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Melanie Cole (Host): Welcome to the show. Our topic today is blood pressure management in children, and my guest is Dr. David Chan. He's the Medical Director of Pediatrics at The Carle Foundation Hospital. Welcome to the show, Dr. Chan. Explain a little bit about hypertension in children. People don’t think of children as coming up with high blood pressure. Did you ever used to see this, and what’s different now?

Dr. David Chan (Guest): I think that’s a great question. I think in the past, something like this is that diagnosis of elevated blood pressure or hypertension was always thought to be an adult-type disease. The major thing that we have noticed and have recognized over the last decade or so, is that we do see this problem as a medical issue even in our youth – and I can explain a little bit more as we go ahead why that is the case today and not perhaps 30 years ago when we rarely ever saw this as a problem.

The major emphasis that I want to talk about is the importance of recognizing hypertension in the youth is because there is some information out there as far as data that suggest that elevated blood pressure in childhood could truly lead to significant health issues in the adults, and we all know that preventative care is far better than trying to treat the problem after it’s already occurred. That’s why we have taken an interest in managing high blood pressure in our young people as a very important project at Carle Foundation Hospital.

Melanie: Speak a little bit about the etiology. Do we know what some common conditions and factors that could lead to hypertension in children? We obviously see an obesity epidemic and diabetes on the rise in kids. Are all of these comorbidities combined? Are they all sort of a collective of what you see now, as a pediatrician?


Dr. Chan: Yes, Melanie, I think you really pointed out some of the things that are making this diagnosis a much more common problem in the youth. In the past, when I started doing this back in the early 1990s, when we see a child with high blood pressure, usually they have other reasons for it like there is truly a family reason to do that – to have a genetic predisposition – or the child actually has kidney disease that is chronic in origin as leading to high blood pressure. The most common – not the most common, but another common reason is that they are born with some sort of congenital heart defect that leads to them having increased blood pressure.

Nowadays, what we’re seeing is quite a few of these kids with what we call pre-hypertension or actual primary hypertension, and one of the identified comorbidities that could be associated with it is being overweight – being an obese child, which may lead to yet a secondary problem such as sleep apnea where there is obstruction of the airway while the child is asleep that can also lead to elevated blood pressure.

Melanie: Are pediatricians taking blood pressures at well-visits? Is this something that’s done as a natural course – as a vital sign for adults, for sure – but is it being done for children? If not, then how are you identifying hypertension? What are some of the clinical presentations if there are any?

Dr. Chan: Right. I think the good news is that most pediatricians are aware of the importance of getting a good set of blood pressure measurements in the children at all their visits. The recommendation from the American Academy of Pediatrics is that any child greater than 3 years of age should have a routine blood pressure check at least on an annual basis, if not on every visit that they come. I think one of the questions that have been brought up is that what is the best way to measure blood pressure? Anybody who has tried to examine a 3-year-old knows that that can be a challenge depending on their mood, and it really is one of the things that can limit our ability to be accurate, but it should not deter us from trying to get some increased awareness that high blood pressure still can exist in this group of patients.

We can speak to the technique of measuring blood pressure for a bit. For those that are old enough to cooperate, I think it’s important for us to know that these children should be allowed to be in a state that can give us an accurate measurement that does not give us artificially elevated blood pressure.  We do know that if someone has been exercising, if they are talking while they’re getting their blood pressure checked, something as silly as crossing the legs, that can artificially elevate the numbers of the blood pressure, and it doesn’t indicate true elevated problems, but rather that these are just a technical issue.

We prefer the child when they come in if this allows them – if it’s allowable, then they are given at least about a 5-minute rest period where they’re not running around and exercising, and they’re sitting still, or even better, laying down. We prefer the blood pressure to be taken in the right arm, and then we also need to make sure that the cuff size is appropriate for the child. There are many articles that talk about that, and basically, the bladder part of the cuff should cover 80% to 100% of that arm or limb that that pressure is being measured from.

The last thing that I really want to mention is that if possible, it really is preferable that the blood pressure is measured using what we call the manual method. Using a regular sphygmomanometer and using a stethoscope and actually listening to the sounds – what we call the Korotkoff sounds – in order to measure the blood pressure. Using the electronic versions of these -- what we usually call Dynamap or whatever – has its place, but it can give you numbers that may not be as accurate. One of the things that need to be emphasized is that we need the child to sit still, not talk, feet flat on the ground, and then to measure the blood pressure, again measuring from the right arm and trying to get a number that you can be certain is fairly accurate.

If the child is moving around, you may need to actually bring the child in another time or even measure it after the visit to determine if the number is truly accurate or not in order to make any judgment to how to respond to the blood pressure.

As for those children that are younger and that you know they are just not cooperative during the blood pressure measurement, you need to try to find another way to measure it at another time or just know that the number that you received from the measurement may not be accurate and not to respond to those numbers. In other words, put it into the context of how that data was collected.

Melanie: As we’re learning that technique to get squirmy, little kids to really be able to get a good, accurate blood pressure, Dr. Chan – when we’re looking at optimal goals with – the blood pressure guidelines have recently been changed for adults to what determines high blood pressure, what about for children? What do you want other physicians to know about the guidelines for what is considered hypertension and what is considered normal?

Dr. Chan: Yes, I think the fun part about pediatrics is that we’re dealing with kids. The challenge with that is that for every age group and for every size of the child it does come with a different set of parameters. Obviously, in the context of this podcast, we’re not going to be able to give you specific numbers, but there are very good data out there. I would encourage people to look up these norms form the National Heart and Lung Institute that gives the numbers based on the child’s height, age, and to know where they fall as far as what should be abnormal and not normal.

The key thing here is that the criteria are almost exactly the same as adults based on percentile. We know that those blood pressure that falls between the 90^th and the 95^th percentile are considered classified as pre-hypertension. Those that are greater than the 95^th percentile is considered hypertension or hypertensive. If you do find those numbers are abnormal, one of the recommendations is that as long as there are no symptoms involved, those measurements are repeated at least two more times to note that it wasn’t just an outlier. You want to make sure that those numbers are truly real. The frequency of doing that, it really depends on the child, the social situation, and how suspicious you are that this child actually has elevated blood pressure. Nonetheless, if you do find an abnormality and the child is otherwise asymptomatic and doing well, you may just want to repeat that again to make sure that that truly is an abnormality.

Melanie: As we’re talking about steps to manage a child with truly elevated blood pressure, how does treatment with lifestyle versus an antihypertensive agent – are you going to, first of all, look towards lifestyle, unless it’s secondary hypertension? Are you going to talk to talk to the parents? What do you want other physicians to know about initial treatment?

Dr. Chan: Right. Yeah, I think that’s a great question as well. And obviously, when we look at the reasons why so many more kids are being recognized to have blood pressure abnormalities, it truly is related to their lifestyle as far as diet and exercise level. The first and the foundational thing that really needs to be recommended is truly a lifestyle change. Let’s just talk about diet. First of all, there are guidelines to amount of sodium that is recommended for children and it’s a little bit different per age group per size. And again, those things are available from the American Academy of Pediatrics as far as what should be given. Without any detail in all of this, the general thought is that you should not be overly salting your food and minimizing your sodium intake to try to decrease that.

The second things are really related to obesity. We do know that obesity can lend itself to elevated blood pressure in this population, and obviously, weight management is very important. Weight management is a topic all to itself. Although it sounds fairly simple to tell the family “You know what? You need to eat better. You need to make sure the child is losing weight.” We know the reality is that it is a very complex situation, oftentimes social determinants really make it exceedingly difficult for some of these kids who have weight management – and this is one of the true challenges facing pediatricians in dealing with this problem is trying to manage that.

The reality is that unless you address these issues, medication is not going to be truly effective to deal with blood pressure problems if you’re not also doing the right things with your diet and exercise. Antihypertensives really should be reserved for those patients who have truly tried nonmedical therapy, the lifestyle changes. If they continue to have elevated blood pressure, then they should be managed with antihypertensives.

At this point in time, usually, these children are referred to specialists like nephrologists, kidney specialists, as well as cardiologists. What we’re going to be looking for is secondary organ involvement like the thickness of the heart muscle to indicate that this patient truly sees elevated blood pressure. We may actually do some additional blood pressure measurements called ambulatory blood pressure monitoring where we actually have 24-hours with the data so that we really are getting a much better picture of what the blood pressure variation is in that child. With this, we can tailor the therapy much more succinctly, and this really becomes less of a problem for the pediatrician to manage, and it really should fall into the category of the specialist in order to manage this problem.

Melanie: Dr. Chan, what great information, and so important. Wrap it up for us, with your best advice for other providers about management of hypertension in children and what you consider some of the best techniques to obtain a good, solid, proper blood pressure reading, and what you’d like them to know about treatment, and lifestyle, and working with the parents, and working with their patients to get this under control.

Dr. Chan: I think a short summary is that we need to be diligent. We know that measuring blood pressure especially in small children is challenging, but that doesn’t mean we should just give up. We should just try again at another time and have the mom bring the child in when they’re most likely to cooperate. When there is an elevated blood pressure problem, and if it is not that severely elevated, I think the first steps are the things that most pediatricians and primary care physicians can handle, offering lifestyle changes. And then check in with the parents, are they really following it. If so, and there is still a problem, then certainly refer them to a specialist and we will take on those cases that need additional work to help them try to manage the blood pressure and really protect the organs, not only for the next 5-years, but potentially for the next 80- to 90-years for these young people to grow into adulthood so that they can remain healthy well into their senior years.

Melanie: Thank you so much, Dr. Chan, for being with us today and sharing your expertise on this very interesting topic. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle-sponsored educational activities, please visit CarleConnect.com, that’s CarleConnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole. Thanks so much, for listening.