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 Sanobar um Siddiq, um, I'm one of the pediatric nephrologists, um, that works at UCSF, 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 ninety-fifth percentile, and the diastolic blood pressure, um, uh, greater than equal to ninety-fifth percentile, um, that also defines hypertension. So it's just not the systolic blood pressure, but also the diastolic blood pressure or 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 patient. 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 2 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, 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 98th to less than 95th percentile for age, sex, and 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 139/80 to 89. So this is where um the diastolic hypertension comes in and then stage two hypertension is greater than equal to 95th percentile plus 12 millimeter 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 4th 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 non-modifiable ones include genetics, lower birth weight. The reason for lower birth weight, um, is, um, uh, there's 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, uh, this in further detail in the, um, um, in the, uh, 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 explained 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 factors. 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 eclamps pre-eclampsia, 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 tuberous sclerosis, neurofibromatosis, Turner syndrome, and then of course if they have any, um, sort of, um. Genital abnormalities, so, um, um, cocktation of aorta, um, type 1 and 2 diabetes. Um, and then treatment with medication that are known to increase blood pressure. So, of course, in the general pediatric population, patients who are on ADHD 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 calcineurin inhibitors or, um, uh, anyone who is on high dose of steroids, so 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 BMI, Uh, with hyperlipidemia, with risk for diabetes, um, or risk for like transseminitis too, um, or elevated liver function enzymes. So, obesity, I just want to give this, uh, I wanted to dedicate one slide 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, um, uh, for names found that, uh, children with obesity were more likely to have hypertension compared with children with normal weight. 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, the, this was a saying, um, which I, uh, took from a slide, uh, uh, given by one of the other nephrologists that works at UCSF, Doctor Paul Brickman. So, the higher the blood pressure and the younger the child, the more likely is hypertension to be secondary in 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, um, 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 parenchymal 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 caucation, 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 a hypertension in teenagers is associated, predicts adult, um, cardiovascular mortality. Um, so, um, as you see, um, Patients with hypertension, they are, they are just at more risk for, um, uh, cardiovascular-related mortality versus those who were nontensive. And then increased atherosclerosis seen at higher blood pressure levels in youth in 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 patient's sleeping. Questionnaire or the 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 higher blood pressures um or hypertension um did have both um the parent brief or BRIT T 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 6 years. Um, 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 140/95 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 oscillometric device. Um, I know it sometimes can be a challenge to measure it by auscultation, um, um, and so, most of the time, it's, um, oscillometric 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, quiet, 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 90th percentile, um, then firstly, making sure is it auscultatory or not, and then remeasure baby twice by using auscultatory technique or bridge these two, and then classify blood pressure according to table 3. So, this is the, uh, uh, the, uh, basically the blood pressure med management, um, uh, tables that we mostly use. Um, and this is based on the height, uh, which is 1 inch in centimeter, and then the 50th percentile, 90th percentile, 95th, 95th plus, uh, 12 millimeter mercury, which is on the x 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 plot 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 we're not looking at their 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 90th 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 an auscultatory 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 greater than equal to 33 years old or less than 3 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, quiet 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 lens 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 90th percentile, then it should be obtained by oscillometric 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 olecrinod process. And then the bladder length should be 80 to 100% of arm circumference, and then the cuff bladder with, uh, 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 BP cuff placed. So, when to measure blood pressure in children less than 3 years old. So, if they are, um, I, I think we talked most about most of the risk factors that they are premature, very low birth weight, um, they have been treated in the ICN. They have congenital heart disease, they have recurrent UTIs, hematuria, proteinuria, so there is this concern for either a reflux nephropathy or a glomerular 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, tuberous sclerosis, or receiving any sort of anti-hypertensive drug treatment, sorry. So, um, 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 140/95, 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 ABPM to rule out white coat hypertension. Um, ABPM, 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 oscillometric 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 nighttime, 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 120 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're, um, 5 or, um, 6 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, uh, living, uh, but again, um, uh, it should, uh, we recommend that they should not be wearing it, um, if they're 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 recording on a school day or wearing it on a school day may be helpful, but, but people, uh, or kids or patients do, uh, 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, 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, uh, the ABPM itself, um, that is, um, so, uh, it, so, uh, of course, I'm from UCSF Pediatric Nephrology, and we run the ABPM program. So, um, anyone who needs an ABPM 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 ABPM 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, What to expect when you're wearing this 24 hour ABPM, 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 ABPM monitor, um, delivered to their place, and then they wear it for 24 hours, and then we recommend that they, 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, uh, sorry, the AVPM 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, uh, the normatensive is they have both, uh, the office blood pressure is normal, the ABPM is normal. Um, the white coat hypertension, um, is, uh, if the office blood pressure is high, but the ambulatory blood pressure or the ABPM 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, and the office blood pressure is normal. The ambulatory blood pressure, um, is high. Um, so, uh, uh, just talking briefly about this, so normatensive, uh, we would only see normal, uh, normatensive, uh, we usually do AVPMs, um, in our, uh, CKD patients, even if they don't have hypertension. So CKD is, sorry, as in chronic kidney disease patients, 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, uh, the revised chemo for staging of ambulatory blood pressure levels in children. Um, so they, they, uh, changed it to, uh, the ninety-fifth percentile and the, for the ABPM, 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, there are, there are things in which ABPM 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 1 and 2 diabetes mellitus. So, in this ones, um, it can, it, uh, ABPMs 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 microalbuminuria and vascular changes, um, and then, um, obesity. So obesity can cause mass hypertension, it can cause hypertension, like, 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 higher stage 2 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, it's 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, 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, uh, 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 AVPM, 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, uh, so, you know, definitely there's a long waiting time if we do refer someone for an ABPM. Um, secondly, there are, uh, 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 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 ABPM in babies or toddlers. So, in those, uh, in those patient population, it's a good, um, to, uh, 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, moms 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, uh, 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 measure blood pressure, height, weight, and calculate BMI and then determine blood pressure category for sex, age, and height. So, um, starting from the, uh, starting from the right, so normotensive, uh, 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 6 months. Um, and then usually, um, if it's still greater than 90 90%, then Repeat blood pressure at 12 months. And if it's still, then do an ABPM diagnostic workup, which I'm going to talk about in the next slides, and then consider referral to a specialist. So, again, it talks about having 3 blood pressure measurements, um, at separate visits greater than 90%, um, and then consider doing the workup. And then stage one hypertension, uh, which is 95th percentile, greater than 95th 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, uh, if it's still high, then repeat blood pressure in 3 months greater than equal to 95 5th percentile, and then consider doing an ABPM. Um, are referring to, uh, referring to us, uh, pediatric nephrology, or, and thinking about doing a diagnostic workup. And then, um, thinking about what do they have? Is it primary hypertension, secondary hypertension based on the workup that comes back? And then if it's stage 2 hypertension, um, then repeat BP or refer to a specialist in 1 week, so that is, um, greater than 95th percentile plus 12 millimeter, uh, mercury, um, uh, then it's, it should, it should be done sooner, uh, as compared to stage one and elevated blood pressure. Um, class, and so they should get an ABPM done. They should have diagnostic workup 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, uh, this basically, so this is the screening test, um, or the diagnostic workup that we think about in anyone who has hypertension. So, it has changed a lot. Uh, previously, we used to do, um, CBC, um, uh, lipid panel, hemoglobin A1C. Actually, lipid profile comes in the, um, all patients, but we used to do hemoglobin A1C, thyroid screening, CBC. Uh, but now what they say is that the first pass for, uh, the screening test is, um, UA, um, chemistry panel, which includes electrolytes, uh, blood urea, nitrogen, creatinine, lipid profile, fasting or non-fasting to include high density lipoprotein and total cholesterol. And then only thinking about renal ultrasonography in those less than 6 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 else has almost been done, and, you know, they may have some findings on their UA or they may have some findings on their 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, BMI greater than ninety-fifth percentile, um, and, um, They, it, it's basically, uh, uh, now the, the screening is a little bit more, um, thinking about, so optional tests to be obtained on the basis of history, physical examination, and initial studies. So, hemoglobin A1C, um, uh, Again, 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 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 A1C 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, um, uh, uh, basically, there is concern that there might be some 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 I 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 the patient himself doesn't, or 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 OSA, 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, is useful too. So lifestyle recommendations. So, um, again, so they should, uh, exercise is very, very important, especially in, um, you know, in the young pediatric patients, uh, because I think, and I, 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, and 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's a clear cardiac contraindication. So, anything, you know, that, um, uh, for example, aortic stenosis, cocktation, um, usually for that heavy weightlifting, um, is, uh, is contraindicated or not advised, but otherwise, they can do the aerobic, um, exercise. Uh, 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, citrullin, 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, uh, it's just, it's just good to know because I know with, uh, uh, anyone, uh, when we think about. We think about renal, uh, 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 nutritionists, and, um, they, uh, they do have that option. And so, usually what our nutritionists 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 sweets, so less than 5 servings per week of sweets, and then less than 6 servings per day of lean meat, poultry, and fish, and then 5 to 4 to 5 servings per week of nuts, seeds, and legumes. Dark chocolate has recently been shown to have, um, uh, it has shown to help with hypertension, uh, but again, I don't, the 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, BMI, um, decrease of approximately 10% is associated with decrease in blood pressure of 8 to 12 millimeter mercury. Um, it can cause, um, sodium, 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, 6 millimeter mercury reduction in BB in blood pressure. So, 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. 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, reduce 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 mortality, morbidity, and I'm going to talk about that in the next slide. But for that too, dietary changes are recommended, uh, Including, uh, thinking about a dash diet, reduced sodium intake, and then vigorous exercise, reduced screen time, especially, you know, if they are also, um, if they, if they're also obese or overweight. Primary hypertension, so dietary changes, uh, physical activity, and then initiation of hypertensive medications. 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, um, skipping things, uh, uh, skipping meals for those, um, usually giving them at least 6 months or so. And how I tell them is that maybe they can have a goal, uh, uh, like, after 6 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, um, 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 a, uh, the, the rate of noncompliance 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, 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 ABPM is normal. And for this one, 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 detection by ABPM prior to performing the routine evaluation of hypertension is around. Um, 2000 approximately $2000 per patient. So that's how much we can save if we just do an ABPM 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 to, um, it's important, firstly, that, um, you know, 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 ABPM done every year to make sure they are not developing true hypertension. And so that's why we continue to see them. If we start seeing them for um hypertension, and if they have white coat hypertension, then we just see them yearly with um repeat ABPM. And so, uh, now, why do we treat hypertension? So, firstly, um, I think we, this, this is going to be a little redundant, but, um, there is concern, there's, 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, this indication that echocardiogram should be performed, especially if someone has a stage 2 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 from before or is new and wasn't there, then that's an indication to start or start or intensify drug therapy. And I'm going to talk about medication classes in the next slides, but if they, if, um, it's, uh, if they are, usually, um, then thinking about medications that can help with, um, remodeling as well. So thinking about ACE 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 target and organ damage. So thinking about left ventricular hypertrophy, this is a picture of an echo, which does show that. And then arterial waves, uh, arterial stiffness, and then atherosclerosis. So arteriosclerosis and then atherosclerosis. And then this is hypertensive retinopathy, so it can cause flame hemorrhages, papilloedema, cotton wool spots, and hard exudates. And in kidneys, it can cause AKI or acute kidney injury, microalbuminuria, a neurologic or neurocognitive delays, strokes, seizures, posterior reversible encephalopathy syndrome or stress. So these are the pharmacologic agents that we use. So diuretics, um, uh, direct acting vasodilators, so hydralazine, monoxidil, sympathetic blockers, so central, um, is clonidine. We mostly use a clonidine patch. Uh, there's also clonidine tablets and clonidine suspension available. Beta, uh, blockers, so metoprolol, propranolol, um, and then angiotensin blockade with ACE inhibitor, enalapril, benazepril, ARBs are angiotensin receptor blockers, uh, which are candesartan and calcium channel blockers, which are the most common ones. So, um, 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, the calcium channel blockers, ACE inhibitors, ARBs, RAN inhibitors. Um, alpha-one antirenergic, um, antagonist direct vasodilators, and then on the kidneys is the diuretics that works, and then also the ACE inhibitors and the ARBs. 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, then thinking about the third antihypertensive 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, clonidine patch is not included, but again, the same risk for that too. It can cause hypertension, bradycardia, um, and then for ACE inhibitors and ARBs, um, 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 ARB, um, which doesn't cause cough. Um, uh, again, um, ACE inhibitors and ARBs, they are associated with, um, hyperkalemia, AKI, so 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, so making sure they're, uh, you know, uh, they're 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 have blurry vision, they may have, um, dizziness, um, but not, nothing life-threatening. So, um, this is usually treated with oral or IV short-acting. Medications. If they do have hypertensive emergency, then, um, it's acute severe blood pressure elevation, which is associated with severe CNS, cardiovascular or other symptoms. So seizures, encephalopathy, um, congestive heart failure, AKI papilloedema, 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 induced and then ischemic damage from overly rapidly lowering of blood pressure. So this was my talk. Um,
