Hypertension in Children and Adolescents – Diagnostic Challenges and Management Table 3: Hypertension Toolkit for Patients, their Care-givers and Clinicians
Tools for Patients and Caregivers General
information Exercise
www.heart.org/HEARTORG • Information about high blood pressure from the American Heart Association
www.cdc.gov/Healthyyouth/physicalactivity/guidelines.htm#1 • Physical activity guidelines from the US Centers for Disease Control and Prevention
www.nhlbi.nih.gov/health/public/heart/obesity/wecan/get-active/index.htm www.phac-aspc.gc.ca/hp-ps/hl-mvs/pa-ap/04paap-eng.php • Information on getting active from the US National Heart Lung and Blood Institute (NHLBI)’s Ways to Enhance Children’s Activity and Nutrition (We Can!) national movement, and from the Public Health Agency of Canada, respectively
www.nhlbi.nih.gov/health/public/heart/obesity/wecan/reduce-screen-time/index.htm • Information on reducing time spent in front of television/computer screens from the NHLBI’s We Can!
Diet
www.nhlbi.nih.gov/health/public/heart/obesity/wecan/eat-right/index.htm • Information on eating well from the NHLBI’s We Can!
www.nhs.uk/Livewell/Goodfood/Pages/salt.aspx • Information on reducing salt consumption from the UK National Health Service
www.cnpp.usda.gov/dietaryguidelines.htm • 7th edition of the Dietary Guidelines for Americans published in 2010 by the US Department of Agriculture and the US Department of Health and Human Services
www.fda.gov/food/labelingnutrition/consumerinformation/ucm078889.htm www.nhs.uk/Livewell/Goodfood/Pages/food-labelling.aspx www.hc-sc.gc.ca/fn-an/label-etiquet/nutrition/cons/index-eng.php • Information on how to read and use nutrition fact labels from the US Food and Drug Administration, the UK National Health Service and Health Canada, respectively
Tools for Clinicians
Clinical
www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf guidelines
• The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents from the US Department of Health and Human Services
www.nhlbi.nih.gov/health/public/heart/hbp/bp_child_pocket/bp_child_pocket.pdf • A Pocket Guide to Blood Pressure Measurement in Children from the US Department of Health and Human Services
http://pediatrics.aappublications.org/content/122/1/198.full www.aafp.org/afp/2009/0415/p703.html • American Academy of Pediatrics clinical report on lipid screening in children59 Physician60
respectively
labels (see Table 3). Understanding how to read nutrition fact labels, and being aware of the confusing jargon used on those labels, can help patients and care-givers make healthier food choices when shopping and planning their meals. This will enable families to ensure they are eating a low-sodium, low-fat and well-balanced diet. Furthermore, patients and their families should consider adopting strategies to reduce salt in their diet such as rinsing canned foods in water prior to eating, flavouring food with spices instead of salt and requesting that no salt be added in restaurant meals. Not all families will have the possibility to participate in intense obesity programmes conducted by multidisciplinary teams in specialised medical institutions. Thus counselling families to promote a heart-healthy diet on a regular basis is important to stimulate changes in daily living. In summary, the slogan ‘Eat less, eat better, and move more’, used by some to describe the Dietary Guidelines for Americans, is one everyone should adhere to daily.
Other management strategies to decrease high blood pressure through a healthy lifestyle include better sleep practices, techniques for handling stress, and the avoidance of smoking and excessive alcohol intake.8 Screening for alcohol and smoking is not often carried out in childhood or adolescence, yet the estimated rates of alcohol and tobacco use among youths aged 12–17 in the US in 2006 were 16.6 % and 10.4 %, respectively.36
These figures vary according to the community, but they still indicate the need for paediatricians to consider risky social behaviours as contributing factors.
EUROPEAN NEPHROLOGY
When managing high blood pressure associated with unhealthy lifestyle, education is imperative. There are numerous books, websites and groups offering information on hypertension; however, many of these resources may contain misleading information. Toolkits provided by healthcare professionals in clinics and containing recommendations on appropriate resources (see Table 3) may enable patients and families to actively strive towards a healthier lifestyle.
To achieve success, the healthcare community and the public must be aware of, and committed to modifying, detrimental behaviours that contribute to high blood pressure in children and adolescents. When a healthy lifestyle alone is not sufficient to attain target blood pressure levels, it may be necessary to combine lifestyle measures with pharmacological interventions.
Pharmacological Interventions
The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents recommends pharmacological therapy in children with symptomatic hypertension, secondary hypertension, hypertensive end-organ damage, diabetes and hypertension that continues despite non-pharmacological interventions.8
For the purpose of this article, we reviewed the 16 published randomised controlled trials of children with primary or secondary hypertension. The majority of them were conducted to determine short-term efficacy and safety rather than cardiovascular risk
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and practice guidelines published in the American Family
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