[04.13] PED - Pediatric Hypertension V2.1.pdf

Rare nature of pediatric hypertension

Why is the fact that children can develop hypertension often unrecognized in clinical practice?

Future hypertension and metabolic syndrome

What future metabolic and cardiovascular risks are increased in children with elevated blood pressure?

BP surveillance during well-child visits

What clinical practice enables early detection of elevated blood pressure to reduce pediatric morbidities?

Degree of BP elevation associated with risk of cardiovascular outcomes

On what basis is the adult definition of hypertension established?

Normative distribution of blood pressure among healthy children

On what basis is the definition of pediatric hypertension established?

Age, sex, and height

What three normative parameters determine the definition of blood pressure percentiles in children?

Height

What is highlighted as the single major physical determinant of blood pressure in growing children?

Less than the 90th percentile for age, sex, and height

What blood pressure range defines normal BP in children aged 1 to 13 years?

90th percentile to <95th percentile, or 120/80 mmHg to <95th percentile (whichever is lower)

What blood pressure criteria define elevated BP in children aged 1 to 13 years?

95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower)

What blood pressure criteria define Stage 1 hypertension in children aged 1 to 13 years?

95th percentile + 12 mmHg, or ≥140/90 mmHg (whichever is lower)

What blood pressure criteria define Stage 2 hypertension in children aged 1 to 13 years?

Less than 120/80 mmHg

What blood pressure cutoff defines normal BP in adolescents aged 13 years and older?

120/<80 mmHg to 129/<80 mmHg

What blood pressure range defines elevated BP in adolescents aged 13 years and older?

130/80 mmHg to 139/89 mmHg

What blood pressure range defines Stage 1 hypertension in adolescents aged 13 years and older?

140/90 mmHg or higher

≥140/90 mmHg

What blood pressure cutoff defines Stage 2 hypertension in adolescents aged 13 years and older?

Blood pressure above the 95th percentile on 3 different visits

What clinical criterion is required to formally diagnose hypertension in a child or adolescent?

For easier clinical application

Why are blood pressure definitions for adolescents aged 13 and above aligned with adult cutoffs?

Seated quietly for 3 to 5 minutes with back supported, feet flat on the floor, and no talking

What patient preparation is required before measuring pediatric blood pressure?

40% of the arm circumference

What percentage of the mid-upper arm circumference should the BP cuff bladder width cover?

80% to 100% of the arm circumference

What percentage of the mid-upper arm circumference should the BP cuff bladder length cover?

Falsely elevated blood pressure

What artifactual error occurs when a blood pressure cuff that is too small is used?

Falsely low blood pressure

What artifactual error occurs when a blood pressure cuff that is too large is used?

Right arm

Which arm is explicitly preferred for measuring blood pressure in children?

At heart level, supported, and with the cuff uncovered

How should the patient's arm be positioned during blood pressure measurement?

Screening for coarctation of the aorta

Why is using the right arm specifically important when measuring pediatric blood pressure?

Auscultatory method using a sphygmomanometer

What is the preferred clinical method for measuring blood pressure in children?

Must be confirmed by auscultation

What action must be taken if an oscillometric device is used to measure blood pressure in a child?

Average of 3 blood pressure measurements taken in the same clinic visit

How is the official office blood pressure categorized during a pediatric evaluation?

2017 American Academy of Pediatrics (AAP) clinical practice guideline

In which clinical practice guideline can the full expanded pediatric blood pressure tables be accessed?

Device that records blood pressure every 15 to 30 minutes over 24 hours during daily activities and sleep

What is Ambulatory Blood Pressure Monitoring (ABPM)?

Every 15 to 30 minutes

How frequently does ABPM record blood pressure during waking hours?

Every 30 to 60 minutes

How frequently does ABPM record blood pressure overnight during sleep?

Left ventricular hypertrophy (LVH)

Which cardiac end-organ lesion correlates particularly well with ABPM parameters in children?

Office BP in the elevated category for 1 year, or Stage 1 HTN for more than 3 visits

When is ABPM indicated to confirm hypertension based on office measurements?

White coat hypertension and masked hypertension

Which two blood pressure phenomena can be diagnosed using ABPM?

Evaluating the effectiveness of antihypertensive drug therapy

What therapeutic monitoring role does ABPM serve in hypertensive pediatric patients?

Chronic kidney disease (CKD), diabetes, and severe obesity

Which three high-risk pediatric populations warrant ABPM to evaluate blood pressure patterns?

Annually

How frequently should healthy children aged 3 years and older undergo blood pressure screening?

Obesity, chronic kidney disease, diabetes, taking BP-elevating medications, or history of aortic arch obstruction / coarctation

In children aged 3 years and older, what five clinical conditions mandate BP measurement at EVERY healthcare visit?

History of prematurity (<32 weeks AOG, VLBW, UAC)

What perinatal history dictates measuring BP at every visit in children under 3 years?

Congenital heart disease

What cardiac history dictates measuring BP at every visit in children under 3 years?

Recurrent UTI, hematuria, or proteinuria

What urinary symptoms dictate measuring BP at every visit in children under 3 years?

Known kidney or urologic disease

What renal history dictates measuring BP at every visit in children under 3 years?

Family history of kidney disease

What genetic risk dictates measuring BP at every visit in children under 3 years?

Solid-organ transplant or bone-marrow transplant

What transplant history dictates measuring BP at every visit in children under 3 years?

Malignancy

What oncologic condition dictates measuring BP at every visit in children under 3 years?

Medications known to increase blood pressure

What pharmacologic risk factor dictates measuring BP at every visit in children under 3 years?

Neurofibromatosis, tuberous sclerosis, or sickle cell disease

Which three systemic illnesses dictate measuring BP at every visit in children under 3 years?

Evidence of increased intracranial pressure

What neurological sign dictates measuring BP at every visit in children under 3 years?

Essential hypertension

What is the alternative medical term for primary hypertension?

Usually asymptomatic

Is primary pediatric hypertension typically symptomatic or asymptomatic?

Older children and adolescents

In which pediatric age group is primary hypertension more commonly encountered?

Obesity, family history of hypertension, and metabolic syndrome

What three clinical features are strongly associated with primary hypertension in older children?

Younger children

In which pediatric age group is secondary hypertension more commonly encountered?

Usually symptomatic

Is secondary pediatric hypertension typically symptomatic or asymptomatic?

Renal and renovascular disease

What is the single most common cause of secondary hypertension in children?

Coarctation of the aorta

Which cardiac structural lesion is a primary cause of secondary hypertension in children?

Hyperthyroidism, Cushing's syndrome, pheochromocytoma, and hyperaldosteronism

Which four endocrine conditions cause secondary hypertension in children?

Corticosteroids, cyclosporine, and tacrolimus

Which three drug classes cause secondary hypertension in children?

Child's age

What patient demographic factor serves as a major clinical clue for formulating a differential diagnosis of hypertension?

Prematurity, low birth weight, maternal pregnancy complications (maternal HTN), stormy ICU stay, and umbilical artery catheterization

What five perinatal factors should be elicited in the medical history of a hypertensive child?

High sodium intake, saturated fat intake, sugary drinks, and sedentary lifestyle

What four nutritional and lifestyle factors should be reviewed in a child with high BP?

Depression, anxiety, bullying, body perception issues, and vices (smoking, alcohol, drug use)

What psychosocial factors and vices should be evaluated in adolescent hypertension?

Hypertension, metabolic disease, kidney disease, and early cardiovascular events

What four family history elements should be screened in a child with hypertension?

Steroids, oral contraceptive pills (OCPs), illicit drugs, and BP-elevating medications

Which four medication categories should be reviewed during history taking?

Growth retardation

What anthropometric finding during physical examination suggests an underlying chronic illness?

Leg BP is normally higher than arm BP

How does normal lower extremity blood pressure compare to upper extremity blood pressure in children?

Coarctation of the aorta

What structural vascular diagnosis is suggested when leg BP is lower than arm BP with delayed or absent femoral pulses?

Thyroid mass or syndromic facies

What head and neck physical exam findings point toward an etiology for pediatric hypertension?

Palpitations and cardiac murmurs

What cardiac signs on physical exam point to a secondary cause of hypertension?

Palpable abdominal masses or audible bruits

What abdominal physical examination findings indicate a secondary etiology for hypertension?

Hypertensive retinopathy

What vascular pathology is assessed during a fundoscopic examination in a hypertensive child?

Hematuria, edema, or ambiguous genitalia

What three genitourinary physical exam findings suggest a cause for hypertension?

Café au lait spots, neurofibromas, malar rash, hirsutism, and striae

What five dermatologic signs provide diagnostic clues for secondary or syndromic hypertension?

Neck or abdominal mass, genitourinary abnormalities, significantly higher upper extremity BP vs lower extremity BP, and delayed femoral pulse

What four physical exam findings strongly indicate secondary hypertension?

Café au lait spots and neurofibromas

Which two dermatologic signs point specifically to neurofibromatosis associated with hypertension?

Urinalysis, chemistry panel (electrolytes, BUN, creatinine), and lipid profile

What three basic laboratory tests are recommended for all children with hypertension?

Complete blood count (CBC)

What laboratory test is added to the basic panel if chronic kidney disease (CKD) is suspected?

Renal ultrasound

What imaging study is indicated if secondary HTN is suspected or if urinalysis/renal function tests are abnormal?

Doppler ultrasonography

What specialized imaging modality is indicated if renovascular hypertension is suspected?

HbA1c and liver function tests

What two additional laboratory tests are ordered if the hypertensive child is obese (BMI >95th percentile)?

2D Echocardiography

What diagnostic test is used to evaluate cardiac target organ damage such as left ventricular mass, geometry, and function?

Thyroid hormones, plasma renin, aldosterone, catecholamines, cortisol, and drug screen

What targeted laboratory studies may be ordered based on history and physical exam findings?

Reducing the risk of target organ damage and risk of hypertension and cardiovascular disease in adulthood

What is the overall primary goal of treating hypertension in children?

Lifestyle modification and pharmacologic therapy

What are the two primary management pillars for pediatric hypertension?

SBP and DBP <90th percentile (and <130/80 mmHg for adolescents ≥13 years old)

What is the target blood pressure reduction goal for pediatric hypertension treatment?

Lifestyle modification

What is the mainstay of therapy for asymptomatic pediatric hypertension without target organ damage?

Dietary modifications (DASH diet) and physical activity (moderate-to-vigorous)

What two non-pharmacologic interventions comprise lifestyle modification?

Dietary Approaches to Stop Hypertension (DASH) diet

Which specific dietary model is recommended by the AAP for children with hypertension?

Fruits and vegetables

How many servings of fruits and vegetables per day are recommended in the DASH diet? (4-5 servings/day)

Low-fat milk products

How many servings of low-fat milk products per day are recommended in the DASH diet? (≥2 servings/day)

Whole grains

How many servings of whole grains per day are recommended in the DASH diet? (6 servings/day)

Fish, poultry, and lean red meats

How many servings of fish, poultry, and lean red meat per day are recommended in the DASH diet? (≤2 servings/day)

Legumes and nuts

How many servings of legumes and nuts per day are recommended in the DASH diet? (1 serving/day)

Oils and fats

How many servings of oils and fats per day are recommended in the DASH diet? (2-3 servings/day)

Added sugar and sweets / sweetened beverages

How many servings of added sugar and sweetened beverages per day are allowed in the DASH diet? (≤1 serving/day)

Less than 2300 mg per day (with 1500 mg/day low-sodium target)

What is the daily sodium restriction limit recommended under the DASH diet?