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Pediatric Hypertension Morning Report January 8, 2004
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Why Worry? Atherosclerotic heart disease remains the leading cause of death and disability in North America. Pathologic studies have shown that both the presence and extent of atherosclerotic lesions at autopsy in children and young adults correlate with certain established risk factors: LDL, TGs, systolic/diastolic blood pressure (BP), BMI, and tobacco use.
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Why Worry? Additionally, in adults, hypertension has been shown to be a risk factor for the development of renal disease.
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Background The 1987 Report of the Second Task Force on BP control in childhood resulted in: The provision of BP norms for children and adolescents, and The standardization of BP measurement. The task force recommended that all children 3 years and older have their BP recorded during HCM and urgent visits.
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Background (cont’d) In 1996, new BP tables were published that reanalyzed data from the 1987 task force report. These tables, adjusted for height and age, alter the BP percentile estimates of boys and girls of all ages.
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Neonates and Infants The average systolic BP at 1 day of age in term infants is 70 mmHg; BP increases to 85 mmHg by 1 month of age. In a large cohort of premature infants studied during the first 3 to 6 hours of life, the limits of systolic and diastolic BP were independent of birth weight and gestational age but tended to correlate with low apgar scores and maternal hypertension.
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Neonates and Infants (cont’d) Studies of older premature infants found significant correlation between systolic BP and length and weight. In children younger that 1 year, systolic BP has been used to define hypertension.
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Racial Variances Although blood pressure has been shown to be higher in black versus white children, the differences are not believed to be clinically significant. Therefore current reference standards do not distinguish between racial and ethnic groups.
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Predispositions Approximately 25% of the adult population in the United States has hypertension, with 90% classified as having essential aka primary hypertension. Familial and longitudinal studies have shown that there is a link between genetic and environmental influences on BP during childhood and the development of primary hypertension.
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Predispositions Other factors contribute to the risks for primary hypertension, aside from genetic predisposition. These include reactivity of vascular smooth muscle, the kidney and the interaction of the RAS, cardiac index, obesity, and hormonal and environmental factors.
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Predispositions A direct relationship between weight and BP has been observed at as early as age 5 and is even more prominent in the 2nd decade. Genetic factors that impact sodium, potassium, and calcium regulation may also influence BP in young populations.
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Technical Issues The right arm is preferred for consistency and comparison with the standard tables. If 2 cuffs are close in size to the measured width of the arm, go with the larger cuff so as not to give falsely elevated readings.
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Technical Issues (cont’d) BP should be measured in a controlled environment after 3 to 5 minutes of rest in the seated position with the cubital fossa supported at heart level. The cuff should be inflated to a pressure of 20-30 mm above systolic pressure with a deflation rate of 2-3mm/sec. Automated devices are acceptable in newborns and infants, but true diastolic pressure is not accurately assessed by the indirect methods used by these devices.
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Technical Issues (cont’d) Systolic pressure is determined by the onset of the “tapping” Korotkoff sounds. The definition of the diastolic pressure has been modified and is now described as the disappearance of the sounds (the 5th Korotkoff sound). In some children, Korotkoff sounds can be heard to 0 mm Hg. This occurrence excludes diastolic hypertension.
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Diagnosis Normal is a systolic and diastolic pressure less than 90th percentile. High normal is an average systolic or diastolic pressure greater than or equal to the 90th percentile, but less than 95th percentile. Hypertension is an average systolic or diastolic pressure of greater than or equal to the 95th percentile, and measured on at least 3 separate occasions.
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Diagnosis BP varies widely throughout the day in the context of normal diurnal fluctuation, changes in physical activity, emotional stress and other factors, making diagnosis difficult. Only 1% of children are found to have significant hypertension as defined by the task force recommendations.
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Diagnosis Ambulatory BP monitoring (ABPM) has become a valuable tool in evaluating hypertensive adults for diagnosis and ongoing care. In children ABPM is well tolerated and reproducible and seems to be a useful tool in the diagnosis of borderline hypertension.
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History A hypertension-oriented history should be elicited with emphasis on the following factors: symptoms referable to hypertension, neonatal course (? umbilical lines), growth pattern, history of renal/urologic problems, medications (OCP’s, decongestants, stimulants, NSAIDS, steroids), symptoms of endocrine etiology, and a family history of primary hypertension/genetic disorders known to be associated with secondary hypertension.
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Physical Exam Exam should focus on: evidence of hypertensive encephalopathy, Bell’s Palsy, retinopathy neurofibromas, café-au-lait spots, Von Hippel-Lindau disease, lesions of tuberous sclerosis hirsutism, moon facies, buffalo hump, truncal obesity, striae, thyromegaly cutaneous findings of SLE or HSP evidence of BPD, pulmonary edema, CHF, bruits, edema, diminished pulses, pregnancy, Turner syndrome, William syndrome, enlarged kidneys, abdominal masses.
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Etiologies The likelihood of identifying a secondary cause of hypertension is directly related to the degree of BP elevation and inversely related to the age of the child.
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Newborns Renal artery thrombosis Renal artery stenosis Renal venous thrombosis Congenital renal abnormalities Coarctation of the aorta Bronchopulmonary dysplasia (less common) Patent ductus arteriosus (less common) Intraventricular hemorrhage (less common)
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First Year of Life Coarctation of the aorta Renovascular disease Renal parenchymal disease
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Age 1 to 6 Years Renal parenchymal disease Renovascular disease Coarctation of the aorta Endocrine causes (less common) Primary hypertension (less common)
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Age 6 to 12 Years Renal parenchymal disease Renovascular disease Primary hypertension Coarctation of the aorta Endocrine causes (less common) Iatrogenic (less common)
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Age 12 to 18 Years Primary hypertension Iatrogenic Renal parenchymal disease Renovascular disease (less common) Endocrine causes (less common) Coarctation of the aorta (less common)
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Evaluation Phase 1 CBC UA Urine culture BUN, CR, electrolytes, calcium, uric acid Lipid panel Renal ultrasound Echocardiogram
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Evaluation Phase 2 Renal scan with angiotensin-converting enzyme inhibitor Renin profiling Urine collection for catecholamines Plasma and urinary steroids
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Evaluation Phase 3 Renal artery imaging Mataiodobenzguanidine (MIBG) scan of adrenals Caval sampling for catecholamines
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Evaluation In the first year of life, virtually all hypertension is secondary, and even in infants in whom no cause was found secondary disease must still be suspected. Given the low prevalence of secondary disease in the adolescent population with mild hypertension, only minimal studies are warranted.
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Evaluation Whenever a young child is found to be hypertensive, renovascular disease should be strongly suspected, and the initial evaluation should entail assessment of the renal anatomy and blood flow. Echocardiography is more sensitive than ECG for detecting early left ventricular hypertrophy.
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Nonpharmacologic Measures Generally, management should begin with smoking cessation, weight loss, aerobic exercise, and dietary modifications. Although demonstrated in adults, the limitation of sodium intake and its positive impact on BP is less clear in children. Despite the lack of large scale trials demonstrating the effectiveness of such interventions, it is reasonable to recommend them given the benefits observed in the adult population.
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Indications for Pharmacologic Therapy Absolute Symptomatic hypertension Target organ damage (LVH, retinopathy, microalbuminuria) Secondary hypertension Persistent hypertension despite nonpharmacologic measures
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Indications for Pharmacologic Therapy Relative Sustained or nocturnal hypertension on ambulatory monitoring Presence of other cardiovascular risk factors (smoking, elevated lipids) Obesity related hypertension Family history of hypertension
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Pharmacotherapy The goal of treatment is to achieve a decrease in BP to below the 90 to 95th percentile and prevent long term sequelae of persistent hypertension. The majority of children with secondary hypertension require pharmacotherapy and frequently more than one medication. Patients with high-renin hypertension as with chronic renal disease and renovascular disease as well as those patients with diabetes would likely benefit more from ACE inhibitors.
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Summary When discovered, elevated BP should be appropriately investigated with the evaluation tailored to the age of the child and the severity of the BP elevation. Despite the absence of clear links between childhood hypertension and adult cardiovascular disease, it seems logical to suppose that the treatment of childhood hypertension would reduce cardiovascular and renal morbidity risk in adulthood.
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Bibliography Bartosh S, Aronson A: Childhood Hypertension An update of Etiology, Diagnosis, and Treatment. Pediatric Clinics of North America 46:235, 1999. Flynn Joseph: Recognizing and Managing the
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