Blood Pressure Measurement (children> 3 yrs)

Transcription

1

2

3 Blood Pressure Measurement (children> 3 yrs) If initial BP elevated, repeat BP manually 2x and average, then classify Normal BP Systolic and diastolic <90% Elevated BP 1-13yo: Systolic +/or diastolic 90% but <95% 13yo: 120/<80 to 129/<80 mm Hg Hypertension Systolic +/or diastolic BP >95% Therapeutic Lifestyle Changes Repeat BP in 6mo Check UE/LE BP, continue lifestyle modifications Repeat BP in 6mo Still 90% but <95% Stage I HTN 1-13yo: Systolic +/or diastolic 95 th to <95 th % +12mmHg 13yo: 130/80 to 139/89 mm Hg Therapeutic Lifestyle Changes Repeat BP in 1-2 weeks BP = Stage 1 Check UE/LE BP, continue lifestyle modifications Repeat BP in 3 months BP = Stage 1 Ambulatory BP monitoring Stage 2 HTN 1-13yo: Systolic +/or diastolic 95 th % +12mmHg 13yo: 140/90 mm Hg Check UE/LE BP, Therapeutic Lifestyle Changes Repeat BP in 1 week BP 95% Still 90% but <95% BP = Stage 1 BP = Stage 2 Stage I HTN path or Stage II HTN path Ambulatory BP monitoring * Diagnostic Workup, Consider referral, and **initiate treatment if ***primary HTN *Diagnostic Workup with eval for target-organ damage AND Specialty referral within 1 week Normal Abnormal Routine BP screening *Diagnostic Workup Consider subspecialty referral *Diagnostic workup: Urinalysis, BMP, Lipid profile, Renal ultrasonography in those <6 y of age or those with abnormal urinalysis or renal function, consider - polysomnography if snoring, cardiac ECHO to eval for LVH, thyroid function tests, urine catecholamines, drug screen, retinal exam **Drug therapy indications: include symptomatic HTN, secondary HTN, hypertensive target-organ damage, DMI or II, persistent HTN despite nonpharmacology measures Consider ACE inhibitors (ACEI) for patients with BP 90%ile while being worked up Use ACEIs with caution among women of reproductive age Monitor potassium and creatinine while on ACEIs ***Primary HTN more likely in children>6, with overweight/obesity, and +FH of HTN, and no H&P findings suggestive of secondary causes, DBP elevation may be more predictive of secondary HTN AAP Clinical Practice Report for Screening and Management of High Blood Pressure in Children and Adolescents, 2017 Updated 09/28/17

4 LIPID SCREENING *CVD risk factors: FH of dyslipidemia or early CVD ( <55, <65); BMI 85%ile; BP > 95%ile; Cigarette smoking; Diabetes Mellitus. See Disease Specific Guidelines if a personal history of: Cardiac disease, Kidney Disease, Inflammatory Disease, HIV/AIDS Check cholesterol values if: Age 2 yo: Only if familial hypercholesterolemia or signs of high cholesterol Age 2 years: Selective Screening Age 9 yo: Consider universal Screening for those with no risk factors (2011 NHLBI guidelines) 2-9 yo: If BMI > 95%ile ( or other high risk conditions or risk factors*) If child has had cholesterol screening tests in the past, and values were normal: recheck every 3-5 yrs 9-21 yo: If BMI > 85% ( or other high risk conditions or risk factors*) Check Fasting Lipid (Total chol, LDL, TG) Test Once between ages 9-11 yo AND Once between ages yo This is controversial, non fasting lipids ok for initial universal screen If non fasting are high; check 2 fasting lipids and use average. LDL <190: If normal BMI, no RF* Lower Risk (High BMI with no other RF) Higher Risk (Higher BMI with other RF*) Target Values : LDL-Chol = 130 TG<130 Non-HDL-C<140 Total Chol<200 LDL-Chol = 100 TG<90 Non-HDL-Chol <120 Interventions: Not Within Acceptable Range Within Acceptable Range Therapeutic Lifestyle changes for weight management. [Consider plant sterols] Consult Cardiology if values very elevated (e.g. LDL>250, or TG>400) and delay in referral likely Plant Sterols, esp. if Tchol>200 or LDL>130 Fiber (dose = age in yrs + 5gm/day; max dose 20g/day) Flax seed oil (1tsp/day) or ground flaxseed Oatmeal: decreases hepato-enteric circulation of lipids Therapeutic Lifestyle changes & Plant Sterols Low Saturated fat diet Daily physical exercise <2 hours per day sedentary activity (eg. Screen time) weight loss if needed Recheck FLP after 6 months Recheck after 3-5 years depending on success with weight changes. Within Acceptable Range Not Within Acceptable Range Continue Treatment and Recheck after 2 yrs Consider Cardiology Referral for possible medication management Updated 09/28/2017

5 Screening Fasting Lipid Panel Lipid Screening in Childhood Recommended for all children older than 2 years of age with any of the following risk factors: Positive family history of dyslipidemia or premature CVD event (men<55 or women <65 years old) Unknown family history Diabetes mellitus Cigarette smoking HTN (BP 95 th percentile) BMI th percentile BMI 95 th percentile Interpreting Lipids Panels The American Heart Association suggests abnormalities TG > 150 mg/dl HDL < 35 mg/dl No TG or HDL recommendations from the NCEP (National Cholesterol Education Program) LDL>95 th percentile range for age or HDL<5 th percentile range for age are abnormal Retest every 3-5 years if levels are within normal range Medications Recommended LDL Concentrations for Pharmacologic Treatment of Children 8 Years of Age* Patient Characteristics No other risk factors for CVD Other risk factors present, including obesity, HTN, smoking, or FamHx premature CVD Recommended Cut Points LDL is persistently >190 mg/dl despite diet therapy LDL is persistently >160 mg/dl despite diet therapy * Children with diabetes mellitus Pharmacologic treatment should be considered when LDL 130 mg/dl * Pharmacologic intervention < 8 years of age is only for severely elevated LDL (>500 mg/dl) as in familial hypercholesterolemia Follow more aggressive treatment of LDL in children with DM, renal disease, congenital heart disease, collagen vascular disease, or cancer survivors. Goal of medications is to lower LDL<160 mg/dl, or <130 mg/dl, or <110 mg/dl when there is strong family history of CVD or with other risk factors such as obesity, DM, or metabolic syndrome. Statins inhibit cholesterol synthesis and increase LDL clearance Monitor CK levels (rhabdomyolysis) and LFTs,(hepatic side effects) Fiber supplements can help reduce plasma LDL Supplemental fiber dose = child s age in years + 5 gm (max 20 gm/day) Plant sterols (additive found in orange juice, yogurt drinks, dietary supplements) decrease absorption of dietary cholesterol but decrease absorption of fat-soluble-vitamins and beta carotene Daniels and Greer, Lipid Screening and Cardiovascular Health in Childhood, Pediatrics, 2008,122:198 Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics Dec;128 Suppl 5:S

6 NAFLD=Non Alcoholic Fatty Liver Disease Definition: Histologic findings of macrovascular steatosis on liver biopsy Diagnosis: Elevated ALT/AST ratio (2:1 ) and steatosis in absence of other causes of fatty liver

7 Diabetes Screening Fasting Glucose Levels HbA1c <100 Normal Recheck based on BMI Guidelines Elevated. Confirm that glucose was fasting. Consult Pediatric Endocrinology 126 Elevated, suggests diabetes. Confirm lab was fasting. If random >200, proceed 5.6 Normal Reassess and recheck in 12 mos Mildly elevated Risk factor assessment Abnormal Repeat HbA1c, check one month three times a week pre and postprandial glucose, or order 2 hr OGTT, Consult Peds Endo 6.5 Highly suggestive of DM Repeat HbA1c,, do 2 hr OGTT, draw GAD65 and islet cell antibodies. (e)consult Peds Diabetes. Risk Factors Polyuria, polydipsia Unexplained weight loss High risk ethnic group (African American, Hispanic, SE Asian) Family History + DM2 On antipsychotics 0-1 Positive Reassess in 3-6 months Oral Glucose Tolerance Test Interpretation 2 positive Order 2 hr OGTT, or check one month three times a week pre and postprandial glucose and consider metformin; (e)consult Peds Diabetes 2 hour: <140 Normal 2 hr: Abnormal. Impaired glucose tolerance Any result 200 Abnormal glucose tolerance, response in diabetic range Reassess patient according to BMI guidelines (e)consult Peds Diabetes Consult Peds Endo American Diabetes Association. Standards of medical care in diabetes Diabetes Care. 2016;39(suppl 1):S1-S106

8 Anti-Androgenic Evaluation of PCOS Clinical concerns: Abnormal menses (>2y after menarche), hyperandrogenism AM labs: DHEA-S, Androstenedione, free testosterone, 17-OH progesterone, 17-OH pregnenolone, β-hcg, TSH, ft4, prolactin ± FSH, estradiol, karyotype Labs suggestive of PCOS: - Mildly elevated free testosterone Labs suggestive of Non-PCOS Endocrine Disorder (any of the following): DHEA-S, Androstenedione, testosterone, 17-OH progesterone, 17-OH pregnenolone, prolactin Obese and/or signs associated with insulin resistance (Acanthosis nigricans, hypertension, dyslipidemia) Refer to Pediatric Endocrinology Not Obese Consider Rx according to major Sx Encourage diet/lifestyle changes Screen for other comorbidities Consider Metformin over OCPs Oligomenorrhea Hyperandrogenism Progesterone in OCPs: Fourth Generation: Drospirenone Cyproterone acetate Consider OCPs after review of safety profile for individual patient Consider OCPs and/or Metformin after review of safety profiles for individual patient Third Generation: Desogestrel Gestodene Norgestimate Second Geenration: dl-norgestrel Levonorgestrel Reassess in 6 months Refer to Pediatric Endocrinology if no improvement/worsening Sx First Generation: Norethindrone acetate Ethynodiol diacetate Lynestrenol Norethynodrel