Children and high blood pressure: Watch your child's weight
From MayoClinic.com
Special to CNN.com
Unhealthy snacks, sugar-laden sodas and too many hours playing video games are taking their toll on children. One very real problem these unhealthy habits may be contributing to is high blood pressure. Like diabetes, this condition, once thought only a threat to adults, is now striking more children, jeopardizing their potential for a healthy future.
Bruce Z. Morgenstern, M.D., chief of the Division of Pediatric Nephrology, Phoenix Children's Hospital, and a physician liaison at Mayo Clinic Scottsdale, Ariz., is one of the authors of new national guidelines on diagnosing and treating high blood pressure in children. Here, he explains how high blood pressure (hypertension) is threatening the health of toddlers, children and adolescents, and what can be done about it.
Why are more children developing this "adult" condition?
We have a nationwide epidemic of obesity, and there's a clear relationship between increasing fatness and increasing blood pressure. So if we see more obesity in children — and we are seeing that — we will see more high blood pressure in children.
Childhood obesity: What parents can do
Why worry about high blood pressure in children?
We are beginning to recognize that there are long-term health consequences in children with high blood pressure and that they need to be dealt with. The reality is that high blood pressure can cause stroke, heart failure and kidney disease in children, just as in adults. We even see changes in the way children think when they have hypertension. For instance, they may not do as well in math skills testing, according to one preliminary report. And being overweight, with or without having high blood pressure, can also put them at risk of other cardiovascular problems, as well as diabetes.
At which age should children start getting their blood pressure checked?
All children age 3 and older should get their blood pressure checked during routine medical visits. And they should also get their blood pressure checked at least once during a course of treatment for any acute illness. If the child has pneumonia, for example, and has two or three visits to the doctor, the blood pressure should be checked at least once.
How often should children have their blood pressure checked?
If it's normal at one visit, they should have it rechecked at the next scheduled physical exam. If it's slightly elevated, they should get it rechecked within six months. If it's high, there should be more measurements taken on at least two separate occasions, generally within a few weeks, to confirm that they truly have high blood pressure.
What if they're not having symptoms?
High blood pressure is a relatively silent condition. That is, it typically doesn't have symptoms, not until it becomes severe.
In some cases, even children under 3 should have their blood pressure checked?
Yes, in cases where they have certain health issues. Those include:
Prematurity, low birth weight or other neonatal complications
Congenital heart disease
Certain urinary or kidney problems
Organ or bone marrow transplant
Treatment with medications known to raise blood pressure
Illnesses associated with high blood pressure, such as neurofibromatosis
All of these are conditions in which there is a well-established risk of hypertension in infants and toddlers.
How is blood pressure classified in children?
Unlike in adults, blood pressure in children varies based on sex, age and height, so it's classified by percentile norms. This way, children aren't misclassified if they're very tall or very short.
What are the categories of blood pressure in children?
We categorize blood pressure by what percentile the child's average systolic or diastolic pressure falls in:
Normal. This means the child's average systolic or diastolic blood pressure is at the 89th percentile or lower for their sex, age and height. In other words, 89 percent of children of that sex, age and height would have blood pressure below this level.
Prehypertension. This is the precursor to full-blown hypertension. It means the child's average systolic or diastolic blood pressure is between the 90th and 94th percentile. In adolescents — ages 12 to 18 — it means the blood pressure exceeds 120/80 millimeters of mercury (mm Hg), up to the 95th percentile for their sex, age and height.
Stage 1 hypertension. This is high blood pressure in which the average systolic or diastolic pressure ranges from the 95th percentile up to 5 mm Hg above the blood pressure measurement at the 99th percentile.
Stage 2 hypertension. This is more severe high blood pressure, which means the child's average systolic or diastolic blood pressure is 5 mm Hg or more above the 99th percentile for their age, sex and height.
What causes high blood pressure in children?
Some children have an identifiable medical cause of their high blood pressure, most often related to diminished kidney function or abnormal blood flow to a kidney. When an identifiable medical condition causes high blood pressure, it's called secondary hypertension.
But for an increasing number of children today, there's no known medical cause. Their high blood pressure is called primary or essential hypertension. Poor lifestyle habits, such as an unhealthy diet and lack of exercise, are the most common risk factors associated with primary hypertension. And with the growing prevalence of obesity, we'll likely see more high blood pressure in children.
Can primary hypertension in children be prevented?
Changing modifiable risk factors may help. These are risk factors you can do something about. For instance, if the child is overweight or obese, he or she can try to lose weight through diet and exercise.
Smoking and drinking are also modifiable risk factors. Obviously you don't see a lot of that in 7-year-olds, but you may see it in adolescents — and secondhand smoke is a risk no matter what the age. Muscle-building steroids in athletic children and other street drugs may also contribute to an elevated blood pressure, as may excessive dietary sodium. Genetics also plays a role, but that's not a risk you can modify. Children who get more exercise and eat a healthier diet may be less likely to develop high blood pressure, even if they're genetically prone to hypertension.
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What if a child doesn't have outright hypertension but is a little overweight, doesn't get much activity and eats too much junk food? Should parents be concerned?
Yes, and that's because on average, children's blood pressure is increasing and that means they're at higher risk of health problems. It's also part of the reason why we now have a category of blood pressure called prehypertension. It's in the prehypertensive child that weight, diet and exercise become especially important because we can stop it from becoming full-blown hypertension.
A lot of our knowledge is based on the phenomenon of tracking. We know from long-term studies of adolescents and younger children that blood pressure tends to track over time. That is, if it's elevated when they're young, the odds are quite high that it'll be elevated in adulthood — again, putting them at risk of a variety of potentially life-threatening health problems.
Sensible approaches to children's weight problems
Besides diet and exercise, what else can parents watch out for?
They can watch for breathing problems their children may have while sleeping. There's no question that children who have sleep-disordered breathing, such as sleep apnea, have problems with hypertension, particularly children who are overweight. We are now recommending routine screening for sleep-related breathing problems, which can be done in about five minutes in the medical office.
Sleep apnea
What happens when a child is diagnosed with high blood pressure?
In general, we would take a three-pronged approach. We would see if we could find an identifiable, curable cause of the hypertension to distinguish between secondary and primary hypertension. We would also do tests to determine if the hypertension is causing any subtle organ damage, such as kidney disease or heart disease. And we would check for other modifiable risk factors for cardiovascular disease like you'd find in adults, such as high cholesterol. And then we would treat the high blood pressure based on those findings.
How is high blood pressure in children treated?
Much the same as in adults. For all children, positive, therapeutic lifestyle changes are important, such as weight management and getting more physical activity. Children should be encouraged to monitor how much time they spend in front of the television or computer and limit those activities to no more than two hours a day.
Like adults, they should get 30 to 60 minutes of physical activity a day. Following a healthier diet is also important, including increased intake of fresh fruits and vegetables, eating a healthy breakfast, and reducing consumption of sugary snacks and drinks.
Are lifestyle changes all that it takes to treat high blood pressure?
Healthy lifestyle changes can have a dramatic effect, but they're not always enough to control high blood pressure sufficiently. And some children may not make the extent of changes they need to in order to see a difference.
If lifestyle changes alone aren't effective enough after several months, some children may need medications to control their blood pressure. Children may also need medications immediately to treat their hypertension if they have certain other health conditions, such as diabetes, heart disease or kidney disease, or if the hypertension has started causing health problems. They're also more likely to need antihypertensive medications right away if their hypertension is more severe, such as stage 2 hypertension.
How long will they have to take medication?
There's usually no cure for hypertension. So, much like adults, children are likely to have to stay on blood pressure medication for a lifetime. However, if their high blood pressure is based solely on obesity and they can lose the weight, they sometimes can come off of the medications. While secondary hypertension can't be prevented, it can be cured in some cases, once it has been detected.
Aren't there risks from long-term or even short-term medication use in children?
Most of the antihypertensive drugs are remarkably well tolerated in children. Some of the side effects that adults complain about, like sexual performance, are not really an issue in children, except perhaps adolescents. There are extensive long-term studies in adults that suggest there are no long-term consequences of taking these medications, and that's reassuring.
In adolescents, we're more likely to encounter compliance issues. It doesn't matter what medication you want them to take, they may not want to take it. Not only does that mean their blood pressure may not be well controlled, but with some antihypertensive medications the risks of episodic compliance — starting and stopping the medication erratically — may be far greater than the risk of taking the medication consistently over the long term.
Aren't we just adding more labels to children with this talk of high blood pressure?
Infants used to ride in cars without car seats, children rode bikes without helmets and babies were put on their stomachs to sleep. Just because people didn't recognize these problems didn't mean the risks weren't there.
Likewise, we need to change people's feelings about high blood pressure in children, to make them more aware that it's a serious threat to their health. Just because most children don't have heart attacks at the age of 18 doesn't mean they aren't laying down the foundation of health problems that could kill them in their 50s.
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