Resources

  1. Khoury M, Madsen N. Screening and Management of High Blood Pressure in Children and Adolescents. JAMA Pediatr. 2018;172(11):1087–1088. doi:10.1001/jamapediatrics.2018.288https://jamanetwork.com/journals/jamapediatrics/fullarticle/27021992
  2. Flynn JT, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published correction appears in Pediatrics.2017;140(3):e20171904]. Pediatrics. 2017;140(3): pii:e20171904.









Transcript

Dr. Frank Domino:

Tyler is a 10-year-old male here for a well-child visit. His delightful talkative young man who has no complaints today. Mom, tells you, "Tyler, loves to read, play video games and is doing well in school. He has a nice group of friends, but he's not interested in sports like his brothers and would rather sit and read than get up and move." Tyler's father had hypertension at a fairly young age and that his paternal grandparents both have heart disease. On review of his vital signs, you note that Tyler's weight is in the 95th percentile for his age and height, and his blood pressure is 118 over 80 in his left arm. This puts him in the 90 to 95 percentile range for his age and height. How would you interpret Tyler's blood pressure? And what, if anything, would you do regarding these findings?

Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health. Joining me today is Susan Theni, DMP and Assistant Professor and Coordinator of the Family Nurse Practitioner Tract at the University of Massachusetts Medical School Graduate School of Nursing.

Susan, thank you very much for bringing these new blood pressure guidelines to our attention today.

Susan Feeney:

My pleasure, Frank.

Dr. Domino:

So Tyler sounds like more than a few boys in our practice, and understanding, managing elevated blood pressures is something I think we've all been confused about. So, Susan, how do we diagnose children before age 13, with hypertension?

Susan Feeney:

Those folks, kids under age 13, we use normative tables, and that's based on their height and their age, and basically if they're under 90th percentile, that's normal. If they're between the 90th and 95th, that's considered elevated, and anything over 95th percentile would be stage one, or higher than that would be a stage two. For 13-year-olds and older, we are looking at a fixed blood pressure, so if it's normal would be less than 120 over 80, and elevated would be greater than 120 over 80.

Dr. Domino:

Okay. Great. And then how do we decide on those blood pressure readings when to initiate treatment?

Susan Feeney:

Well, they give us pretty good guidelines. We need to check elevated pressures that would fall into that elevated range, both for kids under 13 and over 13. They want us to check it three separate times at three different visits. If it's stage one, they want us also to check three more times before we make a diagnosis. If it's stage two, they want two distinct visit checks, and then if it's still elevated after the second then you can make the diagnosis of a stage two hypertension.

Dr. Domino:

Well, you raise a really good point. How common are we going to be finding hypertension in our pediatric population?

Susan Feeney:

Well, the literature says it has increased but we're also checking them more frequently, so it's really somewhere between 2 and 3% are in the elevated range, for children and teens. And then for the kids that fall in the higher categories, again 3%, so not a large amount, but the problem is there's significant problems and evidence of target organ damage if this isn't rectified. But what is really stressed is the lifestyle changes, that needs to be instituted for all people, all kids, regardless of whether they are an elevated range, or even if they have a normal range, but if their weight is up beyond 95 percentile. We really need to think about instituting these lifestyle modifications.

Dr. Domino:

Okay. Let's talk a little about that. We've got new screening guidelines, we've got new diagnostic criteria and the diagnostic criteria is based upon their height before age 13 or based upon 120 over 80 after age 13. So now we've got treatment recommendations. Can you talk a little bit about what we should be doing first and second line?

Susan Feeney:

First line would be to institute, let's say with Tyler, he comes in, he's running in the elevated range he's not stage one, we really wanna need to talk to him and his mom about; what's his usual diet? What's his usual exercise pattern? Are there ways that we could look at getting rid of things that might be adding to his weight, such as soda or salt or fats, or fast foods and find some low-hanging fruit to try to change and see if we could get his blood pressure down by some weight reduction, not putting him on a diet, but looking at his diet, and trying to make it more healthy. Then also exercise, mom says he's not doing much. So how could we encourage some activity? Sometimes it's going up and down the stairs a couple of times, taking the stairs at school if there's in lieu of an elevator, but find ways in which to increase his exercise, because we know that's going to be give us the most bang for our buck, and have the most greatest impact on his health his whole life.

Dr. Domino:

Alright. That's always the challenge with both children and adults, but I think you're right, talking to both him and his mom are gonna be critical to both helping him improve his diet and improve his activity. When do we need to start thinking about medication?

Susan Feeney:

Well, you would really look at a child who is in the stage one category, so this would be somebody who's greater than 120 over 80, and who with... He's supposed to check three times, within a year to see if this blood pressure is accurate. If it continues that way, above that level, then the American Academy of Pediatric says you need to think about instituting treatment, which would be the standard medications; ACEs, ARBs, calcium channel blockers or diuretics, and they don't pick one over another, even they didn't indicate anything about ethnicity in here that I could see. And then really stressing the lifestyle changes. They also made a point that echocardiogram might be something you'd wanna order prior to... If you were thinking you're gonna initiate therapy, they want you to evaluate the left ventricular mass with an echocardiogram. If you're at that point in primary care, you may wanna refer to a cardiologist at that point, if that was your concern. And then if it's stage two, initiation of therapy would happen after two verified blood pressures in that range.

Dr. Domino:

Alright. Well, this sounds like a fairly big challenge. One thing I always worry about is when children wanna participate in a variety of after-school and summer activities, people look for clearance. What can we tell Tyler should he wanna play a sport. Is he going to be allowed to, with an elevated blood pressure?

Susan Feeney:

Absolutely. They made a very clear statement here that participation in sports would only be if someone had a stage two, or greater. And then once someone is stage two and is in well-controlled blood pressure, they can go into playing sports.

Dr. Domino:

So having hypertension in the pediatric population should not preclude you from being involved in sports activities, unless it's quite severe. And then it can be as soon as you get it under control.

Susan Feeney:

And also, the other thing too, I just wanna point out is a lot of times we feel obliged to do a lot of work up on these kids. What they're saying is if the child is six or greater, and is overweight or obese, has a strong family history of hypertension, like Tyler. Or has other risk factors, that we don't have to do a deep dive into those secondary risk factors, unless there are obviously symptoms either physical or history symptoms that would make you worried about thyroid or artery stenosis or something like that. But otherwise, we don't have to go off that. Clearly if somebody has a co-morbidity that's causing their blood pressure like diabetes and things like that, you would need to get specially care involved before you clear them for sports. But most of the kids we're gonna see are gonna fall into this category like Tyler. He needs to join a team, he needs to be out and run around.

Dr. Domino:

Susan, this is a really complicated guideline. Thank you very much for discussing it with me today.

Practice pointer: The American Academy of Pediatrics new hypertension guidelines require checking blood pressure at their well visit, repeating if the pressure is elevated, and initiating treatment of lifestyle change first line for all those at risk. Join us next time when we talk about the role of aspirin for the primary prevention of cardiovascular disease.