Clinical Case Report
Diagnosis of primary versus secondary pediatric hypertension
By Dawn Lee Garzon, PhD, CPNP, PMHS, FAANP
CL is a 5-year-old boy who presents for a sick visit. His height is at the 65th percentile, and his weight is at the 60th percentile. Family history is positive for maternal hypertension and dyslipidemia. There is no significant past medical history, and he is up-to-date on his immunizations. His mother reports a 2-day history of sore throat, fever to 102.5° F (39.2° C), headache, listlessness, and refusal to eat or drink secondary to dysphagia. Further questioning reveals he has taken in about 20 oz (591.5 mL) of fluid on the day of the visit, and he ate a bowl of ice cream and some macaroni for lunch. His temperature is 102° F (38.9° C), pulse is 102, respirations are 17, BP in the right arm is 115/75. Physical exam reveals a quiet, ill-appearing child, and flushed skin. His cardiac exam is normal, as there is no palpable hepatomegaly or splenomegaly. There are palpable anterior cervical and tonsillar lymph nodes. His throat is diffusely red, and he has 2+ exudative tonsils. CL’s BP is confirmed by repeating measurements in the left arm and right leg. A rapid strep test is positive, and urine dipstick (obtained to determine degree of dehydration) reveals a specific gravity of 1.020 and is negative for glucose, ketones, leukocyte esterase, and nitrites; but it is 1+ positive for hemolyzed blood and 2+ positive for protein. www.tnpj.com
After consultation with a nephrologist, CL was hospitalized for additional workup and BP control. His diagnosis was acute poststreptococcal glomerulonephritis, and he required inpatient care for 3 days. He was placed on a low sodium diet upon discharge and prescribed amoxicillin for his pharyngitis and the diuretic, hydrochlorothiazide for his hypertension. CL was under the care of the pediatric nephrologist for 4 months following hospital discharge, during which time he was gradually weaned from his diuretic therapy, and his hypertension resolved. He had no residual kidney dysfunction. ■ Hypertension in children and adolescents Pediatric hypertension is an emerging health problem that is closely linked to the pediatric obesity epidemic. The long-term sequelae of this condition include kidney and cardiovascular disease as well as significant morbidity and mortality when poorly managed. Unfortunately, almost half of pediatric patients with hypertension are not diagnosed in primary care.1 It is important to note that secondary causes of hypertension are significantly more common in pediatrics, especially in children who are less than 12 years of age at the time of diagnosis. National estimates conclude that as many as 14% of 12- to 18-year-old children in the United States meet criteria for either prehypertension or hypertension.2 The
national prevalence rates have increased significantly in the last few decades, with some studies indicating that hypertension may have greater health effects in individuals from non-Hispanic, Black, and Mexican heritage.3 The purpose of this clinical case report is to describe the diagnosis and evaluation of pediatric hypertension. A brief discussion about the primary care approaches to this condition is also included. Pediatric hypertension is defined as a systolic and/or diastolic BP that is greater than or equal to the 95th percentile for the child’s age, gender, and height.4 Those who have BPs greater than the 90th percentile but less than the 95th percentile can be diagnosed with high normal (or elevated) BPs, a category equivalent to the adult diagnosis of pre- or developing hypertension. In addition, the current treatment guidelines maintain that any adolescent with BPs above 120/80 regardless of the percentile is to be considered prehypertensive and at increased risk for adverse cardiovascular outcomes.4 ■ Diagnosis and evaluation BP monitoring is a routine part of the recommended episodic care for all children and adolescents older than 3 years of age to allow for the early diagnosis and intervention in children and adolescents with abnormal BPs.5 Children with specific medical conditions should have a BP assessment before age 3. These The Nurse Practitioner • February 2015 13
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Case Report include: history of prematurity, neonatal ICU treatment, or very low birthweight; congenital heart disease regardless of repair status; recurrent urinary tract infections; children with hematuria or proteinuria; congenital defects of the genitourinary tract; history of solid organ transplantation; history of a condition that is a secondary cause of hypertension; those who have undergone treatment for cancer; and children with known elevated intracranial pressure.4 Clinical practice guidelines confirm that auscultation is the preferred measurement and, therefore, diagnosis must be confirmed with a sphygmomanometer.4 Measurement accuracy is contingent on proper technique, which includes proper cuff selection, identification of the arm used, and correct placement of the stethoscope. Coarctation of the aorta may lead to false low readings in the left arm (thus, the right arm is preferred), and serial measurements should occur on the same extremity.5 Cuffs should cover no more than two-thirds the length of the arm from the axilla to the antecubital space and 80% to 100% of the arm’s circumference. Failure to select an appropriate cuff will potentially cause inaccurate results and may
lead to underdiagnosis or overevaluation. Small cuffs can cause inaccurately high readings, while large cuffs can cause inaccurately low readings. Stethoscope placement during the procedure is equally important. The stethoscope should be placed directly over the brachial pulse and below the lower edge of the cuff.1,4,6 There is some evidence that stethoscope bells are more sensitive than diaphragms for quieter Korotkoff sounds.4 Also, BP readings are most accurate when the child is quiet and has been in the seated position for at least 3 to 5 minutes. As previously defined, definitions of normal, elevated, and hypertensive BPs are made based on the gender, age, height, and weight of the child. Clinicians should keep and refer to the BP tables from the most recent National Heart, Lung, and Blood Institute guidelines due to the complexity of these calculations. These tables are available at no cost and may be downloaded from: www.nhlbi.nih. gov/guidelines/hypertension/child_ tbl.htm. Although abnormally high BP readings may be recognized in a single visit, confirmation of hypertension requires three elevated BP readings obtained on separate visits. Children and adolescents with readings above
Causes of secondary pediatric hypertension4,6-9 • Kidney disease—renovascular (10% of cases), parenchymal disease (68% of cases) • Coarctation of the aorta, Kawasaki disease, and other congenital cardiovascular abnormalities • Endocrine disorders (11% of cases)—hyperthyroidism, Cushing syndrome, systemic lupus erythematosus, adrenal hyperplasia, hyperaldosteronism, and chronic inflammation • Genetic disorders—Williams syndrome, neurofibromatosis, tuberous sclerosis, and Turner syndrome • Medications—anabolic steroids, oral contraceptives, decongestants, and stimulants including caffeine and nicotine • Central nervous system tumors—neuroblastoma and pheochromocytoma • Sleep disorders—sleep apnea • Environmental factors—secondhand smoke exposure
the 95th percentile should have their pressure measured twice during the same visit and with the average systolic and diastolic readings recorded.4 Stage I hypertension is defined as pressures between the 95th to 5 mm Hg above the 99th percentile. Stage II hypertension is defined as more than 5 mm Hg higher than the 99th percentile.4 ■ Causes of pediatric hypertension Essential (or primary) hypertension is rare in children younger than 10.6 Contributors to pediatric essential hypertension are similar to those in adults with obesity with metabolic syndrome being the largest risk factors. Of course, the obesity prevalence and relative inactivity of today’s youth are significant contributors to primary hypertension. Secondary hypertension is much more common in pediatric than adult patients and results in up to 70% to 85% of cases for children under the age of 12 years.6 It should be considered with young children, those with isolated diastolic elevation, in nonobese individuals, and those with significantly elevated BPs.4,7,8 Renal parenchymal disease is the leading cause of this condition. Disorders of the renal parenchyma that are known contributors to hypertension include acute and chronic glomerulonephritis, renal scarring from vesicoureteral reflux or pyelonephritis, polycystic kidney disease, and chronic kidney disease.9 Other common contributors to this phenomenon include cardiovascular, genetic, endocrine, and sleep disorders (see Causes of secondary pediatric hypertension).4,6-9 More than 90% of secondary hypertension cases are caused by endocrine and kidney disease; therefore, these conditions should be given the highest degree of suspicion during initial evaluation.9
14 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Clinical Case Report ■ Clinical evaluation Because of the high prevalence of secondary hypertension, all children and adolescents with Stage I or Stage II hypertension, regardless of suspected causation, require additional workup to determine the presence of precipitating causes and to identify end-organ damage. Therefore, history and physical exam should focus on the most common causes. It is important to note family history of premature cardiac disease (sibling or parent before the age of 55 in males and 65 in females), diabetes, hypertension, kidney disease, and cerebrovascular disease. Personal medical history should focus on diet (including caffeine and salt intake), exercise history, medication use, history of urinary or kidney conditions, headaches, vision changes, palpitations,
www.tnpj.com
and symptoms of obstructive sleep apnea.7,9 Physical exam should include a full cardiac evaluation, including the presence of murmurs and additional heart sounds, assessment of enlarged tonsils and thyromegaly, signs of heart failure, facial and peripheral edema, truncal obesity, fundoscopic abnormalities, and the character and equality of peripheral and femoral pulses.7,9 Diagnostic evaluation may vary depending on the findings from the history and physical exam. However, all hypertensive children and adolescents require body mass index calculation, fasting serum lipids (including triglycerides), basic metabolic panel, urinalysis, urine culture, complete blood cell count, fasting serum glucose, and thyroid function testing.4,7 Those with Stage II disease or persistent Stage
I disease should have an echocardiogram to determine the left ventricular mass, as this study is the most effective for determining cardiac target organ damage.9 Additional testing should be conducted if there are symptoms consistent with known causes of secondary pediatric hypertension. These evaluations may include a renal ultrasound if kidney function is impaired, or if urologic or kidney abnormalities are suspected, a drug screen for suspected substance use, sleep studies for suspected sleep apnea, and ambulatory BP monitoring if white coat hypertension is suspected.4,7,9 ■ Management and follow up Therapeutic lifestyle modification is the first line of treatment for children and adolescents with elevated BP and Stage I hypertension. Diet
The Nurse Practitioner • February 2015 15
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Case Report modifications include increasing the consumption of fresh fruit and vegetables, the inclusion of low fat dairy, and caffeine and sodium restriction. Research indicates that a weight loss of 10% can significantly decrease BP, so overweight and obese adolescents should begin an active weight loss program.5 The incorporation of regular physical activity and decreasing sedentary activities is equally important. It is recommended that children engage in 30 to 60 minutes of moderate physical activity on most days and screen time (TV, computer, and videogames [sedentary activities]) should be restricted to no more than 2 hours daily.5 Adolescents should be counseled to avoid nicotine, energy drinks, and alcohol. Nurse practitioners can achieve excellent patient outcomes when they are able
All pediatric patients with Stage II hypertension and those with persistent Stage I hypertension that is unresponsive to lifestyle modification should be immediately referred to a specialist with experience managing pediatric hypertension for further treatment and evaluation.5,7 Those who present with target organ damage or those with secondary hypertension should be managed by the appropriate specialist for the affected system (for example, cardiology for ventricular thickening, endocrine for thyroid disorders, and nephrology for parenchymal abnormalities). Pediatric patients who initiate lifestyle modifications should be reevaluated every 6 months to track weight and BP changes.5 Monthly follow up is required for those who have abnormal BPs but have not met
association with child, adolescent, and adult morbidity and mortality. Primary care providers have the responsibility to incorporate routine BP evaluation into the episodic care of children over the age of 3 years. Additionally, vigilance is needed to identify children and adolescents who present for acute care. Most cases of hypertension in preadolescent children are caused by kidney and endocrine disorders. Prompt evaluation and intervention are essential to rule out primary causes and to improve patient outcomes. REFERENCES 1. Bijlsma MW, Blufpand HN, Kaspers GJ, Bökenkamp A. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Pediatr. 2014;164(1):173-177.e7. 2. May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease risk factors among US adolescents, 1999-2008. Pediatrics. 2012;129(6): 1035-1041. 3. Flynn J. The changing face of pediatric hypertension in the era of the childhood obesity epidemic. Pediatr Nephrol. 2013;28(7):1059-1066.
Research indicates that a weight loss of 10% can significantly decrease BP. to foster increased motivation of affected children and their families. Health behavior change is difficult, yet it is the most effective strategy for many chronic conditions, including hypertension. Antihypertensive medications are reserved for those who fail lifestyle modification. Many primary care providers are uncomfortable prescribing antihypertensives, but when used, monotherapy is the only option for primary care management. Appropriate classes for use in children include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, beta-blockers, calcium channel blockers, and diuretics.5,7,8 Special caution should be used to avoid drugs with teratogenic effects in sexually active adolescent females (for example, ACE inhibitors).
4. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents. Bethesda, MD: National Institutes of Health.
the diagnostic requirement for abnormal readings on three separate occasions, those with evolving symptomatology, and those who require additional education and/or counseling.5 School nurses are excellent resources for regular BP monitoring. The addition of these professionals to the management team allows for the additional benefit of obtaining a professional BP measurement from a nonhealthcare environment.
5. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213-S256.
■ Improving patient outcomes Pediatric hypertension is a significant disorder with a marked increase in prevalence often attributed to the rising pediatric obesity epidemic. Identification of hypertension is an important secondary health promotion strategy because of the clear
9. Brady TM, Feld LG. Pediatric approach to hypertension. Semin Nephrol. 2009;29(4):379-388.
6. Agency for Healthcare Research and Quality. Screening for Hypertension in Children and Adolescents to Prevent Cardiovascular Disease: Systematic Review for the US Preventative Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2013. 7. Martchenke J, Blosser C. Cardiovascular disorders. In: Burns CE, Dunn AM, Brady MA, Barber Starr N, Blosser CG, eds. Pediatric Primary Care. 5th ed. Philadelphia, PA: Elsevier; 2013:669-707. 8. Lande MB, Kupferman JC. Pediatric hypertension: the year in review. Clin Pediatr. 2014;53(4): 315-319.
Dawn Lee Garzon is a Teaching Professor and PNP Emphasis Area Coordinator at University of Missouri, St. Louis, Mo. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NPR.0000459735.30769.35
16 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Diagnosis of primary versus secondary pediatric hypertension
By Dawn Lee Garzon, PhD, CPNP, PMHS, FAANP
CL is a 5-year-old boy who presents for a sick visit. His height is at the 65th percentile, and his weight is at the 60th percentile. Family history is positive for maternal hypertension and dyslipidemia. There is no significant past medical history, and he is up-to-date on his immunizations. His mother reports a 2-day history of sore throat, fever to 102.5° F (39.2° C), headache, listlessness, and refusal to eat or drink secondary to dysphagia. Further questioning reveals he has taken in about 20 oz (591.5 mL) of fluid on the day of the visit, and he ate a bowl of ice cream and some macaroni for lunch. His temperature is 102° F (38.9° C), pulse is 102, respirations are 17, BP in the right arm is 115/75. Physical exam reveals a quiet, ill-appearing child, and flushed skin. His cardiac exam is normal, as there is no palpable hepatomegaly or splenomegaly. There are palpable anterior cervical and tonsillar lymph nodes. His throat is diffusely red, and he has 2+ exudative tonsils. CL’s BP is confirmed by repeating measurements in the left arm and right leg. A rapid strep test is positive, and urine dipstick (obtained to determine degree of dehydration) reveals a specific gravity of 1.020 and is negative for glucose, ketones, leukocyte esterase, and nitrites; but it is 1+ positive for hemolyzed blood and 2+ positive for protein. www.tnpj.com
After consultation with a nephrologist, CL was hospitalized for additional workup and BP control. His diagnosis was acute poststreptococcal glomerulonephritis, and he required inpatient care for 3 days. He was placed on a low sodium diet upon discharge and prescribed amoxicillin for his pharyngitis and the diuretic, hydrochlorothiazide for his hypertension. CL was under the care of the pediatric nephrologist for 4 months following hospital discharge, during which time he was gradually weaned from his diuretic therapy, and his hypertension resolved. He had no residual kidney dysfunction. ■ Hypertension in children and adolescents Pediatric hypertension is an emerging health problem that is closely linked to the pediatric obesity epidemic. The long-term sequelae of this condition include kidney and cardiovascular disease as well as significant morbidity and mortality when poorly managed. Unfortunately, almost half of pediatric patients with hypertension are not diagnosed in primary care.1 It is important to note that secondary causes of hypertension are significantly more common in pediatrics, especially in children who are less than 12 years of age at the time of diagnosis. National estimates conclude that as many as 14% of 12- to 18-year-old children in the United States meet criteria for either prehypertension or hypertension.2 The
national prevalence rates have increased significantly in the last few decades, with some studies indicating that hypertension may have greater health effects in individuals from non-Hispanic, Black, and Mexican heritage.3 The purpose of this clinical case report is to describe the diagnosis and evaluation of pediatric hypertension. A brief discussion about the primary care approaches to this condition is also included. Pediatric hypertension is defined as a systolic and/or diastolic BP that is greater than or equal to the 95th percentile for the child’s age, gender, and height.4 Those who have BPs greater than the 90th percentile but less than the 95th percentile can be diagnosed with high normal (or elevated) BPs, a category equivalent to the adult diagnosis of pre- or developing hypertension. In addition, the current treatment guidelines maintain that any adolescent with BPs above 120/80 regardless of the percentile is to be considered prehypertensive and at increased risk for adverse cardiovascular outcomes.4 ■ Diagnosis and evaluation BP monitoring is a routine part of the recommended episodic care for all children and adolescents older than 3 years of age to allow for the early diagnosis and intervention in children and adolescents with abnormal BPs.5 Children with specific medical conditions should have a BP assessment before age 3. These The Nurse Practitioner • February 2015 13
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Case Report include: history of prematurity, neonatal ICU treatment, or very low birthweight; congenital heart disease regardless of repair status; recurrent urinary tract infections; children with hematuria or proteinuria; congenital defects of the genitourinary tract; history of solid organ transplantation; history of a condition that is a secondary cause of hypertension; those who have undergone treatment for cancer; and children with known elevated intracranial pressure.4 Clinical practice guidelines confirm that auscultation is the preferred measurement and, therefore, diagnosis must be confirmed with a sphygmomanometer.4 Measurement accuracy is contingent on proper technique, which includes proper cuff selection, identification of the arm used, and correct placement of the stethoscope. Coarctation of the aorta may lead to false low readings in the left arm (thus, the right arm is preferred), and serial measurements should occur on the same extremity.5 Cuffs should cover no more than two-thirds the length of the arm from the axilla to the antecubital space and 80% to 100% of the arm’s circumference. Failure to select an appropriate cuff will potentially cause inaccurate results and may
lead to underdiagnosis or overevaluation. Small cuffs can cause inaccurately high readings, while large cuffs can cause inaccurately low readings. Stethoscope placement during the procedure is equally important. The stethoscope should be placed directly over the brachial pulse and below the lower edge of the cuff.1,4,6 There is some evidence that stethoscope bells are more sensitive than diaphragms for quieter Korotkoff sounds.4 Also, BP readings are most accurate when the child is quiet and has been in the seated position for at least 3 to 5 minutes. As previously defined, definitions of normal, elevated, and hypertensive BPs are made based on the gender, age, height, and weight of the child. Clinicians should keep and refer to the BP tables from the most recent National Heart, Lung, and Blood Institute guidelines due to the complexity of these calculations. These tables are available at no cost and may be downloaded from: www.nhlbi.nih. gov/guidelines/hypertension/child_ tbl.htm. Although abnormally high BP readings may be recognized in a single visit, confirmation of hypertension requires three elevated BP readings obtained on separate visits. Children and adolescents with readings above
Causes of secondary pediatric hypertension4,6-9 • Kidney disease—renovascular (10% of cases), parenchymal disease (68% of cases) • Coarctation of the aorta, Kawasaki disease, and other congenital cardiovascular abnormalities • Endocrine disorders (11% of cases)—hyperthyroidism, Cushing syndrome, systemic lupus erythematosus, adrenal hyperplasia, hyperaldosteronism, and chronic inflammation • Genetic disorders—Williams syndrome, neurofibromatosis, tuberous sclerosis, and Turner syndrome • Medications—anabolic steroids, oral contraceptives, decongestants, and stimulants including caffeine and nicotine • Central nervous system tumors—neuroblastoma and pheochromocytoma • Sleep disorders—sleep apnea • Environmental factors—secondhand smoke exposure
the 95th percentile should have their pressure measured twice during the same visit and with the average systolic and diastolic readings recorded.4 Stage I hypertension is defined as pressures between the 95th to 5 mm Hg above the 99th percentile. Stage II hypertension is defined as more than 5 mm Hg higher than the 99th percentile.4 ■ Causes of pediatric hypertension Essential (or primary) hypertension is rare in children younger than 10.6 Contributors to pediatric essential hypertension are similar to those in adults with obesity with metabolic syndrome being the largest risk factors. Of course, the obesity prevalence and relative inactivity of today’s youth are significant contributors to primary hypertension. Secondary hypertension is much more common in pediatric than adult patients and results in up to 70% to 85% of cases for children under the age of 12 years.6 It should be considered with young children, those with isolated diastolic elevation, in nonobese individuals, and those with significantly elevated BPs.4,7,8 Renal parenchymal disease is the leading cause of this condition. Disorders of the renal parenchyma that are known contributors to hypertension include acute and chronic glomerulonephritis, renal scarring from vesicoureteral reflux or pyelonephritis, polycystic kidney disease, and chronic kidney disease.9 Other common contributors to this phenomenon include cardiovascular, genetic, endocrine, and sleep disorders (see Causes of secondary pediatric hypertension).4,6-9 More than 90% of secondary hypertension cases are caused by endocrine and kidney disease; therefore, these conditions should be given the highest degree of suspicion during initial evaluation.9
14 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
Clinical Case Report ■ Clinical evaluation Because of the high prevalence of secondary hypertension, all children and adolescents with Stage I or Stage II hypertension, regardless of suspected causation, require additional workup to determine the presence of precipitating causes and to identify end-organ damage. Therefore, history and physical exam should focus on the most common causes. It is important to note family history of premature cardiac disease (sibling or parent before the age of 55 in males and 65 in females), diabetes, hypertension, kidney disease, and cerebrovascular disease. Personal medical history should focus on diet (including caffeine and salt intake), exercise history, medication use, history of urinary or kidney conditions, headaches, vision changes, palpitations,
www.tnpj.com
and symptoms of obstructive sleep apnea.7,9 Physical exam should include a full cardiac evaluation, including the presence of murmurs and additional heart sounds, assessment of enlarged tonsils and thyromegaly, signs of heart failure, facial and peripheral edema, truncal obesity, fundoscopic abnormalities, and the character and equality of peripheral and femoral pulses.7,9 Diagnostic evaluation may vary depending on the findings from the history and physical exam. However, all hypertensive children and adolescents require body mass index calculation, fasting serum lipids (including triglycerides), basic metabolic panel, urinalysis, urine culture, complete blood cell count, fasting serum glucose, and thyroid function testing.4,7 Those with Stage II disease or persistent Stage
I disease should have an echocardiogram to determine the left ventricular mass, as this study is the most effective for determining cardiac target organ damage.9 Additional testing should be conducted if there are symptoms consistent with known causes of secondary pediatric hypertension. These evaluations may include a renal ultrasound if kidney function is impaired, or if urologic or kidney abnormalities are suspected, a drug screen for suspected substance use, sleep studies for suspected sleep apnea, and ambulatory BP monitoring if white coat hypertension is suspected.4,7,9 ■ Management and follow up Therapeutic lifestyle modification is the first line of treatment for children and adolescents with elevated BP and Stage I hypertension. Diet
The Nurse Practitioner • February 2015 15
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Case Report modifications include increasing the consumption of fresh fruit and vegetables, the inclusion of low fat dairy, and caffeine and sodium restriction. Research indicates that a weight loss of 10% can significantly decrease BP, so overweight and obese adolescents should begin an active weight loss program.5 The incorporation of regular physical activity and decreasing sedentary activities is equally important. It is recommended that children engage in 30 to 60 minutes of moderate physical activity on most days and screen time (TV, computer, and videogames [sedentary activities]) should be restricted to no more than 2 hours daily.5 Adolescents should be counseled to avoid nicotine, energy drinks, and alcohol. Nurse practitioners can achieve excellent patient outcomes when they are able
All pediatric patients with Stage II hypertension and those with persistent Stage I hypertension that is unresponsive to lifestyle modification should be immediately referred to a specialist with experience managing pediatric hypertension for further treatment and evaluation.5,7 Those who present with target organ damage or those with secondary hypertension should be managed by the appropriate specialist for the affected system (for example, cardiology for ventricular thickening, endocrine for thyroid disorders, and nephrology for parenchymal abnormalities). Pediatric patients who initiate lifestyle modifications should be reevaluated every 6 months to track weight and BP changes.5 Monthly follow up is required for those who have abnormal BPs but have not met
association with child, adolescent, and adult morbidity and mortality. Primary care providers have the responsibility to incorporate routine BP evaluation into the episodic care of children over the age of 3 years. Additionally, vigilance is needed to identify children and adolescents who present for acute care. Most cases of hypertension in preadolescent children are caused by kidney and endocrine disorders. Prompt evaluation and intervention are essential to rule out primary causes and to improve patient outcomes. REFERENCES 1. Bijlsma MW, Blufpand HN, Kaspers GJ, Bökenkamp A. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Pediatr. 2014;164(1):173-177.e7. 2. May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease risk factors among US adolescents, 1999-2008. Pediatrics. 2012;129(6): 1035-1041. 3. Flynn J. The changing face of pediatric hypertension in the era of the childhood obesity epidemic. Pediatr Nephrol. 2013;28(7):1059-1066.
Research indicates that a weight loss of 10% can significantly decrease BP. to foster increased motivation of affected children and their families. Health behavior change is difficult, yet it is the most effective strategy for many chronic conditions, including hypertension. Antihypertensive medications are reserved for those who fail lifestyle modification. Many primary care providers are uncomfortable prescribing antihypertensives, but when used, monotherapy is the only option for primary care management. Appropriate classes for use in children include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, beta-blockers, calcium channel blockers, and diuretics.5,7,8 Special caution should be used to avoid drugs with teratogenic effects in sexually active adolescent females (for example, ACE inhibitors).
4. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents. Bethesda, MD: National Institutes of Health.
the diagnostic requirement for abnormal readings on three separate occasions, those with evolving symptomatology, and those who require additional education and/or counseling.5 School nurses are excellent resources for regular BP monitoring. The addition of these professionals to the management team allows for the additional benefit of obtaining a professional BP measurement from a nonhealthcare environment.
5. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213-S256.
■ Improving patient outcomes Pediatric hypertension is a significant disorder with a marked increase in prevalence often attributed to the rising pediatric obesity epidemic. Identification of hypertension is an important secondary health promotion strategy because of the clear
9. Brady TM, Feld LG. Pediatric approach to hypertension. Semin Nephrol. 2009;29(4):379-388.
6. Agency for Healthcare Research and Quality. Screening for Hypertension in Children and Adolescents to Prevent Cardiovascular Disease: Systematic Review for the US Preventative Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2013. 7. Martchenke J, Blosser C. Cardiovascular disorders. In: Burns CE, Dunn AM, Brady MA, Barber Starr N, Blosser CG, eds. Pediatric Primary Care. 5th ed. Philadelphia, PA: Elsevier; 2013:669-707. 8. Lande MB, Kupferman JC. Pediatric hypertension: the year in review. Clin Pediatr. 2014;53(4): 315-319.
Dawn Lee Garzon is a Teaching Professor and PNP Emphasis Area Coordinator at University of Missouri, St. Louis, Mo. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NPR.0000459735.30769.35
16 The Nurse Practitioner • Vol. 40, No. 2
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.tnpj.com
