By Janus Kartal, RN, Katie Dart, RD, and Jens Goebel, MD

[Editor's note: Part 1 of this series appears in the March 2008 issue of aakpRENALIFE.]

Another helpful test is an echocardiogram, also called an ultrasound of the heart. With this test, the jelly-like substance is applied to the chest, and the technician moves the wand around on the chest, bringing images of the heart and adjacent large vessels to a screen. This test is helpful in determining if the high blood pressure has been a long standing problem. It will reveal a condition known as left ventricular hypertrophy (LVH). The heart is a muscle. If a child’s blood pressure is high, it creates increased resistance in the vessels through which the heart pumps blood and thus increase work demand on the heart. The heart muscle responds to this increased workload by increasing its size, essentially not different from any other muscle in the body. However, if the heart muscle grows too much, it can compromise its own blood supply, and LVH, therefore, is an ominous finding. An echocardiogram is also a helpful screening tool for coarctation of the aorta (as found in Tykster’s case told in Part 1) as the aorta is one of the largest blood vessels close to the heart that is seen during an echocardiogram.

While hypertension in children can have specific and even correctable causes, it can also require long-term treatment. The most basic and first step along these lines are therapeutic lifestyle changes (TLCs). A healthy diet and regular physical activity are important for people of all ages no matter what their health status, but a healthy lifestyle is especially important in the prevention and treatment of hypertension in children and teens. Healthy eating and regular physical activity help kids achieve or maintain a healthy weight, which can help reduce the risk of hypertension and heart disease.

According to the Center for Disease Control (CDC), 16 percent of children and adolescents ages 6-19 years were overweight between 1999-2002. This number continues to grow at an alarming rate. Overweight is defined as a body mass index (BMI) greater than the 95th percentile on the CDC growth chart. The BMI is based on a child’s height and weight as body weight in kilograms divided by the squared height in meters (kg/m2). A doctor can calculate and plot a child’s BMI at his/her next visit. Being overweight increases a child’s risk of many diseases, not just hypertension, but also type 2 diabetes, high cholesterol, stroke, heart disease, sleep apnea, some cancers, and problems with joints and bones. Type 2 diabetes used to be considered an “adult” disease, but now it is being diagnosed in children and teens as young as 10 years old.

The best way to help a child is to get the entire family involved in developing healthy eating and exercise habits. The National Institutes of Health (NIH) have published the DASH (Dietary Approaches to Stop Hypertension) Eating Plan (http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm). It has been shown to lower blood pressure in adults and is being recommended to treat high blood pressure in children. This eating plan consists of four to five servings of fruits, four to five servings of vegetables and three servings of lowfat dairy products daily.

Limiting processed foods can help lower sodium in a diet. Too much sodium may increase blood pressure. Some frozen meals, canned soups and canned vegetables, as well as pickles, soy sauce, and processed meats such as hot dogs, ham and sausage tend to be high in sodium. Look for products that say “no added salt” or reduced sodium if buying canned or packaged foods. Use herbs and spices to season pasta and rice instead of using the pre-packaged mixes. Avoid adding salt in cooking and fill the salt shaker with dried herbs or a salt-free flavoring. Foods can still be flavorful without salt; try red pepper flakes and garlic powder to start.

Eating out can make eating healthy difficult. Most fast food menu items are high in sodium and fat. However, there are healthy options available. If possible, review the menu before arriving at the restaurant and select a healthy option with the child before arriving. Many fast food chains offer fruits or vegetables instead of fries. AAKP also offers the AAKP Nutrition Counter which contains the nutritional values of 11 fast food restaurants and 300 commonly eaten foods. Call (800) 749-AAKP to order a FREE copy, or visit the AAKP Web site to download a copy.

Make it easy for a child to eat healthy by keeping only healthy snacks at home. Some examples include fresh fruits and vegetables, whole grain cereal, low-fat yogurt and unsalted nuts. Keep fresh fruit on the counter and cut up vegetables in an easy to spot part of the refrigerator. Get rid of any junk food so the kids aren’t tempted.

Physical activity is also an important part of a heart healthy lifestyle. Even if the child does not enjoy sports, find other ways to be active. Ask what he/she likes to do to get their body moving. Walking is a good way for the family to be active together. Plan family walks or hikes around the neighborhood or park, have a dance contest or let the child dance to music alone. Keep balls, jump ropes and other sports equipment available at home. Limit television, video games and computer time to no more than two hours per day.

Now is the time to help children be healthy. Make it fun and remember these changes will work best if everyone in the family participates! More fruits and vegetables and more active play will benefit the entire family. Unfortunately, not all children achieve blood pressure normalization just with TLCs or because they have entirely correctable causes for their hypertension. For these individuals, long-term drug treatment is required to prevent the dismal effects of long-standing hypertension such as stroke, heart disease or kidney damage. Several different groups of medications are available, although a number of these drugs still have not been tested specifically in children. Accordingly, family practitioners or general pediatricians at times prefer to ask pediatric nephrologists or cardiologists to become involved in the drug treatment of their young patients’ high blood pressure, even if it may be caused by essential hypertension.

The drug groups typically used include fluid pills (diuretics), drugs that relax the blood vessels by changing how the muscle tissue in the vessel wall handles calcium (calcium antagonists), drugs that suppress the formation or block the action of hormones that raise blood pressure (angiotensin converting enzyme blockers or angiotensin receptor blockers), drugs that down-modulate the “stress” response part of the nervous system (beta-blockers) and sometimes other medications. Usually, one agent is prescribed and its dose adjusted until adequate blood pressure control is achieved, but a combination of agents can sometimes also be necessary. While the initial choice of drug depends largely on the patient’s individual diagnosis and overall medical status, diuretics are commonly prescribed for teenagers with essential hypertension. Other factors guiding drug selection are drug availability in liquid form for younger patients and ease of administration, i.e. only once or twice daily. Lastly, there is blood pressure medication available as a skin patch that only needs to be replaced once a week for individuals who may have a lot of trouble remembering to take their daily pills.

To summarize, high blood pressure in children has become a growing problem. While a number of children have high blood pressure because they have specific conditions such as kidney disease, a substantial percentage of hypertensive children, especially teenagers, are otherwise healthy and thus have essential hypertension. Essential hypertension in children, in turn, is often associated with obesity and can be controlled and even corrected by TLCs as outlined above. These TLCs not only help children be healthier and thus more selfconfident, but – if instituted by the whole family – improve the well-being of all generations in the family unit. Moreover, they are key contributions to our battle against the obesity and inactivity epidemic affecting our society.

For more information on this topic, please consult these resources:
American Academy of Pediatrics
(AAP, www.aap.org)
American Heart Association
(AHA, www.americanheart.org)
National Heart, Lung and Blood Institute
(NHLBI, www.nhlbi.nih.gov)

All authors work at Cincinnati Children’s Hospital. Janis Kartal, RN, is a nurse in the pediatric nephrology and hypertension division, and Katie Dart, RD, is a dietitian. Both regularly see patients in a clinic specially held for children with high blood pressure. Jens Goebel, MD, is a pediatric nephrologist.

This article originally appeared in the May 2008 issue of aakpRENALIFE.

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