Transcription:
Pediatric Hypertension

Melanie Cole (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids HealthCast by Weill Cornell Medicine. I'm Melanie Cole. And today we're talking about Pediatric Hypertension. We have a panel for you today. And my guests are Dr. Radha Gajjar. She's an Assistant Professor of Clinical Pediatrics in the Division of Pediatric Nephrology at Weill Cornell Medicine and an Assistant Attending Pediatrician at New York Presbyterian, Phyllis and David Komansky Children's Hospital.

And Dr. Diane Liu, she's an Assistant Attending Pediatrician at New York Presbyterian Hospital, Weill Cornell Medical Center, and an Assistant Professor of Clinical Pediatrics at Weill Cornell Medical College, Cornell University. Doctors, I'm so glad to have you with us today. This is such a great topic and not one that is often spoken about.

I'd like to start with you, Dr. Liu, can you explain a little bit about hypertension in children? Did we use to see this? Is it a new phenomenon? Is a generally a primary condition or secondary to another issue as we're starting to see this obesity epidemic and diabetes in children. Tell us a little bit about what you're seeing with hypertension in children.

Diane Liu, MD (Guest): Yes. Thanks so much for having us. So hypertension in children is not a new condition, but it is becoming increasingly recognized with the obesity epidemic. Hypertension can either be from a primary condition or a secondary to another issue. So primary or essential hypertension is more common in adolescents and risk factors include obesity and a family history of hypertension. Secondary hypertension, however, is more common in younger pre-adolescent children and can be caused by a variety of conditions, including renal, cardiac, endocrine and other conditions.

Radha Gajjar, M.D., MSCE (Guest): So thanks for having us, Melanie. We're increasingly seeing hypertension in pediatric patients like Dr. Liu said, and what's important is that we have better and better metrics to be able to identify hypertension that are used in pediatrics clinics across the country that help get the patients who need to be seen by specialists into our clinics.

Host: Wow. That's so interesting, isn't it? How one epidemic or one comorbidity crosses over and really looks to other ones and causes other ones. So let's talk about blood pressure in kids. Dr. Liu, what's the optimal blood pressure for children and adolescents, and I'd like you to also speak how it's identified. I took my kids to well visits and I remember them getting it described as a little hug when they were little, of course they're adults now. But if it's only one time, do we do it again and again, tell us a little bit about the optimal blood pressure and really, how do you identify this?

Dr. Liu: Yes. That's a great question for children, their optimal blood pressure depends on their age, height and sex. So for children 12 and under their optimal blood pressure is less than 90th percentile for those parameters. For adolescents, we use the same parameters as we use for adults, which would be less than 120 over 80.

Now, you asked about how we can screen children for hypertension and children should be screened for hypertension annually, starting at the age of three. And high risk patients should be screened at each visit with their pediatrician. So these high risk patients would include patients who have obesity, are taking medications known to increase their blood pressures. Those who have renal or cardiac disease or diabetes.

Dr. Gajjar: So like Dr. Liu said, there are parameters that we use for children that are based on their age, sex and height, which the pediatricians use. And I can't stress enough, the importance of partnering with the general pediatrician to help identify children whose blood pressures are abnormal, who then guide children to our clinic for further workup, if that's what's appropriate. Sometimes children get nervous at doctor's visits. And so the pediatrician is the main person to really help catch true high blood pressure, work with families to make sure that they're measuring it appropriately. And then if it's truly concerning for hypertension to then refer those patients to us.

Host: Well, Doctors, as an exercise physiologist myself, I know when I take blood pressure, if someone's as high and we can look at it as white coat, and then we take it another time, we wait a little bit, maybe try the other arm. What about for children? If they get a high reading once Dr. Gajjar, you can answer this one. If they get a high reading once at the pediatrician's office, do we wait a while? Take it again. Do we ask the parents to monitor? Keep a little record. So, the parents listening, know if they've gotten a high reading and they keep a journal and then bring it in. And at that point, is it the pediatrician who says, yeah, this looks like hypertension. Now go see a cardiologist or do you guys jump in? How how does all of that work?

Dr. Gajjar: Yeah. So that's a really good question. So typically what happens is, children get a blood pressure checked during their well-child visit. And there are a lot of strategies that we and pediatricians use to confirm whether the blood pressure reading is accurate or not. So, the first thing that typically happens is, if the pediatrician goes in, they see a high blood pressure from triage at the beginning of the appointment, the first step is to really recheck it at the end of the visit.

So that's after the child has had the visit with the doctor, hopefully before any shots that they might get. But to give them a chance to rest, for their blood pressure to normal. Oftentimes families are busy, people have to rush to appointments and so that first blood pressure might be falsely elevated.

Also children have relationships with their pediatricians, pediatricians have tricks to help kids relax. And so oftentimes rechecking that blood pressure within the context of that first visit, can help stratify whether the blood pressure is actually normal or if it is truly elevated. If in that initial visit, the blood pressure is truly elevated, depending on how severely elevated it is, the pediatrician can make a decision about whether to contact the hospital and refer the patient emergently if it's severely high. But if it's mildly elevated, higher than it should be, but not an emergency, typically the recommendation is that the pediatrician brings the child back for two more visits to confirm the blood pressure is truly elevated because there can be variability based on diet, on stress levels, sleep, anxiety, things like that. But after, two extra checks, if the blood pressure is truly high, then the pediatrician is that link to reach out to our office by providing either a referral, which we have a great internal referral system within Weill Cornell, or to give the family contact information, to schedule an appointment with us.

Host: Really important information and probably not information that all parents know about. So, Dr. Liu, before we get into treatments, tell us a little bit about why blood pressure monitoring and management is important for these kiddos, because there are complications that can happen if blood pressure is not kept under control when it's found, when they're young.

And while you're telling us that, I'd like you to give a little bit of a lesson for parents listening, please on how to take blood pressure. If they go to their pharmacy and they get one of those machines, really, how do they do it? How tight do they make the cuff? Can you give us a little lesson?

Dr. Liu: Absolutely. So blood pressure monitoring and management is extremely important because longstanding hypertension can cause injury to blood vessels, that affects basically every part of a child's body, including their kidneys, their heart, their eyes, the central nervous system. So catching hypertension early and treating it effectively, is really important for preventing those long-term outcomes and promoting a child's overall health as they grow.

So, you asked about how we check blood pressures. If you are bringing a child to a pharmacy, it's really important that the child is sitting down, calmly with both feet on the ground. And they have their arm at the level of their heart. Generaly we recommend that a child is able to sit down for about 15 minutes to sort of calm down, not look at their phone.

Only after that, we would check their blood pressures. In terms of the cuff, it's important that the cuff is appropriate for a child size. So what the pharmacist can do is measure the child's arm and choose the cuff, according to the circumference of the child arm.

Host: What about those little cuffs that you buy for home care? If they're not taking them to the pharmacy, but you're buying one, Dr. Liu from the pharmacy? Is there anything in particular you'd like parents to look for when keeping track of blood pressure and their own for that matter?

Dr. Liu: In terms of buying their own blood pressure cuff, one thing that you can do is measure your child's arm, which would give you the most accurate way to choose a cuff or they have blood pressure cuffs that correspond to adult sized, children, young children and babies.

Host: Thank you for that. So Dr. Gajjar, how do we manage a child with elevated blood pressure? Millions of adults are on hypertensive medications of all kinds. Tell us a little bit about the management options when you're talking about children and when medication is used, how does treatment versus lifestyle change work together?

Dr. Gajjar: One of the reasons why I love pediatrics is that children are resilient and have an incredible ability to heal and improve their health. And so the management of hypertension really depends on the cause. And that's one of the reasons why it's important for an expert like us to be able to assess the child, figure out the cause of high blood pressure to then help guide the family with the appropriate management plan.

Like Dr. Liu had mentioned earlier, we're seeing increasing incidence of hypertension related to obesity, some of the lifestyle issues that are prevalent across the country, as far as poor diet, decreased exercise, things like that. But there are children who have hypertension related to an underlying kidney problem.

And it's important that we identify those cases that need to be treated in a different way. So, the first step is really making the distinction and understanding what's causing the high blood pressure and then making a management plan, accordingly. For the children who we think that their blood pressure is related to lifestyle issues, the first recommendation is actually to implement lifestyle modification. So, that involves increasing physical activity, specifically to at least 30 minutes, five times. Improving diet, implementing a low salt diet. There's a lot of hidden sodium in the Western diet, especially in processed foods, which can significantly impact blood pressure.

So, we work with families to identify areas that can be changed one step at a time, to start lifestyle modification. We also have them meet with our nutritionist to identify specific areas that they can take action on. So those are the children who, would benefit from lifestyle modification first.

And then there's the second category of children who have an underlying condition that's causing their hypertension. And in those children, it really depends on what the cause is, so do they have a structural problem with their kidney, did their kidney developed abnormally and they have high blood pressure as a result of that? Are they on a type of medication that's causes high blood pressure as a side effect? There are a lot of different possibilities for secondary hypertension that is hypertension that's related to another medical issue. And so that's one of the reasons why we spend so much time with these families to truly identify the cause and then make a management plan that's appropriate for the child. You'd asked about using medication. When we use medication, there are two reasons why we start a medication.

One is if the hypertension is severe. So, even if it seems to be obesity related that might improve with lifestyle modification, if the blood pressure is severely elevated, such that it could cause damage in the short term, then we pair medication management with an antihypertensive, along with lifestyle modification, to try to be able to use both of those together, to get the blood pressure to a good place.

The other situation in which we use blood pressure medicine is for the children who are unlikely to benefit from lifestyle modification. So those children, like we talked about who have an underlying cause and need a medication to actually treat the high blood pressure because they have this different cause for the hypertension.

Host: That was an excellent, comprehensive explanation Dr. Gajjar. And Dr. Liu, as we're talking about lifestyle factors and Dr. Gajjar mentioned a nutritionist in such as we're getting ready to wrap up this podcast, can you speak about the importance of this multidisciplinary approach and your clinic at Weill Cornell Medicine? And the importance for these patients to be able to work with maybe a personal trainer and a nutritionist and their nephrologist and their pediatrician and their medical home, and tie this all together for us.

Dr. Liu: So an interdisciplinary approach for treating hypertension is extremely important. We work very closely with a child's pediatrician, and we also work with many other sub-specialists on an as needed basis. In terms of promoting a healthy lifestyle, we can help patients access Health for Life or a Healthy Weight Program. Both are, which are geared towards empowering children to work towards improved health, improved nutrition. And as Dr. Gajjar mentioned, we partner with our dedicated, renal nutritionist, to really get a comprehensive history of the dietary intake and to help identify adjustments that can be made. Other sub-specialists that we work with also include cardiologists.

And they are a very important part of the routine workup, for children who need to start medications, and many other sub-specialists. So, it's definitely a team approach. We work very closely, with all of these specialists to make sure that a child will have optimal care of their blood pressures moving forward.

Host: So important. Dr. Gajjar, last word to you, what would you like parents listening to know about hypertension in children? And whether it's preventable or whether healthy lifestyle and behaviors can be learned by the whole family. Because I think that that is definitely something that goes together when it is related secondarily to something like obesity or diabetes that they can learn together to help manage it, wrap it all up for us with your best advice.

Dr. Gajjar: The most important thing that children and families and parents can do to prevent hypertension is to make sure that a child is maintaining a healthy weight. And that they're given the opportunity to be physically active, like we talked about. Oftentimes when we diagnose a child with hypertension, the counseling that we do, affects change for the entire family. So, everyone starts eating a low salt diet. Everyone starts being physically active together. And I can't tell you how many families have come back to us and said, you know what, we've made these changes. We all made them together and everyone's in a better place because of it. So, for children who have high blood pressure related to these modifiable lifestyle environments, it's important to be mindful of what children are eating, making sure that they can do physical activity, and then for families who have children with high blood pressure, for other reasons, it's important that they're identified and that they seek out care. Hypertension is, as we know from the adult population, it's a silent condition that oftentimes doesn't cause complications until much, much further down the line. But our goal is to really keep all children as healthy as possible, by keeping their blood pressure in a good range, and promoting overall health.

Host: What a great goal. Certainly the goal of all of us in the health field right now, as we're seeing things happening to our children we didn't use to see quite so often. And thank you both for joining us and sharing your incredible expertise on this topic with us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell. That concludes today's episode of Kids Health Cast .We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple podcast, Spotify and Google podcast. And for more health tips, go to weillcornell.org and search podcasts. And don't forget to check out our Back to Health. I'm Melanie Cole. Thanks so much for joining us today.

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