Hypertension in Children

Prof. Dr. Farkhanda Hafeez

M.B.B.S, D.C.H, M.C.P.S, F.C.P.S (Pak), MCCEE (Canada)Consultant

Paediatric Nephrologist

Introduction

HTN a Global issue- Major risk for CVD

Currently affects 3-4% of children

Pre HTN more prevalent and affects 10-15% of youth

Children > Sec HTN

Primary inc - over last two decades- linked to Obesity

HTN is defined as average SBP and/or DBP that is ≥ 95th percentile for gender, age, and height on three or more separate occasions.

In children younger than 1 year of age, SBP has been used to define HTN.

National High Blood Pressure Education Program(NHBPEP) Working Group

Method:

Taken on three separate occasions in a controlled environment

Preferably in the right arm with the cubitalfossa at heart level when the patient is seated

Has rested quietly for 5 min

Avoided stimulant drugs, foods, or activities like video games.

The inflatable bladder of the cuff, not the entire cuff, should be an appropriate size for the patient.

The bladder width should be approximately 40 % of the arm circumference midway between the acromion and olecranon.

The length of the bladder should cover 80–100 % of the circumference of the arm without overlapping.

The bladder width-to-length ratio should be at least 1:2.

STAGING OF HTN

Factors Influencing Blood Pressure

Age Birth Weight Gender Prematurity Height

Breast Feeding Obesity /Uric Acid Nephron Number Physical Activity Salt intake

Race and Ethnicity Family History Environment Genetics Sleep-Disordered Breathing Epigenetics Emotional/Mental stress

Primary Hypertension

For those hypertensive individuals without underlying secondary causes.

uncommon, accounting for less than25 % of hypertensive children (1990)

Recently up to 90% in US.

Many children develop PH as manifestation of obesity.

Primary HTN is a multifactorial disorder

Primary HTN

Causes of Secondary HTN :Renal

Poor Urinary Stream

Polyuria / Polydipsia

Resp. Distress

Growth failure

Bony Deformities

Unexplained pallor

Abdominal Pain/

Passage of Gravel

Swelling/ Rash/ Jt pain

Oligo/Polyhydramnios

Inherited Causes (Monogenic)

Hypertension in Dialysis Patients

Hypertension After Renal Transplantation

Coarctation of the Aorta

Vasculitis

Endocrine Diseases

Hypertension in Pulmonary Diseases

(BPD, Sleep Apnea)

Hypertension in Neurologic Disorders

Drug-induced hypertension

Neonatal HTN:

Incidence 1.3-2%

( Flush, osillometer, Intra arterial Transducer)

B. P > 95%tile on three separate occasions

Renal thromboemboli sec to Umbilical vascular access, PCKD.

Right to Left shunts (VSD, PDA), Co-arctation

Acute cortical Necrosis (Birth Asphyxia, Sepsis)

Circulatory Shock ( RVT, AKI)

BPD ( Na & Water Retention)

ICH, Iatrogenic, Pain

Evaluation

FMD / NF1 / Takayasu William Turner

Management of HTN

Goals of Therapy

In asymptomatic children, the NHBPEP recommends achieving the target BP of:

Non-pharmacologic & Lifestyle Measures :pre-hypertension or stage 1 HTN.

Pharmacologic Therapy Stage I HTN (95th–99th percentile plus 5 mmHg)

who are unresponsive to changes in lifestyle Stage II HTN: (>99th percentile plus 5 mmHg). Symptomatic HTN: including headaches, changes

in mental process or consciousness , or irritability. Secondary HTN. Evidence that the high BP is causing end-organ

damage

Pharmacotherapy

primary Secondary

ARB/ACEI

P.H & TachycardiaNon cardio-selective β Blockers

(Carvedilol)

Obese & Metabolic syndβ Blocker/vasodilator

(Nebivolol)

CarbenoxoloneBlocks 11 β HSD1 which converts

inactive Glucocorticoids - Cortisol

GN : Diuretics ± CCB

CKD:ARBs/ACEI ± Diuretics

(Ramipril)

Combination of ACEI+ CCB

(Benazopril+Amlodipine)

Avoid Thiazide diuretics if GFR< 30 / Cr > 1.5mg/dl

RAS bilateral/ unilateral with solitary kidney- ARB Contraindicated

Neonates

> 99%tile 95-99%tile

Short acting I.V to reduce B.P< 95%tile

CCB ( Nicardipine)

β Blockers ( labetalol, Esmalol)

Na Nitropruside

Not able to Absorb:

Hydralazine / Labetalolbolus

Who can absorb:

Short acting CCB-Isradipine

Long ActingCCB – less suitable

Avoid ACEI & β Blockers

Prevention

Children ≥ 3 years have their B.P checked at every clinic visit.

Awareness about prevalence of HTN in association with obesity.

Information on dietary and life style modification.

Improvement in prenatal & natal care.

Early detection of Sec HTN.

Timely management to prevent end organ damage.

Sequelae of HTN

LVH

Non dipping & M.H - inc LVMI & PreHTN

Inc cIMT - Measure of atherosclerosis

Retinal arteriolar narrowing

Microalbuminuria even nephrotic range

Sys. HTN predictor of progression of CRI

Arterial stiffness

Cognitive impairment