1. Pediatric Hypertension and Hyperlipidemia: Screening and Referral
Jeffrey Harris, MD
Pediatric Cardiology
Marshall Pediatrics
Hoops Family Children’s Hospital
6/17/2015

2. Objectives
1. Learn screening guidelines for dyslipidemia in children and adolescents
2. Learn screening guidelines for hypertension in children and adolescents
3. Understand appropriate technique/cuff size for measuring BP
4. Understand basic workup for pediatric HTN, including labwork and imaging.
5. Understand indications for referral to a lipid or hypertension specialist.

5. Cardiovascular Disease
Atherosclerosis begins in childhood
Risk factors can be identified in childhood
Clinical events include: MI, stroke, PDA, and ruptured aortic aneurysm
Risk factors track from childhood into adult life
Interventions exist for management of identified risk factors

6. Cardiovascular Disease

7. Hypertension Definitions
Hypertension is defined as average SBP and/or DBP ≥95th percentile for gender, age, and height on ≥3 occasions
Prehypertension: average SBP or DBP levels ≥90th but <95th percentile
Adolescents: BP levels ≥120/80 mmHg should be considered prehypertensive.
White coat hypertension: >95th percentile only in a physicians office or clinic
Pediatrics 2004;114;555

9. Measurement
Children >3 years old who are seen in a medical setting should have their BP measured
The preferred method of BP measurement is auscultation
Correct measurement requires correct cuff size
Measurements >90th %tile with oscillometric devices needs repeated

10. Technique Sitting quietly for five minutes
Avoid stimulant drugs and food
Sitting upright with right arm supported at the level of the heart
Right arm is preferred

11. Technique
SBP is determined by the onset of the “tapping” Korotkoff sounds (K1)
DBP is association with disappearance of Korotkoff sounds (K5)
If K5 persists, then K4 should be used which is “muffling” of the sounds

12. Cuff Size
Length of BP cuff bladder should be 80% of the circumference of the upper arm
Width of BP cuff bladder should be at least 40% of the circumference of the upper arm
If cuff is too small, BP value may be elevated
If cuff is too large, BP value may be underestimated

14. Cuff Size

15. Special Circumstances
What about younger children?
Conditions Under Which Children <3 Years old Should Have BP Measured
History of prematurity, VLBW, or other neonatal complication requiring intensive care
Congenital heart disease (repaired or unrepaired)
Recurrent urinary tract infections, hematuria, or proteinuria
Known renal disease or urologic malformations
Family history of congenital renal disease
Solid-organ transplant
Malignancy or bone marrow transplant
Treatment with drugs known to raise BP other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc)
Evidence of elevated intracranial pressure

16. Classification

19. Lifestyle modifications
Cardiovascular Health Integrated Lifestyle Diet (CHILD-1)
First stage dietary intervention for cardiovascular abnormalities
Encourage maintenance of a healthy weight
Encourage regular activity
Decrease screen time
Tobacco exposure/use counseling

20. Caloric Intake

21. Clinical Evaluation of Confirmed Hypertension
History, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking alcohol; physical examination
H&P help focus subsequent evaluation
All children with persistent BP 95th percentile:
BUN, creatinine, electrolytes,
Urinalysis +/- urine culture
CBC
Renal U/S
Fasting lipid panel, fasting glucose
Retinal exam and echocardiogram – Evaluate for end-organ damage
Pediatrics 2004;114;555

22. Pediatrics 2004;114;555 Additional evaluation as indicated:
Drug screen - History suggestive of possible contribution by substances or drugs.
Polysomnography - History of loud, frequent snoring
ABPM - ?white-coat HTN, and when other information on BP pattern is needed
Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
Renovascular imaging
Plasma renin determination
Plasma and urine steroid levels
Plasma and urine catecholamine levels
Pediatrics 2004;114;555

24. Treatment Indications Symptomatic hypertension Secondary hypertension
Hypertensive target-organ damage
Diabetes (types 1 and 2)
Persistent hypertension despite non-pharmacologic measures

25. Medical Management General principles
Therapy should be initiated with a single drug
Acceptable drug classes include ACE inhibitors, angiotensin-receptor blockers, β-blockers, calcium channel blockers, and diuretics
Goal for treatment should be less than the 95th percentile
If concurrent conditions are present, goal should be less than the 90th percentile
Severe, symptomatic hypertension should be treated with IV meds

27. HTN Indications for referral:
Preferably initial labwork/testing already started
Secondary HTN – referral to appropriate subspecialist
Stage 2 HTN?
anyone you are not comfortable treating!

28. Cholesterol Screening
Family history has been used historically
History of coronary artery disease in a parent or grandparent
Definition- heart attack, treated angina, interventions for coronary artery disease, stroke, or sudden cardiac disease
Men less than 55 years of age
Women less than 65 years of age
Parents with elevated cholesterol

29. Screening Insensitive predictor
May miss 30-60% of children with dyslipidemia
CARDIAC project—Dr. Neal, WVU
20,266 fifth grade students in WV public school system
Rate of abnormal LDL in children with a positive family history was similar to that found in children without a concerning family history

30. NHLBI 2011 Universal screening Selective screening
First screening performed between 9 and 11 years of age
Second screening performed between 17 and 21
Selective screening
Between 2 and 8 years of age (see next slide)
Between 12 and 16 years of age (if new risk factors identified)

31. Selective screening Special conditions Family history of premature CAD
Parent with known dyslipidemia or total cholesterol > 240 mg/dL
Smoker
Hypertension
BMI ≥ 95th %tile
Diabetes (Type I or 2)
Chronic kidney disease/ESRD/post-renal transplant
Post-orthotopic heart transplant
Kawasaki disease with current or regressed aneurysms
Chronic inflammatory disease (SLE, JRA)
HIV infection
Nephrotic syndrome
Kavey REW et al. Pediatrics 2011;128: S1-44

32. Screening Test
Universal screening may be done with a fasting or nonfasting sample
A fasting lipid panel is recommended for selective screening
What is the difference?

33. Cholesterol Testing Fasting lipid profile Non-fasting lipid profile
Total cholesterol (TC), HDL, and triglyceride levels (TG) directly measured
LDL calculated
LDL= (TC – HDL) – (TG/5)
Non-fasting lipid profile
Measures TC and HDL
Non-HDL calculated
Non-HDL= TC - HDL

34. Testing
Non-HDL cholesterol seems to be predictive of persistent dyslipidemia than TC, LDL, or HDL in both children and adults
No need for direct LDL measurement
Most studies have shown that measurement of apolipoprotein B and apolipoprotein A-1 for universal screening provides not additional advantage
Measurement of lipoprotein A is useful in the assessment of children with both hemorrhagic and ishchemic stroke

35. Normal Values

36. Lipid Levels in Children and Adolescents
Cut points for a high or borderline high value are 95th and 75th percentile, respectively. Cut points for a low or borderline low value are 5th and 25th percentile, respectively Kwiterovich P, J Clin Endocrinol Metab 2008 S1-44
Kavey REW et al. Pediatrics 2011;128:

37. Confirmation Testing
If the fasting lipid profile is abnormal, repeat should be measured in 2 weeks to 3 months
If non-HDL screening is abnormal, fasting lipid profiles should be measured twice in 2 weeks to 3 months
**Average value is used to determine the need for treatment

38. Controversy
Previous guidelines had not recommended universal screening
Other concerns
Many patients may be harmed by screening
Lack of evidence regarding treatment in children
Cost
Side effects of statins

40. Diet – Dyslipidemia/Overweight (CHILD-1)
Total fat 25%-30% daily kcals
–Saturated fat < 10 % daily kcals
–Mono-and poly-unsaturated fats up to 20% daily calories
Avoid trans fats
Cholesterol < 300 mg daily
Limit sweetened beverages
>5 servings fruits & vegetables daily
Fiber: Age + 5g/day (2-10 yrs) 14 g/1000kcal (11-21 yr)
NCEP expert panel of blood cholesterol levels in children and adolescents. Pediatrics 1992;89:

41. Diet: Persistent High LDL-c
After 3-6 months of low-saturated fat diet and LDL-c remains >130 mg/dL
Reduce saturated fat intake to <7% of total calories
Dietary cholesterol < 200 mg/d
Meet with registered dietitian
Soluble fiber
6 g/d for children 2–12 years
12 g/d for those ≥12 years
Daniels SR, Pediatrics 2008

42. Diet - High Triglycerides
Limit simple sugars and carbohydrates
Increase fiber and complex carbohydrates
Omega-3 fatty acids
Ex: wild salmon, flaxseed, walnuts, winter squash
EPA + DHA, 2-4 grams/day
Hard to get through diet alone
OTC or prescription
Weight loss or stabilization
Kris-Etherton PM et al, Circulation

47. Treatment Summary
CHILD-1  CHILD-2 (LDL or TG) plus lifestyle modifications for 6 months
Consider referral to dietician
Exclude secondary causes
Repeat fasting lipid profile
Medical therapy may be recommended depending on the response
Consult with a lipid specialist
TG ≥ 500 mg/dL or LDL ≥ 250
Age < 10 years
Any patient with whom you are uncomfortable managing!

48. SUMMARY BP screening for all kids >3yo
younger if risk factors
Cholesterol screening ages 9-11, then 17-21
Additional selective screening as needed
For both BP and lipids:
Confirm the diagnosis
Evaluate for secondary causes
Dietary/lifestyle modifications

49. References
The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 2004;114;555
Kwiterovich P. Recognition and Management of Dyslipidemia in Children and Adolescents. J Clin Endocrinol Metab 2008 S1-44
Kavey REW et al. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics 2011;128
NCEP expert panel of blood cholesterol levels in children and adolescents. Pediatrics 1992;89:
Daniels SR, Lipid Screening and Cardiovascular Health in Childhood. Pediatrics 2008;122; DOI: /peds