Pediatric hypertension

Hypertension in children is not just a specialty problem. It's much more common in general pediatrics than community pediatricians might realize, said Joseph T Flynn, MD, MS, FAAP.

In his talk "Pediatric hypertension: A rising problem. The role of ambulatory BP monitoring and medication management" given at the American Academy of Pediatrics 2016 National Conference, Flynn pointed out that in a typical general pediatrics practice, around 3% to 4% of patients are hypertensive, but more than 10% of children will have an elevated blood pressure (BP) reading at some point.

Many community pediatricians do not know what to do with a BP measurement. It is well-documented: Misdiagnoses occur frequently because clinicians are not recognizing when children have high BP in the first place.¹ Various authors have speculated that perhaps some clinicians don't understand the complex criteria for hypertension, or they lack the time to apply them properly.

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The fact that most CME lectures regarding pediatric hypertension all but ignore management, focusing almost exclusively on evaluation, has not helped matters. Community pediatricians are seeking this information, as evidenced by the number and specificity of management-related questions they typically ask after these lectures.

When a child in the office has hypertension, deciding whether to use medication management or lifestyle change depends on the individual clinical situation. For a child with obesity and hypertension-a common clinical scenario-lifestyle change might not be enough. Diet and exercise alone may not bring some children's BP into the desired range. A child with secondary hypertension might require frequent changes in management after treatment has been initiated if, say, the initial dose or medication fails to control the hypertension.

In such clinical scenarios, ambulatory blood pressure monitoring (ABPM) can help not only with diagnosis, but also with management, as it provides an objective assessment of BP for tracking response to antihypertensive medications and/or lifestyle changes. Additional conditions in which ABPM can prove particularly helpful include chronic kidney disease, diabetes, sleep apnea, and genetic syndromes. The American Heart Association recently updated its guidelines for using and interpreting ABPM.²

REFERENCES

1. Brady TM, Solomon BS, Neu AM, Siberry GK, Parekh RS. Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics. 2010;125(6):e1286-e1293.

2. Flynn JT, Daniels SR, Hayman LL, et al; American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63(5):1116-1135.

COMMENTARY

With the relatively recent epidemic of childhood obesity comes an increase in the prevalence of children with systemic hypertension. A 2002 school-based hypertension obesity screening study showed that the prevalence of hypertension in obese children (33%) was 3 times that in nonobese adolescents.¹

Yet 20% of overweight and obese children do not undergo blood pressure (BP) screening at their routine visits.² Even when BP in children and adolescents is measured, 75% of hypertension cases and 90% of prehypertension cases go uninvestigated.³

Accurately gauging children's BP requires more than a single reading. Ambulatory blood pressure monitoring (ABPM) measures BP changes, usually over 24 hours, occurring with daily activity and environmental stimuli during sleep and wake periods. Along with helping to confirm elevated BP on initial evaluation, ABPM indeed can identify patients at risk and assess response to treatment. It is particularly useful in diagnosing "white coat" hypertension (elevated BP occurring only in the doctor's office) and its opposite, masked hypertension (normal office BP, hypertensive readings elsewhere).

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The National Heart, Lung, and Blood Institute recommends that children and adolescents with mild hypertension (and no hypertensive target-organ disease) initially try lifestyle changes including diet modification and exercise.⁴ Thirty to 60 minutes of exercise daily has been shown to reduce blood pressure, particularly in overweight children. However, those with uncontrolled stage 2 hypertension should avoid competitive and high static-resistance sports such as gymnastics, weightlifting, and wrestling.

Regarding pharmaceutical interventions, the National High Blood Pressure Education Program recommends an individualized, stepwise approach: starting with a single agent (combined with nonpharmacologic therapies) and titrating upward until reaching target BP or maximum recommended dose. If the latter fails to control BP, add a low dose of medication from a different class (assuming the child tolerates the first drug).

Most patients require continued follow-up to ensure BP control: monitor compliance (especially in adolescents) and watch for adverse effects. After a sustained period of satisfactory BP control, consider gradually reducing medications-ideally to a point where the child can discontinue drug therapy and continue nonpharmacologic treatments and BP monitoring.

-P. Syamasundar Rao, MD, FAAP, is professor of Pediatrics and of Medicine, Division of Pediatric Cardiology, and emeritus chief of Pediatric Cardiology, University of Texas McGovern Medical School at Houston, and Children's Memorial Hermann Hospital, Houston. He reports no relevant financial interests.

REFERENCES

1. Sorof JM, Poffenbarger T, Franco K, Bernard L, Portman RJ. Isolated systolic hypertension, obesity, and hyperkinetic hemodynamic states in children. J Pediatr. 2002;140(6):660-666.
2. Shapiro DJ, Hersh AL, Cabana MD, Sutherland SM, Patel AI. Hypertension screening during ambulatory pediatric visits in the United States, 2000-2009. Pediatrics. 2012;130(4):604-610.
3. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874-879.
4. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl 4th report):555-576.

Mr Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.