Ep. 75: Pressures of Childhood - Understanding and Managing Pediatric Hypertension with Dr. Carissa Baker-Smith

The overall prevalence of hypertension in childhood is 2% to 5%, and it can be worse (or, worse yet, go undetected) in high-deprivation neighborhoods in the United States. Learn more about the research done in this area by Dr. Carissa Baker-Smith, Director of Pediatric Preventive Cardiology at Nemours Children’s Health. She also shares her insights on outcomes for undetected pediatric high blood pressure, and mitigation strategies to better detect and treat it. 

This episode was recorded live at the Pediatric Academic Societies (PAS) Annual Meeting in Toronto, Canada on Saturday, May 4.

Watch on YouTube. 

Guests:
Carissa Baker-Smith, MD, MPH, MS, Director of Preventive Cardiology, Nemours Children’s Cardiac Center, Delaware Valley

Host: Carol Vassar
Producers: Carol Vassar, Joe Gillespie and Sebastian Riella

Views expressed by guests do not necessarily reflect the views of the host or management.

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Transcript

Carol Vassar, podcast host/producer:

Welcome to Well Beyond Medicine, the Nemours Children's Health Podcast. Each week, we'll explore anything and everything related to the 80% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar. And now that you are here let's go.

Music:

Let's go, oh, oh, well beyond medicine.

Carol Vassar, podcast host/producer:

With me right now from the Pediatric Academic Societies meeting, PAS 2024 in Toronto, Canada, is Dr. Carissa Baker-Smith. Dr. Baker-Smith is director of the Pediatric Preventive Cardiology Program at Nemours Children's Health and co-director of the Nemours Center for Cardiovascular Research and Innovation. Dr. Baker-Smith, thank you so much for coming onto the podcast again.

Dr. Carissa Baker-Smith, Nemours Children's Health:

Well, thank you for having me. It really is an honor. Thank you.

Carol Vassar, podcast host/producer:

We are thinking about hypertension, and I don't think of it in children and adolescents. I usually think about it in adults. How common is a diagnosis of hypertension in children?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah. It's interesting that you say that. Hypertension is 4 to 5% of children.

Carol Vassar, podcast host/producer:

How much?

Dr. Carissa Baker-Smith, Nemours Children's Health:

4 to 5%. 4 to 5 out of 100 kids have hypertension.

Carol Vassar, podcast host/producer:

That's amazing to me. Now, what are the symptoms in children? How is this found? How is this discovered? Do parents notice it? Do pediatricians notice it?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah, so one of the hard parts I think about this diagnosis is that often kids have no symptoms. Most will not have symptoms related to hypertension. It must be diagnosed with screening. And so, it's recommended that every child undergo a blood pressure assessment when they visit their doctor. If they have no other underlying conditions, then that's at every annual visit, beginning at age 3 years of age. And if they have other underlying conditions like obesity or diabetes or high cholesterol or heart disease or kidney disease, then their blood pressure should be checked beginning at birth and checked with each visit, whether it's a well visit or a sick visit.

Carol Vassar, podcast host/producer:

When we talk about kids with hypertension, and we talk about them in the long term, what are the consequences?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah. So, unfortunately, hypertension is not benign. And though underdiagnosed in about 74% of kids, most parents whose kids have hypertension may not even be aware that their child has hypertension because, frankly, it just wasn't diagnosed. The long-term consequences of that blood pressure being high can have a tremendous impact on not just the blood vessels but also the heart and the kidneys. And so it's really important that we know that as blood pressure, as children age, first, the prevalence goes up as children age, the prevalence of hypertension. And that the cumulative burden of having elevated blood pressure has an impact on the other organs.

Carol Vassar, podcast host/producer:

I want to highlight a statistic that you just stated, and that is hypertension in children is underdiagnosed at a rate of up to 74%. Talk about that.

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah. So this data is based upon a large health center looking for the diagnosis of hypertension in the electronic health record. But yes, one of the challenges of making the diagnosis of hypertension in kids is that it requires repeat in-office blood pressure assessment. It also requires recognizing that some kids actually have just white coat effect, meaning they come into the doctor's office, their blood pressure is high because they're nervous. But if you let them relax, the blood pressure is actually okay. And those kids don't have hypertension. So that's the difference. But there are some kids who, with a repeated measure, continue to have high blood pressure. And those are the kids that we're describing.

Carol Vassar, podcast host/producer:

One of the areas that you concentrated on was hypertension in children who live in higher-deprivation areas. Define for us a higher deprivation area.

Dr. Carissa Baker-Smith, Nemours Children's Health:

So, higher deprivation is referring to the neighborhood in which one lives. The neighborhood can be a hard construct to describe, but we are really referring to the place in which they live. And when we talk about deprivation, we're talking largely about socioeconomic deprivation. Lower housing costs, lower rental costs, but sometimes those property values, those rental costs, the housing costs are also related to access to resources or lack thereof, public transportation, ways of getting to healthy sources of food, safe places to exercise, education level of those in the community and also the school. So, access to higher levels of education, quality education.

Carol Vassar, podcast host/producer:

All of the social determinants of health that we talk about time and again.

Dr. Carissa Baker-Smith, Nemours Children's Health:

Time and again. 80% of a health outcome is really not related to what happens in the doctor's office. It's everything that happens outside of the doctor's office.

Carol Vassar, podcast host/producer:

Absolutely. What are the main factors that contribute to high blood pressure for children in those higher-deprivation areas?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Well, first, it's not that only children who live within higher deprivation areas have hypertension. I mean, this diagnosis exists across all populations. And what it's tied to, sometimes there are familial factors, which is a small percent, but other times it's related to the content and the quality of the child's diet. So diets high in salt and fat can contribute. There's a relationship between a child's body mass index and blood pressure. So as the weight goes up, the weight for height goes up. The risk chance of having high blood pressure also goes up. And then there are other factors, stressors. There are different ways of making the diagnosis of hypertension. Traditionally and by guidelines, we talk about in-office measurement, but we're also identifying a number of kids who have higher blood pressures at night. And that we are able to detect the replacement of something called an ambulatory blood pressure monitor.

That device is something that's not always available, but we use it when there's questions about the diagnosis, whether or not a child has just high blood pressures in the office, or if they have high blood pressures at home as well. And that's important information to have as well. So, some kids have hypertension at night, and that may be related to other aspects of things like sleep-disordered breathing or obstructive sleep apnea. You think even maybe the environment and the quality of their sleep. So all of those things, the duration of their sleep can also contribute. So there are a number of factors.

Carol Vassar, podcast host/producer:

As we look at those higher-deprivation areas, are we also talking about areas that are food deserts, if you will?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah, I think people have caught it. Deserts and people have other terms for them. The idea, though, is that you are in an environment in which there's less equitable access to higher-quality foods, fresh fruits, fresh vegetables. Situations, neighborhoods in which there's a high prevalence of processed food. And again, these things aren't just isolated to high deprivation. I mean, certainly, you can be within a lower-deprivation neighborhood and still choose a diet and activity that's not healthy and have a risk for hypertension. But certainly not having access can contribute to that risk.

Carol Vassar, podcast host/producer:

As you are here at PAS, you're presenting on this very topic, it's called Trajectories of Blood Pressure and Importance of Neighborhood Level Risk. What did you find? Talk about the protocol that you went through, the data that you looked at, and the outcomes that you found.

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah. So, I've looked at the relationship between deprivation and hypertension and cardiovascular health status in kids through three distinct data sets. So, we looked first using Medicaid data that we published in the JAMA network. We've looked at PEDSnet, which is currently under review. PEDSnet is an electronic health record data set. It's nationwide and summons about 12 health systems in the larger PEDSnet. We use the Delaware Nemours rather, PEDSnet data, about 122,000 kids. And then we also use publicly available national health statistic data.

Carol Vassar, podcast host/producer:

Talk about the outcomes.

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah. So, what we found is that through the life course, you do see a decline in cardiovascular health. So, worsening blood pressure and blood pressure scores as children age through adolescence. And we did find that there was a relationship between loss or having poor cardiovascular health across the adolescent lifespan and latter childhood into adolescent lifespan in higher deprivation. So if you reside within a higher deprivation community as a population level, there were higher trajectory, higher prevalence of hypertension, but also the blood pressures themselves were higher. And then, as children age, you would see that the blood pressure status would decline. So in terms of having the percentage of kids who have good blood pressure declined over time, over age. And that those who had good blood pressure were more likely to reside within lower deprivation, and those with poor blood pressure status were more likely to reside within higher deprivation.

Carol Vassar, podcast host/producer:

Now that we know all of this, what are some strategies to mitigate it?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah, I think education is key. I mean, one of the things that I see is, my goal in conducting this research is really defined solutions. It's not just about describing the relationships. So much of what we've considered to be a risk for hypertension, traditionally, we thought of things that we cannot change. We talked about race and those things. And yes, race is a social construct, but we have to think about what are things that we can change. I think if we think about neighborhood level factors, if we think about diet, if we think about safe places to exercise, if we think about the education of the community, then we can change those things.

The other thing that we can do is we can take into consideration the challenges that maybe families face in trying to get to the diagnosis of hypertension and come up with creative strategies and ways to shorten that time to diagnosis and make it easier for the diagnosis to be made.

Carol Vassar, podcast host/producer:

Talk about the involvement of physicians. How can healthcare providers ensure equitable access to diagnosis and treatment for children with high blood pressure regardless of their social economic status?

Dr. Carissa Baker-Smith, Nemours Children's Health:

So I think it's on the pediatrician to make sure they're always checking children's blood pressure in accordance with the guidelines. So, making sure that during each child visit, the blood pressure is assessed and that it's assessed appropriately. The child's seated, back supported, arm and heart level, not making a fist, not legs crossed, getting good quality measurements. And that needs to happen at every visit, every well-child visit. And like I said, if a child has other underlying conditions, then that's in every sick visit, well-child visit, blood pressure needs to be assessed. And if there's concern or question, then it needs to be further evaluated until we can make things like some of the technologies that we have more readily available or come up with other protocols that can help make the diagnosis in a way that doesn't put the burden on the family to come back to so many outpatient visits.

Carol Vassar, podcast host/producer:

Is this an area that's well-studied, or do we need to do more work here? More research?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Oh, we definitely need more research. And I think what it also takes is understanding that this is a real diagnosis, a real condition, a real issue that blood pressure tracks or can track from childhood into adulthood. We think about hypertension in adults as a community and as a population, but many still are unaware that hypertension in kids exists. And I think the more that we can get that message out, I think that it'll make it easier to get funding and research in the areas that we so desperately need work to be done in.

Carol Vassar, podcast host/producer:

Anything else in this area that I haven't asked you about that you'd like to share?

Dr. Carissa Baker-Smith, Nemours Children's Health:

Yeah, like I said, I think education is key. I think that I hope people take from this podcast and from the work that's being done just the importance of the issue. And I would just like to highlight that so much of what happens in our lives and our trajectories is impacted by what happens in our childhood. So we do need to take into consideration the quality of the foods that we're giving our kids, the physical activity that we encourage, the lifestyle, the quality of the sleep, all of those things that we know to be so important so that they can live the longest and healthiest lives that they can.

Carol Vassar, podcast host/producer:

This is work that certainly goes well beyond medicine.

Dr. Carissa Baker-Smith, Nemours Children's Health:

Well beyond medicine.

Carol Vassar, podcast host/producer:

Dr. Carissa Baker-Smith, thank you so much for being here.

Dr. Carissa Baker-Smith, Nemours Children's Health:

Thank you for having me.

Carol Vassar, podcast host/producer:

Dr. Carissa Baker-Smith is the director for the Pediatric Preventive Cardiology Program and co-director for the Nemours Center for Cardiovascular Research and Innovation. Thank you for your time. And thank you for listening and watching. Keep an eye on the Nemours' YouTube channel as we work on presenting more live Well Beyond Medicine podcasts from PAS, from Toronto. Check our website, nemourswellbeyond.org, to hear from other subject matter experts that we're interviewing off-camera here in Toronto.

For Joe Gillespie, Sebastian Riella, Che Parker, Cheryl Munn, Drew Landmeier, and the entire Nemours team here at PAS, as well as stateside: Susan Masucci and Lauren Tata, I'm Carol Vassar. And remember, together we can change children's health for good well beyond medicine.

Music:

Let's go, oh, oh, well beyond medicine.