The Child With Hypertension: Diagnosis and Management

This transcript has been edited for clarity.

Justin L. Berk, MD, MPH, MBA: Welcome back to The Cribsiders, our Medscape video recap of our pediatric medicine podcast. We interview leading experts in the field to bring clinical pearls and practice-changing knowledge, and answer lingering questions about core topics in pediatric medicine. Chris, what is our topic today?

Christopher J. Chiu, MD: I was really happy to be able to talk about our recent episode with Dr Carissa Baker-Smith, a pediatric cardiologist and director of the Nemours Preventive Cardiology Program. She helped us review the pediatric screening guidelines for blood pressure, including initial workup and treatment.

Berk: This was a really great episode that a lot of people found really helpful. What were some of the key takeaway pearls that you think listeners would be interested in?

Chiu: We talked about when and how we should be checking blood pressures in children. Blood pressure should be checked at every well-child visit starting at age 3. But if they have other risk factors like kidney disease or a condition such as coarctation of the aorta, then blood pressure should be checked at every visit.

Berk: One thing she spoke about was how blood pressures should be measured. How should we be checking blood pressures in the clinic?

Chiu: Clinic blood pressures are usually checked with oscillometric devices. They can differ by manufacturer, but basically they find a mean arterial pressure and then each device has a method of calculating systolic and diastolic pressures. Now after that, if the child's blood pressure is maybe abnormal, you want to double-check a manual blood pressure using Korotkoff sounds to confirm the blood pressure.

She reminded us that blood pressure should be measured with the child sitting with their back supported, feet flat on the floor, and arm at the level of the heart. Make sure you use the right size cuff. The bladder of the cuff should be 40% of the width of the arm, and about 80%-100% of the arm circumference. She recommends sizing up if you have to.

Berk: Accuracy of blood pressure management was a really important point, especially for diagnosis at this stage. Can you walk us through what we learned about diagnosis of hypertension?

Chiu: The definitions of hypertension come from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Up until the age of 13, they define prehypertension as systolic and diastolic blood pressures between the 90th and 95th percentile, or if the blood pressure exceeds 120/80 mmHg. Hypertension is defined when blood pressure reaches the 95th percentile. Now age 13 is when it gets a little hazy. Many changes in the guidelines happen at age 13, when hypertension starts being defined by adult guidelines. The 2017 adult hypertension guidelines define stage 1 hypertension as 130/89 to 139/89, and stage two hypertension as > 140/90.

Berk: How about workup of hypertension? The work of pediatric hypertension is always a little bit complex. What are some of the pearls you took away?

Chui: She talked about tailoring the workup to the child. So when we're doing our workup, obviously physical exam should be the first thing we do. You have to assess and compare pulses, which is one of the most important parts of the initial evaluation. Obviously, looking at coarctation of the aorta, but also looking for things like a cushingoid appearance. If the child is less than 6 years of age, she recommends a referral to nephrology for more comprehensive renovascular workup, which probably will include renal ultrasound, urinalysis, metabolic panel, and thyroid studies.

We have to be cognizant of secondary causes of hypertension, such as endocrine tumors, hyperthyroidism, aortic disease, or even medication-induced hypertension. She told us that in the majority of these cases, especially with our obese older children, primary hypertension or essential hypertension is the most likely cause.

Berk: That was my big takeaway. If they're really young, they need a big workup, but otherwise it is likely primary hypertension. What did we learn about treatment?

Chui: Just as we tailor our assessment to the child, we also have to tailor treatment. We know that lifestyle modification is usually the first line of treatment, especially for primary hypertension, and Dr Baker-Smith tells us that we really need to perform counseling that meets the patient where they are. So if they like dancing to the newest TikTok trends or music videos, maybe we can encourage them to move more that way. Using our motivational interviewing skills is really key here.

If you want to start medication, Dr Baker-Smith uses things like low-dose ACE inhibitors or calcium channel blockers, but obviously it'll be tailored to the patient and any underlying conditions.

Berk: That's great — a lot of wonderful pearls on the diagnosis and management of pediatric hypertension. Thank you for joining us for another Medscape video recap of The Cribsiders pediatric podcast. You can download the full podcast, Off the Cuff: Managing Pediatric Hypertension in Your Primary Care Clinic, on any podcast player, or check out our website at www.theCribsiders.com.

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