Hypertension in Pediatrics New Guidelines

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1 Hypertension in Pediatrics New Guidelines MARISELIS ROSA-SAN CHEZ, M D PEDIATRIC NEPHROLOGY Disclosure Information In the past 12 months, I have had no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this presentation. 1

Learning Objectives Understand the changes in the new American Academy of Pediatrics (AAP) childhood hypertension guideline published in 2017-Joseph Flynn, MD Diagnosis Screening Timing for referral

2 Learning Objectives Understand the changes in the new American Academy of Pediatrics (AAP) childhood hypertension guideline published in 2017-Joseph Flynn, MD Diagnosis Screening Timing for referral Fourth Report (2004) Hypertension guidelines from 1-17 y/o based on gender, age and height Pediatric normative BP values are based on auscultation Data from multiples studies that also included obese patients Diagnosis: Pre-Hypertension, Stage 1 and Stage 2 HTN: average measure over 3 different clinic visits 2

New Guidelines 2017 30 Key Action Statements (weak, moderate, strong recommendations) Derived from a comprehensive review of almost 15, 000 published articles between January 2004 and July 2016:

3 New Guidelines Key Action Statements (weak, moderate, strong recommendations) Derived from a comprehensive review of almost 15, 000 published articles between January 2004 and July 2016: Revised definitions of BP categories in alignment with American Heart Association (AHA)/American College of Cardiology (ACC) guideline New Normative Tables based on BPs from normal-weight children New Simplified Screening Table Importance Increase in prevalence due to obesity High BP in childhood increases the risk for adult HTN and cardiovascular disease Avoid other complications: Retinopathy, Posterior Reversible Encephalopathy, Neurocognitive delay, Acute kidney Injury To decrease extensive workup and costs 3

4 Pathophysiology of Hypertension Sinny DelaCroix et at Differential Diagnosis of Hypertension Among Children, by Age Birth to 1y/o (Secondary 99%) Cardiac Coarctation of aorta Patent ductus arteriosus Renal Renovascular defect Renal parenchymal disease Pulmonary Bronchopulmonary dysplasia Neurologic Intraventricular hemorrhage Pain Neoplasia Wilms tumor Neuroblastoma Endocrine Congenital adrenal hyperplasia Hyperaldosteronism Hyperthyroidism 4

5 Differential Diagnosis of Hypertension Among Children, by Age Age 1 12 y Renal Renal parenchymal disease Renovascular defect Cardiac Coarctation of aorta Urologic Reflux nephropathy Endocrine Congenital adrenal hyperplasia Hyperaldosteronism Hyperthyroidism Neoplasia Wilms tumor Neuroblastoma Miscellaneous Secondary (70% 85%) Primary (15% 30%) Age y Renal Renal parenchymal disease Renovascular defect Cardiac Coarctation of aorta Urologic Reflux nephropathy Endocrine Congenital adrenal hyperplasia Hyperaldosteronism Hyperthyroidism Neoplasia Wilms tumor Neuroblastoma Miscellaneous Primary (85% 95%) Secondary (5% 15%) Primary Hypertension Children and adolescents 6 years of age do not require an extensive evaluation for secondary causes of HTN if they have positive family history of HTN overweight or obese do not have history or physical examination findings suggestive of a secondary cause of HTN 5

Hypertension and Nephrology Renal parenchymal disease or renal structural abnormalities account for 34% 76% Renovascular disease accounts for 12% 13% Renal causes especially likely among children <6

6 Hypertension and Nephrology Renal parenchymal disease or renal structural abnormalities account for 34% 76% Renovascular disease accounts for 12% 13% Renal causes especially likely among children <6 years of age Renovascular HTN Stage 2 HTN Significant diastolic HTN Discrepant kidney sizes on ultrasound Hypokalemia on screening laboratories Epigastric and/or upper abdominal bruit on physical examination 6

7 Monogenic Hypertension Rare 3% of the population Liddle syndrome Pseudohypoaldosteronism type II (Gordon syndrome) Apparent mineralocorticoid excess Familial glucocorticoid resistance Mineralocorticoid receptor activating mutation Congenital adrenal hyperplasia HTN with abnormal plasma renin activity, increased sodium absorption in the distal tubule, Serum potassium abnormalities, metabolic acid-base disturbances, and abnormal plasma aldosterone. QUESTION 9 months old elevated BP during each of his health maintenance evaluations. He was born 30 weeks and Discharged from NICU at 2 months old. He takes breast milk. No family hx. Growth at 25 th percentile. BP elevated >95% percentile. Further hx most likely to reveal the following: a)coartation of aorta b)elevated maternal caffeine c)history of neonatal seizures d)history of umbilical catheter placement e)hyperthyroidism 7

8 Comorbid Conditions History of prematurity History of low birthweight/nicu stay Congenital heart disease Recurrent urinary tract infection, hematuria, proteinuria Known renal disease or genitourinary abnormalities Family history of congenital kidney disease Solid organ transplant Malignancy or bone marrow transplant Taking medications known to increase blood pressure Presence of systemic illness associated with hypertension Evidence of increased intracranial pressure Systemic illness associated with HTN: Diabetes mellitus, Thyroid disease, Cushing syndrome, Systemic lupus erythematosus QUESTION 10 y/o girl elevated BP on several measurements during several clinic visits in the last year. She is healthy, No PMH, No Family hx, Physical exam normal, Height is 3%, Weight 25%, BP in the right arm 140/85 and in her right leg is 108/68. Most probably has this underlying syndrome: a)cushing syndrome b)neurofibromatosis c)tuberous sclerosis d)turner syndrome e)william syndrome 8

9 Syndromes associated with HTN Williams syndrome (supravalvular aortic stenosis, midaortic syndrome, renal artery stenosis, renal anomalies) Turner syndrome (coarctation of the aorta, renal anomalies) Tuberous sclerosis (coarctation of the aorta, renal artery stenosis, brain tumors) Neurofibromatosis (renovascular HTN) Polycystic kidney disease, both autosomal recessive and autosomal dominant variants MEDICATIONS ASSOCIATED WITH HTN Corticosteroids Decongestants/cold preparations Nonsteroidal anti-inflammatory medications Herbal medications/supplements Oral contraceptive pills Antihypertensive medications (recent discontinuation of clonidine) β-adrenergic agonists/theophylline Erythropoietin Cyclosporine/tacrolimus Caffeine Stimulants for attention deficit/hyperactivity disorder Tricyclic antidepressants Illicit drugs Amphetamines Cocaine 9

Oscillometric Devices Estimate blood pressure using formulas from waveforms or oscillations

10 Blood Pressue Measurement Bladder width that is at least 40% of the child's midarm circumference Bladder length that encircles 80% to 100% of the midarm circumference Oscillometric Devices Estimate blood pressure using formulas from waveforms or oscillations of the blood flow Pediatric Normative data tables with percentiles are from Auscultatory BP measurements 10

11 Best BP Measurement Practices Seated in a quiet room for 3 5 min before measurement Back supported and feet uncrossed on the floor BP should be measured in the right arm The arm should be at heart level and supported The patient and observer should not speak The cuff should be inflated to mm Hg above the point at which the radial pulse disappears Overinflation should be avoided The cuff should be deflated at a rate of 2 3 mm Hg per second To measure BP in the legs, the patient should be in the prone position *The SBP in the legs is usually 10% 20% higher than the brachial artery pressure. Definition of Hypertension (1 18 years) BP >90 th percentile or > /<80 in adolescents now termed: Elevated BP Hypertension Stage 1: >95 th or > /80-89 in adolescents >13 y/o Hypertension Stage 2: >95 th + 12 mmhg or >140/90 in adolescents >13 y/o 11

12 Neonatal Hypertension by Gestational Age Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, Hypertension in Infants Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology,

Recheck BP in 6 months (auscultation) If BP is still elevated after 12 months (i.e. 3 time points)

13 Evaluation and Follow up Elevated Blood Pressure Lifestyle recommendations at each visit, Recheck BP in 6 months (auscultation) If BP is still elevated after 6 months Check upper and lower extremity BP, Recheck BP in 6 months (auscultation) If BP is still elevated after 12 months (i.e. 3 time points) Referral-ABPM and workup If BP normalizes at any point, return to annual screening Evaluation and Follow Up 13

14 Ambulatory Blood Pressure Monitoring Patient wears a BP cuff continually for 24 hours Readings q20 30 min Captures BP in many settings: Home, school, work o Awake, asleep ABPM allows for evaluation of Out-of-office BP and Circadian BP patterns Ambulatory Blood Pressure Monitoring Confirm Hypertension screening with clinic BP alone results in high numbers of falsepositive results Cost effective Treatment effectiveness ABPM should be performed for confirmation of HTN in children and adolescents with Office BP measurements in the elevated BP category for 1 year Stage 1 HTN over 3 clinic visits 14

15 HIGH RISK CONDITIONS 15

Additional Tests to Determine Secondary Causes of Hypertension Test Urine toxicology screen Plasma and urine steroid levels Plasma metanephrines Polysomnography 24-hour ambulatory blood pressure

16 Additional Tests to Determine Secondary Causes of Hypertension Test Urine toxicology screen Plasma and urine steroid levels Plasma metanephrines Polysomnography 24-hour ambulatory blood pressure monitoring Renal arteriogram with venous renin sampling Purpose illicit drug use steroid-mediated hypertension pheochromocytoma obstructive sleep apnea white coat hypertension renal artery stenosis Left Ventricular Hypertrophy Prevalence is 30% 40% in childhood HTN Echocardiography To assess for cardiac target organ damage (left ventricular mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN Picture: Kumar. Your Article library.com 16

17 Acute Hypertension Asymptomatic? Target organ? Drug of choice short acting agents (orally ) If Symptoms: Intravenous agents are indicated or when oral therapy is not possible Reduced by no more than 25% over the first 8 hours The ultimate short-term BP goal - around the 95th percentile HTN and the Athlete May participate in competitive sports once hypertensive target organ effects and risk have been assessed Limit competitive athletic participation among athletes with LVH until BP is normalized Restrict athletes with stage 2 HTN from participating in high-static sports (eg, weight lifting, boxing, and wrestling) until HTN is controlled 17

RECOMMENDATIONS At the time of diagnosis of elevated BP or HTN advice DASH diet Moderate to vigorous physical activity at least 3 to 5 days per week (30 60 minutes per session) DASH Diet

18 RECOMMENDATIONS At the time of diagnosis of elevated BP or HTN advice DASH diet Moderate to vigorous physical activity at least 3 to 5 days per week (30 60 minutes per session) DASH Diet Recommendations Food Servings Fruits and vegetables 4 5 Low-fat milk products 2 Whole grains 6 Fish, poultry, and lean red meats 2 Legumes and nuts 1 Oils and fats 2 3 Added sugar and sweets (including sweetened beverages) 1 Dietary sodium <2300 mg per day 18

19 QUESTION 15 y/o obese with persistent hypertension after 6 months of lifestyle modification. His father has HTN. PMH is significant for asthma. Physical exam normal. You decided to start this treatment: a)furosemide b)propranolol c)labetalol d)lisinopril e)hydrochlorothiazide QUESTION 5 y/o male with gross hematuria, elevated serum creatinine, decrease in urine output. Recently diagnosed with strep throat infection 3 weeks ago. Physical exam with periorbital edema and mild ascites. Bp 150/90. What is the drug of choice to tx HTN. a)nifedipine b)clonidine c)furosemide c)labetalol d)lisinopril 19

20 Pharmacologic Treatment Patient has failed at least 6 months of lifestyle change Symptomatic HTN Stage 2 HTN without clearly modifiable risk factor (e.g. obesity) 1st line agents: Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) Long-acting calcium channel blocker Thiazide diuretic In CKD or diabetes: ACE inhibitor or ARB GOAL With nonpharmacologic and pharmacologic therapy should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents 13 years old 20

21 GOAL IN CKD HTN should be treated to lower 24-hour MAP to <50th percentile by ABPM Regardless of apparent control of BP with office measures, HTN should have BP assessed by ABPM at least yearly to screen for masked hypertension Summary and Key Learning Points BP should be measured annually in children and adolescents 3 years of age Any age, in each clinic visit if high risk conditions Use of similar BP levels as adults for adolescents 13 y/o of age. Importance of Referral for ABPM and Assessment of Target organ damage 21

REFERENCES American Academy of Pediatrics: New Guidelines on Identifying and treating High Blood pressure in Children by Dr Joseph Flynn Pediatric Nephrologist-Published in August 2017 Dionne JM,

22 REFERENCES American Academy of Pediatrics: New Guidelines on Identifying and treating High Blood pressure in Children by Dr Joseph Flynn Pediatric Nephrologist-Published in August 2017 Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrology, Azar Nickavar and Farahnak Assadi. Managing Hypertension in the Newborn Infants. Int J Prev Med. March 2014 Flynn JT, Kaelber DC, Baker-Smith CM, et al., and AAP Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e Sinny Delacroix, Ramesh G Chokka and Stephen G Worthley. Hypertension: Pathophysiology and Treatment Journal of Neurology and Neurophysiology Nov 2014 THANK YOU Appointments: Office locations Medical Art Building-South Miami Hospital West Boca Medical Center Homestead Hospital Baptist 22

2017 AAP Guidelines for Childhood Hypertension

2017 AAP Guidelines for Childhood Hypertension Joseph T. Flynn, MD, MS, FAAP Professor of Pediatrics, University of Washington Chief, Division of Nephrology, Seattle Children s Hospital Disclaimer In the