Chil­dren can have high blood pres­sure, too

The Globe and Mail (Prairie Edition) - - HEALTH & FITNESS - JANE E. BRODY

Un­treated hy­per­ten­sion in pe­di­atric years can re­sult in early heart at­tacks, strokes and kid­ney dis­ease – so early checks are key

HadMatthew Good­win’s blood pres­sure been checked at the age of 3, when it should have been, he most likely would have been spared a med­i­cal emer­gency a year later. He spent two weeks in the pe­di­atric in­ten­sive care unit while doc­tors tried to de­ter­mine why his blood pres­sure had spiked off the charts fol­low­ing mi­nor surgery.

Matthew turned out to have a con­gen­i­tal kid­ney dis­or­der that caused se­vere hy­per­ten­sion and re­quired sur­geons to re­move one of his kid­neys and im­plant it in a new lo­ca­tion, a pro­ce­dure known as a kid­ney au­to­trans­plant. Now a 15-year-old hon­ours stu­dent from Prairieville, La., Matthew takes pres­sure-low­er­ing med­i­ca­tion and ad­heres closely to a low-sodium diet loaded with fresh fruits and veg­eta­bles and no soft drinks.

Know­ing his ex­pe­ri­ence is not unique and that mil­lions of young Amer­i­cans with el­e­vated blood pres­sure don’t know they have it, Matthew, who hopes to be­come a pe­di­atric nephrol­o­gist, vol­un­teers for the Na­tional Pe­di­atric Blood Pres­sure Aware­ness Foun­da­tion, a non-profit ad­vo­cacy group his mother, Ce­leste Good­win, cre­ated to ed­u­cate par­ents and pro­fes­sion­als about the im­por­tance of reg­u­lar blood-pres­sure checks in chil­dren and ado­les­cents.

Boost­ing this ef­fort, in Au­gust, the Amer­i­can Academy of Pe­di­atrics pub­lished a 74-page re­port up­dat­ing its guide­lines for screen­ing and man­ag­ing high blood pres­sure in young­sters. The re­port in­cludes a much­sim­pli­fied chart to help physi­cians read­ily de­ter­mine whether a child’s blood pres­sure is within nor­mal pa­ram­e­ters.

Just as chil­dren’s blood pres­sure can­not be mea­sured with a cuff meant for an adult-size arm, it also can­not be in­ter­preted on an adult scale.

For chil­dren, the def­i­ni­tion of nor­mal blood pres­sure is not based on a sim­ple read­ing of sys­tolic over di­as­tolic blood pres­sure, such as 110 over 70 or 120 over 80. Rather, be­cause nor­mal blood pres­sure varies with a child’s age, gen­der and height, doc­tors typ­i­cally needed to con­sult pages of charts to de­ter­mine whether a pa­tient’s pres­sure was nor­mal or not.

Now, the new guide­lines pro­vide a short, easy-to-use ta­ble based only on a child’s gen­der and age, from 3 to 18, that doc­tors can read­ily con­sult and even hang in the of­fice where they and par­ents can see it.

Study af­ter study has demon­strated that el­e­vated blood pres­sure is cor­rectly di­ag­nosed in less than one-quar­ter of the chil­dren who have it.

For ex­am­ple, the largest study, pub­lished last year in the jour­nal Pe­di­atrics, cov­ered more than 1.2 mil­lion pa­tients ages 3 to 18. Elec­tronic health records showed that 398,079 had their blood pres­sure mea­sured at three or more vis­its.

Of th­ese, read­ings in 12,138 chil­dren met the cri­te­ria for hy­per­ten­sion and 38,874 for pre­hy­per­ten­sion (now called el­e­vated blood pres­sure). But only 23.2 per cent with hy­per­ten­sion and 10.2 per cent with pre­hy­per- ten­sion were di­ag­nosed as such and duly noted for fol­low-up in their health records.

Dr. David Kael­ber, a pe­di­a­tri­cian and in­ternist at the MetroHealth Sys­tem in Cleve­land who di­rected the study and was cochair­man of the team that de­vel­oped the new guide­lines, said in an in­ter­view, “It’s great to have guide­lines, but they’re only as good as the peo­ple who ac­tu­ally fol­low them.”

You may won­der why a di­ag­no­sis of high or el­e­vated blood pres­sure in chil­dren is im­por­tant.

Although chil­dren don’t usu­ally suf­fer the con­se­quences of high blood pres­sure in the pe­di­atric years, Kael­ber said, un­less treated, it can re­sult in early heart at­tacks, strokes and kid­ney dis­ease.

El­e­vated blood pres­sure in chil­dren pre­dicts high blood pres­sure in adults, a lead­ing risk fac­tor for heart at­tacks and strokes.

Al­ready, in young adults who’ve had el­e­vated blood pres­sure as chil­dren, “you can see two kinds of car­dio­vas­cu­lar dam­age,” Dr. Joseph Flynn, lead au­thor of the new guide­lines, said in an in­ter­view.

“There is thick­en­ing of the left ven­tri­cle, the heart’s main pump­ing cham­ber, and thick­en­ing of blood ves­sel walls that is clearly tied to ath­er­o­scle­ro­sis and heart at­tacks in adults.”

Be­cause high blood pres­sure of­ten runs in fam­i­lies, de­tect­ing it in a child may prompt a check of the par­ents and other fam­ily mem­bers and end up sav­ing their health and lives, Flynn said.

And, as demon­strated by Matthew Good­win’s ex­pe­ri­ence, in about 20 per cent of cases there is an un­der­ly­ing and cor­rectable cause for high blood pres­sure in chil­dren. Fail­ing to make the cor­rect di­ag­no­sis can be dis­as­trous. As his mother put it bluntly, “Matthew could have died.”

The preva­lence of el­e­vated blood pres­sure and frank hy­per­ten­sion in chil­dren and ado­les­cents has risen dra­mat­i­cally in re­cent decades, largely the re­sult of in­creas­ing over­weight and obe­sity in the young. An es­ti­mated 17 per cent of chil­dren the ages of 2 to 19 are obese and ap­prox­i­mately two mil­lion chil­dren have hy­per­ten­sion.

Other con­trib­u­tors to the preva­lence of hy­per­ten­sion in chil­dren in­clude a grow­ing de­pen­dence on fast foods, pro­cessed foods and snacks that are high in salt, caus­ing ex­cess sodium and fluid in the blood and an added strain on the del­i­cate blood ves­sels that feed the kid­neys.

The new guide­lines from the pe­di­atric academy urge health­care prac­ti­tion­ers to mea­sure and record blood pres­sure at ev­ery well-child or pre­ven­tive care visit, whether or not the child is over­weight or there ap­pears to be any­thing wrong. If the blood-pres­sure read­ing is recorded in an elec­tronic health record, the com­puter does the nec­es­sary cal­cu­la­tion to de­ter­mine if the read­ing is nor­mal.

To pre­vent this exam from be­ing over­looked, Kael­ber sug­gested that par­ents gen­tly nudge the prac­ti­tioner by ask­ing, “By the way, how is my child’s blood pres­sure do­ing?”

If, based on the chart, blood pres­sure is above nor­mal, the guide­lines of­fer clear fol­low-up pro­ce­dures, for ex­am­ple, when to recheck the child, whether to pre­scribe life­style mea­sures such as di­etary changes and phys­i­cal ac­tiv­ity or drug treat­ment, and when to look for a pos­si­ble un­der­ly­ing cause of blood pres­sure that is per­sis­tently el­e­vated de­spite treat­ment.

A di­ag­no­sis of high or el­e­vated blood pres­sure should be based on three con­sec­u­tive el­e­vated read­ings. Kael­ber noted that an un­der­ly­ing cause of hy­per­ten­sion is more com­mon in chil­dren than in adults, es­pe­cially in chil­dren younger than 9.

Flynn, chief of pe­di­atric nephrol­ogy at Seat­tle Chil­dren’s Hospi­tal, said his team, among oth­ers, solves a ma­jor prob­lem in get­ting an ac­cu­rate blood­pres­sure as­sess­ment by us­ing an am­bu­la­tory blood-pres­sure mon­i­tor for 24 hours on ev­ery child with a high read­ing. In 30 per cent to 40 per cent of cases in which of­fice blood-pres­sure read­ings are con­sis­tently el­e­vated, the cause is so-called “white­coat hy­per­ten­sion” – mean­ing the child is sim­ply stressed from see­ing a doc­tor. The mon­i­tor, which is a lit­tle big­ger than a smart­phone, takes many mea­sure­ments dur­ing the child’s nor­mal wak­ing and sleep­ing hours.

The mon­i­tor has the added ad­van­tage, Flynn said, of greatly re­duc­ing the num­ber of chil­dren who must un­dergo fur­ther test­ing to de­ter­mine why their blood pres­sure is high, sav­ing both money and stress on the fam­ily and the health-care sys­tem.

It’s great to have guide­lines, but they’re only as good as the peo­ple who ac­tu­ally fol­low them. Dr. David Kael­ber Pe­di­a­tri­cian and in­ternist at the MetroHealth Sys­tem in Cleve­land

PAUL ROGERS/NYT

The Amer­i­can Academy of Pe­di­atrics has pub­lished a re­port up­dat­ing its guide­lines for screen­ing and man­ag­ing high blood pres­sure in chil­dren. The re­port in­cludes a much-sim­pli­fied chart to help physi­cians read­ily de­ter­mine whether a child’s blood pres­sure is within nor­mal pa­ram­e­ters.

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