Childhood Hypertension – PediaCast 268

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Join Dr Mike and Dr Andrew Schwaderer in the PediaCast Studio as they discuss childhood hypertension. From diagnosis and treatment to complications and prevention, we cover the ins and outs of high blood pressure in kids.

Topics

  • Nationwide Children's Hospital Columbus Marathon

  • Childhood Hypertension

  • High Blood Pressure

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Transcription

Announce 1: This is PediaCast.

[Music]

Announce 2: Welcome to PediaCast, a pediatric podcast for parents.  And now direct from the campus of Nationwide Children's, here is your host Dr. Mike.

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast, it is a pediatric podcast for moms and dads, this is Dr. Mike coming to you from the campus of Nationwide Children's Hospital.  We're in Columbus, Ohio it is October 16, 2013, it's episode 268 and we're calling this one childhood hypertension. I want to welcome everyone to the program. We have another nuts and bolts show lined up for you today and this week it is on the topic of hypertension, also known as high blood pressure.

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I think most of you out there think of high blood pressure as an adult disease, and of course there are plenty of moms and dads, and grandmas and grandpas who have high blood pressure.  But hypertension can also be a problem during childhood, and our plan today is to explore that, what is the definition of high blood pressure in kids?  When should screening start?  How high is too high?  And what about anxiety and pain, can those result in an elevated blood pressure reading at the doctor's office, or an urgent care, or the emergency department, and if so how do you tell the difference between high blood pressure from anxiety or pain and a real honest to goodness problem.  If a child does indeed have hypertension, what causes it?  How do you treat it?  What complications can arise if you don't treat it?  And what complications can arise from the treatment itself?  And what about prevention, care and a long term outlook?  All these questions we're going to answer, plus the hottest topics in the world of childhood hypertension research.

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That is all coming your way and as usual I have a fantastic studio guest lined up to talk about it, Dr.  Andrew Schwaderer is a pediatric kidney doctor here at Nationwide Children's Hospital, we'll get to him in a moment.  Before we do, those of you living in Central Ohio, we are just four days away from the 34th running of the Nationwide Children's Hospital Columbus marathon and half marathon.  That's right, this Sunday is marathon day, so be prepared for close street and snarled traffic, but it's for a good cause, and we're excited about the race which by the way is completely booked with 18,00 athletes ready to run the course.  The Nationwide Children's Hospital Columbus marathon is the 16nth largest marathon in the United States, and it's one of the top marathons to qualify runners for the Boston marathon, which is impart because Central Ohio is so flat. The Race starts near the intersection of Broad and 3rd streets in downtown Columbus at 7:30 in the morning on Sunday, October 20th.

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I'm inviting participants to a large portion of the city including the iconic Ohio stadium on the campus of the Ohio State University.  And like last year, the course is going to be divided in to 24 miracle miles with patient champions on the course ready to cheer on participants, so get lined up early, I promise to be a wonderful all day full of passion and memories.  If you like more information including a map of the route and biographies of this year's patient champions, just look on the show notes for this episode 268 at pediacast.org and I'll provide links for you to get you pointed in the right direction.  One more item before we get started, PediaCast is your show so if you have a question for us, or you'd like to suggest a topic or point us in the direction of a news article or research article, it's easy to get in touch, just head over to pediacast.org and click on the contact link.  I do read each and every one of those that come through so just write a line and we'll try to get your comments or your question on the show.

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Also I want to remind you, the information presented in PediaCast is for general educational purposes only, we do not diagnose medical conditions or formulate treatment plans for specific individuals.  If you do have a concern about your child's health make sure you call your doctor and arrange a face to face interview and hands on physical examination.  Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org.  We'll get Dr. Schwaderer settled in to the studio and be back to talk to him about high blood pressure right after this.

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Dr. Mike Patrick: We are back, Dr. Andrew Schwaderer is a pediatric nephrologist, also known as a renal or kidney doctor here at nationwide Children's Hospital and an associate professor of pediatrics at the Ohio State University, College of Medicine. Dr. Schwaderer serves as the research director for the section of nephrology and he joined us in the PediaCast studio nearly a year ago to talk about urinary tract infections and vesicoureteral reflux that was PediaCast episode 235.  He's back today to talk about childhood hypertension, so it's with a warm returning welcome that we say hello to Dr. Schwaderer.  Welcome back to PediaCast.

Dr. Schwaderer: Thank you, I'm glad to be back.

Dr. Mike Patrick: We are glad to have you.  Let's just start with a simple definition, what is meant by the term hypertension?

Dr. Schwaderer: What hypertension means is the pressure of the blood in our arteries is consistently above and beyond what our body is designed to handle.

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Dr. Mike Patrick: And do we have a specific definition of what would constitute hypertension at a given age?

Dr. Schwaderer: Yes, in adults it's easy, it's one simple number, if it's above 140/90 it's considered hypertension, and if it's above 120/80 but less than 140/90 it's considered pre-hypertension.  In children it's more complex, the blood pressures can vary by age, gender, and height.  So we have a variable we call the 95th percentile, a large number of children are screened and the top five percentile readings for certain age, or certain gender, and a certain height are considered hypertension levels.

Dr. Mike Patrick: Then you could really look up at child's what the 95th percentile of what their blood pressure should be based on their age, weight, height?

Dr. Schwaderer: According to their age, gender, and height.

0:06:58.6

Dr. Mike Patrick: Oh age gender, and height sorry.  Now you mention those two numbers like the 120/80 or 140/90, what do each of those numbers really?  What are those measuring?

Dr. Schwaderer: The top number is referred to as the systolic reading, and that is the pressure in the arteries when the heart is contracted, the bottom number is referred to as the diastolic reading, and that is the pressure in the arteries when the heart is relaxed.

Dr. Schwaderer: I think some parents maybe scratching their heads out there and thinking why did Dr. Mike have a renal or kidney doctor come on the program to talk about something that's happening in the arteries and the blood vessels?  Why is it that this wouldn't necessarily be a cardiologist that we would bring into the studio?  Why do kidney doctors typically take care of blood pressure problems?

Dr. Schwaderer: Kidney doctors take care of blood pressure problems because in children there is a higher rate of kids that have high blood pressure that's caused by an underlying problem, usually that underlying problem is in the kidneys.

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Dr. Mike Patrick: How common is this problem, and who exactly is affected in terms of childhood hypertension?

Dr. Schwaderer: Unfortunately it's both common and increasing.  If we went back to the 1970's and 1980's, about one percent of children would have hypertension, at present the estimates range from 3.5 to 5%.  In terms of who's affected, some populations are at high risk.  If we look at children that are obese, their rates of hypertension can be as high as 10 to 15% the same for certain race and ethnicity.  For instance Mexican-Americans, African-American children have higher rates of hypertension, and their certain medical conditions, I mentioned kidney diseases being a problem with high blood pressure in kids that have chronic kidney disease where they have some permanent damage to their kidneys have rates of high blood pressure up to 60%.

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Dr. Mike Patrick: We don't want to completely discount the cardiologist and certainly congenital heart disease could be another reason that a baby might present with high blood pressure, it's not just the kidneys.

Dr. Schwaderer: Actually most high blood pressures are not caused by the heart, there's one condition called the coarctation of the aorta where the main blood vessel coming out of the heart is narrowed, and that is the one heart condition that's associated with high blood pressure, most of them are not.

Dr. Mike Patrick: What about different age ranges, do you see childhood hypertension more at certain ages or is it pretty much spread out from infants, to toddlers, to children, to teens?

Dr. Schwaderer: There is a small peak for kids that are pre-mature and in the neo-natal intensive care unit, it is lower for small children then increases as children progress into adolescence.

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Dr. Mike Patrick: Do you think there's a genetic component to this as well?  I guess if you see differences from one culture to another, or one ethnic group to another, there's probably some genetic component to this?

Dr. Schwaderer: Kids that don't have an underlying problem causing the high blood pressure almost always have a family history, there's a strong genetic component to most hypertension.

Dr. Mike Patrick: And you mentioned that increase in incidence today compared to the 1970's, and we also were seeing an increase in obesity, do you think that's the main reason for that increase in hypertension, or is there something else going on?

Dr. Schwaderer: It's most likely obesity but certainly dietary changes in terms of eating more salty foods, more processed foods might also be contributing.

Dr. Mike Patrick: And diagnosis I would think would probably do more screening, or look at that blood pressure number and do something about it where is in the past maybe more kids have hypertension that just wasn't diagnosed.

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Dr. Schwaderer: The past it was easy, a child might have a blood pressure and it would be high if it was above 117/70 for instance which seems like a normal blood pressure for adults, so in the past it was often under recognized.

Dr. Mike Patrick: Let's talk specifically then causes of hypertension, you had mentioned that kidney disease for instance often results in hypertension.  Can it take us down to the tissue or cellular level and maybe not quite cellular?  Just give us an idea of how a problem in the kidneys would cause a blood pressure issue.

Dr. Schwaderer: Kidney disease can cause blood pressure issues in a variety of way, it can be an issue where there's not enough blood getting to the kidney.  The kidney realizes that there's decrease blood flow once more so will create hormones that increase the blood flow and can cause high blood pressure.  It can also cause high blood pressure when there's inflammation in the kidney, we see this when there's inflammations of the filters of the kidneys.

0:12:00.4

When kids have recurrent urinary tract infections, they can have scars of the kidneys.  We discuss this last time when we talked about the UTI's and vesicoureteral reflux, and that's a very common cause of high blood pressure particularly in girls that have UTI's.

Dr. Mike Patrick: So the kidneys are really trying to get more blood flow and they do that by increasing blood pressure and the rest of the body sort of suffers along with the needs of the kidney?

Dr. Schwaderer: Throughout those inflammations they secrete more hormones that cause high blood pressure when they really should not be.

Dr. Mike Patrick: For children, if you look at hypertension in adults, and correct me if I'm wrong, but I would think that the majority of hypertension in an adults is just what we would call essential hypertension such as kind of that we don't really know exactly why it happens and it's most likely to be genetic.  But in kids it's a little bit different that hypertension is more likely to be caused by an underlying medical condition such as a kidney problem.

0:12:56.7

Dr. Schwaderer: Historically essential hypertension where we aren't able to define a reason why it's being caused is still the most common, but the more high the blood pressure is and younger the child, the more likely they are to have something causing it such as the kidney problem.

Dr. Mike Patrick: What about signs and symptoms, is the only way to find out if you have hypertension through screening or there's some symptoms associated with hypertension that might give a parent a clue that that's a problem in their child?

Dr. Schwaderer: Most high blood pressure is silent, the American Heart Association refers to it as the silent killer because of the problems it can cause later in life.  Historically several symptoms have been attributed to blood pressure, it's uncertain to how much are those are really caused by blood pressure or just a casual association.  Most people think of headaches is being associated with high blood pressure, and with people that have a rapid increase in blood pressure, we do see patients that have very high blood pressures and headaches that resolve as soon as the blood pressure is treated.

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Dr. Mike Patrick: Nose bleeds are another one that often families will come in and be concern that their child has had recurrent nose bleeds and could that be a blood pressure problem?

Dr. Schwaderer: Only if the blood pressures very high, most nose bleeds are caused by allergies plus headaches are caused by migraines or tension headaches or other causes.

Dr. Mike Patrick: What about hypertensive crisis?  If someone had extremely high blood pressure, what sort of symptoms could you see in that case?

Dr. Schwaderer: In that case we would see headaches, we had possibly seen nose bleeds, we often see blurred vision or visual changes if the blood pressure is high enough, sometimes we can even see seizures.

Dr. Mike Patrick: We want to avoid that obviously if possible.

Dr. Schwaderer: A hypertensive crisis is an emergency, and that's something we want to avoid or treat very quickly.

Dr. Mike Patrick: One of the reasons that screening is so important and getting into see your pediatrician on a yearly basis to have blood pressure screened at that point.  When do you recommend that blood pressure screening be started?

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Dr. Schwaderer:  The blood pressure is screened for when a baby is born, and then yearly after their three years of age.  There's certain condition where kids might be a more risk for blood pressure when they more frequent screenings.

Dr. Mike Patrick: When kids go in to see the doctor, a lot of times there's some anxiety involved, or there may be some pain involved if they're there for injury or they know they're going to get immunizations.  We do know that high blood pressure can also be caused by pain or anxiety, how do you tell the difference between what's a real high blood pressure and what is just falsely elevated because of the emotional and environmental conditions that a child is in?

Dr. Schwaderer: First we have to make sure the blood pressure is checked for correctly.

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It can be pain, anxiety, stress, but it can also be a cuff that's too small, or a child that hasn't measured over their sleeve rather than on their arm and it's measured in their leg rather than their arm which results in higher blood pressures.  The next important point is that the blood pressure has to be high on multiple occasions because at any given time there might be anxiety, stress the patient might have just exercised, there could be a number of things that would cause our blood pressure to be high, but it's not something where the patient would have sustained high blood pressure or just be a normal physiologic response to the conditions we mentioned.

We often have the patient checking in something outside of the medical office setting so they can have a check at home or we even have a technique where we do a 24 hour blood pressure monitoring.  What we have a monitor that checks a blood pressure every so many minutes for 24 hours, and it records it when they're sleeping and clearly at that point anxiety and pain should not be a factor.

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Dr. Mike Patrick: Do you find the difference between checking a blood pressure the old fashion way, with the cuff and someone listening versus the automated blood pressure machines is there ever a time when there's a preference of one over the other, or the automated ones pretty accurate?

Dr. Schwaderer: The automated machines are fairly accurate, where I've seen them give readings that I am concern aren't accurate are usually in young children that are very anxious, that are moving or very wiggly and then often we have to go back and do a manual to confirm that the blood pressure's accurate.

Dr. Mike Patrick: I think back in episode 263 we talked about research that was published in the journal Pediatric, it was a collaborative effort with Kaiser Permanente, Colorado and Northern California and also health partners in Minnesota, and they looked at 72,000 kids and 6,000 of them, so 8.4% had at least one visit where elevated blood pressure was recorded and they were asked to come back for a re-check and only 20% of them in the study group returned for subsequent screening and 80% of them did not return to get their blood pressure rechecked.

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Of those who returned, so of that 20% only 1.4% went on to have it diagnose as sub-childhood hypertension where they had three readings at different times that did show it.  But the authors pointed out that if you look at 1.4% of the 80% who did not return in this 72,000 kids or probably 67 of them with undiagnosed hypertension because they didn't return and 67 out of 72,000 kids may not seem like a lot, and my point was just unless one of those 67 kids is your kid.  Have you seen that where folks have one high reading that's recommended they get it repeated and then they don't show up?

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Dr. Schwaderer: I was a journal pediatrician before I was a kidney specialist and I saw that setting, when most patients come to our clinic there's already some kind of awareness that there's a potential problem, they need to see a specialist so usually we're able to get the follow up readings that we need.

Dr. Mike Patrick: Did you find when you are a general pediatrician that folks would have a high blood pressure and not necessarily return for their screening?  Would that your experience as well?

Dr. Schwaderer: It would happen at times, as I mentioned before most of the time blood pressure doesn't have symptoms with it, so it's often difficult to realize there's a problem when you feel just fine.

Dr. Mike Patrick: My point for parents would be, if someone does find an elevated blood pressure reading and they say "Well let's not get too concern about it yet," but make sure you follow up and get a re-check, make sure you do go and get that recheck done.

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Let's talk a little bit about, you have a kid who they do have three elevated readings at three different visits and the readings are above the 95th percentile for the child's age, gender or height.  Let's say that you do have that condition, what kind of work up do you do at that point to try to figure out what might be causing these high blood pressure readings?

Dr. Schwaderer: First we would want to interview the patient in the family and examine them and see if we could find a reason why their blood pressures are high.  Conditions that we would look for would be, are they overweight?  Do they have things in their diet or they consuming lots of energy drinks or caffeine?  Do they have symptoms of chronic kidney disease or other kidney disease such as blood in the urine, excessive thirst to urination, decrease energy that could signal some kind of underlying kidney disease?

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We would also screen even though we're kidney doctors for other body systems that could cause high blood pressures.  We would look at the pulses and listen to the heart and make sure there's not a heart condition, we would question whether they have snoring, a sleep apnea can be associated with high blood pressure, we would look for symptoms of hormonal problems that could cause high blood pressure which would be excessive sweating, excessive flushing especially at inappropriate times.  Next we would want to see if they have any symptoms that could be caused by the high blood pressure.  So we would screen for headaches, we would screen for the blurred vision, and measure the blood pressure and make sure that it's not markedly high to the point that something would need to be done immediately.  In terms of the screening test, we would perform a renal ultra sound, look for kidney problems, we would perform a urinalysis to look for blood or protein in the urine, things that could signal kidney damage, we would perform a complete blood count to look for underlying chronic disease.

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Dr. Mike Patrick: There may be some other test depending on what you find in the history in physical if there's a family history of a particular thing, or there's a concerning finding that would make you want to go down another route.

Dr. Schwaderer: In certain cases we would need do more extensive testing or look for some, or unusual causes of high blood pressure.

Dr. Mike Patrick: Once you've gone through this route, obviously if you find something, you're going to want to treat the underlying condition or if it's not related to the kidney, if it is a heart issue for instance then you would get a cardiologist involved, or if it's a hormone issue an endocrinologist might be someone that would get involved, they're like a thyroid problem or something like that.  But aside from their being an underlying medical condition that you're dealing with, what sort of things do you do to treat childhood hypertension?

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Dr. Schwaderer: The first thing that we would want to do in most cases is see if lifestyle changes could treat the high blood pressure.  If the blood pressure is markedly higher, if there's underlying cause there might be a reason just to go straight to a medicine.  But in most cases if the patient has a high salt diet they may need to decrease the sodium in their diet, there's a diet called the dietary approach to stop hypertension or DASH diet.  That is well studied in adults and can lower the blood pressure, and there's beginning to be some studies in children to show its effective too, it consist of high fruit intake, high vegetable intake, low red meat intake, and low processed food intake, and that would be recommended.  The next step we would want to do is, if those were ineffective or if they had dietary changes like if they were having lots of energy drinks they would need to cut out the caffeine for the energy drinks as well.  If those were ineffective or if the blood pressure was very high we might need a medicine.

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Dr. Mike Patrick: What kind of groups of medicines and how they work, obviously we don't want to go on to the like a pharmacy class but I think some moms and dads would be interested in what different sorts of medicines can decrease blood pressure and how they work.

Dr. Schwaderer: In general, to start out, we would use a medicine that would have the least likely chance of causing side effects and we would start with a very low dose.  With that being said, there's several classes of medicine we have to choose from, and the primarily once used in children are either calcium channel blockers which indirectly relax the blood vessels and can lower the blood pressure, or ace inhibitors which decrease the secretion of a hormone in the kidneys that can cause high blood pressure.

Dr. Mike Patrick: I do want to go back to diet here for just a moment, you mentioned salt intake.  Is that salt always a bad thing?  Should parents not add extra salt to their kids' food, or is it only an issue for those with blood pressure problems?

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Dr. Schwaderer: Some people are salt sensitive, in general less salty foods is better for all of us, but in terms of blood pressure, decrease salt intake will only be recommended for kids that have high blood pressure.  And many of those kids, their blood pressure will improve for every gram of salt they decrease on the diet, the blood pressure will go down by about half a point.

Dr. Mike Patrick: I also want to point out, we have had discussions on this program before, there're some medical conditions that actually increasing salt intake may help if folks have problems with lower blood pressure.  Does salt influences blood volume so that if you have a higher intake of salt, then your blood sodium level is going to want to increase.

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And so you have then more water component of blood to dilute the sodium back to where it ought to be and then you have increased volume which then increases blood pressure, and then you could say the opposite if you lower the salt intake your blood sodium is going to be less and your body's going to want to take out volume in order to get the level of sodium back in the range where it wants to be and so you decrease blood volume.  Am I off on that, or is there some other mechanism that by which salt influences blood pressure?  

Dr. Schwaderer: Conceptually that's how I explain it to families as well, it's probably an over generalization, it also can over tell our kidneys regulate the hormones and do some other things as well.

Dr. Mike Patrick: It's true but it's probably more complicated than just that, correct?

Dr. Schwaderer: Yes.

Dr. Mike Patrick: In terms of untreated hypertensions.

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We know that there is no, unless it's extremely high you're not really going to expect to see any signs or symptoms from it, so then someone might ask, well why we are even bothered with it?  Why treat it if it's not causing a problem?  But signs and symptoms are different than what's really happening internally.  Can you just discuss a little bit of the complications that can arise even though there aren't any symptoms from untreated hypertension.

Dr. Schwaderer: High blood pressure is hard on several aspects of our body, it can affect the blood vessels.  It affects the blood vessels on the cellular level and causes a phenomenon called as remodeling where our blood vessels aren't as elastic in able to dilate with changes in blood pressure or volume and that can cause high blood pressure, it can cause thickening of the arteries or arteriosclerosis which can lead to heart disease going to the heart.

0:28:03.2

It can cause the heart to become thick if our blood has to pump against the higher pressure it will get bigger muscles just like if lift weights we get bigger muscles.  It's good of we lift weights but with our heart it's not good.  And in some cases that can even lead to heart failure mostly in the adult range, it can affect the kidneys, it puts extra stress in the kidneys and can cause a very slow progressive decrease in renal function or chronic kidney disease and it can also affect the brain, and adults it's well known to cause strokes and the risk factor for that and kids we'll talk about this more when we talk about research that's were beginning to realize it can affect how a childhood brain learns and how our cognition develops.

Dr. Mike:  Some of these complications then may not really be diagnosed until adulthood, but if the problem and damage is starting in childhood obviously we would want to get ahead of the curve and treat it as soon as we know about it.

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Dr: Schwaderer: That's an important concept, it's easy to take a medicine if for instance you're really hurt and you take a medicine for seven days to make the otitis media, or ear infection be treated and the pain to get better.  With high blood pressure or hypertension, we're protecting the child for 10, 20, 30 years down the road and at the time they have no symptoms, they might actually even feel different in some cases when they're being treated with blood pressure medicines, so it's an important concept that people understand.

Dr. Mike Patrick: We talked about complications with untreated hypertension, just to be fair there can be some complications with the treatment, what sort of things could occur with the treatment for hypertension?

Dr. Schwaderer: The first major complication of treatment that we want to work hard to avoid is over treatment.  When we start a blood pressure medicine, we started at a very low dose and then we increase it very slowly.  If we were to give too much blood pressure medicine, you might have low blood pressure, in which case you would be potentially dizzy or light headed particularly if you stood up rapidly.

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Some of the medicines can have side effects.  We mentioned calcium channel blockers before, they can cause flushing and headaches in some patients, we mentioned ace inhibitors which are the ones that work at the kidney level, they can cause a dry cough that doesn't go away unless you stop the medicine, and then there's other medicines that we use less commonly in kids because they do have more side effects, this would be diuretics or water pills which to help with your blood pressure are used commonly in adults, kids would often have to go to the bathroom more, they can cause some imbalances in salts in our blood stream and cause some muscle cramps.  And there's another medicine called beta blocker that is often used in adults too, we use less commonly in kids and it can cause exercise intolerance.  If the child isn't involved in organized sports they will notice the difference in their performance on these medicines.

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Dr. Mike Patrick: What is the long term outlook for kids with hypertension?  Does it become more difficult to manage as time goes on?  Is there the possibility that they could be weaned off of their medicines and the hypertension would just go away on its own?  Or is it something that could go away and then flare back up as an adult.  What is that look like in terms of from childhood into adulthood?  What are some of the possibilities?

Dr. Schwaderer: Unfortunately we don't know, we've never had a good study where we followed children into adulthood with high blood pressure.  We require very long time period of observations so that's difficult to do, conceptually I'm concerned about our children with high blood pressure.  If you get high blood pressure in your 20's, or 30's, or 40's we know into adulthood that it can progress to the complications with the blood vessels, with the heart, with the brain that we previously discussed.  With children they have a longer time period of potential exposures to the high blood pressure, so conceptually they would be more risk for these complications over time.

0:32:02.9

Certainly in the pediatric age range, if we treat the high blood pressure we notice that we can limit progression to this, and organ damages for instance we often screen children with high blood pressure with an ultrasound to look for the thick heart and then we can follow it over time to see if the heart is getting too thick or not.  In cases when kids have a thick heart starting out, if we appropriately treat the blood pressure, there have been studies that show that the heart can go back to a normal size.  Other children that have underlying causes for instance if they're obese and they do the lifestyle modifications and get their rate and weight gain in under control, can come off a blood pressure medicines, or have decrease needs for blood pressure medicine in the future, if they have underlying kidney disease and some cases for instance if there's a scar kidney that's not functioning it can potentially cause high blood pressure at times we'll have that removed or if there's a narrowing of the artery going into the kidney causing high blood pressure, that can be fixed and the high blood pressure can resolve totally.

0:33:09.0

Dr. Mike Patrick: It really kind of depends on what sort of high blood pressure, whether there's an underlying medical cause or whether it's essential hypertension.  Now with essential hypertension, is it been your experience that once you've put a child on a medicine for that as long as you see them at least into adulthood that they have to be on that medicine, or can they be weaned off of it?

Dr. Schwaderer: Most likely, some children eventually will become more diligent in doing dietary modifications or other lifestyle changes, will learn stress relief techniques.  I have had children with essential hypertension that have been able to come off, but most of the time it would be considered a lifetime need to be in blood pressure medicine.

Dr. Mike Patrick: For the kids who could come off, do they start to have symptoms of low blood pressure, is that how you get the idea that maybe they can't be weaned off of this, or is it something that you purposefully say, "Hey we're going to try to wean you off of this", even though things seem to be going well.

0:34:05.6

Dr. Schwaderer: Yes, if they are not on too high dose of a medicine, sometimes if they are able to demonstrate that they are following instructions for the lifestyle modifications for the dietary changes, we can try them off the medicine for a period and then monitor their blood pressure and see if it remains high or not.

Dr. Mike Patrick: Is there a way to prevent hypertension from happening in the first place?

Dr. Schwaderer: Again that depends on the underlying ideology, if we're at risk for high blood pressure, if we have a family history of high blood pressure, diligence would be called for in terms of watching your diet, avoiding salts, not having excess of caffeine, avoiding smoking and certain things that could either cause the high blood pressure or potentially contribute to the damage that high blood pressure causes.

0:35:00.3

Dr. Mike Patrick: There are some risk factors that we have some control over and then there's some risk factors that we really don't have control over and obviously the one's that we could control are more like things have it wise not smoking, making sure that we're eating healthy diets and that we're exercising and that sort of thing.  I guess another would be identifying in treating underlying medical conditions, so if you know a particular kidney disorder runs in the family then you're more likely to want to be screened for that disorder at an earlier age.

Dr. Schwaderer: There's certain conditions where the patients are more risk for high blood pressure, if you have diabetes along without high blood pressure you can have many at the same in organ effects that we describe for hypertension same thing with chronic kidney disease.  Those patients need to be extra diligent to having their blood pressure monitored and properly more aggressive treatment is called for.

Dr. Mike Patrick: And then because we always talk about this with each disease process that we cover, is there the possibility of a cure for hypertension?

0:36:03.8

And I guess we've really kind of talked about that, I mean if you have an underlying condition that's causing the high blood pressure and you get that taken care of, then obviously the blood pressure is going to be cured unless that condition flares back up.  But for essential hypertension there's really just medicine there's no way to make that go away.

Dr. Schwaderer: No, that's something that's intrinsic to the particular individual and neither needs be controlled with medicine or needs be controlled with lifestyle modifications preferably.

Dr. Mike Patrick: What are some of the hot topics in high blood pressure research in kids that are going on right now?

Dr. Schwaderer: There's several areas where active research is taking place, one of them is what medicines can we give to children.  Historically many medicines were tested in adults and were safe and effective on adults but doesn't necessarily mean that they're safe and effective in children.  Even at present 30% of blood pressure medicines aren't tested in kids under six and approved by the FDA for the treatment of high blood pressure.

0:37:04.2

So testing medicines that are used in adults in the pediatric populations and obtaining FDA approval is an area of active research.  We mentioned the effects of the body that can be caused by high blood pressure.  These are not well studied in children, so there's active research taking place on how it affects the brain, does it cause decrease in short term memory increase in ADHD symptoms, decrease in mental flexibility and there's increasing evidence that it does.  We're learning new ways to monitor for the effects of high blood pressure, we mentioned the measurement of the thickness of the heart particularly the left ventricular part that pumps the blood to the body of the heart.  We're looking at thickness of the carotid artery in some other measures that are used in adults that we don't know yet or not in children.

0:37:59.4

In terms of what causes blood pressure, we're finding out that there's certain factors that might contribute to even what we term essential hypertension, now even though we don't know what the cause is and we know there's a genetic contribution we don't know what's causing it.  There's increasing evidence that's substance called uric acid plays a role, particularly when obesity is present.  Too, this is a substance that is normally been attributed to gall or kidney stones and there's some trials where we're looking at medicines that lower uric acid and demonstrating that it improves blood pressure.

Dr. Mike Patrick: One of the things that is great about being involved with a children's hospital is diverse and as large as Nationwide Children's.  We have a great nephrology renal clinic here and with several kidney doctors such as yourself that see kids that are referred by primary care doctors who they might be concerned, tell us a little bit about the renal clinic here and how that referral process works.

0:39:03.0

Dr. Schwaderer: If a child has high blood pressure and their primary care provider's office, and it's high on three repeated occasions they're often referred to us for further work up and evaluation.  At times the initial work up I described will be take place in the primary care setting, other times they will be sent for us to complete that.

Dr. Mike Patrick: I do want to point out so that's something that I think a lot of families have in their mind that this is kind of a black or white sort of thing, either you're going to go see the nephrologist or you're not, but primary care doctors can get in touch with you guys to bounce off of you, what the readings are, or maybe what the family history is, and maybe even star a work up suggestions from you before they would actually come to see you.  And I want to point out because I know that we do have lots of family practice doctors and pediatricians and nurse practitioners in our audience.

0:40:04.3

And I'm going to put on the show notes, I've not really talked about this before because this podcast is primarily aimed moms and dads, and each show we do let folks know that there's a link in the show notes where they can get in touch with the hospital in terms of having an advocate to help with the referral process, if a parent wants to get in to see a specialist.  But we also have a resource for physicians where they can have 24 hour access to any of our specialists and it's called the Physician Direct Connect Line, and it's basically a phone number and I'm going to put that phone number in the show notes.  It's also available on children's hospital website, but I'm going to put it in the show notes over at pediacast.org because I think it's something that physicians and nurse practitioners ought to have handy and basically put you directly in connection with one of our specialist if you have a question they may be able to help you out.  We really appreciate you stopping by and talking to us about hypertension, I really appreciate that.

0:41:09.6

Dr. Schwaderer: OK, thank you, I'm glad you invited me.

Dr. Mike Patrick: We do have several links also in the show notes for you this week the Nationwide Children's Hospital Columbus marathon and the 2013 Nationwide Children's Hospital Columbus marathon patient champion, if you like to read their biographies those will be in the show notes for this episode 268 over at pediacast.org we also have a link to the pediatric nephrology division at Nationwide Children's Hospital and then we do have an article in the children's hospital health library on high blood pressure in children and adults, so I'll put a link to that in the show notes as well.  And then again we'll have that physician direct connect line the local number as well as the 1-800 number so that practitioners out there can use that and get in direct connection with one of our specialist if you need to.  We are going to take a quick break and I'll be back to wrap up the show right after this.

0:42:04.3

[Music]

Dr. Mike Patrick: I want to just thank each and every one of you for listening to the program this week, I really appreciate our listeners and all the support that you've given us through the years.  I also want to thank Dr. Andrew Schwaderer for stopping by and chatting up childhood hypertension with us.  Don't forget PediaCast and our single topic short format programs which we call PediaBytes those are both available for you on iHeart Radio Talk which you'll find on the web and inside the iHeart radio app for mobile devices.

0:43:07.3

So there's an android one and one for iPhones and iPods as well.  Reviews and comments on iHeart Radio and in iTunes would be most helpful, we also appreciate links, mentions, shares, re-tweets, re-pens all those good things on the various social media sites.  PediaCast is on Facebook, Twitter, Google Plus, and Pinterest and be sure to tell your family, friends, neighbors, and co-workers about the program.  Most of all tell your child's doctor, that's probably the most important thing that you can do to help spread the word about the program, just let your child's doctor know next time you're in for a well check-up, or a sick office visit that you listen to an evidence based pediatric podcast for moms and dads out in Nationwide children's Hospital and point them in the direction of pediacast.org so they can share this resource with their other patients, and we do have posters available under the resources tab at pediacast.org.

0:44:01.2

Once again in order to get in touch, just look for the contact link at pediacast.org and again I read each and every one of those that come through, so if you do have a question, or a topic suggestion, or want to point me in the direction of a new story or journal article be sure to do so, it's really easy to get in touch.  We're going to go ahead and wind things down and until next time this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids, so long everybody.

[Music]

0:44:41.1

 

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