Dr. Halabi reviews the epidemiology and risk factors of hypertension, describes the diagnostic approach and evaluation of a pediatric patient who presents with elevated blood pressure, and discusses the treatment options for pediatric hypertension.
All right. Uh, good morning everybody. Uh, for those of you who don't know me, I'm a pediatric nephrologist. I actually came here in 2009, uh, and trained as a resident for a residency. I did my fellowship here and I have stayed on, and, um, uh, I, uh, I was recently, uh, appointed as the chief of the, uh, of our division, and so, um, I'm, I'm really excited to talk to you guys today about, uh, pediatric hypertension. Uh, and when I was putting these slides together, I know that I typically, I, a lot of my time I spend doing basic science research and so in my presentations, I'm used to having a lot of pictures and data slides and, and things like that. And when I was making this presentation, Um, I noticed that it's a lot of lists and, of things, and I don't want it to be boring, and so please, please, uh, I am OK with interrupting. So if you have a question throughout, I want this to be as, you know, as interactive. I don't want to just keep on talking and reading, reading off slides. So if you have questions throughout, I don't know that I'm gonna have the answers to them, but I will, uh, I will try. And so, uh, really the way, uh, OK, so first and foremost, I have no, uh, no conflicts of interest or disclosures. Um, so what I'd like to do today is really summarize the, uh, all the big guidelines that came out in 2017, uh, uh, from the AAP and the American American Academy of Pediatrics as well as the American Heart Association on, um, pediatric hypertension. How do we define it, which is the definition. changed a little bit uh since 2017 and uh review how that affected the epidemiology of hypertension and review risk factors, uh, describe, OK, we have somebody uh who presents with a high blood pressure, what do we do about it? So the diagnostic approach and evaluation process of a patient who presents with, um, uh, high blood pressure and then, uh, I'll very briefly touch on treatment options for hypertension. Um, OK, so first and foremost, what is, what is hypertension? What are, what do we call hypertension? So, based on the 2017, uh, AAP guidelines, uh, uh, we, in children less than 13 years of age, uh, we, uh, normal blood pressure should be less than the 90th percentile, uh, uh, or both systolic and diastolic less than the 90%. percentile or less than 120/80, whichever is lower. So if the 90th, 90th percentile says uh that the blood pressure is 125, we will take, it should be 120. So whichever is lower, that's what we take as normal blood pressure. Uh, so then elevated blood pressure, that category is when the blood pressure is 90th percentile to to less than the 95th percentile. Uh, again, always whichever is lower, if, if the, uh, 95th percentile reaches above that, uh, above the 80 or 120/80, and then for stage one hypertension, that's 95th percentile to 9 95th plus 12, or that's the 99th percentile, 95th percentile plus 12 millimeters of mercury. And then stage 2 hypertension uh is anything above the 95th plus 12. So, anything uh at or above the 99th percentile or Uh, 140/90. So for, however, for children, uh, less, uh, greater than 13 years and older, so any teenager, um, uh, we use similar, the, the, the parameters we're using to define normal blood pressure, elevated blood pressure, and so on and so forth are really exactly what, uh, what is used in the adult world. Uh, so for systolic blood pressure, it should be less than 120/80 for normal. 120 to 129/80, uh, should be, uh, that's elevated now. 130 to 139 is stage one over, and then, uh, greater than 140/90 or equal to, uh, that would be considered stage two. It's important to note that these, that these values, the data, uh, were the normative values for, for these percentiles, uh, in pediatrics, they were obtained from healthy children, uh, from the National Health and Nutrition Examination Survey and other screening studies, as opposed to in the adult world where these, these numbers came based on cardiovascular outcomes. Thankfully, in children, they don't have the Heart attacks and strokes that we, as an outcome, the only cardiovascular consequence is typically LVH and so, and that's not very, very common. So, that's why the percentiles in uh for blood pressure, for defining blood pressure in children came from norm these normative values came from screening studies, not based on outcomes. That's unlike uh in the adult world. And so they are based on sex, age, and height of the patient. And, um, uh, these nor normative values included, uh, only healthy children uh with BMI is less than 85%. And so, um, I see a lot of residents, uh, in the room and so when I, if I don't know if I, if you've been with me on service, I often say, uh, and I don't, I, I don't have any, uh, anything to do with the app, but there's this pediatric blood pressure app that I, I purchased for 99 cents in 2018 and that's what I, I plug in. The height of the patient, whether they're boy or girl and um and uh I, I get what the 90th, 95th, and 9 95th plus 12th percentile is and uh I, I, I looked today to see like I wanted to see how much it costs now, uh, but I saw +22 apps of this, in this, of the same name, pediatric blood pressure. One of them was still 99 cents. I don't know. I don't know if it's still 99 cents or not, but it's definitely, it's been actually uh very helpful for me to use in clinic. Yeah. All right, so that's, uh, so that's the definition, uh, that those are some of the the definition, that's what we are all, we've all now been talking about since, uh, 2017. In addition to, OK, norm, you know, calling somebody having, uh, normal blood pressure, normal intensive, or high blood pressure, you know, having hypertension, there are a couple of other categories that, uh, we need to, uh, kinda talk about, and those are white coat hypertension, uh, that refers to, uh, so this is all based on whether it's office blood pressure at the doctor's office versus ambulatory. And that doesn't necessarily mean the 24 hour ambulatory blood pressure monitor. That means, uh, measuring it at home, at school, uh, some somewhere outside of uh the blood of the physician's office. So, white coat hypertension, uh, we, that is defined when, uh, at the doctor's office, the blood pressure is high, the patient's hypertensive at the, uh, at the doctor's office, but then it's normal in an ambulatory setting at home. Uh, that is as opposed to mass hypertension when the blood pressure is normal at the doctor's office that's elevated, uh, at home and, um, in other settings. And so this mass hypertension is really important for us, uh, especially, uh, for children with chronic kidney disease, uh, and so, uh, it's, it's not very common, but it's uh certainly a category that we keep in mind. Uh, of note, about greater than about 1/3 to 50% of children evaluated for persistently elevated blood pressure end up having white coat hypertension. OK. So, uh, since 20 with the change in, um, with the change in the definition of uh hypertension, uh, the prevalence of hyper of, uh, hypertension changed a little, increased a little bit. Uh, so most, most, there are, you know, I see numbers between 2 to 5%. Most, uh, studies show that our, uh, reviews, uh, report, uh, a prevalence of About 4% in the pediatric population having, uh, in the US and a lot in similar developed countries, about 4% of the pediatric population having hypertension, and about 13 to 18% of of kids end up having elevated blood pressure. The prevalence of primary hypertension is about 10 times higher than that of secondary hypertension, you know, and a long time ago, people would say, oh, in kids, it's usually going to be secondary hypertension. Well, that's no longer the case. The most common cause of hypertension in the pediatric population is primary or essential hypertension. OK. So what are some of the risk factors these, I'm sure you are all familiar with, so, uh, of course, there are these modifiable risk factors that we hear about all the time, uh, uh, overweight, obesity, uh, diet, uh, uh, eating high salt diet, processed foods, uh, lower fruits and vegetables, uh, uh, um, stresses, actually, uh, childhood adversity that has, uh, uh, also affects, uh, is a very high risk factor for hypertension. Uh, of note, breastfeeding is protective against hypertension. So some, uh, there are also non-modifiable risk factors, uh, sex. Boys are more likely to have, uh, uh, um, uh, increased risk of hypertension than girls. Family history, if there's a family history, that increases the risk, and then race and ethnicity, so black, uh, individuals. And Hispanic individuals have, uh, are, are at higher uh likelihood of developing hypertension than white individuals and then prenatal neonatal factors, uh, it's interesting some people put those as modifiable versus non-modifiable, so preeclampsia, uh, and low birth weight, those are risk factors for hypertension. OK. Uh, so, as I mentioned, some of the causes, uh, again, primary hyper, so there's primary hypertension or essential hypertension where we really don't know, it's kind of a diagnosis of exclusion. We don't identify a cause that is now the most common cause of, uh, hypertension in children in the US and especially, uh, we, you know, you think about it when the child is greater than 6 years of age and with a positive family history and has excessive body weight. Uh, to the folks who just came in, uh, I, you know, I, I mentioned in the beginning that I like to, uh, please, if you have questions, I don't want to just be listing things because a lot of this is listing things, and I want this to be a little bit more interactive and so if you have questions, please, please, uh, ask what, ask, interrupt me and ask, that's OK. All right. Uh, so then for, uh, secondary causes of hypertension, that, you know, the prevalence of that varies depending on the country and the age, uh, the age group. Of course, when a child, uh, with 6 years of age presents to me with a blood pressure of 140, there has to be a secondary cause for that. So, and actually that happened, uh, last year. So there, and, um, and so. Uh, so the age matters, the, uh, the risk factors that I just mentioned, all that we, we take a look, uh, we take into consideration. And so what are some of the secondary causes and really when you look at this list, you kinda see, uh, it kinda guides you to the evaluation, you know, to the workup that you're gonna do to evaluate for secondary causes of hypertension. So, any kidney disease, uh, any kidney disease really can cause elevated blood pressure, uh, especially GN. Uh, vascular disease, we think of it that we think of vascular disease as renal artery stenosis, but that's not the only thing. Uh, yeah, um, uh, it doesn't have to be the main renal arteries. It can be a little branch renal artery that you don't even see on ultrasound or even a CT. I had to do on that kid I just mentioned. I had to do a, uh, an angio, a true angiogram in order to see branch renal artery stenosis that was causing his renal to be very elevated. Uh, correctation of the aorta is one of is thing, and then, in a, in a newborn baby who has a UAC and a UVC, you have to think about renal vein thrombosis, um, uh, as a cause of hypertension. Endocrine causes, again, so, um, hyperthyroidism, pheochromocytoma is rare, but we've seen it, actually, we've seen a few cases in the last few years here, uh, congenital adrenal hyperplasia and primary aldosterisms. Only once have I diagnosed primary aldosterism. Uh, neuro, there are also neurologic causes if you have trauma, increased intracranial pressure, uh, uh, stress, as I mentioned, can lead to hypertension. Uh, pharmacologic causes, we always have to think about that. Uh, so, uh, stimulants, steroids, uh, caffeine intake, uh, uh, n smoking, all that, that can increase, uh, blood pressure are some of the agents we use, tacrolimus and cyclosporin, calciumur inhibitors, those will, uh, raise blood pressure as well. Uh, other causes, uh, of course, I didn't list here mono monogenic causes, but there's tuberosclerosis, neurofibromatosis, uh, uh, heavy metal poisoning, those all can lead to hypertension. So those are some of kind of largely groups of, uh, secondary causes of hypertension. OK. So how, how, what is it, you know, I told you what it's defined in numbers, but when do we make the diagnosis? How, what's the, what do we need in order to diagnose somebody with hypertension? And so, uh, the diagnosis requires serial values on 3 separate visits. So we have to have three separate num numbers that are above the or equal to the 95th percentile for age or 120 or greater than 130/80, uh, whichever is lower for kids less than 13 or it's greater 130/80 for children 13 and older. There has to be these numbers, 3 numbers have to be elevated on 3 separate visits, and we'll talk a little bit in a, in a few minutes about when uh these visits should happen, like how, how far apart from each other should they be, um, but that's really what we need for the diagnosis, yes. Um, you had mentioned earlier about mass hypertension where why I guess I was wondering why that, why would that. Why do you have a kid who would suddenly great question. We don't know why it happens. Uh, we, yes, we don't know why it happens, but, um, what we do, um, you know, like at first one would think, oh, maybe we, we are measuring it better than it's being measured at like the, that's not the case, uh, because when we give them even ambulatory blood pressure monitor. The 24 hour monitors, it's elevated there but not, um, uh, but not in the office. It probably has to do that it's not persistent hypertension, you know, it's not persistent and you just, uh, happen to get a good number in the office. Yeah, yeah. But I don't know if there's an underlying like under, uh, a physiologic thing that I, to explain it. I have, yeah, uh, I don't think anybody has. OK. Uh, and so what are the recommendations from the AP and the American Heart Association on, on screening in children? Um, uh, so annual screening, uh, at well child visits is, uh, is recommended for children, uh, 3 years of age and and older. Without any risk factors, and I'll mention the risk factors on the next slide, but if a kid has risk factors, uh, uh, any of the risk factors I'm gonna mention, uh, blood pressure should be should be measured at every, um, at every encounter. Of note, this is what uh so of note, we, it should, it should be noted that the US Preventative Service Task Force in 2020 came out with a statement that says that there is inadequate evidence to support for or against blood pressure screening in asymptomatic children, uh, and this is as opposed to all the other, um, agencies, the American Academy of Pediatrics, Heart Association. National Heart and Lung, uh, Lung and Blood Institute and the European uh Hypertension Society that all recommend screening as above in, in children and adolescents. And the reason for why the US Preventative Task Force made that comment is we have, uh, as I mentioned in the beginning, there are no outcomes, outcome data for, for Um, for pediatric hypertension, you know, we, in the pediatric age group that we're not, they're not, there's no direct evidence to support that if we lower blood pressure, we really are improving health later. Uh, there hasn't been this correlation, but, uh, as I'll mention later, there's some indirect evidence to support, um. You know, hypertension kids tend to become hypertensive adults, and so, and we know that hypertension is a risk factor, so there's indirect evidence, but not really direct evidence, and that's why they came out with this statement. Of course measure blood pressure at every single, every single visit. All right, so what are some of the risk factors for hypertension and, and so these will change a little bit in kids less than 3 years. So these are the kids that would need to have their blood pressure measured at every, uh, healthcare visit. Doesn't matter if it's a well child's visit or, uh, for, for a sick visit. So for children less than 3, prematurity, small for gestational age, birth weight of less than 1500, uh, neonatal complications requiring an umbilical or arterial catheter placement, all of these, uh, really require that we check blood pressure every visit. Of course, uh, sorry, there was a question. Yeah, go. It's OK. OK, uh, recurrent UTI. So any kidney involvement, any blood in the urine, any protein in the urine, so we're gonna, any known kidney or neurologic so kid uh kid born with, uh, congenital anomaly of the kidney and urinary tract, we would recommend, uh, measuring blood pressure for every, at every visit. Family history of kidney disease, malignancy, or other systemic illness, and then, of course, if the child is on caffeine or steroids or uh NSAIDs, we need to measure blood pressure. And then for kids older than 3 years of age, uh, if there's if the child has obesity, type 1 or type 2 diabetes, again, kidney disease, if there's even a history of, uh, uh coart of the aorta, even if it's corrected, we still recommend blood. Pressure measurement after because sometimes um uh even after correction, uh they, the kid may have other vascular uh kind of like fibrommuscular dysplasia or mid aortic syndrome or some other uh vascular thing that may, um, uh, recur. Uh, and then, of course, if they're on any of these medications that may raise blood pressure, we recommend, um, uh, uh, a blood pressure measurement at every visit. Sorry, OK, your question. Yes, why does a damaged or injured kidney respond with hypertension? Uh, oh yeah, great question. So, the most likely, the most common cause is when it's injured, when it's unhappy, it releases renin. Renin is an enzyme that uh converts, uh, it's in the renin angiotensin system, so it, uh, basically ultimately results in the generation of Angiotensin 2, which is a very, very potent vasoconstrictor, constrict blood vessels, you raise blood pressure, and downstream is aldosterone that also helps retain salt and water. So you're kind of, uh, you're raising blood pressure, it's actually our, our natural defense way when we're bleeding. Uh, you know, when we're dehydrated or bleeding, renon increases, uh, to try to hold on to salt and water and to try to raise our blood pressure. So like perfusing salt, I guess, yep, exactly. Thank you. Yeah. OK. Uh, all right, so we, uh, all of us, so you, when, whenever we get a consult about hypertension, the first thing we ask is what size cuff are we using, right? What size cuff are we using and are it that being measured manually, you know, manually or by an oscillometric device. So blood pressure measurement is really, really like the technique is is very, very important. Um, and so, what are some of the factors that can affect blood pressure variability, cuff size, the technique used, and the number of measurements made, and the type of instruments used. So cuff size, what should the cuff size be? So the way to determine cuff size is you measure the arm circumference midway between the uh acromion process and the olouron process, OK? So, you measure, you measure the length of the arm, and midway between, you, we actually do this, we get a tape measure and measure the arm circumference, and then the the size of the cuff, the um Width needs to be about 40% of the arm circumference, and the length needs to be double that, 80 to 100%. So, and that is the bladder that's within the cuff. It's not the material, it's not either the plastic or the or the um cloth material that's covering the bladder. It's the bladder itself that's within, that's inside that. So that needs to be, so the height needs to be about 40%, and I mean the width and then the length should be about 80, uh 80 to 100% of the arm circumference at mid midway. Um. If we are using a, if we use a small cuff, that tends to overestimate blood pressure, you know, oftentimes, oh, it's a pediatric patient, let's use a, let's use a small cuff, but even an 8 year old sometimes needs an adult size cuff. And so, uh, really measuring the arms circumference isn't like making sure that we're using the right cuff is absolutely important. Uh, again, small cuff will overestimate blood pressure, a large cuff will lower, um, uh, will, will underestimate blood pressure. OK. So that's a cuff. Uh what about the techniques to measure blood pressure? So, um, Auscultation is, uh, basically, um, these are, um, the, you know, the normative values have been obtained via sigma uh sigmomanometer that's, you know, a mercury, that's gold standard, but then we don't use those anymore. They're so Android devices have been shown to be accurate if calibrated regularly. So, again, how we measure blood pressure and you will see once I go through. Like how, what the patient needs to have happened, we don't do this. We, even in clinic for us, it's hard to do this in the pediatric population. So first, the patient needs to have been at rest for 3 to 5 minutes. Oftentimes, we want the clinics to move fast, right? We have so many patients to see. Everybody's been waiting. So they, as soon as they walk in, we, you know, uh, the MA or the nurse will put a blood pressure cuff and, and, and, and so. So they need to have been sitting for 3 to 5 minutes of rest with the back and feet supported. In a clinic setting, how many of our 7 year olds can reach the, whose feet can reach the floor? Really, we all don't do this very, you know, we all don't do this very well, but technically, that's, um, that's really the way, uh, for, uh, that's supposed to measure and in infants, uh, the infants should be sup uh their blood pressure should be measured while supine. The heart rate should be, you know, they basically after a few minutes of rest, the heart rate should be just steady. Um, uh, it's recommended that blood pressure is measured in the right arm, uh, for consistency, but also, uh, because if somebody has a cowork and, uh, and you use the left arm, then you have a chance of getting a normal blood pressure if, uh, uh, if that's the case. And then, so So then, um, once the proper cuff is used and placed, uh, the bell of the stethoscope is placed over the brachial artery and, uh, at the level of the heart, uh, and then the cuff should be inflated to about 20 to 30 millimeters over what you think the blood pressure will be and then deflated, the speed of deflation should be, uh, 2 to 3 millimeters per heartbeat. And uh this is where some uh uh so that's, that's the proper way of, of measuring uh the technique to measure blood pressure uh by uh auscultation. The number of measurements, this is something that we don't do in our clinic. I, you know, I will admit. So the recommendations are that you measure at least twice that are separated by 1 to 2 minutes. And if the second value is greater than 5 millimeters different than the first, then you repeat. What we do in clinic is that if the first blood pressure we measure is high, then we will repeat, but if it's normal, then we don't. Um, and you know, um, people, you know, there's, there's variability in how, how folks, uh, assess that. OK. What about, so then that's by auscultation. Uh, what about, uh, the oscillometric devices? So these are, these, when you are using an automated machine, these, it's called an oscillometric device. That one measures actually the mean arterial blood pressure, and then the systolic and diastolic are calculated, and each manufacturer will have a different algorithm to give you like to to generate the systolic and diastolic blood pressure. This is, uh, you know, oscillometric devices are actually good, you know, I don't want, we, it's not like they're bad. They're, they're good. So I, we, but then if, if the number is high by oscillometric, we'd like to confirm it by auscultation. So helpful when the auscultation is difficult, and then in reviews, oscillometric devices, uh, in general, the systolic blood pressure is about 1 to 10 millimeters of mercury higher than that obtained by auscultation. That's why if the blood pressure is. Elevated by oscillometric device, then we need to confirm it by auscultation, OK? We're not trying to, you know, when we ask, can you get it by, you know, we're not trying to be mean or increase the workload. It's really because we don't want to overtreat, you know, if somebody does not need to be treated, we don't need to treat them. And so, what are some of the limitation of the oscillometric device, devices? They have a wide range of blood pressure values when different devices are compared, so, um. Uh, I think our hospital system has one, you know, they, and they calibrate them all the time. They require, they require maintenance and repeated calibration, uh, but, having said all that, they are very reasonable to start with, you know, this, it's OK to use them to start with, but it's tie, I, we would, uh, confirm by, uh, auscultation. OK. Uh, so this is really more for, uh, outpatient, uh, outpatient care. So kid comes in, blood pressure is high at the 90th percentile or above via, you know, if it's, again, if it's by oscillometric then you repeat the blood pressure twice on average and still, if you're still using the oscillometric device. Then you get that through auscultation and then you classify that average of the two, is it high? So is it elevated blood pressure? Is it stage, so that's 120/80 and 120 to 129/80. Um, is it stage 1, 130, uh, to 139, or is it stage two hypertension? Uh, and so if it's stayed, if it's, uh, just elevated, you, uh, counsel on, uh, lifestyle modifications, healthy diet, exercise, reducing salt, uh, and you repeat in 6, you see the patient again in 6 months. If it's stage one hypertension, uh, there's the lifestyle counseling for, for every, For you, you try to do lifestyle, uh, counseling and then uh you repeat blood pressure in 1 to 2 weeks. I'll tell you on the next slide what happens if that is still high in 1 to 2 weeks and then if it's stage 2 hypertension, you, um, uh, basically here they say repeat in 1 week and then, um, um, uh, and then start, start basically treatment. But if anybody is symptomatic, they go to the subspecialist or ER. If like if symptomatic, they go to the ER. Well, here's another way of looking at the same thing just in the table. Uh, so if that's, if, uh, the blood pressure is normal, you just do it at the annual wellchild for 3 and older. If it's elevated, you repeat the blood pressure measurement in 6 months, and if that's still elevated, then this is where you start the diagnostic evaluation, uh, and uh consider referral to sub-specialist. Most of the time that we are right, we, we get the patients, uh, at this stage. Uh, and then a stage one hypertension, you repeat the measurement in 1 to 2 weeks and then in 3 months. And if it's still stage one, after all the, you know, trying diet modifications and, uh, behavioral modifications, then we do a diagnostic evaluation and, uh, initiate treatment. Uh, and then for stage 2, really it's, uh, after 2 weeks, you know, just immediately a week later, if it's still that high, you, we do an evaluation and start treatment. All right, so what is the, what are, why do we evaluate? What are we trying to do? The evaluation we're trying to distinguish between I have till 8:30, right? Or yeah, OK, uh, I tend to talk too much if, uh, the, so what are the goals is to distinguish between primary and secondary, and, um, uh, we, and really if there are, so that if somebody has hyperthyroidism, we need to treat it if somebody, you know, and So if we identify a treatable cause that, that we should treat that, identify any comorbid, uh, uh, conditions or risk factors for cardiovascular disease, and then any and then identify patients who require therapy and based on certain things about the patient that kind of tells us, oh, it's more likely to be primary hypertension versus secondary, of course, age always, you know, now we say younger than 6, but if a kid is less than 10, I will, it's, uh, you know, we'll do uh. We'll consider secondary hypertension more, um, uh, more heavily. Um, if somebody has diastolic or nocturnal hypertension, there must be a, you know, generally there's a secondary cause, uh, but if, if a kiddo has overweight or obesity, then, um, or a family history of hypertension, more likely to be primary. Nothing is black or white, you know, it's, it's possible to have a secondary hypertension in somebody with obesity. Uh, so, um. So you have to consider things if things are not making uh sense. And then uh if there's usually primary hyper patients with primary hypertension tend to be asymptomatic as opposed to those with an underlying cause. They tend to have some symptoms like if it's pheochromocytoma, they would have palpitations, flushing, uh, hypothyroidism, they would have tachycardia, feeling hot all the time. And so, uh, OK, so part of the evaluation, always, always, always in medicine, part of it, the evaluation would start with history and physical, right? Before any, any, uh, laboratory testing. And so there are many things, and this is where, like I said, there are lists of things, um. Uh, so really for every system tells us something, you know, if, if somebody presents with head trauma or seizures, then it's more likely to be intracranial pressure, uh, increased intracranial pressure. Somebody has hearing loss, then I, I, and with coming in with hypertension. I'm gonna ask about family history of kidney disease, you know, I, I will think about Alport's syndrome or in somebody with no family history is, uh, is there a lead poisoning that, um, cardiovascular, I mentioned the palpitations, could it be a pheochromocytoma? Could it be a hyperthyroidism, uh, similar, and, you know, and so on and so forth. Somebody has had recent strep, uh. Or, um, or somebody comes in with bloody diarrhea and they have hypertension, then we're thinking about, you know, post infectious GN or HUS medications as I've mentioned, uh, so getting a good history and including family history, is there a history of hypertension and, um, uh, heart attacks, um, the neonatal history, has there been a, a UAC, uh, placed? Uh, growth, is there excessive weight gain or loss, uh, because, you know, with hyperthyroidism, there's weight loss, and then, uh, uh, is the kid crossing percentiles, um, you know, with obesity. Uh, important to take a dietary history and, uh, social history to assess the stressors, uh, in the home or at school. As all of these can, can, can cause or increase the risk of hypertension. OK. Physical exam, again, some of the, some of similar things, obesity, uh, whether it's truncal truncal, we think more about, uh, Cushing's syndrome or steroid, you know, for those kids with steroids, it's usually the face is moon feces and then, uh, uh, the upper body, but the legs are skinnier. Um, uh, uh, growth restriction, then we think we're thinking about chronic kidney disease, uh, tachycardia, hyperthyroidism, and catecholamine, head and neck. That tells us a lot of whether some, some Eudo has a syndrome or not. So faces, Williams associated with Williams syndrome, Moon faces, as I mentioned, steroid therapy or Cushing's, web neck, you, you're thinking Turner Turner, bless you. Uh, if somebody has really, like one time that the tonsils were almost touching each other in in a, in a patient, so you're gonna think about obstructive sleep apnea, which is a huge risk factor for, uh, for, um, hypertension. Uh, if there's papilloedema, you're thinking increased intracranial pressure and then some skin findings like, uh, cafe au lace spots, you're thinking neurofibromatosis, ash leaf spots, tuberosclerosis. There's a rash. Is this an HSB? Is this lupus, uh, type rash? If there's acanthosis nigricans, is this type 2 diabetes? And, uh, with the chest, if there's a murmur. You think could this be cooptation of the aorta, uh, in the abdomen, um, uh, if there's a bruit, you're thinking is there mid-aortic syndrome or, uh, renal artery stenosis, and then if there's a mass in a newborn, hydronephrosis, big mass, is this polycystic kidney disease? Is this a big hydronephrosis that's, uh, compressing on something, or is this neuroblastoma? And then with the extremities, of course, if there's edema, you're thinking uh kidney specific, there's arthritis, arthritis is lupus or HSP and then if there's asymmetry of the legs, could this be uh back with weed and so physical exam really, uh, really tells us, tells us a lot. And then, um. Following that, so we, we did our history, physical exam. We're starting to think about, you know, one way versus the other as a secondary primary, and so what are the recommendations with respect to what, uh, blood work to get, uh, for all children, even pri those with primary hypertension, um, uh, it is recommended to get a, um, Uh, kidney function testing, electrolytes, BUN creatinine, as well as a urinalysis because that will tell you a lot about the electrolyte, about the kidney, you know, all, all the renal causes will, will, um, Uh, you will, you will detect that. And if then you see a, an abnormal kidney function, then you can do further testing tests. That's what the problem is if it was not known previously. Uh, additional testing for children with obesity include A1C and, uh, AST ALT. So in general, we just got a CMP, to be honest with you, in the beginning, and then to, to get all the electrolytes, uh, liver enzymes, uh, and an A1C, lipid profile and a UA. That's often the, for all, for all kids with hypertension, that's often. Uh, the testing that's done. And then, but after that, if there's abnormal kidney so, uh, you will, my practice has changed. When I was younger, I would, um, everybody gets a kidney ultrasound and some centers, uh, still, any patient referred for hypertension will get a kidney ultrasound. We have found that But it has such little utility, uh, in kids who are with obesity and who are teenagers that we, I've, I've stopped getting kidney ultrasound on every child with hypertension, you know, if it's a teenager, first hypertension that's mild, uh, and who presents, I don't get an ultrasound, uh, in older kids, uh, with obesity, who I think that they have, uh, primary hypertension. So kidney ultrasounds, uh, and definitely in kids less than 6, I actually take that maybe up to less than 10. And then patients with lab findings concerning for kidney disease, of course. OK, who gets an echo? Uh, first, a EKGs, no one, EKGs, we don't, uh, at all recommend for in the, in the evaluation, uh, and diagnosis of hypertension, but echoes we do. And the echo, the reason to do an echo is in somebody with diagnosed hypertension is one to assess, uh, for target organ, uh, damage which is mainly left ventricular. Hypertrophy and then, uh, anytime you're thinking about starting, starting a medicine, so anybody with hypertension that we're starting on a medication, we will get often it's not done in the beginning because we have to get prior authorization, but once we have that, then, then the echo is scheduled to assess for end organ end organ damage and then we get it at different intervals based on how bad the hypertension is and whether there was LVH in the beginning. And these are just the values for what normal uh values are used as the LV mass uh on an echo. So, this is kind of what we do with considering like everybody almost, but what about when you're, you know, uh, to complete the workup to kind of look for all, um, most causes of hypertension, especially now that you're thinking secondary causes, you're gonna get a renal, uh, plasma renal activity and an aldosterone. Uh, level, you're gonna get thyroid studies, uh, plasma and urine catecholamines, as well as a sleep study, which, uh, we often do, especially when we see nocturnal hypertension on, uh, ABPMs. OK, and here we go to ABP. So that's the history, physical, uh, workup, lab workup and whatever, so when the kid is referred to us, we often are, uh, going to do ambulatory blood pressure monitoring, and that's a 24 hour ambulatory blood pressure ring. These are, uh, also the metric devices. That again will give you mean blood pressure uh as well as uh the blood pressure load uh and uh the, the nice thing about them is that we look for nocturnal dipping and so if if uh in when we're sleeping our blood pressure should be 10. 10% less or more uh than when we're awake, and if somebody does not have if if a kid's blood pressure doesn't dip by 10%, then we are thinking that this is, they, they have potentially obstructive sleep apnea and so we would refer them for a sleep study, for instance. And so, um, um. This classification here is the same. So this is what we base our ambulatory blood, we, uh, ambulatory, uh, blood pressure monitoring, we, uh, base it on that, uh, same, same thing as I mentioned, sorry. Uh, previously, so normal blood, normal blood pressure is both in clinic and ambulatory white coat, high, high in clinic but normal ambulatory mask is normal in clinic and high ambulatory, and then if it's hypertension, then it's high for both. Uh, so who gets these? Who gets, who does a 24 hour blood pressure monitor? Uh, all kid, uh, uh, I really, all kids, uh, with an elevated clinic blood pressure for over a year. So every kid, to be honest, who is over 66 years of age or older, we will, uh, do an ambulatory blood pressure monitor on because really now this is, uh, our gold standard in a way. Uh. Or any child with stage one hypertension after 3 visits, normal or elevated blood pressure, but clinical suspicion of hypertension to detect the mass hypertension, uh, high-risk conditions like chronic kidney disease, which really this, you know, if we, um, solve. Blood organ transplant, obesity, sleep apnea, uh, uh, uh, and then anytime we are, any kid who's on an antihypertensive therapy, we do, I do blood pressure monitoring, uh, every year, 24 hour blood pressure monitoring every year, once a year. To assess, uh, blood pressure control on that medication. Yes. Yeah, I, it's so I wish I was gonna stop by the nurse's office and see if we have one. basically, it's, uh, the machine is like an I I comp I tell it's like an iPhone. It's not an iPhone, but it's, uh, it's a little bit thicker. You know, like the square machine that has a couple of buttons in it and um uh you just uh attach and it has a its case you can wear it on a belt or put it in your pocket and then um uh you attach a regular cuff, uh, regular cuff, so we have 3 sizes 3 cuff sizes, and then we have a a thigh cuff that we sometimes use for, uh, larger, uh, kids. Uh, but there are 3 cuff sizes, 34 cuff sizes, and we, um, uh, you know, when their kids are in clinic, we measure their arm circumference, choose the cuff, and then we give them instructions. Basically, we schedule, um, the, uh, we program the machine to measure blood pressure every 30 minutes during the day and every hour at night, and we set the daytime for like, I think. Uh, 6 a.m. to 10:00 p.m. and then 10:00 to 6 is nighttime. But we ask, we know teenagers don't sleep these hours. Kids, uh, younger kids will sleep more. So we, on that sheet that we give the families, we ask them to write down when they went to sleep and when they got up, and so then we can assess. And it's, um, uh, a 24 hour monitor is considered to be successful if you have at least one blood pressure. Measurement per hour. So sometimes, you know, there's an error, machine error or something, and then, you know, we give them instructions that no shower, you know, shower right before and right after. That's too often a question. Don't do a huge activity for that one day, uh, you know, uh, things like that. But that's, uh, and then the tube, uh, put it on the side, not around your neck at night when you're sleeping, you know, things, things like that. Thank you. Uh, but those machines are about 1500 and we've had, uh, we lost 3 in the Latin in, in mail versus thing, and so they're, um, so they're precious. We have about 15 of them, I think, in our division, yeah. OK. So, very quickly, actually a couple of slides just on and I'm, I'm not gonna go uh too much into treatment. So what do, so everybody gets counseled on, uh, on, uh, non-pharmacologic treatments, weight reduction, exercise, dietary modifications, everybody gets counseled on that. And then, uh, who do we treat? Again, anybody. With symptomatic hypertension, doesn't matter if there are symptoms, headaches, seizures, whatnot, uh, they're gonna be treated. Uh, anybody with stage 2 hypertension, anybody with stage 1 hypertension that persists after 4 to 6 months of non-pharmacologic therapy, anybody who has LVH or retinal changes, uh, we, uh, will, uh, will be treated and With even stage one hypertension, but let's say they have, um, a little bit of kidney disease or, uh, diabetes, I'm, I tend to more uh treat these children because of the risk of diabetic nephropathy later on in life, uh, uh, and then again, if there's any, uh, chronic kidney disease or diabetes, we, I, we tend to treat those a little bit earlier. And what are our, our first choice, uh, our first line agents are, you can choose either a calcium channel blocker or an ACE inhibitor, ARB, uh, uh, and there are certain times when we use one over the other. For instance, um, ACEs and ARBs, I would use more and I tend to use more in children with diabetes. So if a kid has diabetes, I will Because we are trying to protect that kidney more long term, so we'll use an ACE inhibitor, uh, as opposed to somebody with bilateral renal artery stenosis where I don't want to reduce the GFR anymore, I would tend to use, um, uh, calcium channel blocker. Um, so, but when we use an, uh, an ACE inhibitor or an ARB, especially in teenagers, I counsel all of them. On the teratogenic effects of ACE inhibitors. I tell them that doesn't mean that you can't have children in the future. It's just that, uh, when, if you are, you know, when it's, you have to be careful, uh, either oral contraceptives or, you know, use protection, and then, or if you're planning to have, just let your doctor know, even, you know, when you move on to the adult world, let your doctor know so that, uh, they can take you off of it and I'll use alternative. Uh, and for ACEs and ARBs, because it they reduce the GFR, uh, they can reduce the GFR. Uh, we measure creatinine, uh, we get an RFP about, we, uh, in the outpatient world, we get it 1 to 2 weeks after we start. You see us get it more frequently in, uh, on the inpatient side. Uh, and then, uh, thiazide, when we start it, we also get, uh, electrolytes. Uh, for kidney, uh, and then for kidney disease, we tend to use ACE and ARB again because of the neuro, uh, nephroprotective effects. And then, uh, for renal vascular disease, as I mentioned, if you have, uh, renal artery stenosis, technically, they have elevated renal, so really an ACE and ARB is the best one, but if it's bilateral, you don't want to shut down the kidney. And so if it's unilateral, I tend to use an ACE inhibitor, but if it's bilateral, I don't. And then, uh, for a second agent, now the recommendation is actually to use hydrochlorothiazide. Hydrochlorothiazide now has become the first line agent in the adult world. Uh, and so for us, we, we use that as a second. Uh, if you notice here, beta blockers are not mentioned. Generally, they're like 2nd or 3rd line agents. Our first options you see us use are ACE inhibitors, ARBs, or, uh, calcium channel blockers. Right. That's all I have. I have. Thank you.
