NC Department of Health and Human Services Division of Public Health Now What Do I Need To Do? Blood Pressure in Kids January 2018 Gerri Mattson, MD, MSPH, FAAP Pediatric Medical Consultant Children and Youth Branch Webinar Logistics The sound for this webinar is provided in VoIP--you will use your computer speakers; be sure to turn up the volume; you will use the CHAT function to communicate with the presenters The webinar will be archived and posted on the Child Health Provider resource page. 1
Test for Audio If you cannot hear any sound through your computer speakers at this time try the following: 1) Check to make sure your computer sound is turned up and on 2) For only those who still cannot hear, please call in at 1-877-336-1831 and use Access code: 9728718 We only have limited phone access so please do not call if you have audio through your computer Most slides borrowed from this November 2017 Webinar Slides are used by permission from Dr. Flynn and the AAP 2
Objectives Describe several changes in the American Academy of Pediatrics (AAP) practice guidelines for screening and management of blood pressure (BP) in children and adolescents Understand how the changes will impact the care you deliver to patients Did You Know. Researchers in many studies have identified an association between sleep disordered breathing (e.g., snoring, obstructive sleep apnea) and hypertension (HTN) in the pediatric population Archbold, KH et al, J Pediatr 2012, Javaheri S, et al., Circulation, 2008, Hartzell K, et al., J Am Soc Hypertens 2016 3
2017 Health Check Program Guide (HCPG) The most current HCPG guide can be found towards the bottom of the page at: https://dma.ncdhhs.gov/medicaid/get-started/findprograms-and-services/health-check-and-epsdt The HCPG requires BP and BP percentile starting at age 3 years The HCPG s NC Periodicity Schedule and Coding Guide for Early Periodic Screening schedule includes an asterisk for each visit under age 3 years which means BP should be measured if a child has a risk for an elevated BP (e.g., prematurity, heart defects) 4
5
6
7
NEW Old Slide adapted from webinar 8
9
Current NC HCPG requires BP and BP percentile starting at age 3 years at every well visit 10
Best BP Measurement Practices The child should be seated in a quiet room for 3-5 minutes before measurement, with the back supported and feet uncrossed on the floor. BP should be measured in the right arm for consistency, for comparison with standard tables, and to avoid a falsely low reading from the left arm in the case of coarctation of the aorta. The arm should be at heart level, supported and uncovered above the cuff The patient and observer should not speak while the measurement is being taken Adapted from Pickering, et al. Circulation, 2005. 11
Best BP Measurement Practices (cont.) The correct cuff size should be used; bladder length should be about 80-100% of the circumference of the arm, and the width should be at least 40% For an auscultatory BP, the bell of the stethoscope should be placed over the brachial artery in the antecubital fossa, and the lower end of the cuff should be 2-3 cm above the antecubital fossa Adapted from Pickering, et al. Circulation, 2005. Best BP Measurement Practices (cont.) The cuff should be inflated to 20-30mmHg above the point at which the radial pulse disappears Overinflation should be avoided The cuff should be deflated at a rate of 2-3mmHg per second Adapted from Pickering, et al. Circulation, 2005. 12
Best BP Measurement Practices (cont.) The first (phase I Korotkoff) and last (phase V Korotkoff) audible sounds should be taken as SBP and DBP If the Korotkoff sounds are heard to 0mmHg the point at which the sound is muffled (phase IV Korotkoff) should be taken as the DBP, or the measurement repeated with less pressure applied over the brachial artery The measurement should be read to the nearest 2mmHg Adapted from Pickering, et al. Circulation, 2005. 13
3 14
=Patient Evaluation and Management By Blood Pressure Level 1st 2nd 3rd 15
Recommend this 3 rd visit not be with ERRN 2 nd visit would probably not be with ERRN but if it is, ERRN consult with supervising provider if still elevated 16
ERRN consult with supervising provider Recommend 2 nd and 3 rd visits not be with ERRN ERRN consult with supervising provider Recheck not with ERRN 17
18
19
CKD = chronic kidney disease 20
21
Summary The definitions of BP categories and stages for children and adolescents have been updated The detailed BP tables have been revised and a new simplified BP screening table exists A process needs to be in place if your patients need to access ABPM to confirm HTN and for special populations 22
To Do Post the simplified BP screening table in your clinic Make available the more detailed revised BP tables Review manual BP measurement with your staff and make sure appropriate equipment (all sizes of cuffs) is available Check out the full clinical practice guideline with 30 KAS s which can be found at: http://pediatrics.aappublications.org/content/pediat rics/140/3/e20171904.full.pdf 23