Dr. Amlendra yadav

Resident

Pediatric Hypertension

Background

Adolescents may acquire primary or essential hypertension

In infants and younger children, systemic hypertension is uncommon, but when present, it is usually indicative of an underlying disease process (secondary hypertension).

2

Cont.

Correlate with BP tables for age, height, and weight

Accurate blood pressure measurements should be part of the routine annual physical examination of all children 3 yr or older.

A complete family history of hypertension should be elicited

Use appropriate cuff size for blood pressure (BP) measurement. Width should be between 50-75% of the circumference of arm.Cuff size for :- Infant – 2.5cm ; 1- 12 month – 5cm 1- 8 yrs – 9cm ; Older children – 12.5cm

3

Definition

4

• Pre-hypertension : Systolic or diastolic blood pressure 90th – 95th

percentile• Hypertension : Systolic or diastolic blood pressure > 95th percentile • Stage I hypertension : Systolic or diastolic blood pressure between 95th percentile & 99th percentile + 5mmHg .• Stage II hypertension : Systolic or diastolic blood pressure > 99th percentile + 5mmHg

Etiology and Pathophysiology

Many childhood diseases may be responsible for

both acute and chronic elevation of blood pressure

Secondary hypertension is most common in infants and younger children

5

Cont.Hypertension in the newborn is most often associated with:

1. umbilical artery catheterization

and

2. renal artery thrombosis

6

Cont.

Hypertension during early childhood may be due to :

1.renal disease

2.coarctation of the aorta

3. endocrine disorders

4.medications.

7

In adolescents essential hypertension becomes increasingly common

Cont.

In general, children and adolescents with essential hypertension

have blood pressure values at or only slightly above the 95th

percentile for age

The severity of hypertension is also helpful in distinguishing secondary from primary hypertension

8

Cont.

Renal and renovascular hypertension accounts for the majority of children with secondary hypertension

A history of urinary tract infection is present in 25-50% of these patients and is often related to an obstructive lesion of the urinary tract

9

Conditions Associated with Transient or Intermittent Hypertension in Children

10

• Acute postinfectious glomerulonephritis • Anaphylactoid (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

Renal

11

• Renal trauma • Leukemic infiltration of the kidney • Obstructive uropathy associated with Crohn

disease

Cont.

• Hypervolemia • After surgical procedures on the genitourinary

tract • Pyelonephritis

12

Drugs and Poisons

• 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

13

Central and

Autonomic nervous system

• Increased intracranial pressure • Guillain-Barré syndrome • Burns • Familial dysautonomia

• Stevens-Johnson syndrome

• Posterior fossa lesions • Porphyria • Poliomyelitis • Encephalitis

14

Miscellaneous

• Fractures of long bones • Hypercalcemia

• After coarctation repair • White cell transfusion • Extracorporeal membrane

oxygenation • Chronic upper airway obstruction

15

Conditions Associated with Chronic Hypertension

in Children

16

Renal

• Chronic pyelonephritis • Chronic glomerulonephritis • Hydronephrosis • Congenital dysplastic kidney

• Multicystic kidney • Solitary renal cyst • Vesicoureteral reflux nephropathy • Segmental hypoplasia (Ask- Upmark

kidney)

17

• Ureteral obstruction • Renal tumors • Renal trauma • Rejection damage following transplantation • Postirradiation damage • Systemic lupus erythematosus (other connective tissue diseases

Cont.

18

Vascular

• Coarctation of thoracic or abdominal aorta • Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis,

aneurysm) • Umbilical artery catheterization with thrombus formation • Neurofibromatosis (intrinsic or extrinsic narrowing of vascular lumen)

• Renal vein thrombosis • Vasculitis • Arteriovenous shunt • Williams- Beuren syndrome • Moyamoya disease

19

Endocrine

• Hyperthyroidism • Hyperparathyroidism • Congenital adrenal hyperplasia (11 β- hydroxylase

and 17-hydroxylase defect)

• Cushing syndrome • Primary aldosteronism • Dexamethasone-suppressible hyperaldosteronism

• Pheochromocytoma • Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma) • Diabetic nephropathy • Liddle syndrome

20

Central Nervous System

• Intracranial mass • Hemorrhage • Residual following brain

injury • Quadriplegia

21

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, or seizures)

22

Clinical Features

• Mostly asymptomatic • Presence of symptoms indicates end organ damage• Symptoms attributed to hypertension include headache ,

nausea , vomitting , diziness , irritability and epistaxis.

23

Physical examination

• Four-extremity BP• Funduscopy (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

24

Screening inestigation

• Complete blood count • Blood urea nitrogen, creatinine , electrolytes, glucose , uric acid • Lipid profile • Urinalysis • 24 hr urinary protein or spot albumin to creatinine ratio • Chest radiograph• Electrocardiogram• Ultrasonography for kideneys , adrenals

25

Screening for target organ damage

• Retinal fundus examination • Urine spot protein to creatinine ratio• Echocardiography

26

Consider

• Renin level• Toxicology screen• Thyroid and adrenal testing • Urine catecholamines• Abdominal ultrasound• Renal Doppler ultrasound • Head CT

27

Management

• Each patient must be appropriately evaluated . Efforts must be made to determine the etiology of hypertension .

• Salt restriction : It is useful but difficult to implement in children .

Long term medication

1. Diuretics (thiazide group are commonly employed)

2. Beta – adrenergic antagonist

3. ACE inhibitors and Angiotensin receptor blockers

4. Calcium chanal blockers

28

• Captopril 0.3 - 6 mg/kg/day , three divided doses • Enalapril 0.1 – 0.6 mg/kg/day , single daily dose • Lisinopril 0.06 – 0.6 mg/kg/day , single daily dose • Losartan 0.7 – 1.4 mg/kg/day , single daily dose • Amlodepine 0.05 – 0.5 mg/kg/day , once - twice daily doses • Nifedipine 0.25 – 3 mg/kg/day , once – twice daily doses• Atenelol 0.5 – 2 mg/kg/day , once – twice daily doses • Metoprolol 1 – 6 , two divided doses• Labetelol 1 – 40 mg/kg/day , two – three divided doses• Clonidine 5 – 25 ug/kg/day , three – four divided doses • Prazosin 0.05 – 0.5 mg/kg/day , two divided doses • Hydralazine 1 – 8 mg/kg/day , four divided doses • Frusemide 0.5 – 6 mg/kg/day , one – two doses • Spironolactone 1 – 3 mg/kg/day , one – two doses • Hydrochlorothiazide 1 – 3 mg/kg/day , once daily

29

Management

Hypertensive emergency:

Goal: Lower BP promptly but gradually to preserve cerebral autoregulation

(a) Mean arterial pressure (MAP) = 1/3 systolic + 2/3 diastolic BP(b) Lower by 1/3 of planned MAP reduction over first 6 hours, then(c) Lower by additional 1/3 over next 24–36 hours, then(d) Lower final 1/3 over next 48 hours

After elevated ICP is ruled out, do not delay treatment because of further diagnostic workup

30

31

32

Hypertensive urgency:

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.)

33

34

35

Thank you