PEDIATRIC HYPERTENSION

Dr Mohamed Rafa
Msc pediatrics

Hypertension in children is a growing epidemic

High blood pressure is estimated to be prevalent in 4.5% of children
Why the rise in childhood hypertension?
 Increasing epidemic of childhood obesity
 Sedentary lifestyles
 Epidemiologic studies indicate that about 30% of obese children have hypertension
 Hypertension and obesity are two common preventable disorders facing pediatric
clinicians

Why are health care providers failing to make the diagnosis?

 Blood pressure in children is a function of age, sex, and height percentile
 What is normal for one child may be considered hypertensive in another child of the
same age
 Clinicians usually cannot remember normal blood pressures for the wide range of
children observed in their typical primary care setting

Factors making diagnosis more likely in children

 Older age
 Taller height
 Obesity
 Younger children and adolescents who are not overweight and generally appear healthy
are typically the patients where hypertension is not suspected and often missed

Why is it important to diagnose and treat hypertension in childhood?

Prevent progression and target organ damage of the brain, eyes, heart, and
kidneys. A study by Hanevoid demonstrated that severe target organ damage occurs in
hypertensive children. 41% of the 129 hypertensive children and adolescents studied
had left ventricular hypertrophy (LVH) by pediatric criteria, and 16% had LVH even when
using adult criteria. If caught early, preventative measures can be taken to reduce risks
for other comorbidities in childhood and adulthood.

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Pediatric Classifications
The Fourth Report 2004 includes new classifications for hypertension
 Prehypertension
 Stage 1
 Stage 2

Example for the new blood pressure tables:

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White-coat hypertension is present when BP readings in health care facilities are
greater than the 95th percentile but are normotensive outside a clinical setting. This
condition may not be as benign as once thought to be, and regular follow-up is now
recommended.
Several studies suggest that in some children this may be a prehypertensive state that
eventually may progress to hypertension. Counsel patient about therapeutic lifestyle
changes and monitor for development of true hypertension

Hypertension is classified into two general types, essential (or primary) hypertension, in
which a specific cause cannot be identified, and secondary hypertension, in which a
cause can be.
1. The exact prevalence of essential hypertension in children and adolescents is not
known. It is estimated that about 60% of pediatric patients with hypertension have
essential hypertension. Among the patients with essential hypertension 75% of them are
obese. Thus, the most common cause of pediatric hypertension appears to be obesity;
about 10% to 30% of obese children are reported to have hypertension.
2. Among patients with secondary hypertension, more than 90% of the cases are caused
by three conditions: renal parenchymal disease and renovascular diseases (both
accounting for 70%) and coarctation of the aorta (COA) (20%). Fewer than 10% of
secondary hypertension is caused by endocrine and other disorders.
3. In newborns, the causes of hypertension may include renal artery thrombosis,
congenital renal malformation, and COA. Transient hypertension may be found in
neonates with bronchopulmonary dysplasias, which resolves when oxygenation
improves.
In general, children with essential hypertension are older than 10 years of age,
have mild hypertension, and are often obese. Secondary hypertension is suggested by a
younger age, levels of hypertension (varying from mild to severe, especially stage 2
hypertension), and presence of clinical signs that suggest systemic conditions. Children
with secondary hypertension are rarely obese and are often less than normal height.

Measurement of BP in Pediatrics
The Fourth Report recommends that children 3 years and older have their blood
pressure measured regularly. The preferred method of blood pressure measurement is
auscultation. In order to correctly diagnose hypertension blood pressure must be
measured accurately.
Main source of error – Using wrong cuff size
Small cuff- overestimates BP
Large cuff- underestimates BP
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Appropriate Cuff Size
Inflatable bladder width that covers at least 40% of the arm circumference midway
between the olecranon process and the acromion process
The bladder length should cover 80-100% of the circumference of the arm
The bladder width-to-length ratio should be at least 1:2

Measurement of BP in Pediatrics
 Preparing the child for blood pressure
measurements.
 Sit quietly for five minutes with their back
and right arm supported at heart level
and feet flat on the floor
 If a patient has a reading that is >90th
percentile
 BP should be repeated twice at the same
office visit
 Document average systolic and diastolic
BP

Ambulatory Blood Pressure Monitoring (ABPM)

Ambulatory Blood Pressure Monitoring allows clinicians to observe the patients BP 2-4
times per hour over at least 24 hours
Patients are encouraged to continue normal everyday activities while being monitored
Successful in children even as young as 2 months
Make diagnosis that would otherwise be missed

Nocturnal Blood Pressure

Nocturnal BP Dip- Typically individuals have 10-15% drop in their mean day and night
blood pressure readings.

ABPM can detect:

 An abnormality nocturnal BP dip
 Elevations of nocturnal blood pressure
Both usually indicative of secondary hypertension

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Pediatric Symptoms
Hypertension is often thought of as a silent disease because typically there have not
been any classic symptoms.
A recent study by Croix found that 51% of untreated hypertensive children when
surveyed reported 1-4 Symptoms, and 14% reported more than four symptoms
3 most common symptoms
 Headache
 Difficulty initiating sleep
 Daytime tiredness
These were all reduced with treatment
After Hypertension is Diagnosed:
 Want to rule out secondary causes
 BP should be measured in both arms and a leg to rule out coarctation of the aorta
 Fasting lipid, Fasting glucose, standard chemistry panel, serum urea nitrogen (BUN),
CBC, creatine, urinalysis and urine culture
 Echocardiogram, renal ultrasound
 Screen for major sleep disorders using BEARS:
o Bedtime problems
o Excessive daytime sleepiness
o Awakenings during the night
o Regularity and duration of sleep
o Snoring

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Arm & Leg BPs

In normal children, the oscillometric systolic pressure in the thigh or calf is 5 to 10

mmHg higher than that in the arm. In children with coarctation of Aorta, by using of the
auscultatory method, the leg systolic pressure may be as much as 20 mm Hg higher than
in the arm in normal children.

Treatment
Lifestyle modifications are typically the initial treatment of choice. Nonpharmacologic
intervention should be started as an initial treatment. Counseling should encourage
weight reduction if the patient is overweight or obese, healthful diets, low-salt (and
potassium-rich) foods, regular aerobic exercise, and avoidance of smoking.

Drugs are used when nonpharmacologic approaches have not been found to be effective
because the possible adverse effects of long-term drug therapy on growing children have
not been evaluated adequately and because many antihypertensive agents have side
effects.

Indications for antihypertensive drug therapy in children

1. Severe symptomatic hypertension should be treated with intravenous (IV)
antihypertensive medications.
2. Significant secondary hypertension, such as caused by renovascular and
renoparenchymal diseases
3. Persistent hypertension despite nonpharmacologic measures
4. Hypertensive target-organ damage: LV hypertrophy; increased LV mass, and so on
5. Diabetes (types 1 and 2)
6. Family history of early complications of hypertension
7. Child who has dyslipidemia and other coronary artery risk factors

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The Fourth Report recommends starting with a class of antihypertensive medication
appropriate for each specific patient. [3] Pediatric clinical trials have focused on the ability
of each drug to lower blood pressure (BP), but the effects of these drugs on clinical
endpoints have not been compared. Therefore, the choice of drug is the clinician’s.
The Task Force recommends the use of ACE inhibitors or ARBs only for children with
diabetes and microalbuminuria or proteinuric renal disease and recommends beta-
blockers or calcium-channel blockers for children with hypertension and migraine
headaches. A low dose of 1 drug should be started first. If this dose is unsuccessful, it
should be titrated upward.
In children with uncomplicated primary hypertension, BP is considered controlled when
it is below the 95th percentile. In children with chronic renal disease, diabetes, or
hypertensive target-organ damage, the goal should be a BP below the 90th percentile. If
BP is not controlled, a drug from another class should be added. If control is not
achieved with 2 drugs, reconsider the possibility of secondary hypertension before
adding a third drug.

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Follow-up Evaluation of Patients with Chronic Hypertension
1. Follow-up examinations should include ongoing monitoring of BP levels, target-organ
damage, periodic serum electrolyte determination in children treated with ACE inhibitors
or diuretics, counseling regarding other cardiovascular risk factors, and adherence with a
newly adopted healthy lifestyle.
2. Goals of treatment
a. For children with uncomplicated primary hypertension without hypertensive endorgan
damage, the goal of the treatment is reduction of BP to below the 95 th percentile.
b. For children with chronic renal disease, diabetes, or hypertensive target organ damage,
the goal is reduction of BP to below the 90th percentile.
3. A “step-down” therapy or cessation of therapy may be considered in selected patients
with uncomplicated primary hypertension that is well under control, especially
overweight children who successfully lose weight. Such patients require ongoing followup
of their BP levels and their weight status.

Management of Secondary Hypertension

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Treatment of secondary hypertension should be aimed at removing the cause of
hypertension whenever possible. Table below lists curable causes of systemic
hypertension.
Organ or System Diseases and Conditions

Renal  Unilateral kidney disease (pyelonephritis, hydronephrosis, traumatic

damage, radiation nephritis, hypoplastic kidney)
 Wilms’ and other kidney tumors
Cardiovascular  Coarctation of the aorta
 Renal artery abnormalities (e.g., stenosis, aneurysm, fibromuscular
dysplasia, thrombosis)
Adrenal  Pheochromocytoma and neuroblastoma
 Cushing syndrome (caused by adrenocortical or pituitary tumor)
 Primary aldosteronism
Miscellaneous  Glucocorticoid therapy
 Oral contraceptives
 Hyperthyroidism