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					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
Brittiney           Anthony




            Chris             Caleb
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
http://www.statcoder.com/growthcharts.htm
Stage 2 Hypertension
  > 5 mm above 99%le
Stage 1 Hypertension
95% to 5 mm above 99%le
  Pre-Hypertension
      90-95% le




      Normal
    < 90% le
     Hypertension is Common
    20
    18
    16
    14
    12
%   10
     8
     6
     4
     2
     0

         Hypertension Asthma
Brittiney   161 cm   (72%le)
125/78
            95% BP = 126/82
            90% BP = 122/78

Anthony     114 cm   (75%le)
145/87        95% BP = 113/74
              99% BP = 120/82

Chris       168 cm   (16%le)
180/115       95% BP = 133/85
              99% BP = 141/93

Caleb       98 cm    (64%le)
118/75        95% BP = 110/67
              99% BP = 118/75
   Recognizing or ruling out a
hypertensive emergency is the 1st
    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         Essential Hypertension

     Glomerular               Glomerular
      Disease                  Disease

    Renovascular             Renovascular
      Disease                  Disease

  Aortic Coarctation

Essential Hypertension
     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
       Rule of Thumb #1

The Younger the Patient
 with Hypertension,
the More Likely you’ll find
 a Cause
        Rule of Thumb #2


The Higher the Blood Pressure,
the more likely there’s a cause
Symptoms to Ask About
       History
  UAC as a newborn

UTIs or febrile illnesses

      Medications

     Supplements

    Family History
Physical
    Arm & Leg BPs
      B       What’s Normal?

               1. A = B = C

A              2. A = B > C

               3. A = B < C
          C
               4. A > B > C
Eye Grounds
Heart Findings
Listen for a Bruit
                       Skin

CALMs of NF-1
Acanthosis Nigricans
Skin
              Labs & Imaging

                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
                   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 (http://www.nhlbi.nih.gov/)


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 4th Task Force Report or your
  local pediatric nephrologist once you
  recognize a high blood pressure

				
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