HYPERTENSION IN CHILDREN

DR ROMILA CHIMORIYA
LECTURER
DEPARTMENT OF PEDIATRICS
INTRODUCTION
Systemic hypertension rare in children

Secondary hypertension-usually due to underlying

disease

Incidence-3-4%

10% elevated blood pressure

Etiology
Multifactorial
Obesity
Insulin resistance
Activation of sympathetic nervous system
Disorders in sodium hemostasis and renin-angiotensin
system
Uric acid level
Genetic factors
Hypertension in parents
90% of secondary hypertension –renal or renovascular
abnormalities

Renal causes
-chronic glomerulopnephritis
-reflux or obstructive nephropathy
-polycystic or dysplastic renal diseases
-renovascular hypertension
Coarctation of aorta
Takayasu arteritis
Hyperthyroidism
Hyperparathyroidism
Congenital adrenal hyperplasia
Cushing syndrome
Primary aldosteronism
Pheochromocytoma
Neuroblastoma
TRANSIENT HYPERTENSION
PIGN Guillain barre syndrome
Rapidly progressive Burns
glomerulonephritis Stevens-johnson
Henoch schonlein syndrome
purpura Porphyria
Hemolytic uremic Poliomyelitis
syndrome Encephalitis
 Acute tubular necrosis
Drugs
Raised intracranial
Heavy metal poisoning
pressure
Vitamin D intoxication
Renal trauma
Definition and staging
AAP clinical practice guidelines
Defined as average systolic blood pressure(SBP)
and/or diastolic blood pressure(DBP)>95th percentile
for age,sex and height on different occasions
Elevated BP-SBP or DBP>90th percentile but <95%
Adolescents-
Elevated BP-120/80 and 129/<80mm Hg
Hypertension-BP >130/80 mm Hg
STAGING
STAGE I-B.P-Between 90th and 95th plus 12mmhg
Stage II-B.P>95th plus 12mm Hg

WHITE COAT HYPERTENSION

-SBP or DBP > 95th percentile in a physician office or
clinic who is normotensive outside the clinical setting
Clinical features
Asymptomatic,Headache,Dizziness,irriatbility,epistaxi
s,Anorexia,visual changes,Seizures
Cardiac failure,pulmonary edema,renal dysfuction
Hypertensive encephalopathy
-vomiting,ataxia,stupor and seizures

Hypertensive crisis
-decreased vision,symptoms of encephalopathy,cranial
nerve palsies,cardiac failure,rapid worsening of renal
function
Eye examination-papilledema/retinal hemorrhage

Left ventricular hypertrophy,increased carotid intima

media thikness,retinopathy and microalbuminuria

Chronic renal disease-

polyuria,polydyspia,pallor,weight loss and growth
retardation
EVALUATION
History (sleep,treatment history,Birth
history,smoking,alcohol intake,drug abuse and family
history)

Physical examination(pallor,edema,syndromic
facies,ambiguous or virilised genitalia,rickets,goitre
and skin changes)

Examination of eyes
CARDIAC CAUSES
Asymmetry of peripheral pulses
Upper and lower limb blood pressures
Cardiomegaly
Heart rate
Cardiac rhythm abnormalities
Murmurs
Pulmonary edema
Abdominal examination(hepatomegaly,abdominal
mass or epigastric or renal bruit)
INVESTIGATIONS
Creatinine
Electrolytes
Urinalysis
Renal ultrasound
Fasting lipid profile
Glucose levels
Polysomnography
Echocardiography-LVH/COA
Doppler studies/angiography
Plasma renin and aldosterone
Plasma/urine steroid levels
Plasma/urine catecholamines
TREATMENT
Therapeutic lifestyle
1.Weight reduction
-increased physical activity(30-60 minutes/day atleast 3-5days
per week or more of moderate intensity aerobic exercise plus
limitation of sedentary activity to less than 2 hours per day
2.Dietary interventions(DASH)-
-Increased intake of fresh fruits and vegetables,fiber,non fat
dairy and whole grain as well as reduction in sugar and salt
consumption
-Sodium intake is 1.2gm/day for children 4-8 years old
1.5 gm/day for older children
PHARMACOTHERAPY
Symptomatic essential hypertension
Hypertension associated with CKD
Diabetes –aassociated hypertension
Evidence of target organ damage(LVH)
Failed non pharmacologic interventions

Goal of therapy-reduce B.P below 90th percentile and

<130/80mmHg in adolescent
CKD-reduce B.P to less than 50-75th percentile
Step 1-low dose single agent

Step 2-if B.P not controlled ,dose is titrated 4-6 weeks until
B.P goals are achieved or maximum dose for drug is reached

Step 3-if B.P is not achieved with single agent,a second

agent with complementary mechanism of action should be
added and dose titrated

Step 4-if B.P control is not achieved with a two drug regime
a third agent from different drug class should be added
Drug

ACE inhibitors
Angiotensin receptor blockers
Beta blockers
Calcium channel blockers
Diuretics
HYPERTENSIVE EMERGENCIES

B.P should be reduced by upto 25% over first 8

hours(10% in the first hour)
Remainder planned reduction over next 12-24 hours
Too rapid reduction in B.P-cerebral ischemia
Drug-Labetalol,Nicardipine and sodium nitroprusside
Hypertensive crisis-volume repletion
PREVENTION

Preventing childhood obesity

Regular physical activity
Consumption of fruits and vegetables
Moderate salt intake
Limited consumption of processed food items and
animal fats
Reducing sedentary activities