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CHAPTER I

PREFACE

Pediatric hypertension is now commonly observed. Hypertension is known to be a

major cause of morbidity and mortality in the United States and in many other countries,

and the long-term health risks to children with hypertension may be substantial. In the

United States, extensive normative data on blood pressure (BP) in children are available.

The Task Force on Blood Pressure Control in Children, commissioned by the National

Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH),

developed standards for BP by using the results of 11 surveys of more than 83,000 person-

visits of infants and children (including approximately equal numbers of boys and girls). The

percentile curves were first published in 1987 and describe age-specific distributions of

systolic and diastolic BP in infants and children, with corrections for height and weight.

The Third Report of the Task Force, published in 1996, provided further details

regarding the diagnosis and treatment of hypertension in infants and children.In 2004, the

Fourth Report added normative data and adapted the data to growth charts from the

Centers for Disease Control and Prevention (CDC) for 2000.In accordance with the

recommendations of the Task Force, BP is considered normal when the systolic and diastolic

values are less than the 90th percentile for the childs age, sex, and height.

The Fourth Report introduced a new category, prehypertension, which is diagnosed

when a childs average BP is above the 90th percentile but below the 95th. Any adolescent

whose BP is greater than 120/80 mm Hg is also given this diagnosis, even if the BP is below

the 90th percentile. This classification was created to align the categories for children with

the categories for adults from the recommendations of the Seventh Report of the Joint

National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood

Pressure.

Stage I hypertension is diagnosed if a childs BP is greater than the 95th percentile

but less than or equal to the 99th

percentile plus 5 mm Hg. Stage II hypertension is

diagnosed if a childs BP is greater than the 99th percentile plus 5 mm Hg.[3]
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CHAPTER II

STUDY

II.1 Definition

Hypertension is defined as average SBP and / or diastolic BP (DBP) that is >95th

percentile for gender, age, and height on >3 occasion.

Prehypertension in children is defined as average SBP or DBP levels that are >90 th

percentile but 120/80 mmHg should be considered

prehypertensive.

A patient with BP levels >95th percentile in a physicians office or clinic, who is

normotensive outside a clinical setting, has white-coat hypertension. Ambulatory BP

monitoring (ABPM) is usually required to make this diagnosis.

The definition of hypertension in children and adolescents is based on the normative

distribution of BP in healthy children. Normal BP is defined as SBP and DBP that are 95th

percentile for gender, age, and height on at least 3 separate occasions. Average SBP or

DBP levels that are >90th

percentile but 120 / 80 mmHg and

recommends the application of preventive health-related behaviors, or therapeutic

lifestyles changes, for individuals having SBP levels that exceed 120 mmHg. It is now

recommended that, as with adults, children and adolescents with BP levels >120 / 80 mmHg

but 95th

percentile when measured in a physicians office or clinic. Whereas

the patients average BP is


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II.2 Epidemiology[3]

United States statistics

The true incidence of hypertension in the pediatric population is not known. This

vagueness partly stems from the somewhat arbitrary definition of hypertension.

In adults, hypertension is defined on the basis of data from extensive studies that

allowed correlation of BP with adverse events, such as heart failure or stroke. Similar studies

have not been performed in children, although reports from small populations of children

provided compelling evidence of a relation between hypertension and both ventricular

hypertrophy and atherosclerosis.

In children, the definition of hypertension is based exclusively on frequency-

distribution curves for BP. As a consequence, estimates of the prevalence of pediatric

hypertension lack a scientific basis. The number of children who might be defined as having

hypertension and the frequency with which they develop complications during adulthood

remain unknown.

International statistics

Because of differences in genetic and environmental factors, incidences vary from

country to country and even from region to region in the same country.

Age-related demographics

Height and weight affect BP. However, these relations do not become evident until

children reach school age. The Task Force on Blood Pressure Control in Children considered

these factors when they published their normative data in 1987.

Numerous investigators have noted a correlation between the BP of parents and

that of their offspring. Familial aggregation of BP is detectable early in life. Some data relate

this association to concomitant obesity in both parent and child.

Sex-related demographics

There are no significant differences in BP between girls and boys younger than 6

years. From that age until puberty, BP is slightly higher in girls than in boys. At puberty and
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beyond, BP is slightly higher in male adolescents and men than in comparably aged female

adolescents and women.

Race-related demographics

The Task Force on Blood Pressure Control in Children noted no differences in BP

between African American and white children. However, both peripheral vascular resistance

and sensitivity of BP to salt intake appear to be greater in African American children than in

white children, at any age.

II.3 Etiologies

Most childhood hypertension, particularly in preadolescents, is secondary to an

underlying disorder. Renal parenchymal disease is the most common (60 to 70 percent)

cause of hypertension. Adolescents usually have primary or essential hypertension, making

up 85 to 95 percent of cases. Table 2 shows causes of childhood hypertension according to

age.[5]

TABLE 1

Physical Findings Indicative of a Secondary Cause for Childhood Hypertension

Physical examination

finding Possible etiologies

Abdominal bruit Renal artery stenosis

Abdominal mass Polycystic kidney disease; hydronephrosis/obstructive renal lesions;

neuroblastoma; Wilms' tumor

Acne Cushing's syndrome

Adenotonsillar hypertrophy Sleep disorder associated with hypertensionDecreased perfusion of lower

extremities

Coarctation of the aorta

Diaphoresis Pheochromocytoma

Flushing Pheochromocytoma

Growth retardation Chronic renal failure

Hirsutism Cushing's syndrome

Joint swelling Systemic lupus erythematosus

Malar rash Systemic lupus erythematosus

Moon facies Cushing's syndrome

Murmur Coarctation of the aorta

Muscle weakness Hyperaldosteronism

Obesity (general) Association with primary hypertensionObesity (of the face, neck, or Cushing's syndrome
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Physical examination

finding Possible etiologies

trunk)

Tachycardia Hyperthyroidism; pheochromocytoma; neuroblastoma

Thyromegaly Hyperthyroidism

TABLE 2

Causes of Childhood Hypertension According to Age Group

Age Causes

One to sixyears Renal parenchymal disease; renal vascular disease; endocrine causes; coarctation ofthe aorta; essential hypertension

Six to 12

years

Renal parenchymal disease; essential hypertension; renal vascular disease; endocrine

causes; coarctation of the aorta; iatrogenic illness

12 to 18

years

Essential hypertension; iatrogenic illness; renal parenchymal disease; renal vascular

disease; endocrine causes; coarctation of the aorta

Essential hypertension rarely is found in children younger than 10 years and is a

diagnosis of exclusion. Significant risk factors for essential hypertension include family

history and increasing BMI. Some sleep disorders and black race can be potential risk factors

for essential hypertension. Essential hypertension often is linked to other risk factors that

make up metabolic syndrome and can lead to cardiovascular disease. These risk factors for

metabolic syndrome include low plasma high-density lipoprotein, elevated plasma

triglycerides, abdominal obesity, and insulin resistance/hyperinsulinemia. The prevalence of

metabolic syndrome among adolescents is between 4.2 and 8.4 percent.

Secondary hypertension is more common in children than in adults. It can present in

adolescents, especially if they have physical findings not typically seen with essential

hypertension. Renal disease is the most common cause of secondary hypertension in

children. Other causes include endocrine disease (e.g., pheochromocytoma,

hyperthyroidism) and pharmaceuticals (e.g., oral contraceptives, sympathomimetics, some

over-the-counter preparations, dietary supplements). Transient rise in blood pressure,

which can be mistaken for hypertension, is seen with caffeine use and certain psychological

disorders (e.g., anxiety, stress).[3,5]


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II.4 Pathophysiology

BP is determined by the balance between cardiac output and vascular resistance. A

rise in either of these variables, in the absence of a compensatory decrease in the other,

increases mean BP, which is the driving pressure.

Factors that affect cardiac output include the following[3,9]

:

Baroreceptors

Extracellular volume

Effective circulating volume - Atrial natriuretic hormones, mineralocorticoids, angiotensin

Sympathetic nervous syndrome

Factors that affect vascular resistance include the following:

Pressors - Angiotensin II, calcium (intracellular), catecholamines, sympathetic nervous

system, vasopressin

Depressors - Atrial natriuretic hormones, endothelial relaxing factors, kinins, prostaglandin

E2, prostaglandin I2

Changes in electrolyte homeostasis, particularly changes in sodium, calcium, and

potassium concentrations, affect some of these factors.

Under normal conditions, the amount of sodium excreted in the urine matches the

amount ingested, resulting in near constancy of extracellular volume. Retention of sodium

results in increased extracellular volume, which is associated with an elevation of BP. By

means of various physical and hormonal mechanisms, this elevation triggers changes in both

the glomerular filtration rate (GFR) and the tubular reabsorption of sodium, resulting in

excretion of excess sodium and restoration of sodium balance.

A rise in the intracellular calcium concentration, due to changes in plasma calcium

concentration, increases vascular contractility. In addition, calcium stimulates release of

renin, synthesis of epinephrine, and sympathetic nervous system activity. Increased

potassium intake suppresses production and release of renin and induces natriuresis,

decreasing BP.


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The complexity of the system explains the difficulties often encountered in

identifying the mechanism that accounts for hypertension in a particular patient. These

difficulties are the main reason why treatment is often designed to affect regulatory factors

rather than the cause of the disease.

In a child who is obese, hyperinsulinemia may elevate BP by increasing sodium

reabsorption and sympathetic tone.[3,9]

II.5 Blood Pressure Measurement

According to the NHBPEP recommendations, children three years of age or older

should have their blood pressure measured when seen at a medical facility; however,

according to the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence

to recommend for or against routine screening for childhood hypertension to reduce the

risk of CAD.[5]

The preferred method for blood pressure measurement is auscultation. Aneroid

manometers are used to measure blood pressure in children and are accurate when

calibrated on a semiannual basis.

Correct measurement of blood pressure in children requires use of a cuff that is

appropriate to the size of the child's upper right arm. This is the preferred arm because of

the possibility of decreased pressures in the left arm caused by coarctation of the aorta. By

convention, an appropriate cuff size is one with an inflatable bladder width that is at least

40 percent of the arm circumference at a point midway between the olecranon and the

acromion. The cuff bladder length should cover 80 to 100 percent of the circumference of

the arm. An oversized cuff can underestimate the blood pressure, whereas an undersized

cuff can overestimate the measurement. Blood pressure should be measured in a controlled

environment after five minutes of rest in the seated position with the right arm supported

at heart level. If the blood pressure is greater than the 90th percentile, the blood pressure

should be repeated twice at the same office visit to test the validity of the reading.
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Arm circumference should be measured midway between the olecranon and acromial process.

Blood pressure cuff showing size estimation based on arm circumference.

Ambulatory blood pressure monitoring (ABPM) requires a patient to wear a portable

monitor that records blood pressure over a specified period. This allows measurements

outside of the medical setting, where some patients may experience elevated blood

pressure caused by anxiety (white-coat hypertension). Other uses for ABPM include

episodic hypertension, autonomic dysfunction, and chronic kidney disease. ABPM also may

have a role in differentiating primary from secondary hypertension and in identifying

patients likely to have hypertension-induced end-organ damage. The USPSTF maintains that

ABPM is subject to many of the same errors seen in the physician's office.[4,5]


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II.6 BP Tables

BP standards based on gender, age, and height provide a precise classification of BP

according to body size

The revised BP tables now include the 50th, 90th, 95th, and 99th percentiles (with standard

deviations) by gender, age, and height.

In children and adolescents, the normal range of BP is determined by body size and age.

BP standards that are based on gender, age, and height provide a more precise classification

BP according to body size. This approach avoide misclassifying children who are very tall or

very short.

The BP tables are revised to include the new height percentile data as well as the

addition of BP data from the NHANES 1999-2000. Demographic information on the source

of the BP data is provide in Appendix A. The 50th

, 90th

, 95th

, and 99th

percentile of SBP and

DBP for height by gender and age are given for boys and girls. Although new data have been

added, the gender, age, and height BP levels for the 90th

and 95th

percentiles have changed

minimally from the last report. The 50th

percentile has been added to the tables to provide

the clinician with the BP level at the midpoint of the normal range. Although the 95th

percentile provides a BP level that defines hypertension, management decisions about

children with hypertension should be determined by the degree or severity of hypertension.

Therefore, the 99th

percentile has been added to facilitate clinical decision-making in the

plan for evaluation. Standards for SBP and DBP for infants


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is95th

percentile, the child may be

hypertensive, and the measurement must be repeated on at least 2 additional occasions to

confirm the diagnosis. Staging ofBP, according to the extent to which a childs BP exceeds

the 95th

percentile, is helpful in developing a management plan for evaluation and

treatment that is most appropriate for an individual patient. On repeated measurement,

hypertensive children may have BP levels that are only a few mm Hg >95th

percentile; these

children would be managed differently from hypertensive children who have BP levels that

are 15 to 20 mm Hg above the 95th percentile. An important clinical decision is todetermine which hypertensive children require more immediate attention for elevated BP.

The difference between the 95th

and 99th

percentiles is only 7 to 10 mm Hg and is not large

enough, particularly in view of the variability in BP measurements, to adequately distinguish

mild hypertension (where limited evaluation is most appropriate) from more severe

hypertension (where more immediate and extensive intervention is indicated). Therefore,

stage 1 hypertension is the designation for BP levels that range from the 95th percentile to

5 mm Hg above the 99th percentile. Stage 2 hypertension is the designation for BP levels

that are >5 mm Hg above the 99th percentile. Once confirmed on repeated measures, stage

1 hypertension allows time for evaluation before initiating treatment unless the patient is

symptomatic. Patients with stage 2 hypertension may need more prompt evaluation and

pharmacologic therapy. Symptomatic patients with stage 2 hypertension require immediate

treatment and consultation with experts in pediatric hypertension. These categories are

parallel to the staging of hypertension in adults, as noted in the JNC 7.[4]

Using the BP Tables[4]

1. Use the standard height charts to determine the height percentile.

2. Measure and record the childs SBP and DBP.

3. Use the correct gender table for SBP and DBP.

4. Find the childs age on the left side of the table. Follow the age row horizontally across

the table to the intersection of the line for the height percentile (vertical column).


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5. There, find the 50th, 90th, 95th, and 99th percentiles for SBP in the left columns and for

DBP in the right columns.

BP 120/80 mmHg is prehypertension, even if this figure is 95th percentile may be hypertension.

6. If the BP is >90th percentile, the BP should be repeated twice at the same office visit, and

an average SBP and DBP should be used.

7. If the BP is >95th percentile, BP should be staged. If stage 1 (95th percentile to the 99th

percentile plus 5 mm Hg), BP measurements should be repeated on 2 more occasions. If

hypertension is confirmed, evaluation should proceed as described. If BP is stage 2

(>99th percentile plus 5 mmHg), prompt referral should be made for evaluation and

therapy. If the patient is symptomatic, immediate referral and treatment are indicated.

Those patients with a compelling indication, would be treated as the next higher

category of hypertension.


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II.7 Management

Managing childhood hypertension is directed at the cause of the elevated blood

pressure and the alleviation of any symptoms. End-organ damage, comorbid conditions, and

associated risk factors also influence decisions about therapy.

Nonpharmacologic and pharmacologic treatments are recommended based on the

age of the child, the stage of hypertension, and response to treatment.[7]

Nonpharmacologic Therapy

For children and adolescents with prehypertension or stage 1 hypertension,

therapeutic lifestyle changes are recommended. These include weight control, regular

exercise, a low-fat and low-sodium diet, smoking cessation, and abstinence from alcohol

use.

Obesity increases the occurrence of hypertension threefold while favoring the

development of insulin resistance, hyperlipidemia, and salt sensitivity. Significant obesity

also increases the likelihood of LVH independent of blood pressure level. Exercise has been

shown to lower blood pressure in children but does not affect left ventricular

function. Competitive sports are permitted for children with prehypertension, stage 1

hypertension, or controlled stage 2 hypertension in the absence of symptoms and end-

organ damage.

Data regarding dietary changes in children with hypertension are limited.

Nevertheless, the NHBPEP has taken an aggressive stance on sodium restriction,

recommending a sodium intake of 1,200 mg per day. A no-salt-added diet with more fresh

fruits and vegetables combined with low-fat dairy and protein akin to the DASH (Dietary

Approaches to Stop Hypertension) food plan may be successful in lowering blood pressure

in children. Increased intake of potassium and calcium also have been suggested as

nutritional strategies to lower blood pressure. Whatever lifestyle changes are

recommended, a family-centered rather than patient-oriented approach usually is more

effective.[5,7]


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Pharmacotherapy

Reasons to initiate antihypertensive medication in children and adolescents include

symptomatic hypertension, end-organ damage (e.g., LVH, retinopathy, proteinuria),

secondary hypertension, stage 1 hypertension that does not respond to lifestyle changes,

and stage 2 hypertension. In the absence of end-organ damage or comorbid conditions, the

goal is to reduce blood pressure to less than the 95th percentile for age, height, and sex.

When end-organ damage or coexisting illness is present, a blood pressure goal of less than

the 90th

percentile is recommended. Drug therapy is always an adjunct to nonpharmacologic

measures.

Information about long-term, untreated childhood hypertension and the impact of

antihypertensive medications on growth and development is insubstantial. According to the

NHBPEP, pharmacotherapy should follow a step-up plan, introducing one medication at a

time at the lowest dose, then increasing the dose until therapeutic effects are seen, side

effects are seen, or the maximal dose is reached. Only then should a second agent,

preferably one with a complementary mechanism of action, be initiated. Long-acting

medication is useful in improving compliance, and predictable problems such as the effect

of diuretic medications in young athletes should be avoided.

The choice of initial drug therapy is largely at the discretion of the physician. Diuretics

and beta blockers have documented safety and effectiveness in children. Preferential use of

specific classes of medications for certain underlying or coexisting pathology has led to the

prescribing of ACE inhibitors in children with diabetes or proteinuria and beta-adrenergic or

calcium channel blockers for children with migraines. Becoming familiar with medications in

each major class and with effective combinations of medications will facilitate treatment.

Many medications have growing research to support their use. As with any chronic health

issue, medical follow-up and appropriate monitoring are key to long-term success.[1,2,5,10]


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Treatment Algorithm for Pediatric Hypertension.[4]

Prognosis

High blood pressure is a precursor of heart attacks and strokes, as has been well

established in the adult literature.

Obese children have approximately a 3-fold higher risk for hypertension than non-

obese children. As many as 41% of children with high BP have left ventricular hypertrophy

(LVH).Almost 60% of children with persistent elevated BP have relative weights greater than

120% of the median for their sex, height, and age. As in adults, in whom abdominal girthcorrelates to elevated blood pressure, studies show that this measurement is also to be

considered in the assessment of a teenager with suspected BP elevation at an early age.{3]


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REFERENCES

1. Badminton, S. Bailey, Barret, D.N. Bateman, G.D.L. Bates, H. Bedford, M.W. et al. BNF for

Children 2010-2011. London. 2011.

2. Hay, William W.; Levin, Myron J.; Sondheimer, Judith M. Current Diagnosis & Treatment

Pediatrics 20th

Edition. New York. 2010.

3. http://emedicine.medscape.com/article/889877-overview#showall

4. http://pediatrics.aappublications.org/content/114/Supplement_2/555.full.pdf+html?sid

=ea87dbdb-a961-4581-bab7-efa95eeda5f7

5. http://www.aafp.org/afp/2006/0501/p1558.html

6. http://www.cdc.gov/growthcharts/clinical_charts.htm

7. http://www.medscape.com/viewarticle/510523

8. http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm

9. Lang, Florian. Silbernagl, Stefan. Teks & Atlas Berwarna Patofisiologi. Jakarta. 2007. 208-

213.

10.Tasker, Robert C.; McClure, Robert J.; Acerini, Carlo L. Oxford Handbook of Paediatrics.

New York. 2008.
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