4 Hypertensive Kids in 45 Minutes

Name: Anthony Age: 6 Sex: Male Place: Allergy Clinic BP: 145/87

Name: Chris Age: 17 Sex: Male Place: Inpatient BP: 180/115

Name: Brittiney Age: 13 Sex: Female Place: Clinic BP: 125/78

Name: Caleb Age: 3 Sex: Male Place: Phone Call BP: 118/75

Caleb Anthony Brittiney Chris

The Fourth Task Force Report on Pediatric High Blood Pressure

6 Questions Does the child really have high blood pressure? Do I have time to ask any more questions? Why does the child have high blood pressure? Does the child have other risk factors? What has high blood pressure already done to the child's body? What should we do about it?

6 Questions Does the child really have high blood pressure? Do I have time to ask any more questions? Why does the child have high blood pressure? Does the child have other risk factors? What has high blood pressure already done to the child's body? What should we do about it?

Blood Pressure Measurement Technology is in the Dark Ages. Confirm all blood pressure readings before acting.

It’s a Pain in the A** to Detect HTN Equipment is inherently flawed, hard to find Or gives inaccurate readings if not used right.

It’s a Pain in the A** to Detect HTN Spurious elevations are common

It’s a Pain in the A** to Detect HTN Not everyone has a BP reading.

It’s a Pain in the A** to Detect HTN Mild Hypertension takes weeks to confirm

It’s a Pain in the A** to Detect HTN Norms for Pediatric BP are found in a 4-D table

It’s a Pain, But you Got to Do it

Normal < 90% le Pre-Hypertension 90-95% le Stage 1 Hypertension 95% to 5 mm above 99%le Stage 2 Hypertension > 5 mm above 99%le

Hypertension is Common Hypertension Asthma %

Caleb 118/75 Anthony 145/87 Brittiney 125/78 Chris 180/ cm(72%le) 95% BP = 126/82 90% BP = 122/ cm (75%le) 168 cm (16%le) 98 cm (64%le) 95% BP = 113/74 99% BP = 120/82 95% BP = 133/85 99% BP = 141/93 95% BP = 110/67 99% BP = 118/75

Recognizing or ruling out a hypertensive emergency is the 1 st order of business in any hypertension evaluation.

6 Questions Does the child really have high blood pressure? Do I have time to ask any more questions? Why does the child have high blood pressure? Does the child have other risk factors? What has high blood pressure already done to the child's body? What should we do about it?

Is this an Emergency? Hypertensive Emergency Elevated Blood Pressure with symptoms of end-organ damage Hypertensive Urgency A high BP that makes you uncomfortable

Hypertensive Emergencies Drop the Blood Pressure no more than 10% Use short acting IV medications –IV Labetolol –IV Hydralazine –IV Nicardipine drip Start small and then escalate your dose Get the patient to a PICU

Chris Chest Pain and a splitting headache Labetolol and hydralazine given on the floor – no effect. Nicardipine drip in PICU. BP 150s/80s by noon.

6 Questions Does the child really have high blood pressure? Do I have time to ask any more questions? Why does the child have high blood pressure? Does the child have other risk factors? What has high blood pressure already done to the child's body? What should we do about it?

School Age Teenager Chronic UTIs Glomerular Disease Renovascular Disease Aortic Coarctation Essential Hypertension Glomerular Disease Renovascular Disease

Other Causes of Pediatric Hypertension that you still think about Inpatients –Increased ICP –Pain –Iatrogenic steroid-induced Uncommon outpatient causes –Endocrine causes (Cushing, Pheo) –Pre-eclampsia

The Younger the Patient with Hypertension, the More Likely you’ll find a Cause Rule of Thumb #1

The Higher the Blood Pressure, the more likely there’s a cause Rule of Thumb #2

Symptoms to Ask About

History UAC as a newborn UTIs or febrile illnesses Medications Supplements Family History

Physical

Arm & Leg BPs A B C What’s Normal? 1. A = B = C 2. A = B > C 3. A = B < C 4. A > B > C What’s Normal? 1. A = B = C 2. A = B > C 3. A = B < C 4. A > B > C

Eye Grounds

Heart Findings

Listen for a Bruit

Skin CALMs of NF-1 Acanthosis Nigricans

Skin

Labs & Imaging Pre-Hypertension Lipids Fasting Glucose Echocardiogram Retinal Exam Young Stage 1 or Stage 2 Renin Catecholamines Angiogram Urine Steroids + Teenager Stage 1 RFP Urinalysis Renal Ultrasound +

Pre-Hypertension Lipids Fasting Glucose Echocardiogram Retinal Exam LVH on an echocardiogram is the most common end-organ manifestation in pediatric hypertension Essential hypertension almost always occurs with other risk factors

Teenager Stage 1 RFP Urinalysis Renal Ultrasound Quantitate any abnormal urine protein There’s no normal creatinine in pediatrics, but there is a normal GFR. Renal vessel doppler are of questionable value.

Young Stage 1 or Stage 2 Renin Catecholamines Angiogram Urine Steroids Plasma renin is usually uninterpretable. Elevated urine catecholamines are usually transient and not subtle. Don’t bother with MRAs or nuclear scans; the gold standard is an angiogram.

Caleb Category of HTN: Young Stage 1 History & Symptoms:None Physical:Normal Labs:Normal Imaging: Echo:Mild LVH U/S:Left kidney < Right Angio:Normal

Brittiney Category of HTN: Pre-Hypertension History & Symptoms:Snores Physical:Elevated BMI ~ 98%le Labs:Fasting BG 121 Imaging: Echo:Normal U/S:Normal

Life-style changes Give a TV target of 2 hours per day or less Write a prescription for PE DASH diet ( Surveillance Lipids, Blood Sugars, Weight, Urine Protein Ambulatory Blood Pressure Monitor (ABPM)

Ambulatory Blood Pressure Monitor

Anthony Category of HTN: Young Stage 2 History & Symptoms: Intermittent headaches Physical: Single Café au Lait Labs:Normal Imaging: Echo:Moderate LVH U/S:Normal Angio:

Chris Category of HTN: Teenager Stage 2 History & Symptoms:Transplant; On a drip Physical:Tachycardic Labs:Creatinine 1.7 Imaging: U/S:

Chris Hydronephrosis, Ureteral obstruction Blood pressure dramatically better (off drips) after nephrostomy

6 Questions Does the child really have high blood pressure? Do I have time to ask any more questions? Why does the child have high blood pressure? Does the child have other risk factors? What has high blood pressure already done to the child's body? What should we do about it?

7 Classes of Anti-hypertensives Diuretics Beta-blockers IV labetolol Central Alpha-Blockers Calcium Channel Blockers nicardipine drip ACE Inhibitors Direct Vasodilators IV hydralazine Angiotensin Receptor Blockers Peripheral Blockers

Take Home Points Report the percentile of Blood Pressure on Any BP you get Recognize a hypertensive emergency Refer to the 4 th Task Force Report or your local pediatric nephrologist once you recognize a high blood pressure