CME CME A review of proper screening, diagnosis, evaluation, and treatment CME CME Pediatric Hypertension CME CME EDUCATIONAL OBJECTIVES • Identify children and adolescents for whom hypertension screening is appropriate • Implement an initial workup for pediatric hypertension • Develop treatment plans for children with essential or secondary hypertension N icholas, a 10-year-old boy with a history of intermittent asthma and attention deficit hyperactivity disorder, is seeing you for the first time for a well child visit. He has no complaints and his mom has no specific questions or concerns. On review of symptoms, Nicholas reports that he has some chest pain when he has an asthma exacerbation. Current medications include methylphenidate once daily and an albuterol metered-dose inhaler as needed. His family history reveals hypertension (HTN) in his father and paternal grandfather, and diabetes mellitus in his paternal grandfather. His mother and 12-year-old sister are healthy with no chronic medical problems. On physical exam, his anthropometrics and vital signs are as follows: Height: 140 cm (50%) Weight: 45 kg (95%) Body mass index (BMI): 23 (>95%) Temperature 37 °C Heart rate: 85 bpm Blood pressure (BP): 124/82 mm Hg by automated cuff Physical exam is normal 46 www.contemporarypediatrics.com Vol. 25, No. 11
11
Embed
Pediatric Hypertension - al-ghassani.netal-ghassani.net/cardiopedhnn/site/UserFiles/Hipert-Art-Ped.pdf · Pediatric hypertension, previously reported to affect only 0.3% to 1.2% of
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
CMECME
A review of proper screening, diagnosis, evaluation, and treatment
CMECME
Pediatric Hypertension
CMECME
EDUCATIONAL OBJECTIVES
• Identify children and adolescents for whom
hypertension screening is appropriate
• Implement an initial workup for pediatric
hypertension
• Develop treatment plans for children with
essential or secondary hypertension
Nicholas, a 10-year-old boy with a history of
intermit tent asthma and at tention def icit
hyperactivity disorder, is seeing you for the first
time for a well child visit. He has no complaints and
his mom has no specific questions or concerns. On
review of symptoms, Nicholas reports that he has some
chest pain when he has an asthma exacerbation. Current
medications include methylphenidate once daily and an
albuterol metered-dose inhaler as needed. His family history
reveals hypertension (HTN) in his father and paternal
grandfather, and diabetes mellitus in his paternal grandfather.
His mother and 12-year-old sister are healthy with no chronic
medical problems. On physical exam, his anthropometrics
and vital signs are as follows:
Height: 140 cm (50%)
Weight: 45 kg (95%)
Body mass index (BMI): 23 (>95%)
Temperature 37 °C
Heart rate: 85 bpm
Blood pressure (BP): 124/82 mm Hg by automated cuff
Presence of systemic illness associated with hypertension
(neurofibromatosis, tuberous sclerosis)
Evidence of increased intracranial pressure
•
•
•
•
•
•
•
•
•
•
DisclosuresEditors Toby Hindin, Jeannette Mallozzi, Jeff Ryan, and John Merriman disclose that they do not have any financial relationships with any manufacturer in this area of medicine.
Manuscript reviewers disclose that they do not have any financial relationships with any manufacturer in this area of medicine.
DR. BRADY is an assistant professor of pediatric nephrology at Johns Hopkins University School of Medicine.
DR. SIBERRY is an assistant professor of pediatrics in the divisions of general pediatric and adolescent medicine and pediatric infectious diseases at Johns Hopkins Hospital.
DR. SOLOMON is an assistant professor of pediatrics in the division of general pediatrics and adolescent medicine at Johns Hopkins Hospital, and medical director of the Harriet Lane Clinic at the Johns Hopkins School of Medicine.
Accreditation
cme2 is accredited by the ACCME to provide continuing medical education for physicians.
Credit Designation
cme2 designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Target audience: Pediatricians and primary care physicians
To earn CME credit for this activityParticipants should study the article and log on to www.contemporarypediatrics.com, and click on the “Earn CME Credit” button on the left-hand side. Participants must pass a post-test and complete an online evaluation of the CME activity. After passing the post-test and completing the online evaluation, a CME certificate will be e-mailed to them. The release date for this activity is November 1, 2008. The expiration date is November 1, 2009.
The authors have nothing to disclose with regard to affiliations with, or financial interest in, any organization that may have an interest in any part of this article.
Resolution of conflict of interest
cme2 has implemented a process to resolve conflicts of interest for each continuing medical education activity, to help ensure content validity, independence, fair balance, and that the content is aligned with the interest of the public. Conflicts, if any, are resolved through a peer review process.
Unapproved/off-label use discussion
Faculty may discuss information about pharmaceutical agents, devices, or diagnostic products that are outside of FDA-approved labeling. This information is intended solely for CME and is not intended to promote off-label use of these medications. If you have questions, contact the medical affairs department of the manufacturer for the most recent prescribing information. Faculty are required to disclose any off-label discussion.
Adapted from Flynn JT: Prog Pediatr Cardiol 2001;12:177*Findings listed are examples of physical findings and do not represent all possible physical findings.
Once a comprehensive work-up looking for secondary
causes of hypertension has been completed and found
to be negative, a diagnosis of primary (or “essential”)
hypertension can be made. This diagnosis, while still
considered to be a diagnosis of exclusion, is more frequently
found in post-pubertal and African American children, and
in children with BP on the lower end of the hypertensive
spectrum (ie, just above the 95th percentile). It is also more
frequently found in children with a positive family history
of HTN, and in those who are overweight or obese.12
The role of obesity in this diagnosis should not be
overlooked. The number of children with primary
hypertension is on the rise concomitant with the rise in
childhood obesity.4,5,13,14 Several studies have demonstrated
the increased risk of hypertension that exists among obese
children. For example, for each one unit increase in BMI
z-score, children 8 to 17 years of age have been shown to
have twice the risk of having a BP greater than the 95th
percentile.13 Even children as young as 2 to 5 years of age
are not immune to these effects of obesity and overweight;
their SBP and DBP have also been shown to increase with
increasing BMI.15
Obesity and hypertension both separately and together put
children at increased cardiovascular risk.16 Obese children
are more likely to have clustering of cardiovascular risk
factors in addition to hypertension, such as hyperlipidemia,
insulin resistance, type 2 diabetes mellitus and left
ventricular hypertrophy.5 Autopsy studies of children reveal
that even early in life there is evidence of coronary artery
pathology, associated with BMI, dyslipidemia, and systolic
and diastolic BP.17
The link between OSA and hypertension
The mechanism by which obstructive sleep apnea (OSA) leads to hypertension is still
not well understood. One study has found a linear relationship between the severity
of OSA symptoms, and the incidence of newly diagnosed HTN, independent of body
mass, age, gender, or baseline BP and cigarette and alcohol consumption.1
It is likely that the hypoxemia and hypercapnea experienced by individuals with
OSA leads to an increase in sympathetic nervous system activity, which then leads to
an increase in peripheral vascular resistance. Hypoxia has been shown to increase
levels of endothelin-1, a known potent and long-acting vasoconstrictor, as well as
other circulating vasoconstrictors.
Because appropriate treatment of OSA has been shown to decrease daytime and
nighttime mean systolic and diastolic blood pressures by up to 10 mm Hg,2 screening
for OSA should be included in a clinician’s work-up of a child with hypertension.
Reference
1. Peppard PE, Young T, Palta M, et al: Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342:13782. Becker HF, Jerrentrup A, Ploch T, et al: Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea. Circulation 2003;107:68
Additionally, obesity and hypertension in childhood places
these children at higher risk for obesity and hypertension
as adults,20 with increased risk for CV morbidity and
mortality.21 Blood pressure tracking from childhood to
adulthood is much more likely to occur with increasing
BMI.22 Because of this BP tracking from childhood to
adulthood, lifestyle changes should be emphasized for all
hypertensive children, but should also particularly be aimed
at obese children with primary hypertension.
Management of pediatric hypertension
Who gets treated?
Once a child is diagnosed with HTN and is appropriately
staged and evaluated, treatment should be initiated and
aimed at the underlying etiology. Children with pre-
hypertension or asymptomatic, Stage 1 Primary HTN who
do not have evidence of end-organ damage or diabetes,
should be “prescribed” lifestyle modifications (Table 4)
and be re-evaluated in six months. Children with persistent
hypertension after six months—despite attempts at lifestyle
modification—should be started on an anti-hypertensive
medication. Similarly, any child with symptomatic HTN,
Stage 2 HTN, secondary HTN, diabetes or evidence of end-
organ damage should be started on an anti-hypertensive
medication.
Even after deciding to treat with an anti-hypertensive,
nonpharmacologic lifestyle interventions should continue to
be emphasized at each visit, particularly in overweight or
obese children. It has been shown that weight loss by itself
can decrease blood pressure,23 and other associated CV
risk factors should also be expected to regress or improve
with weight loss.24 Additionally, increased physical activity
and fitness has been shown to be associated with lower
childhood BP and a reduced risk of HTN 16 to 50 years
later.25 Obese children are also more likely to be salt sensitive,
and thus more likely to respond to dietary restriction of
sodium, and improved intake of potassium. The insulin
resistance often seen in obese children leads to salt and
water retention,26 and preliminary studies have indicated
that adipocytes may secrete factors leading to increased
serum aldosterone, which then leads to increased renal
sodium reabsorption.27-29
Often implementing these changes for all family
members is necessary before any appreciable benefit can
be achieved.
How should I treat?
There are multiple medications available to treat hypertension
in children, for which pediatric dosing is now available
(Table 5). The particular agent
chosen shou ld be a imed at
treating the underlying etiology,
with particular attention being
paid to co-morbid conditions
such as diabetes, asthma, and
migraines.
Af ter a fu l l eva luation to
determine etiology is completed
(and any interventions are under-
taken to treat the underlying
disease process), initial antihyper-
tensive therapy for a child who
continues to be hypertensive
should include either a calcium
channel blocker (CCB) or an
angiotensin converting enzyme
(ACE) inhibitor, unless there is a
compelling reason to use an agent
from another class. Both CCBs and
ACE inhibitors are generally well tolerated with a minimal
side effect profile, and can be dosed once daily.
Obese children with primary hypertension may
particularly benefit from ACE inhibitors or angiotensin-
Weight loss by
itself can
decrease blood
pressure, and
other associated
CV risk factors
should also
be expected
to regress or
improve with
weight loss.
Point
Taken
Table 4
Non-pharmacologic interventions1
Aerobic exercise: 30 to 45 minutes “most days” of the week
Limit sedentary activities to less than two hours per day
Weight reduction if overweight
Increased intake of fresh vegetables, fruits, and low-fat dairy (the
Dietary Approaches to Stop Hypertension (DASH) Study eating
plan)18
Salt restriction*
Adequate intake of potassium and calcium (both shown to have
antihypertensive effects)19
Cessation of smoking
•
•
•
•
•
•
•
*Can start with recommending “no added salt” with ultimate goal of achieving the current recommendation of 1.2 grams/day total for 4- to 8-year-olds and 1.5 grams/day for children 9 years and older.1
Pharmacologic interventions for pediatric hypertension
Drug class
Examples Major side effects Comments
Diuretics Hydrochlorothiazide
Metalozone
Furosemide
Torasemide
•
•
•
•
Hypokalemia, hypercholesterolemia,
hyperglycemia
Rare side effects:
Blood dyscrasias, photosensitivity,
pancreatitis
•
•
Would avoid in children active in sports because of risk of
dehydration and/or electrolyte disturbances
Electrolytes should be monitored one week after initiation and
periodically thereafter
Most useful as adjunctive therapy (particularly with calcium
channel blocker, direct vasodilators)
•
•
•
Potassium-
sparing
diuretics
Spironolactone
Amiloride
•
•
Hyperkalemia
Gynecomastia
•
•
Would avoid in children active in sports because of risk of
dehydration and/or electrolyte disturbances
Electrolytes should be monitored one week after initiation and
periodically thereafter
•
•
Beta-
blockers
Atenolol
Timolol
Pindolol
Bisoprolol
Propranolol
Available in pediatric labeling:*
Metoprolol
•
•
•
•
•
Serious side effects:
Bronchospasm, congestive heart
failure, masking of insulin-induced
hypoglycemia, depression
Less serious:
Poor peripheral circulation, insomnia,
fatigue, decreased exercise tolerance,
hypertriglyceridemia
•
•
Preferred for hypertensive children who suffer from migraine
headaches
Non-cardioselective agents are contraindicated in asthma and in
children with heart failure; avoid in diabetics
May decrease athletic performance
Maximum dose may be limited by heart rate
•
•
•
•
Calcium
channel
blockers
(CCBs)
Verapamil, diltiazem
Dihydropyridines
(Felodipine, Isradipine,
Nicardipine, Nifedipine)
Available in pediatric labeling:*
Amlodipine
•
•
•
Conduction defects, decreased
contractility, gingival hyperplasia,
flushing, headache, peripheral edema
• Generally well tolerated
Consider for children active in sports
•
•
Angiotensin-
converting
enzyme
inhibitors†
Captopril
Ramipril
Available in pediatric labeling:*
Benazepril*
Enalapril*
Fosinopril
Lisinopril*
•
•
•
•
•
•
Cough, rash, loss of taste,
hyperkalemia
Rare side effects:
Leukopenia, anemia, angioedema
•
•
Contraindicated in pregnancy and in children with hyperkalemia
and/or bilateral renal artery stenosis (can cause flash pulmonary
edema)*
Preferred medication for hypertensive diabetics or hypertensive
patients with microalbuminuria or proteinuria
Should consider for obese children with primary hypertension
Need to monitor for hyperkalemia and renal failure one week after
starting, with each dose increase, and periodically (every six to
12 mos after that)
•
•
•
•
Angiotensin
receptor
blockers†
Available in pediatric labeling:*
Losartan*
Valsartan*
Irbesartan (label states was
ineffective in children)
•
•
•
Hyperkalemia, cough (less frequent
than with ACE inhibitors), angioedema
• Contraindicated in pregnancy*
Preferred medication for hypertensive diabetics or hypertensive
patients with microalbuminuria, proteinuria
Need to monitor for hyperkalemia and renal failure one week after
starting, with each dose increase and periodically (every six to 12
mos after that)
•
•
•
Alpha-
and
beta-
blockers
Labetalol
Carvedilol
•
•
Postural hypotension, Beta-blocking
side effects
• Preferred medication for hypertensive children who suffer from
migraine headaches
Contraindicated in asthma and in children with heart failure; avoid
in diabetics
May decrease athletic performance
Maximum dose may be limited by heart rate
•
•
•
•
Direct
vasodilators
Hydralazine
Minoxidil
•
•
Headaches, tachycardia, lupus-
like syndrome (hydralazine), fluid
retention, hirsutism (minoxidil)
• Hydralazine: Long-term use not effective secondary to tolerance,
edema
Minoxidil reserved for refractory cases in conjunction with other
medications (particularly diuretics)
•
•
Central
alpha
antagonists
Methyldopa
Clonidine
•
•
Hepatic and “auto-immune” disorders
(methyldopa), sedation, dry mouth,
“withdrawal” (clonidine)
• Abrupt discontinuation can lead to severe rebound HTN•
*These agents have pediatric labeling that includes instructions for extemporaneous suspension preparation.30 † The choice of ACE inhibitor or ARB can be based on the formulation available (only certain members of each class can be compounded into a suspension), and on tolerability (newer formulations of ACE inhibitor reportedly have less cough and angioedema associated with them; some patients are hyperkalemic with one class and not the other).
Depending on provider comfort level, the diagnosis, initial
work-up and treatment can be provided in the primary care
setting, or can be handled by a specialist with expertise in
pediatric hypertension. Ongoing collaboration and frequent
communication between specialists and primary care
providers is essential for successful patient management.
Once presented with refractory hypertension or with a
child very likely to have secondary hypertension, referral
to a specialist should be made for further work-up and
treatment. ◽
References
1. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 2004;114:555. Available at http://pediatrics.aappublications.org/cgi/reprint/114/2/S2/555. Accessed Oct. 17, 20082. Fixler DE, Laird WP, Fitzgerald V, et al: Hypertension screening in schools: results of the Dallas study. Pediatrics 1979;63:323. Sinaiko AR, Gomez-Marin O, Prineas RJ: Prevalence of “significant” hypertension in junior high school-aged children: The children and adolescent blood pressure program. J Pediatr 1989;114:6644. Sorof JM, Lai D, Turner J, et al: Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 2004;113:4755. Sorof J, Daniels S: Obesity hypertension in children: a problem of epidemic proportions. Hypertension 2002;40:4416. Pickering TG, Hall JE, Appel LJ, et al: Recommendations for blood pressure measurement in humans and experimental animals: Part 1: Blood pressure measurement in humans: A statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension 2005;45:1427. Get the most out of home blood pressure monitoring. Mayo Foundation for Medical Education and Research, 2008. Available at: www.mayoclinic.com/health/high-blood-pressure/HI00016. Accessed Oct. 5, 20088. Free blood pressure machines: Are they accurate? Mayo Foundation for Medical Education and Research, 2008. Available at: www.mayoclinic.com/health/blood-pressure/AN00567. Accessed Oct. 17, 20089. Bartosh SM, Aronson AJ: Childhood hypertension: An update on etiology, diagnosis, and treatment. Pediatr Clin North Am 1999;46:23510. Flynn JT: Evaluation and management of hypertension in childhood. Prog Pediatr Cardiol 2001;12:17711. Sinaiko AR: Hypertension in children. N Engl J Med 1996;335:196812. Epidemiology, risk factors, and etiology of hypertension in children and adolescents. UpToDate, 2008. Available at: www.utdol.com/online/content/topic.do?topicKey=pedineph/19132&linkTitle=Essential%20hypertension&source=preview&selectedTitle=1~150&anchor=14#14. Accessed Oct. 17, 200813. Din-Dzietham R, Liu Y, Bielo MV, et al: High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation 2007;116:148814. Muntner P, He J, Cutler JA, et al: Trends in blood pressure among children and adolescents. JAMA 2004;291:210715. Falkner B, Gidding SS, Ramirez-Garnica G, et al: The relationship of body mass index and blood pressure in primary care pediatric patients. J Pediatr 2006;148:19516. Barlow SE, Dietz WH: Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and
Services Administration and the Department of Health and Human Services. Pediatrics 1998;102:E29.17. Berenson GS, Srinivasan SR, Bao W, et al: Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: The Bogalusa Heart Study. N Engl J Med 1998;338:165018. Appel LJ, Moore TJ, Obarzanek E, et al: A clinical trial of the effects of dietary patterns on blood pressure: DASH Collaborative Research Group. N Engl J Med 1997;336:111719. Flynn JT: Hypertension in adolescents. Adolesc Med Clin 2005;16:1120. Lughetti L, De Simone M, Verrotti A, et al: Thirty-year persistence of obesity after presentation to a pediatric obesity clinic. Ann Hum Biol 2008;35:43921. DiPietro L, Mossberg HO, Stunkard AJ: A 40-year history of overweight children in Stockholm: life-time overweight, morbidity, and mortality. Int J Obes Relat Metab Disord 1994;18:58522. Srinivasan SR, Myers L, Berenson GS: Changes in metabolic syndrome variables since childhood in prehypertensive and hypertensive subjects: the Bogalusa Heart Study. Hypertension 2006;48:3323. Rocchini AP, Katch V, Anderson J, et al: Blood pressure in obese adolescents: effect of weight loss. Pediatrics 1988;82:1624 . Williams CL, Hayman LL, Daniels SR, et al: Cardiovascular health in childhood: A statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 2002;106:14325. Textor SC, Townsend RR: Hypertension. NephSAP 2008;7:6326. Rocchini AP, Katch V, Kveselis D, et al: Insulin and renal sodium retention in obese adolescents. Hypertension 1989;14:36727. Goodfriend TL, Calhoun DA: Resistant hypertension, obesity, sleep apnea, and aldosterone: theory and therapy. Hypertension 2004;43:51828. Goodfriend TL, Ball DL, Gardner HW: An oxidized derivative of linoleic acid affects aldosterone secretion by adrenal cells in vitro. Prostaglandins Leukot Essent Fatty Acids 2002;67:16329. Ehrhart-Bornstein M, Lamounier-Zepter V, Schraven A, et al: Human adipocytes secrete mineralocorticoid-releasing factors. Proc Natl Acad Sci USA 2003;100:1421130. Flynn JT: Pediatric hypertension: recent trends and accomplishments, future challenges. Am J Hypertens 2008;21:60531. Mathew B, Patel SB, Reams GP, et al: Obesity-hypertension: emerging concepts in pathophysiology and treatment. Am J Med Sci 2007;334:233132. Sharma AM, Pischon T, Engeli S, et al: Choice of drug treatment for obesity-related hypertension: where is the evidence? J Hypertens 2001;19:667