Latest / Pediatrics in Practice: A CME Podcast / When to Refer a Child with High Blood Pressure

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When to Refer a Child with High Blood Pressure · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Corinn Cross (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:06
  I'm Dr.
• 0:07
  Cori Cross.
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  Today, we're exploring hypertension in the pediatric patient.
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  To discuss this topic, we are very lucky to be joined by Dr.
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  Douglas Blowey, who's the Director of the Hypertension Clinic in the Division of
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  Nephrology in the Department of Pediatrics at Children's Mercy in Kansas City.
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  Dr.
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  Blowey also serves as the Chief Clinical Integration Officer and
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  the Medical Director for Children's Mercy Integrated Care Solutions.
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  Dr.
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  Blowey, thank you for taking the time to join us this morning.
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  Dr. Doug Blowey:
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  It's my pleasure.
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  Thank you for the invitation.
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  Host: So in the past, hypertension was basically considered an adult condition.
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  How common is high blood pressure in children today?
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  And can you explain to us why it's becoming so much more prevalent?
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  Dr. Doug Blowey:
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  So, high blood pressure is actually much more common in
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  children than many people realize.
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  Current estimates suggest that there's about a 2% to 5% incidence of
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  hypertension in children and adolescents.
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  There's even a higher percentage that have blood pressure readings
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  that are considered abnormal, but not in the hypertension range.
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  And then, in children with chronic diseases such as kidney failure,
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  transplantation, the incidence of hypertension may actually approach 50%.
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  So, the question is why do we think it's becoming more prevalent
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  than historically we thought?
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  And the increase is probably being driven by rising rates of obesity and
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  overweight, along with things such as sedentary lifestyles, poor dietary
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  habits, excess sodium intake, poor sleep, and other cardiovascular risk factors.
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  So while obesity is not the only cause, it has become one of the strongest
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  contributors to primary hypertension in children, particularly adolescents.
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  Host: That makes sense.
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  Do you think it's also that perhaps we're looking for it more, so we
• 1:55
  are finding it more than we used to?
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  Dr. Doug Blowey:
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  Well, probably.
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  You know, the guidelines for hypertension have been out for 20, 30 years now.
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  So, I think, the recognition that high blood pressure can be an
• 2:10
  issue in children certainly is embedded now in pediatric practice.
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  But if you think 50 years ago when we didn't even measure blood pressure in
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  kids, or we used reference ranges that were adult reference ranges rather than
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  pediatric specific ranges, there may be some difference between the perception of
• 2:28
  high blood pressure in kids at that time.
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  Host: So you mentioned the gold standard for how often we check blood
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  pressure in children has absolutely changed over the last few decades.
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  Tell us what the gold standard is and how a pediatric clinician
• 2:43
  should evaluate hypertension.
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  Dr. Doug Blowey:
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  So, the gold standard is based on the guideline definition, the
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  last one was put out in 2017, and it defines blood pressure normal
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  values somewhat based on age.
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  So if you're a younger child, say less than 13 years of age, what we consider
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  normal is going to be interpreted using age, gender, and height-based percentiles.
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  So, kind of like a bell-shaped growth curves that all
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  pediatricians are familiar with.
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  So, it's not based on outcomes, but it's based on statistical
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  phenomena, whether you're an outlier would define hypertension.
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  Once you hit 13 years of age, the guidelines now support using adult
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  standards, which are based on outcome for adverse cardiovascular events.
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  And so, in those, rather than using the blood pressure charts,
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  it is simply is 130 over 80 like it is in the adult population.
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  Host: And how often should we be checking blood pressure?
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  I mean, in our clinic, we check it every time they come in.
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  What's the gold standard there?
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  Dr. Doug Blowey:
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  Yeah.
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  So, that's reasonable.
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  The simplest would be to say that it should be done once a year at
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  annual well visits in kids that don't have any chronic diseases.
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  But kids that have chronic diseases, whatever you want to call it,
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  diabetes, kidney issues, and even I think obesity should be checked
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  at every healthcare encounter.
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  Host: And then, you sort of touched on this, but can you explain to our
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  listeners why it is so important to recognize hypertension in children?
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  Dr. Doug Blowey:
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  Well, the main issue has to do with the risk of future events.
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  So fortunately, high blood pressure in children is usually
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  kind of a silent condition, right?
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  Most kids don't have any symptoms.
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  But we do know that children that have high blood pressure do show signs of
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  cardiovascular injury, including left ventricular hypertrophy, increased
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  vascular stiffness, other markers of accelerated vascular aging.
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  Approximately one in three children with documented hypertension already have
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  evidence of left ventricular hypertrophy.
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  So, the other thing is that hypertensive kids tend to be hypertensive adults.
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  There's tracking.
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  And usually, a lot of the risk factors associated with hypertension, like
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  obesity, track into adulthood, too.
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  So, it's more about preventing future cardiovascular events as an adult
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  rather than probably really treating any symptomatology in children.
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  Host: Okay.
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  So, say, you're a primary care clinician, you have pediatric patient comes in, you
• 5:27
  get an elevated blood pressure reading.
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  What do you do next?
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  Dr. Doug Blowey:
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  So, the first step really is just to confirm the reading you've gotten.
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  So, many elevated blood pressure measurements are related
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  to anxiety, activity, pain, incorrect measurement technique.
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  So, the first thing, it should be repeated using the appropriate size
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  cuff and appropriate technique, making sure those are done consistently.
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  If you have elevated readings that persist over multiple visits, you should start
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  evaluating for contributing factors such as obesity, family history, medications,
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  sleep disorders such as obstructive sleep apnea, and lifestyle habits that include
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  activity levels and dietary patterns.
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  Concern for a underlying secondary cause increases when hypertension occurs in
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  younger children, is really severe, develops suddenly, or is accompanied
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  by findings such as abnormal kidney function, urinary abnormalities,
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  or other concerning symptoms.
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  Host: So when we take our second reading, when we bring them back, it depends
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  on how elevated the blood pressure is.
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  I mean, if it's extremely elevated, we're having them back very soon
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  to retake that blood pressure.
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  If it's slightly elevated, we might wait a few months to do that.
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  That's correct, right?
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  Dr. Doug Blowey:
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  That is correct.
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  There's not a one-size-fit-all, but I think it's more kind of your clinical
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  perception of how significant it is.
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  Host: But if we do believe that it is truly elevated, we've already eliminated
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  white coat, doing improper technique, at that time, we should probably get a urine
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  and not wait for the child to come back.
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  Because if they do have underlying kidney issues, that's going
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  to prompt a referral, right?
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  Dr. Doug Blowey:
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  That is correct.
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  So usually, once you get to the diagnosis of hypertension, then
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  the question is always, well, why?
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  Why would a child have high blood pressure?
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  So, you start thinking about some evaluation, right?
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  Are there things I'm missing here or I want to know about?
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  And clearly, the beginning stuff can clearly be done in the
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  primary pediatrician's office, and it should not be extensive.
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  You shouldn't be looking for all the zebras and all the crazy stuff.
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  It can be very simple.
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  As you mentioned, a urinalysis is by far the most common thing that is missed
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  when I see patients in referral, that that just doesn't get done for some
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  reason, but clearly is very important.
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  The other things we typically recommend is if there's no really clear risk
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  factors or anything that you pick up on, serum electrolytes and creatinine.
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  I will get a lipid profile in kids, not because it causes hypertension,
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  but because it's another cardiovascular risk factor we want to be aware of.
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  We do thyroid function study and the urinalysis that you mentioned.
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  And that is about it as far as just a quick screening to make sure there's
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  nothing clearly jumps out at you.
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  And again, that can be done in the primary care provider's office
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  before considering referral.
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  Host: So if we get those back and they're normal, we can continue
• 8:25
  to follow up the blood pressure.
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  But if the blood pressure continues to be elevated, at what point should we be
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  referring to a pediatric hypertension specialist or a nephrologist?
• 8:35
  Dr. Doug Blowey:
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  There's a good list of things that should prompt your referral.
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  The one, kind of like you mentioned, is that the hypertension persists despite you
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  trying to trial lifestyle modifications, behavior modification type things.
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  So, the things that should prompt a referral would include significant
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  blood pressure elevation, so stage II hypertension, which is essentially
• 8:56
  blood pressure that's significantly above normal; symptomatic hypertension.
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  Although a lot of kids have things like headaches and dizziness and maybe chest
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  discomfort, it could be associated with hypertension or a result of hypertension,
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  although in most cases it's not.
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  But that should make you think a little bit about they need to be seen.
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  Keeping in mind that when you have really severely elevated blood
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  pressure with cardiac or neurologic symptoms, that's going to be
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  categorized as hypertensive emergency or urgency, and requires immediate
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  management in a hospital setting.So,
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  let's see the specialists, get to the hospital now.
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  The other group would be children younger than six years of age who
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  have hypertension, because a secondary cause is much more likely to be found.
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  Evidence of kidney disease, you see blood or protein in the urine,
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  or the elevated kidney function test would prompt a referral.
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  You just have a high index of suspicion that something else is
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  going on, that's syn- syndromic associate or something like that.
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  For some reason, they've had, like, an echocardiogram, and they have left
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  ventricular hypertrophy on the echo, or hypertension in a kid with chronic
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  disease, such as, you know, chronic kidney disease, diabetes, or any other
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  chronic medical condition really should prompt a referral to a specialist so they
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  can kind of help confirm the diagnosis, identify underlying cause, and determine
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  whether medication therapy is needed.
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  Host: Right.
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  And we don't want to wait too long to get them in to see someone like you because
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  these are organs that they're going to have for the rest of their lives.
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  So, we'd like to try to make sure that nothing happens to them.
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  So in summary, is there anything else you'd like to
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  share with our listeners today?
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  Dr. Doug Blowey:
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  Well, sure.
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  I think we kind of touched on it, but I think recognizing hypertension in
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  childhood provides an opportunity to kind of improve lifelong cardiovascular health.
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  So as pediatricians, right, we're preventative medicine, and
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  this fits perfectly into that.
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  As I mentioned, children with hypertension are much more likely
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  to become adults with hypertension.
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  And we know that elevated blood pressure can begin causing damage
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  long before symptoms occur.
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  The good news is that hypertension is often treatable.
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  So early recognition kind of allows families and providers to implement
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  lifestyle changes and when necessary, medications that can lower blood pressure
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  and reduce the risk of future heart disease, stroke, and kidney disease.
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  And I think the important thing is that the goal is not simply to treat
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  a number, but to promote kind of lifetime of cardiovascular health.
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  That's the reason we check blood pressure.
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  Host: Absolutely.
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  Dr.
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  Blowey, thank you so much for joining us today and sharing your
• 11:32
  expertise on such an important topic.
• 11:34
  Dr. Doug Blowey:
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  Very much appreciate the opportunity.
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  Host: And as a reminder to our audience, don't forget to claim
• 11:39
  your CME credit after listening to this fascinating episode today.
• 11:42
  You can do so by visiting cmkc.link/cmepodcast.
• 11:50
  That's cmck.link/cmepodcast,
• 11:56
  and clicking on the Claim CME button.
• 11:58
  If you enjoyed this podcast, please share it on your social channels
• 12:01
  and check out the entire podcast library for topics of interest to you.
• 12:04
  I'm Dr.
• 12:05
  Cori Cross, and this has been Pediatrics in Practice, a CME Podcast.