Evaluation and management of elevated blood pressures in hospitalized children

Defining systolic blood pressure normative values in hospitalized pediatric patients: a single center experience

BACKGROUND

Normative blood pressure (BP) values and definition of hypertension (HTN) in children in outpatient setting cannot be reliably used for inpatient therapy initiation. No normative exists to describe HTN in hospitalized pediatric populations. We aimed to study the prevalence of hypertension and produce normative BP values in hospitalized children.

METHODS

Cross sectional observational study of all children hospitalized on acute care floors, ≥2 and <18 years age, at Stanford Children's Hospital, from Jan-01-2014 to Dec-31-2018. Cohort included 7468 hospital encounters with a total of 118,423 automated, oscillometric, BPs measured in the upper extremity during a hospitalization of >24 hours.

RESULTS

Overall prevalence of HTN, defined by outpatient guidelines, was 12-48% in boys and 6-39% in girls, stage 1 systolic HTN in 12-38% of boys and 6-31% of girls, stage 2 systolic HTN in 3-10% of boys and 1-8% of girls. Centile curves were derived demonstrating overall higher BP reading for hospitalized patients compared to the outpatient setting.

CONCLUSION

Higher blood pressures are anticipated during hospitalization. Thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances.

IMPACT

Hospitalized children have higher blood pressures compared to patients in the ambulatory setting, hence outpatient normative blood pressure values cannot be reliably used for inpatient therapy initiation. No normative exists to describe hypertension in hospitalized pediatric populations. The thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances.

Managing severe hypertension in children

Severe childhood hypertension is uncommon and frequently not recognised and is best defined as a systolic blood pressure (SBP) above the stage 2 threshold of the 95th centile + 12 mmHg. If no signs of end-organ damage are present, this is urgent hypertension which can be managed by the slow introduction of oral or sublingual medication, but if signs are present, the child has emergency hypertension (or hypertensive encephalopathy if they include irritability, visual impairment, fits, coma, or facial palsy), and treatment must be started promptly to prevent progression to permanent neurological damage or death. However, detailed evidence from case series shows that the SBP must be lowered in a controlled manner over about 2 days by infusing short-acting intravenous hypotensive agents, with saline boluses ready in case of overshoot, unless the child had documented normotension within the last day. This is because sustained hypertension may increase pressure thresholds of cerebrovascular autoregulation which take time to reverse. A recent PICU study that suggested otherwise was significantly flawed. The target is to reduce the admission SBP by its excess, to just above the 95th centile, in three equal steps lasting about ≥ 6 h, 12 h, and finally ≥ 24 h, before introducing oral therapy. Few of the current clinical guidelines are comprehensive, and some advise reducing the SBP by a fixed percentage, which may be dangerous and has no evidence base. This review suggests criteria for future guidelines and argues that these should be evaluated by establishing prospective national or international databases.

Hypertension, Blood Pressure Variability, and Acute Kidney Injury in Hospitalized Children

Background Although hypertensive blood pressure measurements are common in hospitalized children, the degree of inpatient hypertension and blood pressure variability (BPV) associated with end organ complications like acute kidney injury (AKI) is unknown. Methods and Results All analyses are based on a retrospective cohort of children aged 1 to 17 years with ≥2 creatinine measurements during admission from 2014 to 2018. We used time-updated Cox models to evaluate the association between BPV and hypertension with AKI. Time-varying BPV and hypertension were based on blood pressure in the preceding 72 hours. For the analysis of hypertension and AKI, we excluded patients on vasopressors to ensure comparison between hypertensive and normotensive patients. During 5425 pediatric encounters, 258 430 blood pressure measurements were recorded (median [interquartile range] 22 [11-47] readings per encounter). Among all measurements, 32.7% were ≥95th percentile and 18.9% were ≥99th percentile for age, sex, and height. AKI occurred in 389 (7.2%) encounters. We observed a U-shaped relationship between mean blood pressure and incident AKI. BPV was associated with AKI, with the largest effect sizes in the systolic and mean arterial pressure variability measures. Multiple hypertension thresholds were associated with AKI after controlling for confounders. In an additional multivariable model adjusted for BPV, the association between hypertension and AKI was attenuated but remained significant for hypertension defined as three stage 2 measurements in 1 day (hazard ratio, 1.43 [95% CI, 1.01-2.01]). Conclusions Hypertension and BPV are associated with AKI in hospitalized children. Future studies are needed to determine how pharmacologic and nonpharmacologic interventions modify AKI risk in pediatric inpatients with hypertension.

Case-control study exploring the short-term association of bronchiolitis with high blood pressure and hypertension in hospitalized children

BACKGROUND

Unlike in adults, there are limited pediatric data exploring the association between acute respiratory illnesses and blood pressure abnormalities. The aim of our study was to explore the association of bronchiolitis, a common respiratory illness, with elevated blood pressure in hospitalized children.

METHODS

In this single center retrospective case-control study, we evaluated the association between bronchiolitis and elevated blood pressure and hypertension in hospitalized children, compared to a control group admitted with nonrespiratory conditions, using multivariate regression analyses. Standard published normative data on pediatric blood pressure were used to classify children in various blood pressure categories.

RESULTS

A high prevalence of elevated blood pressure (16%) and hypertension (60%) was noted among children with bronchiolitis; this was not statistically different from the control group (18% for elevated blood pressure; 57% for hypertension; P-values, 0.71 and 0.53, respectively). On multivariate regression analyses, only length of stay was associated with hypertension. No patient with blood pressure abnormalities received antihypertensives nor were any nephrology consults documented.

CONCLUSIONS

A high prevalence of blood pressure abnormalities, without documentation of their recognition, was noted in hospitalized children regardless of diagnosis, pointing to the need for more data on outcomes-driven significance of pediatric inpatient blood pressure measurements.

How Routine are Routine Vital Signs?

BACKGROUND AND OBJECTIVES

Frequent measurement of vital signs has been associated with disruptions to sleep and increased nursing workload. Since vital signs are often measured at the same frequency regardless of patient acuity, there may be inappropriate prioritization of limited resources. We sought to understand what hospitalists report as the default frequency of routine vital sign measurement in hospitalized pediatric patients at academic institutions.

METHODS

We surveyed pediatric hospital medicine leadership at Association of American Medical Colleges-affiliated medical schools on their perception of routine vital signs in general medicine inpatients.

RESULTS

Survey requests were sent to individuals representing 140 unique hospitals. Responses were received from 74 hospitalists, representing a 53% response rate. Routine vitals were most commonly characterized as those collected every 4 hours (78%; 95% confidence interval, 67%-87%), though at least 1 in 5 hospitalists reported obtaining all or select vital signs (eg, blood pressure) less frequently. Strategies to decrease vital sign frequency varied.

CONCLUSIONS

Our results suggest routine vital signs are not a normative concept across all patient populations in pediatrics. We further identify several conditions under which deviation from routines are sanctioned.

Hypertension in Pediatric Acute Lymphoblastic Leukemia Patients: Prevalence, Impact, and Management Strategies

Acute lymphoblastic leukemia (ALL) is the most common cancer diagnosed in children under the age of 18. While modern diagnostic technologies, risk-stratification, and therapy intensification have led to outstanding outcomes for many children with ALL, the side effects and consequences of therapy are not to be underestimated. Hypertension is a well-known acute and chronic side effect of treatment for childhood ALL, although limited data are available regarding the prevalence of hypertension in children undergoing treatment for ALL. In this review of hypertension in pediatric ALL patients, we examine the existing data on incidence and prevalence during treatment and in pediatric ALL survivors. We describe independent risk factors for development of hypertension along with treatment-related causes. Long-term consequences and the risk to survivors of pediatric ALL are further defined. While many ALL patients require antihypertensive medications during some portion of their treatment, there are no clear guidelines on treating inpatient hypertension given challenges that exist in recognizing and managing hypertension in this setting and in this population. Here, we propose an algorithmic approach to diagnose and treat pediatric ALL patients with HTN, along with monitoring and continuation versus cessation of antihypertensive therapy as an outpatient.

Influence of Blood Pressure Percentile Reporting on the Recognition of Elevated Blood Pressures

OBJECTIVES

To explore the impact of displaying blood pressure (BP) percentiles with BP readings in the electronic health record (EHR) on the recognition of children with elevated blood pressures (EBPs).

METHODS

This was a retrospective cohort study of children (ages 1-17), including inpatients and outpatients, with at least 1 EHR noninvasive BP recording. In phase 1, BP percentiles were calculated, stored, and not displayed to clinicians. In phase 2, percentiles were displayed adjacent to the EHR BP. Encounters with 1 BP ≥95th percentile were classified as elevated. EBP recognition required the presence of at least 1 EBP-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision code. We compared recognition frequencies across phases with logistic regression.

RESULTS

In total, 45 504 patients in 115 060 encounters were included. Inpatient recognition was 4.1% (238 of 5572) in phase 1 and 5.5% (338 of 5839) in phase 2. The adjusted odds ratio (OR) associated with the intervention was 1.22 (95% confidence interval [CI]: 0.90-1.66). Outpatient recognition rates were 8.0% (1096 of 13 725 EBP encounters) in phase 1 and 9.7% (1442 of 14 811 encounters) in phase 2. The adjusted OR was 1.296 (95% CI: 0.999-1.681). Overall, recognition rates were higher in boys (outpatient OR: 1.51; 95% CI: 1.15-1.98) and older children (outpatient/inpatient OR: 1.08/1.08; 95% CI: 1.05-1.11/1.05-1.11) and lower for those on a surgical service (outpatient/inpatient: OR: 0.41/0.38; 95% CI: 0.30-0.58/0.27-0.52).

CONCLUSIONS

Addition of BP percentiles to the EHR did not significantly change EBP recognition as measured by the addition of an EBP diagnosis code. Girls, younger children, and patients followed on a surgical service were less likely to have their EBP recognized by providers.

Identification of hypertension in hospitalized children prescribed as-needed antihypertensive medication

Imperfect measurement conditions, transient blood pressure (BP) elevation due to pain or anxiety, and heavy clinical demands complicate hypertension (HTN) diagnosis in hospitalized children, and may prevent recognition of hypertensive episodes for children prescribed as-needed (PRN) antihypertensive medication. The authors sought to describe the incidence and predictors of missed BP elevation among hospitalized children prescribed PRN antihypertensive medication at our hospital. BP data were retrospectively audited for children age 2-18 admitted in 2018 to the general ward, and prescribed PRN oral nifedipine, intravenous [IV] or oral hydralazine, or IV labetalol. Appropriate recognition of BP elevation (exceeding the parameters in the medication order) was defined as administering medication within the ordered dosing interval, administering the medication earlier than planned, or physician documentation of why HTN treatment was withheld. Mixed-effects logistic regression was used to identify factors associated with recognition of BP elevation. Fifty-six hospitalizations including 616 BP measurements were analyzed. BP elevation was appropriately recognized in 230 (37%) instances, in most of which (n = 190) the antihypertensive medication was given after excessive BP was noted. On multivariable analysis, higher systolic BP and BP elevation occurring at night were associated with increased likelihood of appropriate recognition. BP elevations are frequently missed in hospitalized children prescribed PRN antihypertensive medication. Particularly, there was low recognition of diastolic BP elevation and of systolic BP elevation close to but still exceeding the ordered threshold. Further staff education may be needed to raise awareness of lower BP thresholds for HTN in younger and smaller children.

Frequency of moderate-to-severe obstructive sleep apnea syndrome among children with snoring and blood pressure in the hypertensive range

BACKGROUND

It is recommended that children with hypertension and loud snoring should be referred for polysomnography. We aimed to compare the frequency of moderate-to-severe obstructive sleep apnea syndrome (OSAS) among snorers with and without hypertension. Thus, it was hypothesized that systolic or diastolic hypertension among children with snoring is a risk factor for moderate-to-severe OSAS.

METHODS

Data of children with snoring and adenotonsillar hypertrophy and/or obesity referred for polysomnography were retrospectively analyzed. Blood pressure (BP) was measured three times in the morning after polysomnography and percentiles were calculated for the average of the second and third measurement. Association of systolic or diastolic hypertension with moderate-to severe OSAS (apnea-hypopnea index-AHI > 5 episodes/h) adjusted for age and obesity was assessed by logistic regression.

RESULTS

Data of 646 children with snoring (median age, 6.5 years; 3-14.9 years; 25.7% obese) were analyzed. Prevalence of systolic or diastolic hypertension was 14.1% and 16.1%, respectively and frequency of AHI > 5 episodes/h was 18.3%. Systolic hypertension was a significant predictor of moderate-to-severe OSAS (OR 1.87; 95% CI 1.10 to 3.17; P = 0.02) after adjustment for age and obesity, but diastolic hypertension was not (OR, 0.96; 0.55 to 1.67; P > 0.05). Odds of AHI > 5 episodes/h prior to considering systolic hypertension was 0.25 and after considering its presence, increased to 0.46 (Bayes' theorem), or for every three children with systolic hypertension and snoring tested, one had AHI > 5 episodes/h.

CONCLUSIONS

In the context of systolic hypertension and snoring, referral for polysomnography to rule out moderate-to-severe OSAS is a clinically productive practice.