![References
• 6- Sharma AK, Metzger DL, Rodd CJ. Prevalence and severity of high
blood pressure among children based on the 2017 American
Academy of Pediatrics guidelines [published online April 23,
2018].JAMA Pediatr.
• 7- Messerli FH, Bangalore S. Lowering the thresholds of diseases: is
anyone still healthy? J Am Coll Cardiol. 2018;71(2):119-121.
• 8- Dong et al. Updates to pediatric hypertension guidelines: influence
on classification of high blood pressure in children and adolescents.
Journal of Hypertension. 2019.](https://image.slidesharecdn.com/htndefinition1-210205112003/85/Htn-definition-41-320.jpg)
Htn definition
- 2. Powerpoint Templates Hypertension in children definition & diagnosis Alaleh Gheissari, MD Professor of Paediarics, Pediatric Nephrologist IUMS
- 3. Blood Pressure History The circulation of blood? A subject of study for many thousands of years • Ancient China, Blood circulated through the blood vessels • Scholars in India The circulatory system, pulse and its dynamic nature
- 4. Broader underestanding of circulation: • Early 1600’s • William Harvey • The first publication in 1628 entitled “Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus” (On the Movement of the Heart and Blood in Animals). • His work became a foundation for the study of the circulatory system, and is still highly regarded even to this day.
- 5. BP measurment & Instument: • In 1733 Reverend Stephen Hales recorded the first blood pressure measurement on a horse. • In 1881, the first sphygmomanometer was invented by Samuel Siegfried Karl Ritter von Basch.
- 6. Modern BP measurment • Modern blood pressure measurement was not developed until 1905, when Dr. Nikolai Korotkoff discovered the difference between systolic blood pressure and diastolic blood pressure.
- 7. Hypertension in Children: • From a rare possibility • To serious public health challenge. • Increases the risk of end organ damage, including coronary artery calcifications,ventricular hypertrophy, and increased carotid intima–media thickness. • HBP in childhood can be progressive into adulthood and is the strongest predictor of adulthood HBP.
- 8. Hypertension in Children: • Report of the task force on blood pressure control in children. S Blumenthal, R P Epps, R Heavenrich, R M Lauer, E Lieberman, B Mirkin, S C Mitchell, V Boyar Naito, D O'Hare, W McFate Smith, R C Tarazi, D Upson. 1977 May;59(5 2 suppl):I-II, 797-820. • Updated on 2017 AAP guideline
- 9. Hypertension in Children: • In 2017, the American Academy of Pediatrics (AAP) and its Council on Quality Improvement and Patient Safety developed a new pediatric Clinical Practice Guideline (CPG).
- 10. Significant changes in the Forth guideline • 1- The replacement of the term “prehypertension” with the term “elevated blood pressure.” • 2- New normative pediatric BP tables based on normal-weight children at all weight levels. • 3- A simplified screening table for identifying BPs needing further evaluation • 4- A simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines.
- 11. Significant changes in the Forth guideline • 5- A more limited recommendation to perform screening BP measurements only at preventive care visits • 6- Streamlined recommendations on the initial evaluation and management of abnormal BPs • 7- An expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension • 8- Revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy.
- 13. What Is the Prevalence of Childhood Hypertension? It Depends on the Definition • Sharma et al9 demonstrate that using the new clinical practice guidelines results in an increase in the prevalence of elevated blood pressure from 11.8% to 14.2%. • Dong et al found that using new guideline among 50336 Chinese children and adolescents resulted in a higher HBP prevalence, compared with that defined by the Fourth Report, which was developed with a reference population with children and youths of all body weights.
- 14. Hypertension Prevalence in Children: • The actual prevalence: ∼3.5% • The prevalence of persistently elevated BP (formerly termed “prehypertension,” including BP values from the 90th to 94th percentiles or between 120/80 and 130/80 mmHg in adolescents) is also ∼2.2% to 3.5% with higher rates among children and adolescents who have overweight and obesity.
- 15. Classification & more definition • According to the etiology • Essential or primary HTN - when an underlying cause cannot be dentified. • Secondary HTN - when an organic cause is established. • Other definitions of HTN include: • White coat HTN - elevated BP during health care visits, which then normalizes after relaxation or in nonmedical settings(32-46%) • Masked HTN - normal BP during health care visits but elevated in the ambulatory setting (Kidney diseases).
- 16. BP measurement • Auscultation method Vs Oscillometric method • Right arm, resting comfortably in the sitting position. • Using the correct size BP cuff. • The inflatable cuff should cover 80% of the arm circumference and 40% of the arm length.
- 17. BP measurement • ABPM was obtained only from children with height >120 cm and of primarily Caucasian origin. • ABPM should be performed in children more than 5 years of age for confirmation of hypertension if the BP is in the “elevated” category for at least 1 year or with stage 1 hypertension across three clinic visits.
- 19. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation BP measuring annually beginning at 3 years of age. Repeat at every health care for obese children, known case of kidney or heart disease, COA, DM, consumption of certain medication C moderate When available, ABPM should be used to confirm hypertension in children and adolescents. C moderate
- 20. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation Trained health care professionals in the office setting should make a diagnosis of HTN if a child or adolescent has auscultatory confirmed BP readings ≥95th percentile at 3 different visits. C moderate Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a device that has been validated in the pediatric age group. If elevated BP is suspected on the basis of oscillometric readings, confirmatory measurements should be obtained by auscultation. B strong
- 21. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation Home BP monitoring should not be used to diagnose HTN, MH, or WCH but may be a useful adjunct to office and ambulatory BP measurement after HTN has been diagnosed. C moderate Doppler renal ultrasonography may be used as a noninvasive screening study for the evaluation of possible RAS in normal children and adolescents ≥8 y of age who are suspected of having renovascular HTN and who will cooperate with the procedure. C moderate
- 22. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation • Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for LVH. B Strong • It is recommended that echocardiography be performed to assess for cardiac target organ damage (LV mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN. C moderate
- 23. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation • LVH should be defined as LV mass >51 g/m2.7 (boys and girls) for children and adolescents older than age 8 y and defined by LV mass >115 g/BSA for boys and LV mass >95 g/BSA for girls. • Repeat echocardiography may be performed to monitor improvement or progression of target organ damage at 6- to 12-mo intervals. • Indications to repeat echocardiography include persistent HTN despite treatment, concentric LV hypertrophy, or reduced LV ejection fraction. C moderate
- 24. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation • In patients without LV target organ injury at initial echocardiographic assessment, repeat echocardiography at yearly intervals may be considered in those with stage 2 HTN, secondary HTN, or chronic stage 1 HTN incompletely treated (noncompliance or drug resistance) to assess for the development of worsening LV target organ injury. C moderate
- 25. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation • Children and adolescents with CKD should be evaluated for HTN at each medical encounter. • Children or adolescents with both CKD and HTN should be treated to lower 24-hr MAP <50th percentile by ABPM. • Regardless of apparent control of BP with office measures, children and adolescents with CKD and a history of HTN should have BP assessed by ABPM at least yearly to screen for MH. B strong
- 26. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation Children and adolescents with CKD and HTN should be evaluated for proteinuria. B strong Children and adolescents with CKD, HTN, and proteinuria should be treated with an ACE inhibitor or ARB. B strong
- 27. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation All hypertensive children should be screened for hyperlipidemia and underlying renal disease (U/A, BUN/Cr, and electrolytes.) C moderate DO US for children<6 years and those with abnormal tests results C moderate
- 28. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation Obese children and adolescents with hypertension should be evaluated for diabetes mellitus and fatty liver. C modertae All children with elevated blood pressure or hypertension should make therapeutic lifestyle changes. C moderate
- 29. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP ≥95th percentile or >130/80 mmHg in adolescents ≥13 y of age. C moderate Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participation in competitive sport C moderate
- 30. KEY RECOMMENDATIONS FOR PRACTICE Key Action Statement Evidence Quality, Strength of Recommendation Children with symptomatic hypertension, stage 2 hypertension without a modifiable factor such as obesity, evidence of left ventricular hypertrophy on echocardiography, any stage of hypertension associated with chronic kidney disease or diabetes, or persistent hypertension despite a trial of lifestyle modifications require antihypertensive medications. C moderate
- 31. AGE year BP measure BOYS GIRLS SYS BP DBP SYS BP DBP 1 98 52 98 54 2 100 55 101 58 3 101 58 102 60 4 102 60 103 62 5 103 63 104 64 6 105 66 105 67 7 106 68 106 68 8 107 69 107 69 9 107 70 108 71 10 108 72 109 72 11 110 74 111 74 12 113 75 114 75 ≥ 13 120 80 120 80
- 32. A simplified Table of Blood Pressure Normal Cutoffs in Childr • Systolic blood pressure (95th centile) • 1–17 years = 100 + (age in years × 2) • Diastolic blood pressure (95th centile) • 1–10 years = 60 + (age in years × 2) • 11–17 years = 70 + (age in years). •Somu et al. Early detection of hypertension in general practice. Arch Dis Child. 2003
- 33. A simplified Table of Blood Pressure Normal Cutoffs in Children • Badeli et al. Simple Formulas for Screening Abnormal Blood Pressure in Children and Adolescents. IJKD 2010. Age year Hypertension Systolic Diastolic 3-7 age + 96 2 × age + 55 8-13 2 × age + 91 age + 63 ≥ 14 ≥ 120 ≥ 75
- 34. Suspicious patient????? • Based on the guideline • Based on the medical history • birth history; growth and development; and screening for previous urologic, renal, cardiac, endocrine, or neurologic diseases, different medications, sleep disorders, neuro-psychotic problems. • Dysuria, polyuria, polydipsia, Visual disturbance, headache, claudication, seizure.
- 35. Suspicious patient????? • Monogenic HTN • FH of early-onset HTN • Hypokalemia,suppressed plasma renin, or an elevated Aldosterone- Renin Ratio (ARR) >10. • Central obesity • Abnormal phenotype • Syndromin such as Williams, Turner
- 36. Suspicious patient????? • Based on the physical examination • Mostly normal • BMI • 4 limbs BP • Murmur and bruit • Ambiguous genitalia • Muscle weakness • Skin vascular lesion • Incidental findings • ophthalmoscopic findings, End organ damage, microalbuminuria
- 37. Time to Referral to a Nephrology Clinic • Years typically passed from first EBP to nephrology referral. • Most patients (68%) reached diagnostic criteria for HTN prior to referral; • Many pediatricians either fail to routinely check for HTN in their patients or to utilize appropriate reference materials. • The Fourth Report and the recent update set a standard for diagnosis, evaluation, and treatment of pediatric HTN; yet many physicians are unaware of these standards and feel uncomfortable making such diagnosis. • Hamby et al. Time to referral to a nephrology clinic for pediatric hypertension. Pediatric Nephrology. 2020.
- 38. Take-Home Message • Pediatric HTN is often undiagnosed and has a significant effect on long term cardiovascular outcomes. • Accurate diagnosis relies on multiple manual measurements and can be confirmed with the use of ABPM. • Diagnostic workup for an underlying etiology of hypertension should be tailored based on level of • suspicion
- 39. Take-Home Message • Use BP charts for children one to 12 years of age in healthy children of normal weight and interpret on the basis of sex, age, and height (normative population • distribution curve). • Consider Primary hypertension (now accounts for most cases of childhood hypertension).
- 40. References • 1- Thomas et al. Pediatric hypertension: Review of the definition, diagnosis, and initial management. International Journal of Pediatrics and Adolescent Medicine. 2020. • 2- Riley et al. High Blood Pressure in Children and Adolescents. Am Fam Physician. 2018. • 3- Sinha et al. American Academy of Pediatrics Clinical Practice Guidelines for Screening and Management of High Blood Pressure in Children and Adolescents:What is New?. Indian ped. 2019. • 4- Göknar et al. New guidelines for the diagnosis, evaluation, and treatment of pediatric hypertension. Turk Pediatri Ars. 2020. • 5- Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017.
- 41. References • 6- Sharma AK, Metzger DL, Rodd CJ. Prevalence and severity of high blood pressure among children based on the 2017 American Academy of Pediatrics guidelines [published online April 23, 2018].JAMA Pediatr. • 7- Messerli FH, Bangalore S. Lowering the thresholds of diseases: is anyone still healthy? J Am Coll Cardiol. 2018;71(2):119-121. • 8- Dong et al. Updates to pediatric hypertension guidelines: influence on classification of high blood pressure in children and adolescents. Journal of Hypertension. 2019.
- 42. Research Gaps & opportunities • Epidemiology and/or observational studies • Measurement and/or equipment • Clinical trials, including lifestyle interventions • Pharmacologic studies