Hypertension in pediatric

By Dr Tanveer alam khan

What to learn from the presentation What is hypertension How to diagnose hypertension in

children Measuring BP in children Learning normal BP range for

children Causes of hypertension in children Evaluating the cause Management

Pediatric hypertension

NORMAL BLOOD PRESSURE is defined as a systolic and diastolic blood pressure below the 90th percentile for gender, age and height percentile

PRE-HYPERTENSION is defined as the 90th percentile to less than 95th percentile or if BP greater than 120/80 even if below the 90th percentile (up to below the 95th percentile).

STAGE 1 HYPERTENSION is defined as a blood pressure between the 95th percentile and the 99th percentile plus 5mmHg.

STAGE 2 HYPERTENSION is defined as a blood pressure above the 99th percentile plus 5mmHg.

WHITE COAT” HYPERTENSION is defined in a patient with blood pressure above the 95th percentile in the physician’s office or clinic, who is normotensive outside the clinical setting.

Important points to remember Children >3 Years must check BP Children <3 years who have congenital

heart defect/renal disease/malignancies ,recurrent Uti ,solid organ transplant, raised icp.

The preferred method ?. Appropriate to the size of cuff ? Repeated elevated BP must be

confirmed Ambulatory BP monitoring (ABPM)

Continue.. Normally, BP is 10–20 mmHg higher in the legs

than the arms. The blood pressure must be obtained on three separate

occasions. If the systolic and diastolic blood pressure falls into different categories, classify by the higher category.

Child should be calm resting on his/her back for 5 min touching feets on ground

Measures obtained by oscillometric devices that exceed the 90th percentile should be repeated by auscultation in all limbs preferably

Different charts are designed for boys /girls in pediatric

Blood pressure measurement

Blood Pressure Tables

(Year)Percentile 5th10th25th50th75th 90th95th5th10th25th50th75th 90th 95th

12 50th 102103104105107108109 61 61 61 62 63 64 6490th 116116117119120121122 75 75 75 76 77 78 7895th 119120121123124125126 79 79 79 80 81 82 8299th 127127128130131132133 86 86 87 88 88 89 90

Boys SBP, mmHg

Percentile Height

DBP, mmHg

Percentile Height

Evaluation of hypertensive patient

Write few imp of them in one slide

Evaluation of HTN in ChildrenMust begin with: Thorough history (including hx of sleep disorder) Physical examination Laboratory evaluation

Assessment of cardiovascular risk factors:overweightlow plasma HDL cholesterolhigh plasma triglyceridesabnormal glucose tolerance

Laboratory evaluation of HTNBasic: Serum chemistries, BUN, Cr, PRA, Aldosterone level CBC Urinalysis and Urine culture Renal ultrasound with dopplerEvaluation for comorbidity: Fasting Lipid profile Fasting glucose Drug screen (if hx of drug use) Polysomnography (if hx of sleep disorder)Evaluation for end-organ damage: Echocardiogram Retinal exam

Changes seen on retinal exam

Additional Evaluation

24hr ABPM (white coat /masked HTN) Reno vascular imaging -Renal scan -Duplex Doppler flow studies -MRA, CTA -Arteriogram Other labs - Urine for Vma -Plasma and urine metanephrines -Plasma and urine steroids

Classification of Hypertension & Therapy RecommendationsClassification of Hypertension

Therapy Recommendations

Normal Encourage healthy diet, sleep, & physical activity

Recheck on next visitPrehypertension Physical activity & diet management; No

medication unless compelling indications such as CKD, DM, HF or LVH exist

Stage 1 Hypertension Physical activity & diet management; Initiate therapy if indicated as above + Symptomatic hypertension + Persistent hypertension despitenonpharmacologic measures

Stage 2 Hypertension Physical activity & diet management; Initiate therapy

Non-pharmacologic Therapy of HTN in children

Weight reduction

Dietary modifications:consumption of more fruits, vegetables, fiber, nonfat diary,

reduced sodium intake (1.2g/day in younger kids and 1.5g/day in older kids)

Pharmacologic Therapy of HTN in Children

Indications:1. Symptomatic hypertension2. Secondary hypertension3. Target-organ damage4. Poor response to non pharmacologic therapy5. Diabetes mellitus Goal is to reduce BP <95th percentile (<90th

percentile if concurrent conditions or LVH present) Treat severe symptomatic BP with IV

antihypertensives

Drug Options for Initial Therapy1

Class of Drugs Patients’ Characteristics

ACE-Is/ARBs First-line therapy

CCBs First-line therapy(recommended >6years)

Diuretics Adjunct second-line drug

β–Blocker controversial in diabetes

ACE inhibitors (captoril +lisinopril first line therapy

Machanism of action prevents conversion of angiotensin I to angiotensin II, which leads

to an increase in plasma renin activity and a reduction in aldosterone secretion

Characteristic:Renal insufficiency (unilateral renovascular hypertension, renal

parenchymal disease, renal proteinuria)Congestive heart failureDiabetesHyperlipidemia

Comments: Monitor serum potassium and SCr Cough and angioedema May require a dosing adjustment in renal impairment

ARBs lossartan Irbesartan)

Mechanism of action angiotensin II receptor antagonist blocks the

vasoconstrictor and aldosterone-secreting effects of anigotensin II

Characteristic : same as ACE-I Coments: Less cough/ angioedema• Monitor K & s-cr• Less studies then ACE I in pediatrics

CCB ( amlodipine felodipine nifedipine)

mode of action: decrease intracellular calcium concentrations and results in

dilation of peripheral arterioles Characteristics:

Emergency hypertension (nifedipine) Diabetes Chronic obstructive lung disease Broncho-pulmonary dysplasia Gout Hyperlipidemia Peripheral Vascular Disease Renal Transplant (cyclosporine-induced)Coments: edema, arrhythmias, headache, fatigue, dizziness,

flushingMay need adjustment in hepatic impairment

Hypertensive Urgency/emergency

Admit to the ICU! Goal is to safely lower BP Use titratable short-acting IV

antihypertensive for BP management Reduce BP by 25% of goal reduction in first

2 hrs and then down to normal in next 3-4 days