#36: Off the Cuff – Managing Pediatric Hypertension in Your Primary Care Clinic

October 13, 2021 | By Sam Masur

Summary

This episode on Pediatric Hypertension features a heart racing conversation with our guest, Dr. Carissa Baker Smith – a preventive and transplant pediatric cardiologist who serves as the director of the Nemours Preventive Cardiology Program. She also serves as the chair of the Atherosclerosis Hypertension and Obesity of the Young Subcommittee of the American Heart Association Cardiovascular Disease. You’ll want to take off your white coat and sit with your feet firmly planted for this conversation about pediatric hypertension. We will review screening guidelines for blood pressure, initial work up and eventual treatment of hypertension in kids.

Credits

• Producer and Writer: Christle Nwora MD 
• Executive Producer: Max Cruz MD 
• Infographic: Christle Nwora MD 
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD ; Chris Chiu MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Carissa Baker – Smith MD

Pediatric Hypertension Pearls

1. An appropriate cuff size is a cuff with an inflatable bladder width that is at least 40 percent of the arm circumference and a bladder length that covers 80–100 percent of the circumference of the arms.
2. Younger children with elevated blood pressure should raise concern for primary causes of hypertension.
3. Lifestyle modification works best when it fits the context of the child.

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Pediatric Hypertension Notes 

Pitfalls in Measuring Children’s Blood Pressure 

Make sure your data is accurate. Proper blood pressure reading should be done with a child sitting with their back supported and their feet planted. Their hands should be relaxed and their right arm should be at the level of their heart. To estimate the correct size cuff, make sure that the width of the bladder (the inflatable portion) should be 40% of the arm circumference and the length of the bladder should be 80 – 100% the circumference. When in doubt, Dr. Carissa Baker Smith recommends sizing up. 

Defining Pediatric Hypertension 

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents has a table for pediatric values. Children under the age 13 are classified via percentile. 

• under 90% = Normal 
• 90-95% or >120/80 (even if this is lower than 90-95%)) = Elevated
• >95% = Hypertension

Children over the age of 13 are classified using adult guidelines. 

Elevated blood pressure has some vascular changes and hypertension correlates with target organ damage and long term consequences. 

Measuring Blood Pressures 

Blood pressure should be measured at every well child visit starting at age 3. If a child has risk factors (Ex: kidney disease, coarctation of the aorta, etc.), check blood pressures at every visit. 

In office blood pressure monitoring is often done via oscillometric devices that calculate the mean arterial pressure and then estimate systolic and diastolic pressure. Manual blood pressure measurements should be used to confirm if abnormal. Ambulatory devices are oscillometric devices that are sent home with children that are worn for 24 hours on the non-dominant arm. Ambulatory monitoring can distinguish elevated blood pressure from “White Coat Hypertension”. 

Primary vs Secondary Hypertension 

Primary hypertension means there is a predisposition to salt and water retention, increased vascular tone, or genetic reasons. Dr. Carissa Baker-Smith includes obesity-related reasons into primary hypertension as well. 

Secondary hypertension means that there is an independent reason for a child to have hypertension. The most common reason is kidney disease, but children may also have other etiologies like endocrine tumors, hyperthyroidism, aortic disease or medication-induced hypertension. Treatment is addressing the underlying condition. 

A majority of cases (particularly in older children) are related to primary hypertension. 

Workup for Hypertension 

Dr. Carissa Baker-Smith encourages a workup tailored to the child. Some simple screens or even physical examination maneuvers (like making sure pulses are equal) can point towards secondary causes. In Dr. Carissa Baker-Smith’s outpatient clinic at Kashlack, children age 6 (especially premature children) and below are first evaluated by nephrology to undergo a renal vascular workup. Possible workup includes renal ultrasound, urinalysis, basic metabolic panel, and thyroid studies. 

Physical exam is also key:

• Check all of the pulses, assess and compare their quality. 
• Pulsus Tardus = Weak and delayed arterial pulse (suggestive of Aortic Stenosis)
• Assess for Cushingoid Appearance (suggestive of adrenal etiology or steroid use)

Additional Cardiac Workup: 

EKGs have a high false positivity rate for left ventricular hypertrophy in children, so they are not routinely obtained. Imaging can assess for secondary causes (i.e. transthoracic echo to evaluate for coarctation of the aorta) and organ damage (i.e. echo for LVH). 

Treatment 

Lifestyle modification counseling needs to fit the context of the patient. Dr. Carissa Baker-Smith works with what her patients have access to and uses that to motivate an active lifestyle. For example, encouraging movement and dances to the newest TikTok trends or music videos. Diet counseling also must be conscious of cultural differences in food. Encourage family meals or that the entire household makes healthier choices. It is also important to celebrate all the wonderful things a child may already do and use this to continue to motivate a family. 

When starting medication(s), explain to families the purpose of treating hypertension. Dr. Carissa Baker-Smith will order an echo prior to starting medication. Dr. Baker-Smith recommends starting with daily low-dose medications such as ace inhibitors or calcium channel blockers. For “resistant” hypertension, Dr. Carissa Baker-Smith has used multiple medications tailored to the patient. 

Reminder to make sure you treat the underlying causes of secondary hypertension!

Racial Disparities 

Race is a social construct. Racism and bias (even if unintentional) drives differences in access to healthy foods, safe environments, access to care and ultimately differences in outcomes. There are racial disparities in the impacts of hypertension (Viriani 2021). Maternal factors like pre-eclampsia can also have an impact on a child’s vasculature and influence vascular tone (Falkner 2020).  

Dr. Carissa Baker-Smith advocates removing race from the one-liner in presentations and addressing your personal biases. Physicians can be key in educating communities so that patients know that hypertension can happen in the pediatric population!

Goal

Listeners will explain the screening, diagnosis, and management of pediatric hypertension in the outpatient setting. 

Learning objectives 

After listening to this episode listeners will be able to…  

1. Describe how to take an accurate blood pressure in children. 
2. Define pediatric hypertension for children under and over the age 13.
3. Explain why the use of race in the one-liner is problematic.

Disclosures

Dr Baker-Smith reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Nwora C, Baker-Smith C, Cruz M, Masur S, Chiu C, Berk J. “#36: Off the Cuff – Managing Pediatric Hypertension in Your Primary Care Clinic”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ October 13, 2021.