in the well rounded Disclosures child - UT Health Science ... · PDF file• SAP is a 12 yo female in the 50th percentile of height ... – dyyp ,slipidemia, HTN, DM, obesity, sedentary

Pediatrics Grand Rounds12 April 2013

University of Texas Health Science Center at San Antonio, Texas

1

Hypertension in the well rounded child

ICD9 401.1 “benign” essential HTN ¿

Jane Lockwood Lynch, MDUniversity of Texas Health Science Center

San Antonio, Texas

April 12, 2013

Disclosures

I disclose the following relationships with commercial companies:

Grant and Research Support from:Eli Lill M dt i D ii hi S k P l– Eli Lilly, Medtronic, Daiichi Sankyo, Parexel

– National Institute of Health

I do not intend to reference the investigational use of these drugs or products in my presentation today.

Learning Objectives

• At the end of this presentation, the participant will be able to:

1. Recognize stage 1 & 2 hypertension in children and adolescentsand adolescents

2. Treat primary hypertension in children using nonpharmacologic and drug therapy options

3. Understand the risk for hypertension in children with type 2 diabetes

Hypertension in American children is common:Hypertension is estimated to be prevalent in 4.5% of children

101214161820

%

02468

10

Hypertension Asthma

%

• Analysis of the medical records of 507 hypertensive and pre‐hypertensive children and adolescents over a span of seven years

• All the children visited an outpatient clinic at least three times

Underdiagnosis of hypertension:

• 376 patients (74%) had undiagnosed hypertension 80 patients (15.8%) had a true hypertension diagnosis 7 patients had undiagnosed stage 2 hypertension

• Data to make the diagnosis of hypertension or prehypertension was present in the patients' records

Adult Definition of Hypertension &“JNC 7” 2003 guidelines

• Adult 140/90 goals are based on evidence correlating BP data with adverse events

MI i k d d b 20 25%– MI risk reduced by 20‐25%

– Stroke risk reduced by 34‐40%

• 159/100= stage 1

• >160 =stage 2



2

U.S. Department of Health and Human

Services The 4th Report on High Blood Pressure in Children and

National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program

National Institutes of Health

National Heart, Lung, and Blood Institute

August 2004 supplement of Pediatrics

Children and Adolescents

JNC7 vs. 4th Report

• In children, the definition of hypertension is based exclusively on frequency‐distribution curves for BP.

• As a consequence, estimates of the q ,prevalence of pediatric hypertension lack a scientific basis.

• The relevance of pediatric hypertension data to the risk of developing complications during adulthood remain unknown.

4th Report on High Blood Pressure in Children and Adolescents

• BP standards based on sex, age, and height provide a precise classification of BP according to body size.

• The revised 2004 BP tables included the 5th ‐ 99th BP percentiles; which allow for the staging of hypertension in children.

August 2004 supplement of Pediatricswww.nhlbi.nih.gov

SBP (mmHg) DBP (mmHg)Age BP Percentile of Height Percentile of Height

(Year) Percentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64

90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79

Example: Blood Pressure Levels for 12 year old Girls by Age and Height Percentile

95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83

99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

Classification of Stage 1 vs. 2 Hypertension in Children*(done on 3 occasions to confirm)

SBP or DBP Percentile

Normal <90th percentile

Prehypertension 90th percentile to <95th percentile, or if BP exceeds 120/80 even if below theBP exceeds 120/80 even if below the 90th percentile up to <95th percentile

Stage 1 hypertension 95th percentile to the 99th percentile plus 5 mmHg

Stage 2 hypertension >99th percentile plus 5 mmHg

www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm

So Let’s Practice

• SAP is a 12 yo female in the 50th percentile of height and 95% for weight. Her manual BP on is 123/82 as she arrives for a visit.

• What is her BP percentile?• What is her BP percentile?

• What do we do with this information?



3



12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64

90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79

Blood Pressure 123/83 BP: 12 year old Girl with 50% Height Percentile

95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83

99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

Pre‐Hypertension

90‐95% or >120/80

Stage 1 Hypertension95% to 5 mm above 99%

Stage 2 Hypertension> 5 mm above 99%

Normal

< 90%

Auscultation blood pressure measurement is gold standard

Manual auscultation blood pressure measurement is gold standard

• Cuff too small → high reading

• Cuff too big → usually not falsely lowg y y• Prefer right arm if possible for comparison with BP normal values

• Repeat BP in both arms and one leg if elevated

Arm & Leg BP

B A = B < CBP can be 10‐20

mmHg higher in the legs than the arms!

A

C

Korotkoff Sounds

• Artery collapses completely until the systolic pressure is greater than the cuff pressure with first audible sound of a thud or tap = SYSTOLIC

• Phase 2‐4: systolic pressure opens the artery to produce increasing stage 2,3 sounds then muffled blowing sound at phase 4.

• Silence at phase 5= diastolic BP reading



4

Oscillometric blood pressures**measure mean arterial pressureand calculates SPB and DBP

Pediatric Symptoms of Hypertension

“silent disease”? A recent study by Croix found that 51% of untreated hypertensive children when surveyed reported 1‐4 Symptoms, and 14% reported more than four symptoms

3 most common symptoms– headache – difficulty initiating sleep – daytime tiredness These were all reduced with treatment

Expert Panel On Integrated Guidelines for Cardiovascular Health and Risk

Reduction in Children and Adolescents

Pediatrics Dec 2011

NHLBI guidelines are designed for integration into the recommended pediatric health supervision visits in the

AAP Bright Futures Guidelines

Conditions Under Which Children <3 Years oldShould Have BP Measured

• History of prematurity, very low birth weight or other neonatal complication requiring intensive care

• Congenital heart disease• Recurrent urinary tract infections, hematuria or proteinuria• Known renal disease or urologic malformations• Family history of congenital renal disease• Solid organ transplant, malignancy or bone marrow

transplant• Treatment with drugs known to raise BP• Other systemic illnesses associated with hypertension• Evidence of elevated intracranial pressure

Integrated Cardiovascular Health Schedule

• Family History of Cardiovascular Disease– Obtain history by age 3 years– Men < 55 yo, Women < 65 yo with MI, stroke– dyslipidemia, HTN, DM, obesity, sedentary lifestyley p , , , y, y y

• Tobacco Exposure or Medications/Drug Use

• Nutrition/ Diet– Support breastfeeding optimal to 12 months– 2% milk at age 1‐2 yr, fat free milk > 2 yr– Dietary guidance per growth curve

Integrated Cardiovascular Health Schedule • Blood Pressure: Measure annually > 3 yo

• If < 90th % ‐ repeat in 1 year

• If 90‐95th % = prehypertension• Repeat by auscultation x 2 to confirm and repeat in 6 months

• Diet, Activity, Weight management intervention

• If 95% to (99th% + 5 mmHg) = stage 1 HTN• If 95% to (99th% + 5 mmHg) = stage 1 HTN• Confirm on three occasions at least one week apart

• Diet, Activity, Weight management *salt restriction

• Review medications, examination and laboratory evaluation

• If > 99th% + 5 mmHg = stage 2 HTN• Refer to HTN expert within 1 week if possible and begin basic workup with dietary changes

• Start anti‐HTN medication

• Follow q1‐2 weeks until controlled



5

Clinical Evaluation of Confirmed Hypertension

Study or Procedure Purpose Target PopulationEvaluation for identifiable causesHistory, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking

History and physical examination help focus subsequent evaluation

All children with persistent BP >95th percentile

alcohol; physical examinationBUN, creatinine, electrolytes, urinalysis, urine culture

R/O renal disease and chronic pyelonephritis


CBC R/O anemia, consistent with chronic renal disease


Renal ultrasound R/O renal scar, congenital anomaly, or disparate renal size


Clinical Evaluation of Confirmed Hypertension

Study or Procedure Purpose Target PopulationEvaluation for comorbidityFasting lipid panel, fasting glucose

To identify hyperlipidemia, identify metabolic abnormalities

Overweight patients with BP at 90th–94th percentiles; all patients with BP >95th percentilepFamily history of hypertension or cardiovascular diseaseChild with chronic renal disease

Drug screen To identify substances that might cause hypertension

History suggestive of possible contribution by substances or drugs

Polysomnography To identify sleep disorder in association with hypertension

History of loud, frequent snoring

“MONSTER”

• Medication (stimulants, OCP, NSAID, tricyclicscocaine, ecstasy)

• Obesity• Neonatal• Neonatal• Symptoms

• Trends in Family

• Endocrine (hyperthyroid, pheochromocytoma)

• Renal

White Coat Hypertension

• A patient with BP levels above the 95th percentile in a physician’s office or clinic who is normotensive outside a clinical setting.

• Ambulatory Blood PressureMonitoring: a newer technologyWhich measures blood pressure every 15 minutes while awakeand every 30 minutes while asleep (*Night time blood pressure

should drop by 10%)

Infants Children Adolescents1‐6 year 7‐12 year

• renal vein thrombosis, prior UAC

• Renal artery

• Renalparenchymal disease

• Renal artery

• Renal parenchymal

• Renovascular disease

• Essential HTN• Renal

parenchymal disease

Common Causes of Hypertension by Age:

ystenosis

• Congenital renal anomalies

• Coarctation • BPD

ystenosis

• Coarctation of aorta

**82% is secondary HTN

• Essential HTN

>50% Essential HTN

• Renovascular disease

85‐95% is Essential HTN

Clinical and demographic characteristics of children with hypertension. Flynn J, Zhang Y, Solar‐Yohay S, Shi V. Hypertension. 2012 Oct;60(4):1047‐54.

Primary vs. secondary HTN?Diagnosis for 246 patients aged 5–18 years with a mean age of 13.04±3.10 years from 4 pediatric nephrology centers:

15 (6%) secondary hypertension*

151 (61%) primary hypertension*

25 (10%) prehypertension, 8 (3%) white‐coat hypertension

47 (20%) no hypertension

*There was no significant difference in the distribution of patients with stage 1 and 2 hypertension in the primary and secondary hypertension groups

Kapur G et al. Clin Hypertens (Greenwich). 2010; 12(1):34‐9



6

Percentage of U.S. Children and Adolescents Classified as Obese, 1963–2008*

19.6

18.1

*>95th percentile for BMI by age and sex based on 2000 CDC BMI‐for‐age growth charts.

**1963–1970 data are from 1963–1965 for children 6–11 years of age and from 1966–1970 for adolescents 12–17 years of age.

Source: NCHS. Health, United States, 2010: With Special Feature on Death and Dying. Hyattsville, MD. 2011

4.6

4.2

The “Great” State of Texas :

• 2nd youngest population

• Highest number of children per

family

• ~10% of US children

• ~25% of Hispanic children• ~25% of Hispanic children

• South Texas ~ 6.5 million people

• ~1.8 million children <18 years of

age

• several of the fastest growing

areas (Austin, San Antonio

McAllen, and Laredo)



12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64

90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79

Back to our San Antonio patient: she has now had repeat BPs on three occasions which were >95% and she has no

laboratory or clinical evidence for an underlying etiology:

95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83

99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

Therapeutic LifestyleChanges

• Family‐based intervention improves success.

• Weight reduction = primary therapy for obesity‐related prehypertension and hypertension .

• Physical activity* can improve efforts at weight management and may prevent future increase in BP.

*Participation in sports — Children who have controlled high blood pressure are generally allowed to participate in competitive sports. Children and adolescents with high blood pressure are advised to avoid weight lifting until the blood pressure is better controlled. Exceptions to these recommendations include children with uncontrolled stage 2 hypertension, who are generally advised to avoid competitive sports.

DASH: Dietary approaches to stop Hypertension

• Eliminate sugar containing drinks (soda, juice, sugared drinks)

• Decrease White Foods (pasta, rice, potatoes & SALT!)

• Increase Bright Color Foods (vegetables, fruits)

• Goal of < 2,300 mg salt for healthy people (one leveled teaspoon) and 1,500 mg for those with high blood pressure.



7

Insulin Resistance and PubertyHyperinsulinism further increases reabsorption of Na and

increases sympathetic tone

37Moran et al., J Clin Endocrinol Metab 2002; 87:4817-4820

Salt recommendations

What we’re up against

The contiguous United States, visualized by distance to the nearest McDonald’s

Dietary Fruit and Vegetables Daily intake in children Intervention Effect Size Estimates of Behavioral Interventions on Systolic Blood Pressure

• BMI reduction of 10%: 5‐15 mmHg• Exercise intervention: 1‐5 mmHg• Salt restriction: 3‐5 mmHg short termSalt restriction: 3 5 mmHg short term• DASH type diet unknown but positive effect likely



8

Indications for Antihypertensive Drug Therapy in Children

• Symptomatic hypertension

• Secondary hypertension

• Hypertensive target organ damage• Hypertensive target‐organ damage

• Diabetes (types 1 and 2)

• Persistent hypertension despite nonpharmacologic measures

Antihypertensive medications

Evidence based dosing and FDA approval for pediatric use is available in ALL these categories

– ACE‐I :after age 2 preferred– ARB: age 6 and older– Diuretics– Calcium Channel Blocker– Beta Blockers– Centrally acting alpha agonists– direct renin inhibitor, aldosterone antagonist not yet approved for

children:

Antihypertensive medications

ACE‐Inhibitors block angiotensin II productionEx. benzapril , enalapril, fosinopril, lisinopril

ACE Inhibitor:

• Avoid if suspecting renal artery stenosis

• Minimal rise in K, cough SE • Discontinue ACE if markedly sco t ue C a ed y

elevated hepatic serum enzymes develop or pregnant

Angiotensin Receptor Blockers

ARBs block Angiotensin II actionex. irbesartan, losartan – age 6 and ldolder

ARB

Angiotensin Receptor Blockerinterferes with the binding of angiotensin II to angiotensin I receptors

‐do not use in pregnancy or marked liver elevation



9

RAAS targets

Angiotensin Receptor Blocker

Aldosterone antagonist

Direct renin inhibitor

ACE Inhibitor

Diuretics

http://sprojects.mmi.mcgill.ca/nephrology/presentation/images/86no2.gif

Calcium channel blockers

Block the entry of calcium into the cells which decreases vascular peripheral resistanceperipheral resistanceEx: amlodipine‐ long half life

Other agents

–Beta Blockers: propranolol – avoid in DM, asthma, athletes

–Centrally acting alpha agonists: clonidine

– Not yet approved for children: direct renin inhibitor, aldosterone antagonist

Step‐wise Approach to Therapy

1. Start with a small dose of an ACE, ARB or CCB anti‐hypertensive drug with once daily monotherapy preferred

2. Increase initial anti‐hypertensive drug until BP <95%: expect 5 10 mm HG change forBP <95%: expect 5‐10 mm HG change for each dosage increase

3. Add a small dose of a second drug (often diuretic) once monotherapy at maximal dose

4. Increase dose of second anti‐hypertensive medication until BP <95%*

Target‐Organ Abnormalities in Children with Hypertension

• Target‐organ abnormalities are detectable in hypertensive children and adolescents.

• LVH is the most prominent evidence of target‐organ damage and can be evaluated with echocardiographyechocardiography

• The presence of LVH is an indication to initiate or intensify antihypertensive therapy



10

Important Adult BP Trials with Pediatric Implications

• ALLHAT– All drug classes equally effective in BP treatment and CVD mortality reduction

– 64% of adults required 2 drugs for BP control– Some classes had better outcomes in secondary analyses (diuretics, ACE inhibiters usually)

• Trophy– Treating pre‐hypertension (ARB) prevents the onset of future hypertension

ABCD2,3 (132 mm Hg)

AASK1 (134 mm Hg)

High‐Risk Hypertensive Patients Require Multiple Agents to Achieve Goal

ALLHAT4 (135 mm Hg)

AchievedSBP

1Wright JT, et al. JAMA. 2002;288:2421-2431. 2Bakris GL. J Clin Hypertens. 1999;1:141-147. 3Estacio RO, et al. N Engl J Med. 1998;338:645-652. 4The ALLHAT Officers and Coordinators. JAMA. 2002;288:2981-2997. 5Hansson L, et al. Lancet. 1998;351:1755-1762. 6Lewis EJ, et al. N Engl J Med. 2001;345:851-860. 7Bakris GL, et al. Arch Intern Med. 2003;163:1555-1565. 8UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.

1 2 3 4Number of BP Medications

RENAAL7 (140 mm Hg)

IDNT6 (140 mm Hg)

UKPDS2,8 (144 mm Hg)

HOT2,5 (141 mm Hg)

Sad but True

80% of Diabetic patients will either die from or have a major cardiovascular

event

One of my first patients that I treated at UTHSCSA for Type 2 Diabetes lost 140 lbs before he died of a heart attack at

age 23 at UHS

Primary Aim: Comparison of three treatment regimens on time to failure (loss of glycemic control) in children and adolescents with Type 2 Diabetes

Multiple secondary Outcomes

Included:Included:

• Cardiovascular disease risk

• Microvascular & Macrovascularcomplications

TODAY Study Group, NEJM, 2012

Major Comorbidities at Baseline and New(New = <4 years average time in study)

Met alone Met + rosi Met + lifestyle Hypertensionbaseline 12% 12% 11%new 25% 23% 19%

Dyslipidemia – LDL

baseline 4% 3% 3%

60

new 8% 7% 6%Dyslipidemia – Trig

baseline 22% 16% 16%new 9% 12% 9%

Microalbuminuria

baseline 9% 3% 6%new 11% 12% 9%

TODAY Study Group, NEJM, 2012



11

Echocardiography Measures by Treatment Group

(median and quartiles)

by h

eigh

t

2.5

2.6

2.72.8

eigh

t**2

.7

40

45

50

LA diameter indexed by height(population median 2.0 cm/m)

LV mass indexed by height2.7

(population median 30 g/m2.7)

61

LA d

iam

eter

inde

xed

b

1.8

1.9

2.0

2.1

2.2

2.3

2.4

Treatment group

M M+R M+L

LV m

ass

inde

xed

by h

e

20

25

30

35

40

Treatment group

M M+R M+L

In Summary

• Hypertension in American children is a growing epidemic

• High blood pressure is estimated to be prevalent in 4.5% of children and up to 75% of p pcases may be missed in clinical care

• Hypertensive obese children have metabolic factors increasing their risk for early cardiovascular disease which is accelerated by hyperinsulinemia and/or T2Diabetes

The way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not. Mark Twain

References

• Allen DB, Nemeth BA, Clark RR, Peterson SE, Eickhoff J, Carrel AL. Fitness is a stronger predictor of fasting insulin levels than fatness in overweight male middle‐school children. J Pediatr 2007 Apr;150(4):383‐387.

• Chae HW, Kwon YN, Rhie YJ, Kim HS, Kim YS, Paik IY, et al. Effects of a structured exercise program on insulin resistance, inflammatory markers and physical fitness in obese Korean children. J PediatrEndocrinol Metab 2010 Oct;23(10):1065‐1072.

• Orsi CM, Hale DE, Lynch JL. Pediatric obesity epidemiology. Curr Opin Endocrinol Diabetes Obes. 2011 Feb;18(1):14‐22.

• TODAY Study Group A clinical trial to maintain glycemic control in youth with type 2 diabetes N Engl J• TODAY Study Group. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med 2012. DOI: 10.1056/NEJMoa1109333.

• Childs, Dan. "Kids' High Blood Pressure Often Missed." ABC News 21 Aug. 2007. <http://www.abcnews.go.com/Health/CardiacHealth/>.

• Couch, Sarah C., Stephen Daniels. "Diet and Blood Pressure in Children." Current Opinion in Pediatrics Oct. 2005: 648‐652.

• Croix, Beth, and Daniel I. Feig. "Childhood Hypertension is Not a Silent Disease." Pediatric Nephrology 21 (2006): 527‐532. Medline. University of Kentucky. 2 Oct. 2007.

• Din‐Dzietham, Rebecca, Yong Liu, Marie‐Vero Bielo, and Falah Shamsa. "High Blood Pressure Trends in Children and Adolescents in National Surveys, 1963‐2002." Circulation Journal of the American Heart Association (2007): 1392‐1400. PubMed. University of Kentucky. 12 Sept. 2007.

References

Hanevoid, Coral, Jennifer Waller, Stephen Daniels, Ronald Portman, and Jonathan Sorof. "The Effects of Obesity, Gender, and Ethnic Group on Left Ventricular Hypertrophy and Geometry in Hypertensive Children: a Collaborative Study of the International Pediatric Hypertension Association." Pediatrics 113 (2004): 328‐333. University of Kentucky. 2 Oct. 2007.

Hansen, Matthew L., Paul W. Gunn, and David C. Kaelber. "Underdiagnosis of Hypertension in Children and Adolescents." JAMA 298.8 (2007): 874‐879. University of Kentucky. 28 Oct. 2007.

Kavey, Rae‐Ellen W., Daniel A. Kveselis, Nader Atallah, and Frank C. Smith. "White Coat Hypertension in Childhood: Evidence for End‐Organ Effect." The Journal of Pediatrics 150.5 (2007): 491‐497. Science Direct. University of Kentucky. 2 Oct. 2007.

Belfort, Mandy. Size at Birth, Infant Growth, and Blood Pressure at 3 years of Age. Pediatrics. 2007; 151: 670‐674

Dasgupta, Kaberi. Emergence of Sex Differences in Prevalence of High Systolic Blood Pressure. Circulation. 2006; 114:2663‐2670

Falkner, Bonita, et al. The Relationship of Body Mass Index and Blood Pressure in Primary Care Pediatric Patients. Pediatrics. 2006; 148: 195‐200

Sorof JM, et al. Overweight, Ethnicity, and the Prevalence of Hypertension in School aged Children. Pediatrics. 2004; 113:475‐482

Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986‐1998. JAMA. 2001; 286:2845‐2848

U.S. Census Bureau: http://factfinder.census.gov/



12

Computation of Blood Pressure Percentiles for Arbitrary Sex, Age, and Height

Refer to the most recent CDC growth charts, which are available online, and convert the height of h inches to a height Z‐score relative to boys of the same age; this is denoted by Zht.

2. Compute the expected SBP (μ) for boys of age y years and height h inches given by μ = α + Σβj (y‐10)j+ Σγ k (Zht)kwhere α, β1…, β4 and γ1…, γ4 are given in the 3rd column of appendix table B–1.

3. Then convert the boy’s observed SBP to a Z‐score (Zbp) given by Zbp = (x – μ)/σwhere σ is given in the 3rd column of appendix table B–1.

4. To convert the bp Z‐score to a percentile (P), compute P = Φ (Zbp) x 100% where Φ (Z) = area under a standard normal distribution to the left of Z. Thus, if Zbp = 1.28, then Φ (Zbp) = .90 and the bp percentile = .90 x 100% = 90%.

5. To compute percentiles for SBP for girls, diastolic blood pressure (DBP) (K5) for boys, and DBP (K5) for girls, use the regression coefficients from the 4th, 5th, and 6th columns of appendix table B–1.

For example, a 12‐year‐old boy, with height at the 90th percentile for his age‐sex group, has a height Z‐score = 1.28, and his expected SBP (μ) is μ = 102.19768 + 1.82416 (2) + 0.12776 (22) + 0.00249 (23) –0.00135 (24) + 2.73157(1.28) –0.19618 (1.28)2 –0.04659 (1.28)3 + 0.00947 (1.28)4 = 109.46 mmHg.

Suppose his actual SBP is 120 mmHg (x); his SBP Z‐score is then: SBP Z‐score = (x – μ)/σ = (120–109.46)/10.7128 = 0.984The corresponding SBP percentile = Φ (0.984) x 100% = 83.7th percentile.

ACE inhibitors• Renal side effects: Patients with renal artery stenosis should not receive

ACE inhibitors because they maintain glomerular filtration by efferent arteriolar vasoconstriction, which is blocked by ACE.

• Metabolic side effects: moderate, often clinically insignificant rise in potassium due to a mild reduction in serum aldosterone concentrations and beneficial effect on plasma insulin levels

• Hepatic side effects: a rare syndrome that begins with cholestatic jaundice and progresses to fulminant hepatic necrosis and (sometimes) death. DiscontineACE if markedly elevated hepatic serum enzymes develop

• Racial Differences: African American children do not respond to ACE inhibitor therapy as well as children of other races

• Pregnancy: major congenital malformations after first‐trimester exposure to ACE inhibitors. It is not known whether this may apply to all other classes of drugs that block the renin–angiotensin system*

BP tables for Infants

*Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987.Pediatrics.1987;79:1–25(PR)

Measure BP and Height and Calculate BMIDetermine BP category for sex, age, and height

Educate on Heart Healthy

LifestyleFor the family

Prehypertensive

90–<95% <90%

>95%

Normotensive

TherapeuticLifestyleChanges

Stage 2 Hypertension Stage 1 Hypertension

Repeat BPOver 3 visits

90–<95% or 120/80 mmHg

or 120/80 mmHg

Management Algorithm

Rx Specificfor Cause

Drug Rx‡ MonitorQ 6 Mo

>95%

Diagnostic Workup IncludesEvaluation for Target-Organ Damage

SecondaryHypertension

OverweightNormal BMI Overweight

Repeat BPIn 6 months

Consider Diagnostic Workup and Evaluation for Target-Organ Damage

If overweight or comorbidity exists

Weight Reduction

PrimaryHypertension

Normal BMI

Consider ReferralTo provider with expertisein pediatric hypertension

Drug Rx Weight Reductionand Drug Rx

Overweight

Weight Reduction

Still >95%

90–<95% or 120/80 mmHg

Normal BMI

Diagnostic Workup IncludesEvaluation for Target-Organ Damage

Therapeutic LifestyleChanges

SecondaryHypertension

or PrimaryHypertension

Documents

in the well rounded Disclosures child - UT Health Science ... · PDF file• SAP is a 12 yo female in the 50th percentile of height ... – dyyp ,slipidemia, HTN, DM, obesity, sedentary