pediatric healthy weight toolkit · strategies to maintain healthy weight in children adapted from...

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Pediatric Healthy Weight Toolkit

A Toolkit for Health Professionals

Kids and TeensWeight ManagementHealthy Eating HabitsPhysical Activity

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association

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At a minimum, health care professionals should perform an annual assessment of weight status in all children under their care. Assessment should include these components:

Medical and Family History• Identifyfamilialrisks(e.g.,overweight/obesity,

type2diabetes,highbloodpressure,heartdisease, high cholesterol).

• Identifyunderlyingsyndromesorsecondarycomplicationsofoverweightandobesity(e.g.,hypothyroidism,polycysticovariansyndrome,Prader-Willisyndrome,diabetes,sleepapnea).

BMI AssessmentMeasureheightandweight,calculateBMIandusetheenclosedBMIwheeltodocumentBMIpercentileforage.YoumayalsodocumentBMIpercentilebyplottingthevaluesonthegridsfoundonpage19and20ofthistoolkitandplacingthatinformationinthemedical record.*

*Adolescentsage16andolderonlyrequiredocumentationofthestandardBMIvalueofkg/m2.

Physical Examination• Measurebloodpressure.

• Inspectandexaminebodysystemstoidentifyunderlyingsyndromesorsecondarycomplicationsofoverweightandobesity(e.g.,hirsutism,dysmorphicfeatures,slippedcapitalfemoralepiphysis,legbowing,acanthosisnigricans).

Physical Activity and Nutrition AssessmentDocumentcounselingforbothnutritionandphysicalactivity.Counselingmayincludeoneormoreofthese:

• Discussionofcurrentnutritionandphysicalactivitybehaviors(eatinghabits,diets,sports,exerciseroutines, etc.)

• Checklistindicatingbothnutritionandphysicalactivitywasaddressed

Assessment

1• Counselingorreferralforbothnutritionandphysicalactivityeducation

• Providingeducationalmaterialsonbothnutritionandphysicalactivity

• Anticipatoryguidanceforbothnutritionandphysicalactivity

Psychosocial Assessment• Screenfordepression,ifindicated(e.g.,Center

forEpidemiologicalStudiesDepressionScaleforChildren).

• Assessfamilysupportandreadinesstochange.

Laboratory TestingExamplesinclude,butarenotlimitedto,fastinglipidprofile,liverfunctiontests,fastingplasmaglucoseandinsulinlevels,andarebasedonhistoryorexamfindings.IftheBMIforageandsexis:

• 85thto94thpercentile(overweight)withnoriskfactors:Obtainfastinglipidprofile.

• 85thto94thpercentile(overweight)withriskfactorsinhistoryorphysicalexamination:Obtainalsoaspartateaminotransferase,orAST;alanineaminotransferase,orALT;andfastingglucose.

• Greaterthanthe95thpercentile(obese),evenintheabsenceofriskfactors:Obtainallofthetestslistedinsecondbulletpointabove,plusbloodureanitrogen,orBUN,creatinineandHbAIC(withpresenceofotherriskfactorsfordiabetes).

Hyperlipidemia ScreeningAHArecommendstargetingchildrenoverage2whomeet these criteria:*

• Familyhistoryofdyslipidemia

• Unknownfamilyhistoryalongwithriskfactors

• Prematurecardiovasculardisease

• Presenceofoverweightorobesity

*increasedriskifmalewithHDL<45orfemalewithHDL<50

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Assessment/Reference Lab Values

Reference Lab Values

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Glucose testing Normal Impaired Diabetes

FastingPlasmaGlucose <100mg/dl 100–125mg/dl >126mg/dl*

Two-hourmodifiedOGTT(Performtestusingaglucoseloadcontainingequivalentof75ganhydrousglucosedissolvedinwater.)(OGTT is not recommended for routine clinical use.)

<140mg/dl 140–199mg/dl >200mg/dl*

Diabetes Care2006;29(Suppl.1):S47*In absence of unequivocal hyperglycemia, confirm by repeat testing on a different day.

Lipids Cholesterol (mg/dl) LDL (mg/dl) HDL (mg/dl)

Desirable Borderline High Desirable Borderline High Desirable

Child/adolescent <170 170–199 >200 <110 110–129 >130 45

JohnsHopkins:The Harriet Lane Handbook: A Manual for Pediatric House Officers,17thed.,Copyright©2005Mosby

Percentile

Total Triglycerides (mg/dl) 5th Mean 75th 90th 95th

1–4 year

Male 29 56 68 85 99

Female 34 64 74 95 112

5–9 year

Male 28 52 58 70 85

Female 32 64 74 103 126

10–14 year

Male 33 63 74 94 111

Female 39 72 85 104 120

15–19 year

Male 38 78 88 125 143

Female 36 73 85 112 126

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Reference Lab Values

Aspartate Aminotransferase (AST) Normal Values

1–3yr 20–60U/L

4–6yr 15–50U/L

7–9yr 15–40U/L

10–11yr 10–60U/L

12–19yr 15–45U/L


Creatinine (Serum) Normal Values

Child 0.3–0.7mg/dl

Adolescent 0.5–1.0mg/dl


Blood Urea Nitrogen (BUN) Normal Values

Infant/Child 5–18mg/dl


Reference Lab Values continued 3


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Strategies to Maintain Healthy Weight in Children

Strategies to Maintain Healthy Weight in Children Adapted from the AMA/CDC Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity.June2007.

Recommendations Physiciansandalliedhealthcareprofessionalsshouldprovidethefollowingguidanceforchildrenages2–18whoseBMIis≥the5thpercentileand≤the84thpercentile:

• Dietaryintake:

– Limitconsumptionofsugar-sweetenedbeveragesandencourageconsumptionofdietswithrecommendedquantitiesoffruitsandvegetables.

– Eatadietrichincalcium.

– Eatadiethighinfiber.

– Eatadietwithbalancedmacronutrients(caloriesfromfat,carbohydrates,andproteininproportionsforagerecommendedbyDietaryIntakeReferencessuchasUSDAFoodPyramidatUSDA.gov).

• Physicalactivity:

Childrenofhealthyweightshouldparticipatein60minutesofmoderatetovigorousphysicalactivitydaily,unless contraindicated.

– The60minutescanbeaccumulatedthroughouttheday.

– Ideally,suchactivityshouldbeenjoyabletothechild.

– Whereassomehealthandpsychologicalbenefitsmaybeattainedbyachievingthe60-minutegoal,greaterdurationshouldyieldincreasedbenefit.

• ScreenTime:

– Limittelevisionandotherscreentimeto1or2hoursperdayinchildrenasyoungasage5,asadvisedbytheAmericanAcademyofPediatrics,andremovetelevisionandcomputerscreensfromchildren’sprimarysleepingareas.

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2 (cut here) inside front cover• Eatingbehaviors:

– Eatbreakfastdaily.

– Limiteatingoutatrestaurants,particularlyfast-foodrestaurants.

– Encouragefamilymealsinwhichparentsandchildreneattogether.

– Limitportionsize.

• Healthcareprofessionalswhowishtosupportobesitypreventioninclinical,schoolandcommunitysettingsshould:

– Activelyengagefamilieswithparentalobesityormaternaldiabetes,becausethesechildrenareatincreasedriskfordevelopingobesityeveniftheycurrentlyhavenormalBMI.

– Encourageanauthoritative*parentingstyleinsupportofincreasedphysicalactivityandreducedsedentarybehavior,providingtangible,motivationalsupportforchildren.

– Encourageparentstomodelhealthydietsandportionsizes,physicalactivityandlimitedtelevisiontime.

– Promotephysicalactivityatschoolandinchildcaresettings,includingafterschoolprograms,byaskingchildrenandparentsaboutactivityinthesesettingsduringroutineofficevisits.

Strategies to Maintain Healthy Weight in Children

*Authoritativeparentsarebothdemandingandresponsive.“Theymonitorandimpartclearstandardsfortheirchildren’sconduct.Theyareassertive,butnotintrusiveandrestrictive.Theirdisciplinarymethodsaresupportive,ratherthanpunitive.Theywanttheirchildrentobeassertiveaswellassociallyresponsible,andself-regulatedaswellascooperative.”

(Baumrind,1991,p.62).

Strategies to Maintain Healthy Weight in Children continued 5


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.25 grid lineTreatment Recommendations for Overweight and Obese Children (Includes strategies noted previously)Adapted from the AMA/CDC Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity.June2007.

Thetreatmentofoverweightchildrenshouldbeapproachedinastagedmethodbaseduponthechild’sage,BMI,anyrelatedcomorbidities,weightstatusofparentsandprogressintreatment;andthechild’sprimarycaregiversandfamiliesshouldbeinvolvedintheprocess.

Children2–19withBMI>85thpercentile:

Stage 1. Prevention Plus protocol:Theserecommendationscanbeimplementedbytheprimarycarephysicianoralliedhealthcareprofessionalwhohassometraininginpediatricweightmanagementorbehavioralcounseling.Withinthiscategory,thegoalshouldbeweightmaintenancewithgrowththatresultsinadecreasingBMIasageincreases.Stage1recommendationsinclude:

• Dietaryhabitsandphysicalactivity:– Fiveormoreservingsoffruitsandvegetablesperday– Twohoursorlessofscreentimeperday,andnotelevisionintheroomwherethechildsleeps– Onehourormoreofdailyphysicalactivity– Nosugar-sweetenedbeverages

• Patientsandfamiliesofthepatientshouldbecounseledtofacilitatetheseeatingbehaviors:– Eatingadailybreakfast– Limitingmealsoutsideofthehome– Familyeatingmealstogetheratleastfivetimesperweek– Allowingthechildtoself-regulatehisorhermealsandavoidingoverlyrestrictivebehaviors

• Follow-up:After3–6months,ifthereisnoimprovementinBMIorweightstatus,advancetoStage2,basedonpatientandfamilyreadinesstochange.

Treatment Recommendations for Overweight and Obese Children

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Treatment Recommendations for Overweight and Obese Children

Treatment Recommendations for Overweight and Obese Children continued

Stage 2. Structured Weight Management protocol:Theserecommendationscanbeimplementedbyaprimarycarephysicianoralliedhealthcareprofessionalhighlytrainedinweightmanagement.Stage2recommendations include:

• Dietaryandphysicalactivitybehaviors:

– Developmentofaplanforusingabalancedmacronutrientdietemphasizinglowamountsofenergy-dense foods

– Increasedstructureddailymealsandsnacks

– Supervisedactiveplayofatleast60minutesperday

– Screentimeofonehourorlessperday

– Increasedmonitoring(e.g.,screentime,physicalactivity,dietaryintake,restaurantlogs)byhealthcareprofessional,patientorfamily

• Withinthiscategory,goalshouldbeweightmaintenancethatresultsinadecreasingBMIasageandheightincreases;however,weightlossshouldnotexceed1poundpermonthinchildren2–11years,oranaverageof2poundsperweekinolderoverweightorobesechildrenandadolescents.

• IfnoimprovementinBMIweightafter3–6months,patientmaybereferredtoamultidisciplinaryobesitycare team.

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Effective Communication with Families

Effective Communication with FamiliesScottGee,M.D.;SandraRoberts,R.N.;AmandaHowell.AdaptedwithpermissionfromcopyrightedmaterialbyRegionalHealthEducation,PermanenteMedicalGroup,NorthernCalifornia.

With whom do you communicate?Discussissueswithchildreninamannerappropriatetotheirdevelopmentalcapacityandalwaysincludeaparentorprimarycaregiver.

Children of Healthy Weight (BMI <85th percentile)Lifestyleadviceforwell-childorurgentvisitcanbelessthanoneminute.

Can you … every day?B EatahealthyBREAKFAST5 EatatleastFIVEormorefruitsandvegetables4 DrinkFOURglassesofwater3 HaveTHREEservingsofdairy2 Limitscreentime(computer,TV,videogames)tolessthanTWOhours1 Bephysicallyactiveforatleast ONE hour0 AVOIDsweetenedbeveragesSource:SouthCarolinaInstituteforChildhoodObesityandRelatedDisorders

Children Who Are Overweight or Obese (BMI >85th percentile)

1 Engage the Patient and ParentnCanwetakeafewminutestogethertodiscussyourhealth

and weight?n How do youfeelaboutyourhealthandweight?

2 Share InformationnYourcurrentweightputsyouatriskfordevelopingheartdisease

anddiabetes.nWhatdoyoumakeofthis?nWhatareyourideasforworkingtowardahealthyweight?

3 Make a Key Advice Statement Can you … every day?B EatahealthyBREAKFAST

5 EatatleastFIVEormorefruitsandvegetables 4 DrinkFOURglassesofwater 3 HaveTHREEservingsofdairy 2 Limitscreentime(computer,TV,videogames)tolessthanTWO

hours 1 BephysicallyactiveforatleastONEhour 0 AVOIDsweetenedbeverages

Usepatientideasonworkingtowardahealthyweightfromstep2above.8

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Effective Communication with Families

4 Assess Readiness (optional) n Onascalefrom0to10,howreadyareyoutoconsidertakingstepstoachieveahealthyweight?

To explore answer, consider these types of questions:

nStraightquestion:Why a 5?

nBackwardquestion:Why a 5 and not a 3?

nForwardquestion:What would it take to move you from a 5 to a 7?

Readiness Scale

Stage of Readiness

Recommended Approach Key Questions

Not Ready0–3

n Raiseawarenessn Elicitchangetalkn Adviseandencourage

n Wouldyoubeinterestedinknowingmoreaboutreachingahealthyweight?

n HowcanIhelp?n Whatmightneedtobedifferentforyoutoconsiderachangein

the future?

Unsure4–6

n Evaluateambivalencen Elicitchangetalkn Build readiness

n Wheredoesthatleaveyounow?n Whatdoyouseeasyournextsteps?n Whatareyouthinkingandfeelingatthispoint?

Ready7–10

n Strengthencommitment

n Elicitchangetalkn Facilitateactionplanning

n Whyisthisimportanttoyounow?n Whatareyourideasformakingthiswork?n Whatmightgetintheway?Howmightyouworkaroundthebarriers?n Howmightyourewardyourselfalongtheway?

5 Explore Ambivalence (if relevant)Step 1: Ask a pair of questions to help the patient explore the pros and cons of the issue you are

discussing with the patient.nWhatarethethingsyoulikeabout____?ANDWhatarethethingsyoudon’tlikeabout____?

ORnWhataretheadvantagesofkeepingthingsthesame?ANDWhataretheadvantagesofmaking

a change?Step 2: Summarize ambivalence.nLetmeseeifIunderstandwhatyou’vetoldmesofar.(Beginwithreasonsformaintainingthe

statusquo;endwithreasonsformakingachange.)nAsk:DidIgetitall?DidIgetitright?

6 Close the EncounternSummarize:Ourtimeisalmostup.Let’stakealookatwhatyou’veworkedthroughtoday.nShowappreciation,acknowledgewillingnesstodiscusschange:Thankyouforbeingwillingto

discussyourweight.nOfferadvice,emphasizechoice,expressconfidence:Istronglyencourageyoutobemorephysically

active.Thechoicetoincreaseyouractivity,ofcourse,isentirelyyours.Iamconfidentthatifyoudecidetobemoreactiveyoucanbesuccessful.

nConfirmnextstepsandarrangefollowup.

0 1 2 3 4 5 6 7 8 9 10

Effective Communication with Families continued 9


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1Type2DiabetesinChildrenandAdolescents:Screening,Diagnosis,andManagement.Journal of the American Academy of Physician Assistants,Vol20(3),March2007.2Type2DiabetesinChildrenandAdolescents.Diabetes Care,Vol23(3),March2000.3OverviewofDiabetesinChildrenandAdolescents.National Diabetes Education Program.August2006.4AmericanDiabetesAssociation.ClinicalPracticeRecommendations–StandardsofMedicalCareinDiabetes.Diabetes Care2005;28(Suppl.1):S4-36.5PreventiveHealthCounselingforAdolescents.American Family Physician,74(7),October2006.

Type 2 Diabetes In Children

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Overweight and obese children are at increased risk of developing type 2 diabetes throughout their life span.

Risk Factors and Identification• BMI>85thpercentileforageandsex,orweight>120percentofidealbodyweight• Memberofhigh-riskethnicgroups,suchasAfrican-Americans,AmericanIndians,HispanicorLatino

AmericansandsomeAsianorPacificIslanderAmericans• Familymemberwhohastype2diabetes• Age>10years• Havingsignsofinsulinresistance,includingacanthosisnigricans,highbloodpressureanddyslipidemia• Early-onsetpuberty

Diagnosing Diabetes1,2

• Randomglucoselevelis>200mg/dl• Fastingglucoselevelis>126mg/dl• Two-hourpostprandialglucoselevelis>200mg/dl• ElevatedinsulinandC-peptidelevelswithnoautoantibodiestoisletcellsorinsulinalsoindicates

type2diabetes

At Diagnosis3,4

Diabetescareforchildrenshouldbeprovidedbyateamthatcanaddressmedical,educational,nutritionalandbehavioralissues.Theteamusuallyconsistsofaphysician,diabeteseducator,dietitianandasocialworkerorpsychologist,alongwiththepatientandfamily.• Establishtreatmentregimenandgoals.• Checklipidsinchildrenwithasignificantfamilyhistory.Inchildrenwithnosignificantfamilyhistory,check

lipidsatpubertyandifnormal,repeatprofileeveryfiveyears.• Diabetesself-managementeducationon:

– Healthyeatinghabits– Dailyphysicalactivity– Insulinandmedicationadministration– Self-monitoringofbloodglucoselevels,ifappropriate– Routinedentalcare

Theindividualandfamilyneedasolideducationalbasesothattheycanbecomeindependentinmanagingtheirdiabetes.

Anindividualexperiencedwiththenutritionalneedsofthegrowingchildandthebehavioralissuesthatmayimpactadolescentdietsshouldprovidenutritionaltherapy.

Foradolescents,theHEADDSSPsychosocialInterviewforAdolescents(home/health,education/employment,activities,drugs,depression,safety,sexuality)isrecommended.5

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Ongoing Evaluation and Monitoring after Diagnosis: Physical Examination6

Physical Examination Component Frequency

Weight Initiallyevery3months*

Height,BMI Initiallyevery3months*

Blood pressure Initiallyevery3months*

Injectionsites Every3months

Self-testingbloodglucoserecords Every3months

Skin (acanthosisnigricans,hirsutisum,tinea,acne)

Every12months

Examinefeet (pedalpulses,neurologicalexamination,nails)

Every12monthsbutvisualfootcheckevery3months

Referpatientfornutritiontherapy Atdiagnosis;re-evaluateevery12months

ConductpsychosocialassessmentsuchasHEADDSS

Atdiagnosisandeverythreemonths(ifneeded)

Provideophthalmologicexamination Annually(lessoftenontheadviceofaneyecareprofessional)after5yearsofdiabetes

Administerinfluenzavaccination Annually

*Maydecreasetoevery6monthsiflineargrowthiscompleteandglucoseiswellcontrolled.

Ongoing Evaluation and Monitoring After Diagnosis: Laboratory Evaluation*7

Test Frequency

Individualizedselfmonitoringbloodglucose Fasting(andpreprandialglucosedaily)

Fastingplasmaglucosetest Initiallyandongoing

HbA1c Every3months

Urinalysis Every12months

Microalbuminuriatocreatinineratio Atdiagnosisandthenevery12monthsafter5yearsofdiabetes

Creatinine At diagnosis

Lipidprofile(forchildrenwithsignificantfamilyhistory)**

Atdiagnosisandevery1–2years

LFTs(liverfunctiontest) Atdiagnosis(beforeinitiatingoralhypoglycemicagents)

*Arequirementformorefrequentmonitoringmaybedeterminedatdiagnosis,duringinitiationofnewtreatment,andduringmetabolicchanges(illness,stress,increasedactivity,andgrowth).

**Inchildrenwithnosignificantfamilyhistory,checklipidsatpubertyandifnormal,repeatprofileeveryfiveyears.

6OverviewofDiabetesinChildrenandAdolescents.National Diabetes Education Program.August2006.7PreventionandTreatmentofType2DiabetesMellitusinChildren,WithSpecialEmphasisonAmericanIndianandAlaskaNativeChildren.Pediatrics2003;112

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Treatment Strategies and Goals8

Treatmentfortype2diabetesinchildrenshouldincludenutritionmanagement,regularphysicalactivity,regularbloodglucosechecksandtakingallmedicationsasprescribed.

Nutrition plansmaybedevelopedinconjunctionwitharegistereddietitianordiabeteseducator.Formoreinformation,visittheAmericanDieteticAssociationWebsiteateatright.org.

Ideally,childrenwithtype2diabetesshouldengageinatotalof60minutesofphysical activityperday.Physicalactivityiscriticalbecauseithelpstolowerbloodglucoselevelsandhelpschildrenmanagetheirweight.

Youngpeoplewithdiabetesshouldknowtheacceptablerangefortheirbloodglucoselevel.Childrenusinginsulinshouldcheckbloodglucosevaluesonaregularbasiswithabloodglucosemeter.Inaddition,parents,caregivers,andhealthprofessionalscanhelpchildrenlearnhowtotaketheirmedicationsasprescribed.

Treatment goalsincludeadequatemetaboliccontrol(HbA1cconcentration<7%)andpreventionofmicrovascularandmacrovascularcomplications.Morespecifically,treatmentobjectivesinclude:

• Avoidinghypoglycemiaandeliminatingsymptomsofhyperglycemia

• Assistingthepatientinmaintainingareasonablebodyweight

• Decreasingcardiovascularriskfactorsandriskofearlykidneydisease

• Achievingoverallimprovementinthechild’sphysicalandemotionalwell-being

Alltreatmentplansshouldbecustomizedwiththechild’suniquefamilyandsocialcircumstancesinmind.

8NationalDiabetesEducationProgram.Overview of Diabetes in Children and Adolescents.August2006.

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Blood Glucose GoalsTocontroldiabetesandpreventcomplications,bloodglucoselevelsmustbemanagedasclosetoanormalrangeasissafelypossible(70to100mg/dlbeforeeating).Familiesshouldworkwiththeirhealthcareteamtosettargetbloodglucoselevelsappropriateforthechild.

TheAmericanDiabetesAssociationhasdevelopedrecommendationsforbloodglucosegoalsforyoungpeoplewithtype1diabetes.Althoughthereisnounifiednationalrecommendationforchildrenwithtype2diabetes,itmaybereasonabletousethevaluesinthefollowingtableasaguide.

Optimal plasma blood glucose and A1C goals for type 1 diabetes by age group9

Values by Age (Years)

Plasma Blood Glucose Goal Range (mg/dl) A1C

Percent Rationale

Before Meals

Bedtime/Overnight

Toddlersandpreschoolersunderage6

100–180 110–200 ≤8.5but ≥7.5

Highriskandvulnerabilitytohypoglycemia

Ages6to12 90–180 100–180 <8 Risksofhypoglycemiaandrelativelylowriskofcomplicationspriortopuberty

Adolescentsandyoungadults,ages13to19

90–130 90–150 <7.5* RiskofhypoglycemiaDevelopmentalandpsychologicalissues

*Alowergoal(<7.0)isreasonableifitcanbeachievedwithoutexcessivehypoglycemia.

Keyconceptsinsettingglycemicgoals:

• Goalsshouldbeindividualizedandlowergoalsmaybereasonablebasedoncomparingthebenefitstotherisks.

• Bloodglucosegoalsshouldbehigherthanthoselistedaboveinchildrenwithfrequenthypoglycemiaorhypoglycemiaunawareness.

• PostprandialbloodglucosevaluesshouldbemeasuredwhenthereisadisparitybetweenpreprandialbloodglucosevaluesandA1Clevels.

9NationalDiabetesEducationProgram.Overview of Diabetes in Children and Adolescents. August2006.

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Hypertension in Children: Definition and Evaluation

Definition of Hypertension• Hypertensionisdefinedasaveragesystolicbloodpressureordiastolicbloodpressure>95thpercentilefor

gender, age and height on ≥3occasions.

• PrehypertensioninchildrenisdefinedasaverageSBPorDBPlevelsthatare≥90thpercentilebut<95thpercentile;aswithadults,adolescentswithBPlevel≥120/80mmHgshouldalsobeconsideredprehypertensive.

Clinical Evaluation of Confirmed HypertensionStudy or Procedure Purpose Target PopulationEvaluation for identifiable causesPhysicalexamination,historyincludingsleephistory,familyhistory,riskfactors,dietandhabitssuchassmokinganddrinkingalcohol

Historyandphysicalexaminationhelpfocussubsequentevaluation

All children with persistent BP ≥95thpercentile

BUN,creatinine,electrolytes,urinalysisandurineculture

R/Orenaldiseaseandchronicpyelonephritis


CBC R/Oanemia,consistentwithchronicrenal disease


RenalU/S R/Orenalscar,congenitalanomaly,ordisparaterenalsize


Evaluation for target-organ damageEchocardiogram IdentifyLVHandotherindicationsof

cardiacinvolvementPatientswithcomorbidriskfactors*andBP90th-94thpercentile;allpatientswithBP ≥95thpercentile

RetinalExam Identifyretinalvascularchanges PatientswithcomorbidriskfactorsandBP90th-94thpercentile;allpatientswithBP ≥95thpercentile

Selectedexcerptsfrom“TheFourthReportontheDiagnosis,Evaluation,andTreatmentofHighBloodPressureinChildrenandAdolescents,”Pediatrics,Vol.114,No.2,August2004

BUN,bloodureanitrogen;CBC,completebloodcount;LVH,leftventricularhypertrophy;R/Oruleout; U/S,ultrasound.

*Comorbidriskfactorsalsoincludesdiabetesmellitusandkidneydisease.

(HypertensionManagementAlgorithmover)

Hypertension in Children

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Hypertension in Children

Measure BP and height and calculate BMIDetermine BP category for gender, age and height*

Stage 1 Hypertension95th to 99th percentile plus

5 mm Hg

or 120/80 mm Hg90-<95%

90-<95% or 120/80 mm Hg90-<95%

Secondary Hypertension

Normal BMI

≥95%

Still ≥95%

Normal BMI

Normal BMI

Overweight Overweight Overweight

or Primary Hypertension

Primary Hypertension

Secondary Hypertension

≥95%

<90%Repeat BP

over 3 visits

Rx specific for cause

Drug Rx

Drug Rx (2)

Weight reduction

Weight reduction and

drug Rx

Weight reduction

MonitorQ 6 Mo

Therapeutic lifestyle changes (1)

Education on heart healthy lifestyle

for the family (1)

Diagnostic workupincluding evaluation for target-organ damage (2)

Consider referral to provider with expertise in pediatric hypertension

Consider diagnostic workup

including evaluation for target-organ damage (2)

If overweight or comorbidity exists

Diagnostic workupincluding evaluation for target-organ damage (2)

Repeat BP in 6 months

Prehypertensive90th to <95th or if BP exceeds

120/80 even if <90th percentile up to < 95th percentile

Normotensive<90th SBP or DBP percentile

Stage 2 Hypertension>99th percentile plus

5 mm Hg

Therapeutic lifestyle changes (1)

*SeetablestitledBloodPressureLevelsforBoysandGirlsbyAgeandHeightPercentile(1) TherapeuticLifestyleChanges(below)(2) Especiallyifyounger,veryhighBP,littleornofamilyhistory,diabeticorotherriskfactors.

Therapeutic Lifestyle Changes• Weightreductionistheprimarytherapyforobesity-relatedhypertension.Preventionofexcess

orabnormalweightgainwilllimitfutureincreasesinBP.

• RegularphysicalactivityandrestrictionofsedentaryactivitywillimproveeffortsatweightmanagementandmaypreventanexcessincreaseinBPovertime.

• DietarymodificationshouldbestronglyencouragedinchildrenandadolescentswhohaveBPlevelsintheprehypertensiverangeaswellasthosewithhypertension.

• Family-basedinterventionimprovessuccess.

Indication for Antihypertensive Drug Therapy in Children• Symptomatichypertension• Diabetes(types1and2)• Secondaryhypertension• Persistenthypertensiondespitenonpharmacologicmeasures• Hypertensivetarget-organdamage

From“TheFourthReportontheDiagnosis,Evaluation,andTreatmentofHighBloodPressureinChildrenandAdolescents,”Pediatrics, Vol.114,No.2,August2004

Hypertension Management Algorithm 15


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Blood Pressure Reference

16

Blood Pressure Levels for Girls by Age and Height Percentile

Age (Year)

BP Percentile

Systolic BP (mm Hg) Diastolic BP (mm Hg)Percentile of Height Percentile of Height

5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

2 90th 98 99 100 101 103 104 105 57 58 58 59 60 61 6195th 102 103 104 105 107 108 109 61 62 62 63 64 65 6599th 109 110 111 112 114 115 116 69 69 70 70 71 72 72

3 90th 100 100 102 103 104 106 106 61 62 62 63 64 64 6595th 104 104 105 107 108 109 110 65 66 66 67 68 68 6999th 111 111 113 114 115 116 117 73 73 74 74 75 76 76

4 90th 101 102 103 104 106 107 108 64 64 65 66 67 67 6895th 105 106 107 108 110 111 112 68 68 69 70 71 71 7299th 112 113 114 115 117 118 119 76 76 76 77 78 79 79

5 90th 103 103 105 106 107 109 109 66 67 67 68 69 69 7095th 107 107 108 110 111 112 113 70 71 71 72 73 73 7499th 114 114 116 117 118 120 120 78 78 79 79 80 81 81

6 90th 104 105 106 108 109 110 111 68 68 69 70 70 71 7295th 108 109 110 111 113 114 115 72 72 73 74 74 75 7699th 115 116 117 119 120 121 122 80 80 80 81 82 83 83

7 90th 106 107 108 109 111 112 113 69 70 70 71 72 72 7395th 110 111 112 113 115 116 116 73 74 74 75 76 76 7799th 117 118 119 120 122 123 124 81 81 82 82 83 84 84

8 90th 108 109 110 111 113 114 114 71 71 71 72 73 74 7495th 112 112 114 115 116 118 118 75 75 75 76 77 78 7899th 119 120 121 122 123 125 125 82 82 83 83 84 85 86

9 90th 110 110 112 113 114 116 116 72 72 72 73 74 75 7595th 114 114 115 117 118 119 120 76 76 76 77 78 79 7999th 121 121 123 124 125 127 127 83 83 84 84 85 86 87

10 90th 112 112 114 115 116 118 118 73 73 73 74 75 76 7695th 116 116 117 119 120 121 122 77 77 77 78 79 80 8099th 123 123 125 126 127 129 129 84 84 85 86 86 87 88

11 90th 114 114 116 117 118 119 120 74 74 74 75 76 77 7795th 118 118 119 121 122 123 124 78 78 78 79 80 81 8199th 125 125 126 128 129 130 131 85 85 86 87 87 88 89

12 90th 116 116 117 119 120 121 122 75 75 75 76 77 78 7895th 119 120 121 123 124 125 126 79 79 79 80 81 82 8299th 127 127 128 130 131 132 133 86 86 87 88 88 89 90

13 90th 117 118 119 121 122 123 124 76 76 76 77 78 79 7995th 121 122 123 124 126 127 128 80 80 80 81 82 83 8399th 128 129 130 132 133 134 135 87 87 88 89 89 90 91

14 90th 119 120 121 122 124 125 125 77 77 77 78 79 80 8095th 123 123 125 126 127 129 129 81 81 81 82 83 84 8499th 130 131 132 133 135 136 136 88 88 89 90 90 91 92

15 90th 120 121 122 123 125 126 127 78 78 78 79 80 81 8195th 124 125 126 127 129 130 131 82 82 82 83 84 85 8599th 131 132 133 134 136 137 138 89 89 90 91 91 92 93

16 90th 121 122 123 124 126 127 128 78 78 79 80 81 81 8295th 125 126 127 128 130 131 132 82 82 83 84 85 85 8699th 132 133 134 135 137 138 139 90 90 90 91 92 93 93

17 90th 122 122 123 125 126 127 128 78 79 79 80 81 81 8295th 125 126 127 129 130 131 132 82 83 83 84 85 85 8699th 133 133 134 136 137 138 139 90 90 91 91 92 93 93

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Blood Pressure Levels for Boys by Age and Height Percentile

Age (Year)

BP Percentile

Systolic BP (mm Hg) Diastolic BP (mm Hg)Percentile of Height Percentile of Height

5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

2 90th 97 99 100 102 104 105 106 54 55 56 57 58 58 5995th 101 102 104 106 108 109 110 59 59 60 61 62 63 6399th 109 110 111 113 115 117 117 66 67 68 69 70 71 71

3 90th 100 101 103 105 107 108 109 59 59 60 61 62 63 6395th 104 105 107 109 110 112 113 63 63 64 65 66 67 6799th 111 112 114 116 118 119 120 71 71 72 73 74 75 75

4 90th 102 103 105 107 109 110 111 62 63 64 65 66 66 6795th 106 107 109 111 112 114 115 66 67 68 69 70 71 7199th 113 114 116 118 120 121 122 74 75 76 77 78 78 79

5 90th 104 105 106 108 110 111 112 65 66 67 68 69 69 7095th 108 109 110 112 114 115 116 69 70 71 72 73 74 7499th 115 116 118 120 121 123 123 77 78 79 80 81 81 82

6 90th 105 106 108 110 111 113 113 68 68 69 70 71 72 7295th 109 110 112 114 115 117 117 72 72 73 74 75 76 7699th 116 117 119 121 123 124 125 80 80 81 82 83 84 84

7 90th 106 107 109 111 113 114 115 70 70 71 72 73 74 7495th 110 111 113 115 117 118 119 74 74 75 76 77 78 7899th 117 118 120 122 124 125 126 82 82 83 84 85 86 86

8 90th 107 109 110 112 114 115 116 71 72 72 73 74 75 7695th 111 112 114 116 118 119 120 75 76 77 78 79 79 8099th 119 120 122 123 125 127 127 83 84 85 86 87 87 88

9 90th 109 110 112 114 115 117 118 72 73 74 75 76 76 7795th 113 114 116 118 119 121 121 76 77 78 79 80 81 8199th 120 121 123 125 127 128 129 84 85 86 87 88 88 89

10 90th 111 112 114 115 117 119 119 73 73 74 75 76 77 7895th 115 116 117 119 121 122 123 77 78 79 80 81 81 8299th 122 123 125 127 128 130 130 85 86 86 88 88 89 90

11 90th 113 114 115 117 119 120 121 74 74 75 76 77 78 7895th 117 118 119 121 123 124 125 78 78 79 80 81 82 8299th 124 125 127 129 130 132 132 86 86 87 88 89 90 90

12 90th 115 116 118 120 121 123 123 74 75 75 76 77 78 7995th 119 120 122 123 125 127 127 78 79 80 81 82 82 8399th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

13 90th 117 118 120 122 124 125 126 75 75 76 77 78 79 7995th 121 122 124 126 128 129 130 79 79 80 81 82 83 8399th 128 130 131 133 135 136 137 87 87 88 89 90 91 91

14 90th 120 121 123 125 126 128 128 75 76 77 78 79 79 8095th 124 125 127 128 130 132 132 80 80 81 82 83 84 8499th 131 132 134 136 138 139 140 87 88 89 90 91 92 92

15 90th 122 124 125 127 129 130 131 76 77 78 79 80 80 8195th 126 127 129 131 133 134 135 81 81 82 83 84 85 8599th 134 135 136 138 140 142 142 88 89 90 91 92 93 93

16 90th 125 126 128 130 131 133 134 78 78 79 80 81 82 8295th 129 130 132 134 135 137 137 82 83 83 84 85 86 8799th 136 137 139 141 143 144 145 90 90 91 92 93 94 94

17 90th 127 128 130 132 134 135 136 80 80 81 82 83 84 8495th 131 132 134 136 138 139 140 84 85 86 87 87 88 8999th 139 140 141 143 145 146 147 92 93 93 94 95 96 97

Blood Pressure Reference

17


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2 to 20 years: Girls

Body mass index-for-age percentilesNAME

RECORD #

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

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15

17

19

21

23

25

27

29

31

33

35

Date Age Weight Stature BMI* Comments

90

85

75

50

10

25

97

3

95

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Published May 30, 2000 (modified 10/16/00).

cdc.gov/growthcharts

2 to 20 Years: GirlsBody Mass Index for Age Percentiles

Body Mass Index (BMI)

18

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2 to 20 years: Boys

Body mass index-for-age percentilesNAME

RECORD #

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

90

75

50

25

10

85

Date Age Weight Stature BMI* Comments

97

3

95

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Published May 30, 2000 (modified 10/16/00).

2 to 20 Years: BoysBody Mass Index for Age Percentiles

cdc.gov/growthcharts

Body Mass Index (BMI)

19


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CB 5967 AUG 09 (reprint) 092853COSV

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pediatric healthy weight toolkit · strategies to maintain healthy weight in children adapted from...

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