertension in childhood. So, it is considered to be higher in boys versus girls. It's higher in Hispanic, black versus white, it's higher in adolescent versus Children. And then it's more prevalent in overweight and obese. Um uh with um a study which showed um it to be uh more prevalent between 3.8 to 24.8% of overweight individuals had hypertension and then blood pressure tracking. Um This was a study that was done in 2015 which showed that higher blood pressure in childhood did correlate with hypertension in adulthood. And as you can see from the graph, the patients who were hypertensive, which is the Black line. Um They did as they, um as they did age, um they did have more higher systolic blood pressures. So now the causes for hypertension. So there are modifiable and then non modifiable risk factors. So, the modifiable ones include the overweight obesity diet, um, increased salt intake, low, uh less fruits, vegetables, low physical activity, poor sleep. And then the nonmodifiable ones include genetics, lower birth weight. The reason for lower birth weight um is um uh there is also um this association that babies who have had had low birth weight, they just have low nephron mass. And so that's why they are just at more risk for having um hypertension. And then the environment itself does play a role um into it too. Um Now, uh the target organ injury, again, I'm going to talk of this in further detail in the um um in the uh in the next slides, but um it can cause impaired cognitive function, increased vascular stiffness, left ventricular hypertrophy and of course, the kidney damage. Um and then the adult outcome is adult hypertension, heart failure, stroke, um uh kidney dysfunction. And I, you know, I just want to take this time also to mention that um you know, this comes up a lot when we see patients with hypertension and they are always um they always mention or they always say, oh, why are we seeing you? Why are we not seeing cardiology. Um and you know how I explain to them is that um in kids, it's just, you know, the, even the primary hypertension and the secondary hypertension, which I'm going to talk about in the next slide. Um it's just um it can cause kidney damage and they are just at more risk for kidney damage. So that's why they just need more um close full or careful monitoring by us if they do have hypertension and then the predisposing risk factor. So we talked about some of these, but yeah, of course, the overweight obesity. Um if there's family history of hypertension, um abnormal birth history. So that includes prematurity. Um if they are small for gestational age, if there was maternal eclampsia or eclampsia, preeclampsia, um if there's any known kidney disease, if they have any syndromes. So, um the syndromes that we mostly get referred for are um uh the Williams syndrome or the tuber sclerosis neurofibromatosis toner syndrome. And then of course, if they have any um sort of um abnormalities. So, um um cotta of aorta um type one and two diabetes. Um and the treatment with medication that are known to increase blood pressure. So, of course, in the general pediatric population, patients who are on a DH D medications like Adderall, they are at more risk or uh patients who have had a kidney transplant or um any sort of transplant actually like liver transplant. Um they are on Gurin inhibitors or um uh anyone who is on high dose of steroids or corticosteroids. So I just want to give a little bit of time. So basically hypertension, we classify this as primary or essential hypertension and then secondary hypertension. So, primary hypertension in Children, it's usually mild. Um it's stage one, it's associated with positive family history of hypertension or cardiovascular disease. It's associated with obesity. Um and then it clusters with other risk factors. So it can um be associated with hyperlipidemia glucose intolerance. And that is what we call metabolic syndrome is that when they have um um elevated BM I uh with hyperlipidemia with risk for diabetes um or risk for like transmits too um or elevated liver function enzymes. So, obesity, I just want to give this, uh I wanted to dedicate one slight to obesity because it's so um it's so um it's so close or strongly associated with hypertension. So, again, the analysis uh from 2015 to 2018, uh uh for names found that uh Children with obesity were more likely to have hypertension compared with Children with normal pain. And as you see, the relative risk of hypertension does increase with obesity um significantly um um as seen over here. So, secondary hypertension um uh th this was a saying um which I I took from a slide uh uh given by one of the other nephrologist that works at U CS M Doctor Paul Brigman. So the higher the blood pressure and the younger the child, the more likely is hypertension to be secondary on origin because they are just not exposed to those, um, you know, modifiable risk factors that we talked about. So, you know, obesity, um or um you know, uh unhealthy eating habits. So that's why um if they are younger, higher blood pressure, it's more likely to be secondary in origin and this is just a table. So, um secondary hypertension can be caused by renal Permal disease, renal vascular um reasons. So, renal artery stenosis, endocrine um abnormalities. So, um any um abnormalities with the um uh with um the cortisol pathway, um like apparent mineral corticoid axis cah. Um and then cooptation reflux nephropathy, um neoplastic conditions. Um we uh see high blood pressures um uh in a lot of patients with leukemia um which can be from the leukemia itself. But, but, but most of the time it's from the medications or the chemotherapy that they're getting that they um do have hypertension and then uh miscellaneous are the other causes. So, why do we care about hypertension? Um So firstly, it's, it is as, as hypertension in teenagers is associated predicts adult um cardiovascular mortality. Um So, um as you see, uh patients with hypertension, they are, they are just at more risk for um uh cardiovascular related mortality versus those who were no more tensive and then increase atherosclerosis seen at higher blood pressure levels in you than autopsy studies too. So again, as I said, we don't have that much good data on the um cardiovascular outcomes in Children. But um there have been like autopsy study done and that did show that um there was increased atherosclerosis that was seen um at higher blood pressure levels. It's also associated with impaired cognition. So it is associated with um lower digit span. Um it's associated with lower performance at school. Um And then it is associated with low IQ scores as well. Um So this uh graph which is shown over here. So this basically um combined the um the patients sleeping questionnaire or this PSQ score as to how they were sleeping and then what did parents say about their behavior or um at home and those with um a higher blood pressures um or hypertension um did have both um the parent brief or B RT score high and then also they had high PSQ scores. And so I just wanted to present this question. Um uh What does pediatric hypertension look like? So 17 year old female um comes in, she has excessive weight gain for the last six years. Uh Mother and father are also in the room and they are also overweight. Um The patient describes eating no breakfast. Um uh she has a lunch at school and then she has some sort of fast food. Um She has one Red Bull um during the day to stay awake, she sleeps very late at night and then her blood pressure is 1 40/95 on initial check. So what would be the next thing to do um is to repeat the blood pressure again, um as we talked about in the previous slides. Um and um I just wanted to present what it's what, what, what do the guidelines say about um screening blood pressure. So, um basically making, firstly making sure that the child is sitting correctly and then uh measuring blood pressure by auscultation or by using Oslo meric device. Um I know it sometimes can be a challenge to measure it all by auscultation. Um um And so most of the time it's um Oslo meric device that's used. And so if the percentile is greater than equal to 90th percentile, and I'm going to show the table in the next slides. Um then um trying to make sure, firstly, making sure the patient is calm quite um not moving much, not talking and then remeasuring the BP twice and then averaging um these two if the still the blood pressure is greater than equal to 98 percentile, um then firstly, making sure is it osculate three or not? And then remeasure baby twice by using osculated technique or bridge these two and then classify blood pressure according to table three. So this is the uh uh the uh basically the blood pressure me management um uh tables that we mostly use. Um And this is based on the height which is an ancient centimeter and then the 50th percentile, 90th percentile, 95th, 95th plus uh 12 millimeter mercury which is on the ax axis and um or sorry, on the Y axis. And then on the top, it's um basically the height. Um and then uh what percentile are they over there? Um And that's how we basically clot as to where are they um currently. So this is a, a very uh simplified version that was proposed uh for screening blood pressure values. Um So basically, um if they are coming in, uh and so not looking at the height but, you know, just looking at their age and then seeing what is their blood pressure and then um going from there as to, you know, is it high or is it like above um the night percentile or no? Um And then uh if it is then rechecking it again, um And then averaging those out too. Um And if it's still high then thinking, oh, do we need to check in osculated blood pressure or no? Um And if it's still high, then, you know, basically classifying them um as to where, where do they fall? Is it normal, elevated stage one or stage two? So again, I just put it over here. Um So, um as to how to classify them based on the age and then based on um where are they? So blood pressure measurement technique Um So, uh blood pressure should be measured in all Children better than equal to 30 sorry, three years old or less than three years old with chronic illness. Um, and I'm going to talk about that in the uh next upcoming slides. Um Again, the child should be seated in a room quite room for 3 to 5 minutes before measurement. Um, you know, Children can be very active, they are running around and then right after their blood pressure is checked, sometimes it can be high. Um It should be measured on the right arm with patients seated when possible. Auscultation is preferred method. Um And then using the appropriate blood pressure cuff size, which can be very challenging, especially in Children who are either very underweight or overweight. But the bladder, uh the uh basically the blood pressure bladder len should cover 80 to 80% of the upper arm circumference. Um And then if the blood pressure is high, then it should be confirmed on repeated uh measurement. Um And then again, you know, if it's above the greater than 98 percentile, then it should be obtained by osteomed device. It should be repeated by auscultation method. So this is how it should like. Uh so the important landmarks are the acromion process. Um The circumference measured at midline and then the oleo process and then the bladder land should be 82 per 100% of arm circumference. And then the cuff bladder with a 40% of arm circumference. So this is how it looks like and it says um so making uh marking the spine. So um uh uh from the acromion process and then um correct tape placement for upper arm length, which is B figure B. And then it does say that the C is incorrect because it's a little bit more um towards the distal side uh from the acromion spine uh process. And so, and then marking upper arm length, midpoint. So um taking the tape and then marking at the midpoint if it's, you know, harder to um assess what's the appropriate BP cup size. And where should they have the BB cuff placed? So when to measure blood pressure in Children, less than three years old. So, if they are, um I, I think we talk most about most of the risk factors that they are premature, very low birth weight. Um They have been treated in the IC N. They have congenital heart disease, they have recurrent UTIs hematuria, proteinuria. So there is this concern for either a reflux nephropathy or a glome nephritis sort of picture. Um If there is family history of renal disease, um solid organ on bone marrow transplant, um other diseases associated with hypertension. So, neurofibromatosis, um tuber sclerosis or receiving any sort of anti hypertensive drug treatment. Sorry. So I'm coming back to the case again, the same female 17 year old um who um has had excessive weight gain and then her blood pressure is 1 40/95 and you have repeated it at the three separate visits. Um again, and it has been high all three times. So the next step would be to perform an A B PM to rule out white coat hypertension, um A B PM um which is um the ambulatory blood pressure monitoring or the 24 hour um ambulatory blood pressure monitoring is what's what we call it. So, um it's an Oslo meric measurement of blood pressure over a 24 hour period. Um And it takes blood pressure measurements during the daytime, every 20 to 30 minutes and then during the night time, it's every 30 to 60 minutes. And then the normative values for height by height for Children uh uh uh approximately 6 to 18 years. So, for this one, it's uh usually done if the height is um greater than 1, 20 centimeters. So that's why it cannot be done in very young uh babies or um infants or toddlers. It's usually done when they are um five or six years of age. So, um uh it's placed on the non dominant arm um because it has to be placed for 24 hours. Um And so that's why uh we do not place it on the dominant arm because then it just limits um the person's activity. Um And then uh they can continue with activities of daily living. Uh But again, um, uh, it should, uh, we recommend that they should not be very good. Um, if they are playing contact sports or if they're outside because, um, we do not want to get the monitors, uh, wet or, um, you know, basically get damaged. Um, and then it's recommended that regarding on a school day or wearing it on a school day may be helpful but, but people or kids or patients do want to wear it over a weekend. And so we do ask them that they should sort of mimic um to do what they're doing on a weekend to what they would do if they were in school. So, rather than just sitting on the couch and watching TV, you know, trying to do things that they would do in school. So, for example, you know, trying to be a little active, maybe walking here and there or um you know, um at least, um uh tr trying at least trying to mimic um and then having a diary because that helps us as knowing as to, when did they wake up? When did they go to bed and then activities that may influence blood pressure measurements? So, for example, if they were playing a video game or so, then that would um cause um their blood pressures to be high. So, um I, you know, I just wanted to go back a little bit. So, um the A B PM itself, um that is um so uh it. So, uh of course, I'm from U CS, a pediatric nephrology and we run the A B PM program. So um anyone who needs an A B PM needs to be referred to us. And then basically, we have um a group of nurse practitioner, um uh a medical assistant nurse who then basically um uh basically runs this A B PM program. So we put in the referral which is within our pediatric nephrology program. And then um they contact the patient, they set up a time to do either a zoom visit or an in person visit. They go through, ok, how to expect when you are wearing this 24 hour A B PM, how to troubleshoot if there's any issues with the machine. Um and then um they either get the, the monitor placed on the same day. Um If that's an in person visit, if it's a zoom or a telehealth visit, then they get the A B PM monitor um delivered to their place and then they wear it for 24 hours. And then we recommend that they use, they should just return it within 1 to 2 days. Um And it's through the fedex tracking system. And so once we get it back, we download the results and then we see what their uh blood pressure trend looks like. And then we usually um um you know, um have a visit um arranged with the patient and then we go through as to what should be the next steps. So this is how the blood pressure, oh sorry, the A B PM result looks like. So it looks at the um systolic blood pressure, the diastolic blood pressure and then it looks at the 95th percentile. So the lines that you guys see, um uh uh these ones, um these are the 95th percentile and then uh this basically the demarcation over here that tells us when they did, when did they go to bed? So, for example, this patient went to bed at 10 and so he was sleeping and then he woke up at night. So that also gives us an information if they are having nocturnal dipping or not, which is, which should happen. Um They should have a drop in their blood pressure uh by 10 millimeter mercury. Um if they are not having um that's concerning and that we do see in our CKD patients and that's just associated with more um um cardiovascular mortality and morbidity. So, um this is, these are the blood pressure phenotypes according to the office and ambulatory blood pressure. Um So the, the normal tensive is they have both uh the office blood pressure is normal. The AD PM is normal. Um The white code hypertension um is uh if the office blood pressure is high, but the ambulatory blood pressure or the A B PM blood pressure is normal. The ambulatory hypertension is both the office blood pressure and the ambulatory blood pressure are high and then the mass hypertension is on the office. Blood pressure is normal, the ambulatory blood pressure um is high. Um So uh uh just talking briefly about these uh normal tensive, uh we would only see normal uh normal tensive. Uh We usually do A BP MS um in our uh CKD patients, even if they don't have hypertension. So CKD is sorry, as in chronic kidney disease patients. Ee even if they do not, if, even if they are not hypertensive, and the reason is just because they are just at more risk for uh developing hypertension and having more mass hypertension. Um uh And so it's recommended and then mass hypertension, again, it's very common in our chronic kidney disease patients and then transplant patients. So, um this was the s uh the revised chema for staging of ambulatory blood pressure levels in Children. Um So they, they uh changed it to uh the 95th percentile and the for the AD PM. Um um And then basically just classifying normal blood pressure as we talked about in the previous slide. Um And then, yeah, we uh we just go with the uh blood pressures, we don't use the systolic blood pressure load or the diastolic blood pressure load anymore. So, again, um the, the there are, there are things in which A B PM may be um helpful. Um again, in secondary hypertension, um it can be helpful in chronic kidney disease. The things I want to particularly highlight are the type one and two diabetes mills. So in this one, it can it a BB MS may be helpful especially in someone who has hypertension because it's associated with abnormal circadian variation. So maybe it can be associated with nocturnal dipping and then association with micro albuminuria and vascular changes. Um and then um obesity. So, obesity can cause mass hypertension. It can cause hypertension like of it can cause um uh just hypertension too, but mass hypertension is also associated. Um and then it can also cause abnormal nocturnal dipping, um sleep apnea. Um It can give us like a grade of the hypertension severity and then again, the abnormal circadian variation and then genetic syndromes. Um so, um can give a clue as to if they have secondary cause of hypertension if the blood pressures are extremely high or stage two hypertension, um especially with renal artery stenosis. Um It's very, it's a very good tool for patients who are already being treated for hypertension. Um So uh uh assessing their response to anti hypertensive medications or lifestyle changes. Um and then sometimes it's done um in multiple drug trials too. So um going back, going to home blood pressure monitoring. So, um we um especially um so home blood pressure monitoring can be sometimes a useful tool. Um And um it's uh the blood pressure, there are multiple blood pressure monitors that are available and um all of these almost cost around $60. Um So most of the patients can afford it. Um We do have um um um a letter of agreement that we can do with Walgreens and then try to get the patient um a free blood pressure monitor through insurance and sometimes it works. And then our department do have some uh contact blood pressure monitors that we do give to patients who we know are um you know, um that who do have financial constraints and won't be able to afford a blood pressure monitor. So, um it's a useful tool. Firstly, um um especially in um I feel like so firstly, the A V PM, the 24 hour ambulatory blood pressure monitoring, it's a great tool. It's a great blood pressure um uh measurement tool, but there are two limitations to it. Firstly, uh we do not have um enough um blood ambulatory blood pressure monitor devices. We, that our department currently has maybe like 10 ambulatory blood pressure devices um at the San Francisco site. Um And so, um and so, you know, definitely there is a long waiting time if we do refer someone for an A B PM. Um Secondly, there are I it's uh it's the same feeling. So, what we have heard is that a lot of people do experience discomfort with it because it's just imagine someone having their blood pressure checked every 20 to 30 minutes for 24 hours. So it can be very discom it can be very discomforting. And then to the point that patients have complained that, you know, they, they almost felt like their forearm, bruised uh because of um this constant blood pressure monitoring. Um and then especially um as we talked about, we cannot do A B PM in babies or toddlers. So in those uh in those patient population, it's a good um tool to have home blood pressure monitoring. Um And then studies have shown that it is feasible for families to conduct repeated blood pressure at home. And it's appeared to be more reproducible than those conducted in the office. Um likely because of the familiarity of the home um environment and greater comfort with repeated measurements. Um especially I've seen um toddlers, uh mom, mom just get uh you know, uh they, they just know what their um toddler's routine is. So for example, if they are very active during the day, then they might just measure the blood pressures at night when they are more relaxed. Um And then, you know, um give us the readings also with this home blood pressure uh uh monitoring devices. I just want to also highlight that sometimes the home blood pressure monitoring devices do read 20 to 10 to 20 points higher than the office blood pressure readings. And so sometimes it's maybe it may be useful to just ask the patient to bring in the home blood pressure monitoring device with them. Um and then just calibrate it with the office, blood pressure. Um just to make sure just to, just to have an, just to have an idea of uh does a 140 blood pressure at home truly means 140 or is it just like 120 blood pressure reading at home? So, going into the management of hypertension. Um so um I find this table very um useful. So basically, um it tells us uh it measured blood pressure, height weight and calculate BM I and then determine blood pressure category for sex, age and height. So um starting from the uh starting from the right, so no tensive um monitor blood pressure at next well, child visit. Um if they have elevated blood pressure, um which is uh which is basically greater than greater than 90th percentile to less than 95th percentile, then um repeat blood pressure at six months. Um And then usually, um if it's still greater than 90th per 90% then repeat blood pressure at 12 months. And if it's still, then do an A B PM diagnostic work up, which I'm going to talk about in the next slides and then consider referral to specialist. So again, it talks about having three blood pressure measurements um at separate visits greater than 90%. Um and then consider doing the work up and then stage one hypertension uh which is 95th percentile greater than 95 plus 11 m mercury. So that is um stage one and then repeat blood pressure in 1 to 2 weeks. So they should be assessed more sooner. Um and then repeat if it's still high, then repeat blood pressure in three months rather than equal to 95 5th percentile. And then consider doing an A B PM um or referring to uh referring to us a pediatric nephrology or, and thinking about doing a diagnostic work up and then um thinking about what do they have? Is it primary hypertension, secondary hypertension based on the work up that comes back and then if it's stage two hypertension, um then repeat BB or refer to a specialist in one week. So that is um greater than 95th percentile plus 12 millimeter uh mercury. Um uh then it's, it, it should be done sooner uh because compared to stage one and elevated blood pressure um class. And so they should get an A B PM done. They should have diagnostic work up done and they should be referred to a specialist within one week. So an urgent um referral, it also talks about um what we call as um hypertensive urgency um or um you know, emergency um based on what they are having. Um And if they do have greater than 95th percentile um and 30 millimeter mercury or if they are symptomatic, then thinking about referring them to Ed and then with all this, of course, the lifestyle counseling, weight, nutrition management is very, very important. Ok. So um this is um this basically, so this is the screening test um or the diagnostic work up that we think about in anyone who has hypertension. So it has changed a lot. Uh Previously, we used to do um CBC um lipid panel, hemoglobin A one C actually lipid profile comes in the um all patients, but we used to do hemoglobin A one C thyroid screening CBC. Uh But now what they say is that the first pass for uh the screening test is um U A um chemistry panel which includes electrolytes, uh blood urea nitrogen creatinine lipid profile, fasting or nonfasting to include high density lipoprotein and total cholesterol. And then only thinking about renal ultrasonography in those less than six years of age or those with abnormal urinalysis or renal function. Um what I have seen or what I've experienced is that sometimes it's just better to just order everything because by the time they get renal ultrasonography done, um you know, it everything has also has almost been done and you know, they may have some findings on their U A or they may have some findings on the renal function. So it just saves time versus, you know, waiting for the patient to get all the labs done and then, you know, do ordering a renal ultrasonography and then um if they are obese um uh BM I greater than 95th percentile. Um, and um, the, it's, it's basically, uh uh now that the screening is a little bit more, um thinking about the optional test to be obtained on the basis of history, physical examination and initial studies. So, hemoglobin A one C um uh um I typically do it, um, especially if, uh if the patient is obese, um if there is family history of diabetes, um, and then, um, LFTs um to screen for a fatty liver because it gives us the diagnosis of metabolic syndrome. If it's present fasting lipid panel, again, that's in the lipid profile. Um and then fasting serum glucose. Um, again, I think the hemoglobin A NC covers it, thyroid stimulating hormone, especially if they are having other issues going on, um, fatigue, um or uh you know, um sweating, um or any other signs of hyperthyroidism, a drug screen. Um, especially if it's an adolescent kid. Um And uh the uh uh uh basically there is concern that there might be some of concern for substance abuse sleep study. This I have found to be um useful especially to ask um if they do snore at night. Um, and then have they been tired during the day or if there's any reported history of apnea? And how we usually ask is that, has there been a point where you were sleeping and you just basically woke up feeling short of breath. Um, or um, usually the pa the patient himself doesn't him or her doesn't know if they're snoring. So usually I'm asking the family members but this has come out some, some of the times uh for the hypertensive patients that I've seen that um, you know, they do have OS A. Um and um, you know, um so um doing a physical exam making and looking at their tonsils may be helpful too and then a CBC, especially in those with growth delay or abnormal renal function. Um um it's useful too. So lifestyle recommendations. So, um again, so they should exercise is very, very important, especially in um you know, in the young pediatric patients. Uh because I think, and I honestly think it's more important than the, you know, counseling them on um their nutrition. Uh because if they are physically active, it just helps them a lot because they can just be more physically active than adults. Um So at least 30 to 60 minutes, moderate to vigorous physical activity 3 to 5 days per week. Um and then aerobic resistance are combined. Um and then exercise should not be restricted due to high blood pressure unless there is a clear cardiac contraindication. So a anything you know, that um uh for example, aortic stenosis cooptation, um usually for that heavy weightlifting, um is uh is contraindicated or not advised, but otherwise they can do the aerobic um exercise or, you know, play football, soccer, that basketball that should be ok. And then diet. Um So um dash diet or the dietary approach to stop hypertension diet is what it's also known. Um It's a good diet and that focuses on fresh fruits, vegetables, low saturated fat, whole grains, nuts, poultry, and fish. Um Mediterranean diet um is very healthy foods rich in potassium magnesium, um low fat, um calcium fiber, croly, dark chocolate. And I just wanted to um also point out that potassium is um um helps with hypertension because um with the uh in uh in several of the um tubules, the proximal or the distal tubules, there are multiple transporters um which, which uh which are potassium, sodium, potassium transporters. And so, um if someone is eating more potassium that helps with more sodium excretion. And so, um that's why it's just, and it's just, it's just good to know because I know with uh uh anyone uh when we think about pota and we think about renal failure or, you know, can cause kidney injury um or hyperkalemia is not good, but actually, um uh you know, it, it can help with um lowering blood pressures. Um And you know, there are a lot of things that are rich in potassium too. So things like um a lot of fruits, oranges, bananas, strawberries, um or potatoes. Um uh so it's, it's, it's just a, it's just a very important um uh nutrient that we, that everyone should have in their diet. And so, um you know, just coming back to the dash diet. Um, uh, our nut. Uh, so usually if someone, if we are seeing someone for hypertension, um, in our nephrology clinic and, um, they are obese, um, we do always ask them if they want to talk to one of our nutritionist. And, um, they, uh, they do have that option. And so usually what our nutritionist go through is also the same thing. So, um, you know, they should have at least 4 to 5 servings per day of vegetables. Um They should have 6 to 8 servings per day of whole grains, 2 to 3 servings per day of fat free or low fat dairy. Um 2 to 3 servings per day of fats and oils, uh they should have less sweet, so less than five servings per week of sweets and then less than six servings per day of lean meat, poultry and fish and then 5 to 4 to 5 servings per week of nut seeds and legumes. Dark chocolate has recently been shown to have um uh is shown to help with hypertension. Uh But again, I don't, kids don't like it that much, but, you know, um uh just to point that out over here and so the effectiveness of lifestyle changes on blood pressure. Um So um it can cause weight reduction. Uh So BM I um decrease of approximately 10% is associated with decrease in blood pressure of 8 to 12 millimeter mercury. Um It can cause um sodium restrict uh sorry sodium restriction um that can decrease in blood pressure of 1 to 3 millimeter mercury. Um and it may be more effective in patients who are more salt sensitive and then exercise um associated with uh six millimeter mercury reduction in BB and blood pressure. So, uh now coming to recommendations for drug treatment and hypertensive Children and adolescents. So for normal blood pressure, of course, nothing, um elevated blood pressure, nothing unless compelling factors such as chronic kidney disease, diabetes, heart failure, left ventricular hypertrophy is when we closely think about if we should um start treating them. Um Stage one hypertension, start drug therapy based on indications or if compelling factors as above. And then stage two, of course, we start drug therapy if it's confirmed. So again, um you know, just to summarize with the dash diet and then um uh uh with, with, with the treatments elevated blood pressure, um dietary changes. Um So dash diet, reduced sodium intake and then physical activity, uh vigorous exercise, reduce screen time. I also tell them that, you know, they should have a good sleep schedule. So sleeping um for uh getting a good um 8 to 10 hours of sleep is good. Um And then uh white coat hypertension, I just wanted to point that out because of course, we uh you know, white coat hypertension um is also associated with many cardiovascular mor mortality morbidity. And I'm going to talk about that in the next slide. But for that too, dietary changes are recommended uh in including uh thinking about a dash diet, reduced sodium intake and then vigorous exercise, reduce screen time, especially, you know, if they are also, um if they, if they are also obese or overweight, primary hypertension or dietary changes, uh physical activity and then initiation of hypertensive medications if blood pressure is still high after 6 to 12 months of dietary and physical activity measures. So, for this one, we do give them a little bit of, uh, we do give them a little bit of time, especially if they are presenting. And if it's, it's one of the patients who was very similar to the case I presented who's obese, um, and, you know, uh, very minimal, um, uh, activity, um, eating, um, all sorts of food and skipping things, uh, or, uh, skipping meals for those, um, usually giving them at least six months or so. And how I tell them is that maybe they can have a goal, uh, like after six months. If I am, if I have, you know, uh, if I'm doing this, if I'm exercising more, if I'm eating healthy, if I have lost some weight, then I would get this or, you know, I would, maybe I could, you know, uh, go somewhere, um, any, any sort of goal or having a goal in mind is important, especially with adolescent patients. Uh, but at least giving them sometime before starting them on medications because firstly, um, you know, adolescent kids, it's, uh, uh, the, the rate of non-compliance or non adherence is very, very high. And then, um, secondly, you know, once they are started, it's, it's very, very hard to take them off blood pressure medications. Um, and then secondary hypertension, um, dietary changes. So a again, um, and then physical activity and then initiation of anti hypertensive medications on diagnosis of underlying cause and then managing the underlying cause of secondary hypertension if it is secondary hypertension and then white coat hypertension. So, in this one, as we talked about in the previous slide, so clinic, blood pressure is in the hypertensive range, but A B PM is normal. And for this one, the there are almost 13 to 46%. So the range is very wide, uh percent of Children that are referred for high blood pressures. So um the estimated savings of initial deduction by A B PM prior to performing the routine evaluation of hypertension is around um two thou approximately $2000 per patient. So that's how much we can save if we just do an A B PM and diagnose them with white coat hypertension. It is associated with left ventricular mass index and then other preclinical markers of cardiovascular disease. And then adults in adults is associated with cardiovascular and all cause mortality. So that's why uh for these patients too. Um It's important firstly that um you if especially if they have other risk factors including being obese or um unhealthy lifestyle, then working on those. Um and um they should have an A B PM done every year to make sure they are not developing through hypertension. And so that's why we continue to see them if we start seeing them for um hypertension and if they have white good hypertension, then we just see them early with um repeat A B PM. And so, uh now why do we treat hypertension? So firstly, um I think we, this is going to be a little redundant, but um there is concern, there is of course, this prevalence of left ventricular hypertrophy um which does increase with blood pressure stage. Um and the prevalence being 20 to 40%. And so there is um uh this indication that echocardiogram should be performed, especially if someone has a stage two hypertension, they should have an echocardiogram performed at some point and then periodically thereafter. And then if they do have left ventricular hypertrophy, which is worse wrong before or is new. And wasn't there, then that's an indication to start or in start or intensify drug therapy. And I'm going to talk about medication classes in the next slides. But if they, if uh it's uh if they are usually um then thinking about medications that can help with um remodeling as well. So, thinking about a S inhibitors uh would be uh useful. Um Of course, as we talked about hypertension, impaired cognitive function, headaches, sleep orders disorders, uh prevent long term cardiovascular morbidity and mortality and then prevent hypertensive retinopathy. So just some pictures. So this is to target an organ damage. So thinking about left ventricular hypertrophy, this is a picture of an echo which just show that and then arterial waves, uh arterial stiffness and then arteriosclerosis. So, arteriosclerosis and then arteriosclerosis and then this is hypertensive retinopathy. So it can cause flame hemorrhages, pap edema, cotton wool spots and heart ex exed dates. And in kidneys, it can cause A K I or acute kidney injury, micro albuminuria and neurologic or neurocognitive delays, stroke, seizures, posterior reversible encephalopathy syndrome or press. So, these are the pharmacologic agents that we use. So diuretics um uh direct acting vasodilators. So, hydrALAZINE monoxide sympathetic blockers. So central um is cloNIDine, we mostly use a cloNIDine patch. Uh There's also cloNIDine tablets and cloNIDine suspension available beta blockers. So, metoprolol propranolol um and then angiotensin blockade with ace inhibitor. And Alr benazepril A RBS are angiotensin receptor blockers uh which are Candesartan and calcium channel blockers, which are the most common ones though are the first line. One that we use is uh the most common one being amLODIPine. Um and these are some of the pictures and um just quickly going through. So, um um in the different classes and where do they act? Um So um on the brain, um centrally acting agents, the cloNIDine beta blockers on the heart, the beta blockers, the calcium channel blockers um and then um on the vessels itself. Um uh the calcium channel blockers, ace inhibitors A RBS run inhibitors, um alpha one anergic um antagonist vasodilators and then on the kidneys is the diuretics that works. And then also the ace inhibitors and the A RBS and then the pharmacologic. So basically how the approach should be beginning with the recommended initial dose of desired medication. If blood pressure control is not achieved, then increasing dose until desired blood pressure target is reached. And if it's still not achieved, then adding a second medication with a complementary mechanism of action. So not the same mechanism of action. And then if the blood pressure control is not achieved and thinking about the third anti hypertensive drug of a different class and then also um uh you know, of course, thinking about other causes um could be contributing um just most some of the very common side effects. So um the ones I'm going to highlight are uh for the calcium channel blockers, the amLODIPine, um it can cause flushing, peripheral edema dizziness. Um we have, we see peripheral edema uh sometimes in our patients. And so that, you know, we we just have to ask them to stop the medication and it does resolve it can cause gum swelling too. Um And uh the other ones are the beta blockers, of course, they can cause bradycardia hypertension. Um uh uh uh in the on this list, chlorine patch is not included, but again, the same risk for that too, it can cause hypertension, bradycardia. Um And then for ace inhibitors and A RBS, um A ace inhibitors are particularly um associated with cough which can, which can be dry um and can be very annoying. Um And if they do have it, then they can be switched to an A RB um which doesn't cause cough. Um uh again, um ace inhibitors and A RBS, they are associated with um hyperkalemia. A KIS, it's very important that they get routine lab monitoring done and then diuretics. Um so they can cause hyperkalemia. Um as one of the side effects of making sure they, you know, they are also getting frequent um lab monitoring done. So um just uh talking about severe hypertension. So, um there is hypertensive urgency and then hypertensive emergency, hypertensive urgency is if they have severe blood pressure elevation, which is not associated with um life-threatening um symptoms. So they may may have blurry vision, they may have um dizziness um but not nothing life threatening. So, um this is usually treated with oral or IV shot a medications. If they do have hypertensive emergency, then um it's acute severe blood pressure elevation, which is associated with severe CNS cardiovascular other symptoms. So, seizures, encephalopathy, um congestive heart failure A K I papy edema and this is treated with IV medications. And the aim for this is to decrease the blood pressure by 25% over the 1st 6 to 8 hours and then gradually normalize over 24 to 72 hours. And again, the treatment goal over here is to avoid permanent hypertension and um induce and then ischemic damage from overly rapidly lowering of blood pressure. So, this was my dog. Um.
