Blood Pressure: Cases
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Blood Pressure Screening
Amy Lief, M.D.
Learning Objectives
- Understand the rationale for blood pressure screening in pediatrics and the basis for normal values.
- Describe the criteria for determining normal blood pressure versus hypertension.
- Know the proper technique for obtaining blood pressure of a pediatric patient.
- Know the differential diagnosis of hypertension across pediatric age groups.
- Delineate the approach to patients who have primary and secondary hypertension.
Primary Reference
- National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics, 2004;114(2 suppl): 555-76.
- American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Athletic Participation by Children and Adolescents Who Have Systemic Hypertension. Pediatrics, 1997; 99(4):637-638.
- Feld LG, Corey H. Hypertension in Childhood. Pediatrics in Review, 2007; 28(8):283-298.
- Flynn JT. Evaluation and Management of Hypertension in Childhood. Progress in Pediatric Cardiology, 2001;12:177-88.
- Luma GB, Spiotta RT. Hypertension in Children and Adolescents. American Family Physician, 2006;73(9):1558-1566.
- Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics, 1987;79(1):1-25.
The updated blood pressure tables for children and adolescents are based on recently revised child height percentiles and also include the BP data from the 1999-2000 NHANES. The tables are widely published, and can be found, among other places, in the Harriet Lane Handbook and online at: http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.pdf
Case 1A 4 year old girl is brought in by her mother for pre-op clearance for tonsillectomy, adenoidectomy and bilateral myringotomy tube placement next week. You review her chart and see that she has a history of numerous ear infections and chronic middle ear effusions that have affected her hearing. You confirm with her mother that her birth history was unremarkable and that she has no other significant past medical or surgical history. She is not taking any medications and does not have any allergies. She is receiving speech therapy and is doing well in pre-K. She has been growing along the 10th percentile for height and 5th percentile for weight. In the room, the child is cooperative and interactive. Physical exam is remarkable only for 3+ tonsils and bilateral serous effusions behind both TMs. You take her blood pressure (BP) and find that it is 128/88. No previous BP measurements are documented in the chart.
- What is a normal BP for this patient? What should your initial step(s) be?
- You confirm that the child’s BP was taken appropriately, and repeat measurements during this visit are similar. What is your differential diagnosis of hypertension in this child?
- What additional information would help you to make a diagnosis?
Case 2
A 15 year old boy comes to your clinic for an initial physical and the completion of a school form. His prior medical care was in South Carolina. His birth history and past medical history are remarkable only for a broken elbow at age 9 years. His growth and development have been normal, although his mom is concerned about his weight. He complains only of occasional headaches that occur about once a week and resolve with Motrin. He is in 10th grade, does not play sports, and likes playing video games and going to movies. No smoking, alcohol or drug use. His family history is significant for hypertension in his dad and diabetes in both maternal grandparents.
On physical exam you find an overweight teenager (height is 25% for age, weight is 90%, BMI is 27). He appears mildly anxious. You take his BP and it is 136/90. You confirm that the equipment and technique are appropriate for this patient, and repeat the BP and find 130/82. Pulse is 78. Cardiac exam is significant for a hyperdynamic precordium with normal heart sounds. Upper and lower extremity pulses are normal. The rest of the exam is normal. After the exam, repeated BPs range between 128-140/76-92.
- What is a normal BP for this patient? Can you make a diagnosis of hypertension at this visit?
- What about this patient’s presentation should be considered when evaluating him for hypertension? What else might you want to know?
- The patient returns to see you a month later. BPs have been obtained weekly by the school nurse. They are all abnormally high and you make the diagnosis of hypertension. What should be done next?
- Urinalysis, chemistries, lipids, and plasma renin activity are normal. Can you make a diagnosis at this point? Is treatment needed? Would any additional studies help you make this decision?
- If you were going to recommend an exercise program for this teenager, what activities should he be restricted from, if any?
Case 2 adapted from: Flynn JT. Teaching Case at Montefiore Medical Center, March 2001.