Identification and management of pediatric hypertension

1. • Dr.C.S.N.Vittal

2. EPIDEMIOLOGY
• Significant increase in interest in childhood hypertension (HTN)
since 2004 Fourth Report.
• 3.5% of children have HTN;
• Another 10%–11% have elevated blood pressure (BP)
• High BP in childhood increases the risk for adult HTN and
cardiovascular disease.
• Even youth with HTN have evidence of accelerated vascular aging.

3. UPDATED DEFINITIONS OF BP CATEGORIES
CONDITION CHILDREN AGED 1 – 13 YRS CHILDREN > 13 YRS
NORMAL < 90th percentile < 120 / < 80 mm Hg
ELEVATED BP
(prehypertension)
> 90th percentile TO < 95th percentile 120 / < 80 mm Hg TO
129/ < 80 mm Hg
STAGE 1 HTN ≥ 95th percentile to < 95th percentile + 12 mmHg,
OR
130/80 to 139/89 mm Hg (whichever is lower)
130/80 to 139/89 mm Hg
STAGE 2 HTN ≥ 95th percentile + 12 mm Hg, or ≥ 140/90 mm Hg
(whichever is lower)
≥140/90 mm Hg
• Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents,
Pediatrics, September 2017, VOLUME 140 / ISSUE 3, AAP

4. WHITE COAT HYPERTENSION
• Blood pressure above 95th
percentile in the physician’s
office or clinic, and
normotensive outside the
clinical setting

5. MASKED HYPERTENSION (MH)
• MH occurs when patients have normal
office BP but elevated BP on ABPM
• It has been found in 5.8% of unselected
children studied by ABPM.
• These patients have significant risk for end
organ hypertensive damage.
• Patients who are at risk of MH include
patients with obesity and secondary forms
of HTN, such as CKD or repaired aortic
coarctation.

6. ETIOLOGICAL CLASSIFICATION
SecondaryPrimary
or
Essential
Hypertension
• No obvious cause
• ? Genetic
• Renal
• Endocrinal
• CNS, etc.

7. HYPERTENSION IN THE NEWBORN
Most often associated with:
• 1. umbilical artery catheterization
and
• 2. renal artery thrombosis

8. HYPERTENSION DURING EARLY
CHILDHOOD
May be due to :
1. Renal disease
2. Coarctation of the aorta
3. Endocrine disorders
4. Medications.

9. HYPERTENSION IN
ADOLESCENTS
• Essential hypertension becomes
increasingly common

10. RENAL
• Acute postinfectious glomerulonephritis
• Henoch-Schönlein purpura with nephritis
• Hemolytic-uremic syndrome
• Acute tubular necrosis
• After renal transplantation (immediately and during
episodes of rejection)
• After blood transfusion in patients with azotemia
• Pyelonephritis
• Obstructive uropathy
• Renal trauma
CONDITIONS ASSOCIATED WITH
TRANSIENT OR INTERMITTENT HYPERTENSION IN
CHILDREN

11. • Cocaine
• Oral contraceptives
• Sympathomimetic agents
• Amphetamines
• Phencyclidine
• Corticosteroids and
• Adrenocorticotropic hormone
• Cyclosporine or sirolimus
treatment post-transplantation
• Licorice (glycyrrhizic acid)
• Lead, mercury, cadmium, thallium
• Antihypertensive withdrawal
(clonidine, methyldopa,
propranolol)
• Vitamin D intoxication
CONDITIONS ASSOCIATED WITH
TRANSIENT OR INTERMITTENT HYPERTENSION IN
CHILDREN
Drugs and Poisons

12. • Increased intracranial pressure
• Guillain-Barré syndrome
• Burns
• Familial dysautonomia
• Stevens-Johnson syndrome
• Posterior fossa lesions
• Porphyria
• Poliomyelitis
• Encephalitis
Central and Autonomic nervous system
CONDITIONS ASSOCIATED WITH
TRANSIENT OR INTERMITTENT HYPERTENSION IN
CHILDREN

13. CONDITIONS ASSOCIATED WITH
CHRONIC HYPERTENSION IN CHILDREN
RENAL
• Chronic pyelonephritis
• Chronic glomerulonephritis
• Hydronephrosis
• Congenital dysplastic kidney
• Multicystic kidney
• Renal tumor
• Vesicoureteral reflux nephropathy
• SLE

14. VASCULAR
• Coarctation of aorta
• Renal artery lesions (stenosis,,
aneurysm)
• Umbilical artery catheterization with
thrombus formation
• Renal vein thrombosis
• Vasculitis
• Arteriovenous shunt
CONDITIONS ASSOCIATED WITH
CHRONIC HYPERTENSION IN CHILDREN

15. ENDOCRINE
• Hyperthyroidism
• Hyperparathyroidism
• Congenital adrenal hyperplasia (11 β-
hydroxylase and 17-hydroxylase
defect)
• Cushing syndrome
• Primary aldosteronism
• Pheochromocytoma
• Diabetic nephropathy
CONDITIONS ASSOCIATED WITH
CHRONIC HYPERTENSION IN CHILDREN

16. MEASUREMENT OF BP IN CHILDREN
• Every child > 3 years old who is seen in a medical setting should have BP measured
• Conditions under which children < 3 yrs old should have BP measured:
• H/o prematurity, LBW,
• CHD (repaired or not repaired)
• Recurrent UTI, hematuria or proteinuria
• Known urological malformation
• Family H/o. CHD
• Malignancy or bone marrow transplant or solid organ transplant
• Evidence of raised ICP
• Known disorders associated with hypertension (tuberous sclerosis, neurofibromatosis)

17. MEASUREMENT OF BP IN CHILDREN
• Child should be calm and free of
anxiety
• Child should be sitting quietly for
5 min
• Child should be sitting with back
supported, both feet on the floor
and right cubital fossa supported
at heart level

18. • Choose appropriate size cuff (The bladder length should be 80%–100% of the
circumference of the arm, and the width should be at least 40%.)
MEASUREMENT OF BP IN CHILDREN
• Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1:
blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the
American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111(5):697–716.

19. RECOMMENDED DIMENSIONS FOR BP CUFFS
Age Range Width (cm) Length (cm) Maximum Arm
Circumference (cm)
Newborn 4 8 10
Infant 6 12 15
Young Child 9 18 22
Older Child 12 24 26
Adult 13 30 44
Thigh 20 42 52
• BP should be recorded in all the four limps
• Cuff should not be applied too tight (low BP recording) or too loose (high BP recording)
• Subsequent BP should be taken in the same limb and position
• Normally BP is 10 – 20 mm Hg higher in lower limbs compared to upper limbs

20. AMBULATORY BLOOD PRESSURE MONITORING
• Patient wears a BP cuff continually for 24
hours
• Readings q20–30 min
• Captures BP in many settings:
• Home, school, work
• Awake, asleep
• ABPM allows for evaluation of
• Out-of-office BP
• Circadian BP patterns

21. BLOOD PRESSURE PATTERNS BY OFFICE BP
AND AMBULATORY BP
Ambulatory BP Office BP
Normal BP Normal Normal
Sustained Hypertension Elevated Elevated
White Coat HTN Normal Elevated
Masked HTN Elevated Normal

22. New Blood Pressure Tables
Flynn JT, Kaelber DC, Baker-Smith CM, et al., and AAP Subcommittee on Screening and Management of High Blood Pressure in
Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents.
Pediatrics. 2017;140(3):e20171904
• Normal range
is determined
by gender,
age, and
height.
• The new
tables include
50th, 90th,
95th, and
99th
percentiles.
• The average
difference
between 95th
% and 99th %
is 7-10
mmHg.

23. SIMPLIFIED BLOOD PRESSURE
TABLE
• Simplified BP table created for use in
initial screening of BP values
• Based on 90th percentile BP values for
children at 5th height percentile
•New normative BP tables commissioned for this clinical
practice guideline, based only on BP readings from ~50,000
normal-weight children

24. CLINICAL FEATURES
• Mostly asymptomatic
• Presence of symptoms
indicates end organ damage
• Symptoms attributed to
hypertension include
headache , nausea vomiting ,
dizziness , irritability and
epistaxis.
Signs and symptoms that should alert the
physician to the possibility of hypertension in
older children include all of the above, as well
as the following:
• Fatigue
• Blurred vision
• Epistaxis
• Bell palsy

25. APPROACH TO A CHILD WITH HYPERTENSION
History
• Neonatal - prematurity, BPD, umbilical artery catheterization .
• Cardiovascular- History of CoA or surgery for it, history of palpitation ,
• Headache, excessive sweating (excessive catecholamine levels).
• Renal- History of obstructive uropathy, UTI, radiation, trauma or surgery to kidney area.
• Endocrine- weakness, fiushing, weight loss, muscle cramps (hyperaldosteronism).
Constipation
• Medication/Drugs
• Symptoms of obstructive sleep apnea
• Family H/o. Essential HTN, Atherosclerosis, stroke, hereditary renal disease

26. PHYSICAL EXAMINATION
• Four-extremity BP
• Fundoscopy (papilledema, hemorrhage, exudate)
• Visual acuity
• Thyroid examination
• Evidence for congestive heart failure (tachycardia, gallop rhythm,
hepatomegaly, edema)
• Abdominal examination (mass, bruit)
• Thorough neurologic examination
• Evidence of virilization, Cushingoid effect

27. EVALUATION OF HYPERTENSION IN CHILDREN
M.O.N.S.T.E.R. - PNEUMONIC
• Medications
• Obesity
• Neonatal History
• Symptoms & Signs
• Trends in the Family
• Endocrines and
• Renal

28. DIAGNOSTIC ALGORITHM IN EVALUATION OF HYPERTENSION
Documented Hypertension
Gradient between upper and lower limb BPs
Yes No
Coarctation of Aorta Abnormal Urinalysis
Predominant WBC
Predominant RBC
Yes
No
Endocrine Renovascular Essential HTN
•Reflux nephritis
•Rec UTI
•Renal anomaly /
infection
•Post inf nephritis
•Lupus nephritis
•Nephrocalcinosis
•Renal Vein Thrombosis
•Tumor

29. SCREENING TESTS
Patient Population Screening Tests
All patients Urinalysis
Chemistry panel, including electrolytes, blood urea nitrogen, and creatinine
Lipid profile (fasting or nonfasting to include high-density lipoproteina and total cholesterol)
Renal ultrasonography in those <6 y of age or those with abnormal urinalysis or renal function
In the obese (BMI >95th percentile)
child or adolescent, in addition to the
above
Hemoglobin A1c (accepted screen for diabetes)
Aspartate transaminase and alanine transaminase (screen for fatty liver)
Fasting lipid panel (screen for dyslipidemia)
Optional tests to be obtained on the
basis of history, physical examination,
and initial studies
Fasting serum glucose for those at high risk for diabetes mellitus
Thyroid-stimulating hormone
Drug screen
Sleep study (if loud snoring, daytime sleepiness, or reported history of apnea)
Complete blood count, especially in those with growth delay or abnormal renal function
• Wiesen J, Adkins M, Fortune S, et al. Evaluation of pediatric patients with mild-to-moderate hypertension:
yield of diagnostic testing. Pediatrics. 2008;122(5).

30. OVERALL TREATMENT GOALS
• Achieve a BP level that
• Reduces risk for target organ damage
• Reduces risk for hypertension-related
cardiovascular disease in adulthood
• Achieve an optimal BP level:
• <90th percentile / <130/80 mm Hg in
adolescents

31. MANAGEMENT STRATEGIES
Classification of HTN Therapy Recommended
Normal Encourage healthy diet, sleep and physical activity. Recheck on
visit
Elevated BP Physical activity & diet management;
No medication unless compelling indications like CKD, DM, HF or
LVH
Stage 1 Hypertension Physical activity & diet management; Initiate therapy if indicated +
Symptomatic hypertension + persistent hypertension despite non-
pharmacological measures
Stage 2 Hypertension Physical activity & diet management; Initiate therapy

32. LIFESTYLE INTERVENTIONS
• At the time of diagnosis of elevated BP or HTN in a child or
adolescent, clinicians should provide advice on the DASH
(Dietary Approaches to Stop Hypertension) diet
• Consumption of more fruits, vegetables, fiber, non-fat
diary, reduced sodium intake (1.2 gm / day in infants
and 1/5 gm / day in older children)
• Salt restriction
• Recommend moderate to vigorous physical activity at least
3 to 5 days per week (30–60 min per session) to help
reduce BP.

33. PHARMACOLOGIC TREATMENT
• Prescribe antihypertensive medications if:
• Patient has failed at least 6 months of lifestyle change
• Symptomatic HTN
• Stage 2 HTN without clearly modifiable risk factor (e.g. obesity)
• Secondary hypertension
• Associate DM
• Target organ damage
Goal: To reduce BP < 95th percentile. (< 90th percentile if concurrent
conditions like LVH present)

34. PHARMACOLOGIC TREATMENT
Class of Drugs Patients’ Characteristics
ACE Inhibitors Captopril, First line therapy drugs
ARBs Losartan First line therapy drugs
Ca Channel Blockers Nifedepine, Verapamil First line in children > 6 yrs
Diuretics Hydrochlorthiazide,
Frusemide, Spiranolactone
Adjunct second line drugs
b– blocker Propranolol Controversial - ? In diabetics
a & b – blocker Labetalol
• Step 1: Starting with a single antihypertensive in small dose and proceeding to full dose .
• Step-2 :If it produce no clinical improvement, a second antihypertensive drug should be added or
substituted.

35. COMMON ANTIHYPERTENSIVE DRUGS AND DOSAGES
Drug Class Drug Starting Dose
Age
Suggestions
Angiotensin converting
enzyme inhibitor
Enalapril 0.08 mg/kg (up to 5 mg) All except
neonates
Captopril 0.3-0.5 mg/kg p > 6 yr
Lisinopril 0.07 mg/kg (up to 5 mg) > 6 yr
Angiotensin receptor
blocker
Losartan 0.7 mg/kg (up to 50 mg) > 6 yr
Valsartan 1.3 mg/kg (up to 40 mg) > 6 yr
Beta blocker Metoprolol XL 1.0 mg/kg (< 50 mg) > 6 yr
Atenolol 0.5 mg/kg per day
Propranolol 1 mg/kg per day
Calcium channel
blocker
Amlodipine 2.5 mg > 6 yr
Extended release
nifedipine 0.25 mg/kg per day
Diuretic Furosemide 0.5 mg/kg per dose
Hydrochlorothiazide 0.5-1 mg/kg

36. ACUTE HYPERTENSION
Hypertensive urgency:
• Significant elevation in BP
without accompanying end-
organ damage;
• More common in children.
• Symptoms include headache,
blurred vision, and nausea
Hypertensive emergency:
• Elevation of both systolic and
diastolic BP with acute end-
organ damage
• e.g., cerebral infarction or
hemorrhage,
• pulmonary edema, renal failure,
• hypertensive encephalopathy,
seizures

37. ACUTE HYPERTENSION
Goal:
• To lower MAP by 20% over 1 hour and return to baseline levels over 24 to 48
hours
• An oral route may be adequate.
(Use of sublingual nifedipine is not recommended, as a precipitous, uncontrolled fall in BP
may result.)
Drugs Onset (Route) Duration Interval to repeat /
increase dose
Comment
Enalapril 15 min (IV) 12-24 hrs 8-24 hrs May cause hyperkalemia, hypoglycemia
Minoxidil 30 min (PO) 2-5 days 4-8 hr Contraindicated in pheochromocytoma

38. MANAGEMENT OF HYPERTENSIVE
EMERGENCY
Drug Onset (Route) Duration Interval to repeat
/ increase dose
Comment
Diazoxide
(arteriolar
vasodilator)
1-5 mn (IV) Variable (2-12 hrs) 15-30 min May cause edema, hyperglycemia
Hydralazine 5-10 min (IV) 2-6 hrs 4-6 hrs May cause reflex tachycardia,
prolonged hypotension, nausea

39. MANAGEMENT OF HYPERTENSIVE
EMERGENCY
Drug Onset
(Route)
Duration Interval to repeat
/ increase dose
Comment
Nitroprusside
(arteriolar and
venous dilator)
< 30 sec
(IV)
Very short 30-60 min Require ICU setting,
follow thiochyanate levels
Labatalol (a and b
blocker)
1-5 min (IV) Variable (~
6hrs)
10 min Require ICU setup
Nicardipine (Ca
channel blocker)
1 min (IV) 3 hrs 15 min May cause edema,
headache, nausea,
vomiting
Infusions

40. ALL OF THE FOLLOWING ARE THE INDICATIONS FOR
BP MONITORING EXCEPT?
A. Premature birth weight < 1.5 kg
B. Congenital heart or kidney disease
C. Age less than three years
D. Neurofibromatosis (NF)
E. Elevated intracranial pressure

41. AMBULATORY BLOOD PRESSURE MONITOR HELP IN
RECOGNIZING ALL CONDITIONS BELOW EXCEPT?
A. White coat hypertension
B. Infantile Hypertension
C. Secondary hypertension
D. Episodic hypertension & hypotension
E. Mask Hypertension

42. NORMAL BLOOD PRESSURE IN A 5 YEAR OLD
CHILD IS DEFINED AS
A.The blood pressure less than 90% for Height
B.The blood pressure less than 95% for Height & Weight
C.The blood pressure less than 90% for Height & Weight
D.The blood pressure less than 100/60 for Height & Weight
E.The blood pressure between 50 – 95 % for Weight

43. TRUE OR FALSE STATEMENTS
1.BP > 95% in clinic and < 90% at home = White coat syndrome
a. True b. False
2.BP > 75 % but < 95 % = Elevated BP a. True b. False
3.BP > 99% + 5 = Stage II Hypertension a. True b. False
4.BP > 90% but < 99 % = Stage I Hypertension a. True b. False

44. • Dr.C.S.N.Vittal