Guest: Dr. Bonita Falkner
Guest Bio: Dr. Bonita Falkner, Thomas Jefferson University, Philadelphia, Pennsylvania
We discuss what is known and unknown about the long term consequences of pediatric hypertension, including the effects of pharmaceutical drugs on young patients.
Health Professional Radio – pediatric hypertension
Emily: You’re listening to Health Professional Radio. This is Emily and I’m speaking with Dr. Bonita Falkner from Thomas Jefferson University in Philadelphia, Pennsylvania. Dr. Falkner, thank you so much for speaking with me today.
Dr. Bonita Falkner: Glad to be back, Emily.
Emily: We’ve been talking about a recent study that was just published in The Journal of Hypertension, that suggests that hypertension in children might be linked to sodium intake, which is on the rise because of the kinds of foods that we’ve been eating. Dr. Falkner, can you tell me—we know that the lifestyle changes are the first response. Obviously, if something that can be helped through that kind of modification, then the drugs, I’m sure, are a last resort.
But for a child that needs drugs to combat hypertension, do we know a lot about the risks of that kind of medication on a young person and long term effects that might not be as prevalent in adults?
Dr. Falkner: Well, we know more now than we did 20 years ago. I mean, when we knew very, very little about the drugs. The—I guess it’s probably in the 1990s, the FDA or Congress created this act called the FDA Modernisation Act. What it was, was a recognition that there should be more information about medicines, the different new medicines that were being approved by the FDA, in the event that they might be used in children. We do use medications in children a lot, all the time, and quite frankly, we’ve had very few clinical trials on drugs in children.
Dr. Falkner: [indecipherable 02:06] except some of the antibiotics have been tested in children, vaccines, those types of medications. But up to that time, there was not much information on the drugs used to treat hypertension, the typical medications such as beta blockers or ACE inhibitors, and so forth.
Dr. Falkner: This FDA Modernization Act was designed to provide incentives for the pharmaceutical companies to get this data on children, and it was a very significant financial incentive for them to do it. It actually was centred on those drugs that they had that were still on patent. So, they did it. What happened was there was a lot of short paediatric trials on different drugs and the different classes of anti-hypertension medication that did provide some information on the safety and effectiveness of the anti-hypertensive drugs in children.
They’re very short term trials but it’s certainly much better. We had a better idea about dosing and, we had better tools to decide what class of medications to choose. We’re far from having the amount of objective clinical trial data that has been generated in adults with cardiovascular diseases and hypertension.
Dr. Falker: We generally know that the medications are safe and that they are effective. We don’t have long-term data in terms of individual [indecipherable 04:13] medications for years and years and years.
Dr. Falkner: As a consequence, what the paediatric hypertension specialists like myself generally do, is that we decide to treat children with medications. We need to have some indications to do it, such as they’ve not responded at all to the non-drug therapies, they have some evidence of target organ damage. Maybe they have chronic kidney disease or they’re diabetic or they have another condition that adds to the risk.
Dr. Falkner: Usually what we do is we select the drugs to start treatment, and adjust the drug until we get the blood pressure under control. Sometimes, we have to use two drugs to get the blood pressure under control and to keep the blood pressure under control for a while. And, there are some that after a while, the blood pressure has been well-controlled for a period of time, they do try tapering them off to see if it will remain a safe level of medication.
Emily: I see. Are you seeing the same kinds of patterns in terms of symptoms of high blood pressure and consequences of high blood pressure? Are the patterns and the timelines consistent with what happens when an adult’s body has hypertension?
Dr. Falkner: Well, we can see the same—we see in children similar risk factors that there are in adults, probably they’re muted in terms of the manifestations. Usually, children with hypertension do not have symptoms–
Emily: I see.
Dr. Falkner: — unless there’s a very abrupt or severe increase in the blood pressure, then they have symptoms, such as nosebleeds. With really high blood pressure, they can have symptoms of lethargy and headaches and so forth, but usually children with hypertension are without symptoms.
Emily: I see.
Dr. Falkner: So, [indecipherable 06:44] I forget what— you asking that question again [indecipherable 06:47].
Emily: Sure. I asked about the symptoms and about the consequences—the physical ramifications of hypertension for an extended period of time in a young person.
Dr. Falkner: Well, I think we’re learning more about that. One of the problems with hypertension in children is that we don’t have the long-term outcome data. In an adult with hypertension or a certain level of blood pressure, usually around 140 over 90, there’s enough data to predict if there’s no intervention, there’s a marked increase in the risk for an event, such as heart failure, kidney failure, stroke, or death. But there is not similar data in children.
Emily: I see.
Dr. Falkner: We don’t have the outcome data of what happens decades later in a child with high blood pressure. However, I would say since that report in 2004, we have learned a lot more about the intermediate markers, and we know now that hypertensive children, about 40% of them will have [08:19 indecipherable] in the heart.
Dr. Falkner: We know that a significant portion will already have a stiffening of the aorta, and some of them may have [indecipherable 08:34], a greater amount of protein in the urine which is another sign of injury. There’s even new data suggesting that children with high blood pressure, these are the typical asymptomatic children who don’t have anything else wrong with them except for high blood pressure then you [indecipherable 08:54].
There’s data that they can have subtle changes in cognitive function—executive function, the parameters of executive function, which is similar to what’s found in adults, too.
Emily: I see.
Dr. Falkner: There’s research [indecipherable 09:14] investigate this–
Emily: I see.
Dr. Falkner: [indecipherable 09:18] central nervous system target organ damage. These things that I have told you about, the stiffening of the aorta and the stiffening of the carotid artery, the cognitive change, are not really ready for clinical practice yet, these are really issues that are being addressed as a research issue, but they are [indecipherable 09:44] come up with some type of outcome profile related to–
Dr. Falkner: —high blood pressure.
Emily: Wow. Well, let me ask you just one more question. What do you hope will come out of this study?
Dr. Falkner: Well, it’s always good to have your research replicated. I’m certain that there are other databases around that have blood pressure data in children, and some dietary data, and that someone will look to their databases and see if they can find a similar finding. That’s one thing. That other folks out there will—this finding can be replicated to really be certain that it’s real. The next thing is there’s a signal to try and— it becomes a public health message to try and look carefully at the food supply–
Dr. Falkner: —and see, is the food supply we have causing more hypertension, and that’s going to be a big issue. For myself [indecipherable 11:11] it gives me more evidence to really speak more strongly to my patients about getting off the processed foods–
Dr. Falkner: It doesn’t mean you can’t ever have processed food, but cutting back —
Dr. Falkner: —try and cook, if you don’t cook at all, cook once a week, and then twice a week, [indecipherable 11:36].
Emily: It would be interesting to find out if your patients come back to you and say, “Wow, I feel so much better!”, “Wow, I have so much energy!” I wish you the best of luck with all of that, and thanks so much for taking the time to speak with me today.
Dr. Falkner: Okay. It was my pleasure.
Emily: You’re listening to Health Professional Radio. This is Emily, and my guest today has been Dr. Bonita Falkner from Thomas Jefferson University in Philadelphia, Pennsylvania.