The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

SLIDE 1: National Heart, Lung, and Blood Institute National High Blood Pressure Education Program
The 4th Report on High Blood Pressure in Children and Adolescents Slide Set

SLIDE 2: Group on High Blood Pressure in Children and Adolescents

Bonita Falkner, M.D., CHAIR, Thomas Jefferson University

Stephen R. Daniels, M.D., Ph.D., Cincinnati Children's Hospital Medical Center

*Joseph T. Flynn, M.D., M.S., Montefiore Medical Center

Samuel Gidding, M.D., DuPont Hospital for Children

Lee A. Green, M.D., M.P.H., University of Michigan

Julie R. Ingelfinger, M.D., MassGeneral Hospital for Children

Ronald M. Lauer, M.D., University of Iowa

Bruce Z. Morgenstern, M.D., Mayo Clinic

Ronald J. Portman, M.D., The University of Texas Health Science Center at Houston

Ronald J. Prineas, M.D., Ph.D., Wake Forest University School of Medicine

Albert P. Rocchini, M.D., University of Michigan, C.S. Mott Children's Hospital

Bernard Rosner, Ph.D., Harvard School of Public Health

Alan Robert Sinaiko, M.D., University of Minnesota Medical School

Nicolas Stettler, M.D., M.S.C.E., The Children's Hospital of Philadelphia

Elaine Urbina, M.D., Cincinnati Children's Hospital Medical Center

National Institutes of Health Staff

Edward J. Roccella, Ph.D., M.P.H., National Heart, Lung, and Blood Institute

Tracey Hoke, M.D., M.Sc., National Heart, Lung, and Blood Institute

Carl E. Hunt, M.D., National Center for Sleep Disorders Research

Gail Pearson, M.D., Sc.D., National Heart, Lung, and Blood Institute

*Joseph T. Flynn, MD, MS, is a paid contributor to Pfizer, Inc, Novartis Pharmaceuticals, AstraZeneca, Inc, and ESP-Pharma.

SLIDE 3: National High Blood Pressure Education Program Coordinating Committee
American Academy of Family Physicians

American Academy of Insurance Medicine

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Physician Assistants

American Association of Occupational Health Nurses

American College of Cardiology

American College of Chest Physicians

American College of Occupational and Environmental Medicine

American College of Physicians-

American Society of Internal Medicine

American College of Preventive Medicine

American Dental Association

American Diabetes Association

American Dietetic Association

American Heart Association

American Hospital Association

American Medical Association

American Nurses Association

American Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Public Health Association

American Red Cross

American Society of Health-System Pharmacists

American Society of Hypertension

American Society of Nephrology

Association of Black Cardiologists

Citizens for Public Action on High Blood Pressure and Cholesterol, Inc.

Hypertension Education Foundation, Inc.

International Society on Hypertension in Blacks

National Black Nurses Association, Inc.

National Hypertension Association, Inc.

National Kidney Foundation, Inc.

National Medical Association

National Optometric Association

National Stroke Association

NHLBI Ad Hoc Committee on Minority Populations

Society for Nutrition Education

The Society of Geriatric Cardiology

Federal Agencies:

Agency for Healthcare Research and Quality

Centers for Medicare & Medicaid Services

Department of Veterans Affairs

Health Resources and Services Administration

SLIDE 4: Introduction

Purpose

• To update clinicians on the latest scientific evidence regarding blood pressure in children
• To provide recommendations for diagnosis, evaluation, and treatment of hypertension

SLIDE 5: Overview

• New national data have been added to the childhood BP database.
• Updated BP tables now include the 50th, 90th, 95th, and 99th percentiles by sex, age, and height.
• Hypertension in children and adolescents continues to be defined as systolic BP (SBP) and/or diastolic BP (DBP) that is, on repeated measurement, at or above the 95th percentile. BP between the 90th and 95th percentile is now termed "prehypertensive."

SLIDE 6: Overview

• The rationale for identification of early target-organ damage in children and adolescents with hypertension is provided.
• Revised recommendations for use of antihypertensive drug therapy are provided.
• Treatment recommendations include nonpharmacologic therapies and reduction of other cardiovascular risk factors.
• Information is included on the identification of sleep disorders in some hypertensive children.

SLIDE 7: Methods

• The NHBPEP Coordinating Committee (CC) suggested updating the 1996 Working Group Report on Hypertension in Children and Adolescents.
• Prominent pediatric clinicians and scholars were selected to review available scientific evidence and submit manuscripts.
• The NHLBI Director appointed a working group to revise the report.

SLIDE 8: Methods

• Scientific evidence was classified in a process adapted from Last and Abramson (JNC 7).
• A draft was sent to the NHBPEP CC for review and vote.
• The report was published in the August 2004 supplement of Pediatrics.

SLIDE 9: Definition of Hypertension

• Hypertension-average SBP and/or DBP that is greater than or equal to the 95th percentile for sex, age, and height on 3 or more occasions.
• Prehypertension-average SBP or DBP levels that are greater than or equal to the 90th percentile, but less than the 95th percentile.
• Adolescents with BP levels greater than or equal to 120/80 mmHg should be considered prehypertensive.

SLIDE 10: Definition of Hypertension

• White-coat hypertension-A patient with BP levels above the 95th percentile in a physician's office or clinic who is normotensive outside a clinical setting. (Ambulatory BP monitoring is usually required to make this diagnosis.)

SLIDE 11: Measurement of Blood Pressure in Children

• Children >3 years old should have their BP measured.
• Auscultation is the preferred method of BP measurement.
• Correct measurement requires a cuff that is appropriate to the size of the child's upper arm.
• Elevated BP must be confirmed on repeated measurement.
• BP >90th percentile obtained by oscillometric devices should be repeated by auscultation.

SLIDE 12: Conditions Under Which Children <3 Years Old Should Have BP Measured

• History of prematurity, very low birthweight, or other neonatal complication requiring intensive care
• Congenital heart disease, whether repaired or nonrepaired
• Recurrent urinary tract infections, hematuria, or proteinuria
• Known renal disease or urologic malformations
• Family history of congenital renal disease

SLIDE 13: Conditions Under Which Children <3 Years Old Should Have BP Measured

• Solid organ transplant
• Malignancy or bone marrow transplant
• Treatment with drugs known to raise BP
• Other systemic illnesses associated with hypertension
• Evidence of elevated intracranial pressure

SLIDE 14: >Recommended Dimensions for Blood Pressure Cuff Bladders

Age	Range Width (cm)	Length (cm)	Maximum Arm Circumference (cm)*
Newborn	4	8	10
Infant	6	12	15
Child	9	18	22
Small adult	10	24	26
Adult	13	30	34
Large adult	16	38	44
Thigh	20	42	52

*Calculated so that the largest arm would still allow the bladder to encircle the arm by at least 80 percent.

*Calculated so that the largest arm would still allow the bladder to encircle the arm by at least 80 percent.

SLIDE 15: Ambulatory Blood Pressure Monitoring

• Is useful in the evaluation of:
• White-coat hypertension
• Target-organ injury risk
• Apparent drug resistance
• Drug-induced hypotension.
• Provides additional BP information in:
• Chronic kidney disease
• Diabetes
• Autonomic dysfunction.
• Should be performed by clinicians experienced in its use and interpretation.

SLIDE 16: Blood Pressure Tables

• BP standards based on sex, age, and height provide a precise classification of BP according to body size.
• The revised BP tables now include the 50th, 90th, 95th, and 99th percentiles by sex, age, and height.

SLIDE 17: Blood Pressure Levels for Boys by Age and Height Percentile

Age	BP	SBP (mmHg) Percentile of Height	DBP (mmHg) Percentile of Height
(Year)	Percentile	5th	10th	25th	50th	75th	90th	95th	5th	10th	25th	50th	75th	90th	95th
12	50th	102	103	104	105	107	108	109	61	61	61	62	63	64	64
	90th	116	116	117	119	120	121	122	75	75	75	76	77	78	78
	95th	119	120	121	123	124	125	126	79	79	79	80	81	82	82
	99th	127	127	128	130	131	132	133	86	86	87	88	88	89	90

SLIDE 18: Blood Pressure Levels for Girls by Age and Height Percentile

Age	BP	SBP (mmHg) Percentile of Height	DBP (mmHg) Percentile of Height
(Year)	Percentile	5th	10th	25th	50th	75th	90th	95th	5th	10th	25th	50th	75th	90th	95th
12	50th	101	102	104	106	108	109	110	59	60	61	62	63	63	64
	90th	115	116	118	120	121	123	123	74	75	75	76	77	78	79
	95th	119	120	122	123	125	127	127	78	79	80	81	82	82	83
	99th	126	127	129	131	133	134	135	86	87	88	89	90	90	91

SLIDE 19: How To Use the BP Tables

1. Use the standard height charts to determine the height percentile.
2. Measure and record the child's SBP and DBP.
3. Use the correct gender table for SBP and DBP.
4. Find the child's age on the left side of the table. Follow the age row horizontally across the table to the intersection of the line for the height percentile (vertical column).

SLIDE 20: How To Use the BP Tables

• For SBP percentiles in the left columns and for DBP percentiles in the right columns:
• Normal BP = <90th percentile.
• Prehypertension = BP between the 90th and 95th percentile or >120/80 mmHg in adolescents.
• Hypertension = BP >95th percentile on repeated measurement.

SLIDE 21: How To Use the BP Tables

• P >90th percentile should be repeated twice at the same office visit.
• 7. BP >95th percentile should be staged:
• Stage 1 = the 95th percentile to the 99th percentile plus 5 mmHg.
• Stage 2 = >99th percentile plus 5 mmHg.

SLIDE 22: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations

	SBP or DBP Percentile
Normal	<90th percentile
Prehypertension	90th percentile to <95th percentile, or if BP exceeds 120/80 even if below the 90th percentile up to <95th percentile
Stage 1 hypertension	95th percentile to the 99th percentile plus 5 mmHg
Stage 2 hypertension	>99th percentile plus 5 mmHg

SLIDE 23: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations

	Frequency of BP Measurement
Normal	Recheck at next scheduled physical examination.
Prehypertension	Recheck in 6 months.
Stage 1 hypertension	Recheck in 1–2 weeks or sooner if the patient is symptomatic; if BP is persistently elevated on two additional occasions, evaluate or refer to source of care within 1 month.
Stage 2 hypertension	Evaluate or refer to source of care within 1 week or immediately if the patient is symptomatic.

SLIDE 24: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations

	Therapeutic Lifestyle Changes
Normal	Encourage healthy diet, sleep, and physical activity.
Prehypertension	Recommend weight management counseling if overweight; introduce physical activity and diet management.
Stage 1 hypertension	Recommend weight management counseling if overweight; introduce physical activity and diet management.
Stage 2 hypertension	Recommend weight management counseling if overweight; introduce physical activity and diet management.

SLIDE 25: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations

	Pharmacologic Therapy
Normal	None
Prehypertension	Do not initiate therapy unless there are compelling indications such as chronic kidney disease (CKD), diabetes mellitus, heart failure, left ventricular hypertrophy (LVH).
Stage 1 hypertension	Initiate therapy based on indications for antihypertensive drug therapy or if there are compelling indications as above.
Stage 2 hypertension	Initiate therapy.

SLIDE 26: Indications for Antihypertensive Drug Therapy in Children

• Symptomatic hypertension
• Secondary hypertension
• Hypertensive target-organ damage
• Diabetes (types 1 and 2)
• Persistent hypertension despite nonpharmacologic measures

SLIDE 27: Clinical Evaluation of Confirmed Hypertension

Study or Procedure	Purpose	Target Population
Evaluation for identifiable causes
History, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking alcohol; physical examination	History and physical examination help focus subsequent evaluation	All children with persistent BP >95th percentile
BUN, creatinine, electrolytes, urinalysis, urine culture	R/O renal disease and chronic pyelonephritis	All children with persistent BP >95th percentile
CBC	R/O anemia, consistent with chronic renal disease	All children with persistent BP >95th percentile
Renal ultrasound	R/O renal scar, congenital anomaly, or disparate renal size	All children with persistent BP >95th percentile

SLIDE 28: Clinical Evaluation of Confirmed Hypertension

Study or Procedure	Purpose	Target Population
Evaluation for comorbidity
Fasting lipid panel, fasting glucose	To identify hyperlipidemia, identify metabolic abnormalities	Overweight patients with BP at 90th–94th percentiles; all patients with BP >95th percentile Family history of hypertension or cardiovascular disease Child with chronic renal disease
Drug screen	To identify substances that might cause hypertension	History suggestive of possible contribution by substances or drugs
Polysomnography	To identify sleep disorder in association with hypertension	History of loud, frequent snoring

SLIDE 29: Clinical Evaluation of Confirmed Hypertension

Study or Procedure	Purpose	Target Population
Evaluation for target-organ damage
Echocardiogram	Identify LVH and other indications of cardiac involvement	Patients with comorbid risk factors* and BP at the 90th–94th percentiles; all patients with BP >95th percentile
Retinal examination	Identify retinal vascular changes	Patients with comorbid risk factors and BP at the 90th–94th percentiles; all patients with BP >95th percentile
Further evaluation as indicated
Ambulatory BP monitoring	Identify white-coat hypertension, abnormal diurnal BP pattern, BP load	Patients in whom white-coat hypertension is suspected, and when other information on BP pattern is needed

*Comorbid risk factors also include diabetes mellitus and kidney disease

SLIDE 30: Clinical Evaluation of Confirmed Hypertension

Study or Procedure	Purpose	Target Population
Plasma renin determination	Identify low renin, suggesting mineralocorticoid-related disease	Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension Positive family history of severe hypertension
Renovascular imaging	Identify renovascular disease	Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
Plasma and urine steroid levels	Identify steroid-mediated hypertension	Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
Plasma and urine catecholamines	Identify catecholamine-mediated hypertension	Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension

SLIDE 31: Primary Hypertension and Evaluation for Comorbidities

• Primary hypertension is identifiable in children and adolescents.
• Hypertension and prehypertension are significant health issues in the young due to the marked increase in the prevalence of overweight children.
• The evaluation of hypertensive children should include assessment for additional risk factors.

SLIDE 32: Evaluation for Secondary Hypertension

• Secondary hypertension is more common in children than in adults.
• Body Mass Index (BMI) should be calculated as part of the physical examination.
• When hypertension is confirmed, BP should be measured in both arms and a leg.

SLIDE 33: Evaluation for Secondary Hypertension

• Children or adolescents with stage 2 hypertension, and very young children with stage 1 or stage 2 hypertension should be evaluated more completely.
• A comprehensive medical history should be obtained.
• History of drug and substance use should be included.

SLIDE 34: Evaluation for Secondary Hypertension

• A sleep history should be obtained. (There is an association of sleep apnea with overweight and high BP.)
• Family history should include history of hypertension and other cardiovascular disease.

SLIDE 35: Additional Diagnostic Studies for Hypertension

Renin Profiling

Plasma renin level or plasma renin activity (PRA) is a useful screening test for mineralocorticoid-related diseases.

SLIDE 36: Evaluation for Possible Renovascular Hypertension

Evaluation for renovascular disease also should be considered in infants or children with other known predisposing factors, such as prior umbilical artery catheter placements or neurofibromatosis.

SLIDE 37: Invasive Studies

Digital subtraction angiography and formal arteriography are still considered the "gold standard," but these studies should be undertaken only when surgical or invasive interventional radiologic techniques are being contemplated for anatomic correction.

SLIDE 38: Target-Organ Abnormalities in Children with Hypertension

• Target-organ abnormalities are detectable in hypertensive children and adolescents.
• LVH is the most prominent evidence of target-organ damage.
• Echocardiographic assessment of left ventricular mass should be performed at diagnosis of hypertension and periodically thereafter.
• The presence of LVH is an indication to initiate or intensify antihypertensive therapy.

SLIDE 39: Clinical Recommendation

• Echocardiography is the recommended primary tool for detection of target-organ abnormalities.
• Children and adolescents with established hypertension should have an echocardiogram to determine if LVH is present.
• Echocardiographic measurements are used to calculate the left ventricular mass index.

SLIDE 40: Formula for Calculating Left Ventricular Mass

LV Mass (g) =

0.80 [1.04 (IVS + LVED + LVPW)3 - (LVED)3] + 0.6

Echocardiographic measurements are in cm.

SLIDE 41: Left Ventricular Hypertrophy

• Left ventricular mass is indexed by height in meters 2.7.
• A conservative cutpoint that defines LVH is 51 g/m2.7.
• For patients who have LVH, the echocardiographic determination of the left ventricular mass index should be repeated periodically.

SLIDE 42: Therapeutic Lifestyle Changes

• Weight reduction is the primary therapy for obesity-related hypertension. Prevention of excess weight gain can limit future increases in BP.
• Physical activity can improve efforts at weight management and may prevent future increase in BP.

SLIDE 43: Therapeutic Lifestyle Changes

• Dietary modification should be strongly encouraged in children and adolescents with prehypertension, as well as those with hypertension.
• Family-based intervention improves success.

SLIDE 44: Pharmacologic Therapy for Childhood Hypertension

• Indications for antihypertensive drug therapy in children include secondary hypertension and insufficient response to lifestyle modifications.
• Recent clinical trials have expanded the number of drugs that have pediatric dosing information.
• Pharmacologic therapy should be initiated with a single drug.

SLIDE 45: Pharmacologic Therapy for Childhood Hypertension

• The goal for antihypertensive treatment in children should be reduction of BP to <95th percentile, unless concurrent conditions are present. In that case, BP should be lowered to <90th percentile.
• Severe, symptomatic hypertension should be treated with intravenous antihypertensive drugs.

SLIDE 46: Management Algorithm

Image of the management algorithm

SLIDE 47: Educational Materials Web Site www.nhlbi.nih.gov

Clinical Reference Tool for Palm OS

Complete Report

• Published in Pediatrics, August 2004. Volume 114, Number 2.
• Available as National Heart, Lung, and Blood Institute Publication No. 56-091N. 2004

SLIDE 48: Web Site

Screen image of the website: http://www.nhlbi.nih.gov

SLIDE 49: Reference Tool for Palm OS

• Interactive tool to assist the clinician in implementing the reports recommendations
• Available at: http://www.nhlbi.nih.gov

SLIDE 50: Complete Report

• Published in Pediatrics, August 2004. Volume 114, Number 2.
• Available as National Heart, Lung, and Blood Institute Publication No. 56-091N. 2004