Pediatric hypertension

HYPERTENSION

Pediatric Hypertension

Mohammad Ilyas, M.D.

Assistant Clinical Professor

University of Florida / Health Sciences Center

Jacksonville, Florida USA 1

Outline

1. Definition, Regulation and Pathophysiology

2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory Blood Pressure Monitoring

3. Evaluation of Primary Versus Secondary

4. Sequel of Hypertension and Hypertension Emergencies

5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)

6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep Disorders.

7. Hypertension in Renal diseases and Pregnancies

8. Pediatric, Neonatal and Genetic Hypertension

2

Pediatric Hypertension - Outline

• Measurement of Blood Pressure

• Definition and Staging of Hypertension

• Ambulatory Blood Pressure Monitoring

• Evaluation of Essential Versus Secondary

• Management

3

Sequelae of Hypertension

• In Adult, Hypertension is correlated with an increased risk of stroke, heart attacks, kidney failure, and premature death.

• Hypertension in children and adolescents will have the same consequences.

• Management should begin whenever hypertension is diagnosed to prevent similar consequences.

4

Prevalence

• Prevalence of pediatric hypertension in the United States has been calculated to be between 1- 5 percent.

• A direct relationship exist between weight status and systolic blood pressure.

5

Who needs BP Measurement?

• Children > 3 years of age who are seen in a medical setting.

• Children < 3 years of age if:

1. Neonatal complications (Preemie)

2. Congenital heart or kidney disease

3. Known Kidney or Urology Disorders

4. Post organ transplant

5. Drugs that are known to cause hypertension

6. Elevated intracranial pressure

7. Family History of congenital renal disease.

8. Malignancy, BMT, NF, & TS etc… 6

Measurement of Blood Pressure

• The condition of the patient

• The use of appropriate equipment

• The use of appropriate cuff size

• The position of the patient

• The pressure of the stethoscope on the artery

• The rate of deflation

• Home monitoring

7

8

Pediatric Hypertension

Blood Pressure Measurement

Cuff Size

9

Age Range Width,

Cm

Length,

Cm

Maximum Arm Circumference,

cm*

Newborn 4 8 10

Infant 6 12 15

Child 9 18 22

Small Adult 10 24 26

Adult 13 30 34

Large Adult 16 38 44

Thigh 20 42 52

Recommended Dimensions for BP Cuff Bladders

Blood Pressure Tables

• Normal range is determined by gender, age, and height.

• The new tables include 50th, 90th, 95th, and 99th percentiles.

• The average difference between 95th % and 99th % is 7-10 mmHg.

10

11

Age BP Percentile ____________SBP, mm Hg____________

____________Percentile of Height__________

5th 10th 25th 50th 75th 90th 95th

12 50th 101 102 104 106 108 109 110

90th 115 116 118 120 121 123 123

95th 119 120 122 123 125 127 127

99th 126 127 129 131 133 134 135

BP Levels for Boys by

Age and Height Percentile

Normal Blood Pressure

• Definition < 90%

• Frequency of Measurement-Next physical

• Therapy - Encourage Healthy Lifestyle

12

White Coat Hypertension

BP 95th% Stressful clinical setting

< 90th% Relaxed environment

• Frequency of BP measurement Routine

• Lifestyle changes Healthy

• Pharmacologic Therapy None

13

Pre-Hypertension

• Definition: Blood pressure 90 - 95%

• Frequency of Measurement 6 months

• Lifestyle changes yes

• Pharmacologic treatment None unless there is a co morbid factor

14

Stage I Hypertension

• Definition BP > 95% - 99% +5

• Frequency to check BP Repeat every 1-2 weeks x3

• Lifestyle changes Yes

• Pharmacologic Therapy If lifestyle changes are not enough or end organ effect

15

Stage II Hypertension

• Definition Systolic or Diastolic BP > 99% +5 mmHg

• Frequency of BP Measurement: Immediate care if symptomatic or within a week

• Lifestyle Changes, Weight management, Physical activities, Diet management

• Pharmacologic Therapy Immediate Therapy

16

Example

• In a 12-year-old boy with height in the fiftieth percentile (Table ),

• SBP of 123 to 136 mm Hg and DBP of 81 to 94 mm Hg represent with

stage 1 hypertension

• BP >136/94 mm Hg represents stage 2 hypertension.

17

Hypertension

•Primary ?

Versus

•Secondary ?

18

Primary Hypertension

It is becoming a significant health issue in the young because of its

association with overweight.

The evaluation of a hypertension child should include:

- BMI “Metabolic syndrome”

BMI > 95th% Hypertension 30%

- Dysplipidemia

- Insulin & Hgb A1c

- Other risk factors: Uric acid and Homocysteine

• Sleep disorder in children associates with hypertension.

19

Primary Hypertension &

Sleep Disorder

Sleep disorders including sleep apnea is associate with:

• Hypertension

• Coronary heart disease

• Stroke

History of sleeping pattern should be obtained in children with hypertension.

20

Evaluation of

Secondary Hypertension

• More common in children.

• Obesity should be evaluated (BMI).

• Once hypertension is suspected, blood pressure should be measured in both arms and one leg.

• Evaluate very young children with Stage II hypertension and Stage I with symptoms suggestive of an underlying disease associated with hypertension.

21

Evaluation of


- Thorough history of “sleeping patterns and drugs”

- Focused physical examination (BMI)

- Laboratory evaluation is based on H&P, child’s age, and level of blood pressure elevation.

- Symptoms suggesting:

1. Renal disease

2. Cardio vascular disease

3. Endocrinology disease

4. Neurologic disease

5. Oncology disease

22

Renal

• Structural abnormalities

• Anatomic obstruction

• Reflux nephropathy

• Glomerulonephritis (acute and chronic)

• Chronic renal failure

• Diabetic nephropathy

• Renal Trauma

23

Pediatrics in Review, Vol.18, No. 4, April 1997, pg 134

Cardiovascular

• Coarctation of the aorta

• Renal artery stenosis

• Williams syndrome

• Neurofibromatosis

• Systemic arteritis

• Takayasu arteritis

• Henoch-Schönlein purpura

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Endocrine and Neurologic

• Endocrine

• Hyperthyroidism

• Congenital adrenal hyperplasia

• Primary aldosteronism

• Hyperparathyroidism

• Neurologic

• Increased intracranial pressure

• Guillain-Barré syndrome

• Familial dysautonomia

25


Oncologic & Drugs

• Neuroblastoma

• Wilms tumor

• Pheochromocytoma

• Adrenal adenocarcinoma

• Cocaine

• Corticosteroids

• Oral contraceptives

• Sympathomimetics (decongestants)

• Phencyclidine

26


Evaluation of

Secondary hypertension PAST MED. HISTORY

• Hospitalization

• Trauma

• UTI

• Snoring and other sleep

problems

• Drugs

FAMILY HISTORY

• Diabetes

• Obesity

• Sleep apnea

• Renal diseases

• Dyslipidemia

• CVD

27

Physical Examination

• Height

• Weight

• BMI

• Blood Pressure in both arms and a leg

• Examination focused at Etiology and end organ involvement

28

Evaluation of


• Screening tests to detect renal or cardiovascular causes of

hypertension.

• Additional tests must be tailored to the specific child and

situation.

• Co-morbid condition evaluation should be done in all

children. 29

Diagnostic Tests for Renovascular

Hypertension

Plasma renin

• Low with mineral corticoid related diseases.

• High in renal artery stenosis.

Evaluation of renal artery stenosis

• Doppler

• Renal scan with Captopril

• MRA

• Digital subtraction angiography

• Angiography

30

Monogenic hypertension

• Hypertension due to single gene mutations

• Inherited in an autosomal dominant or recessive fashion

• Abnormal potassium levels (low or high) in the presence

of suppressed renin secretion

• Metabolic alkalosis or acidosis

Monogenic Hypertension Three distinct mechanisms

1. Hyperactivity of renal sodium and chloride reabsorption leading to

plasma volume expansion (e.g., Liddle's syndrome, Gordon's syndrome).

2. The deficiencies of enzymes that regulate adrenal steroid hormone

synthesis and deactivation (e.g., subtypes of congenital adrenal hyperplasia,

apparent mineralocorticoid excess (AME)).

3. Excessive aldosterone synthesis that escapes normal regulatory

mechanisms and leading to volume-dependent hypertension in the presence

of suppressed renin release (glucocorticoid remediable aldosteronism).

Renal Artery Stenosis

33 Renal Doppler Study

Renal Artery Stenosis

34 MRA

DTPA Renal Scan

Digital Subtraction Angiography.

35

Abdominal aortic aneurysm and accessory renal artery

Managements

• Non-pharmacology

• Therapeutic life style change

• Pharmacology

36

Therapeutic Lifestyle Changes

1) Weight reduction: decreases BP, dyslipidemia, and insulin resistance

2) Regular physical activity: sedentary activities < 2 hours per day, physical activities 30-60 minutes per day, competitive sports is limited for uncontrolled Stage II hypertension.

3) Dietary modifications: fresh vegetables, fresh fruits, fiber, reduction of fat, reduction of salt. Other recommendations are Ca, Mg, K, Folic acid, unsaturated fat, and fiber.

4) Family based intervention: interventions to improve sleep quality.

37

Therapeutic Lifestyle

38

Pharmacological Therapy

• In Children, long term consequences of untreated hypertension are

unknown.

• No data on the long term effect of medications on growth and development.

• Therefore, a definite indication for treatment should be ascertained.

39

Quiz 1. Which of the following statement is NOT true?

A. In Adult, Hypertension is correlated with an increased risk of stroke, heart attacks, kidney failure, and premature death.

B. Hypertension in children and adolescents will have the similar consequences.

C. Management should begin whenever hypertension is diagnosed to prevent consequences.

D. Primary hypertension is more common in children than Secondary

E. White coat syndrome also appears in children

40

Quiz 1. Which of the following statement is NOT true?

A. In Adult, Hypertension is correlated with an increased risk of stroke, heart attacks, kidney failure, and premature death.

B. Hypertension in children and adolescents will have the similar consequences.

C. Management should begin whenever hypertension is diagnosed to prevent consequences.

D. Primary hypertension is more common in children than Secondary

E. White coat syndrome also appears in children

41

Quiz 2. False or True

1. Prevalence of pediatric hypertension in the United States has been calculated

to be between 1- 5 percent.

a) False

b) True

2. A direct relationship exist between weight status and systolic blood pressure.

a) False

b) True

42

Quiz 2. False or True

1. Prevalence of pediatric hypertension in the United States has been calculated

to be between 1- 5 percent.

a) False

b) True

2. A direct relationship exist between weight status and systolic blood pressure.

a) False

b) True

43

Quiz 3. All of the following are the indications for BP monitoring

EXCEPT?

A. Pre mature birth weight < 1.5 kg

B. Congenital heart or kidney disease

C. Age less than three years

D. Neurofibromatosis (NF)

E. Elevated intracranial pressure

44

Quiz 3. All of the following are the indications for BP monitoring

EXCEPT?

A. Pre mature birth weight < 1.5 kg

B. Congenital heart or kidney disease

C. Age less than three years

D. Neurofibromatosis (NF)

E. Elevated intracranial pressure

45

Quiz 4. True or False about BP Measurement

1. Measurements obtained by Oscillometric device should be repeated by auscultation.

A. True B. False

2. Oscillometric devices are preferred Aneroid Manometry if calibrated every 6 months.

A. True B. False

3. Oscillometric devices are convenient for newborn and ICU setting. It should be repeated using auscultation when possible.

A. True B. False

46

Quiz 4. True or False about BP Measurement

1. Measurements obtained by Oscillometric device should be repeated by auscultation.

A. True B. False

2. Oscillometric devices are preferred Aneroid Manometry if calibrated every 6 months.

A. True B. False

3. Oscillometric devices are convenient for newborn and ICU setting. It should be repeated using auscultation when possible.

A. True B. False

47

Quiz 5. Ambulatory Blood Pressure Monitor help in recognizing all conditions

below EXCEPT?

A. White coat hypertension

B. Infantile Hypertension

C. Secondary hypertension

D. Episodic hypertension & hypotension

E. Mask Hypertension

48

Quiz 5. Ambulatory Blood Pressure Monitor help in recognizing all conditions

below EXCEPT?

A. White coat hypertension

B. Infantile Hypertension

C. Secondary hypertension

D. Episodic hypertension & hypotension

E. Mask Hypertension

49

Quiz 6. Normal Blood Pressure in a 5 year old child is defined as

A. The blood pressure less than 90% for Height

B. The blood pressure less than 95% for Height & Weight

C. The blood pressure less than 90% for Height & Weight

D. The blood pressure less than 100/60 for Height & Weight

E. The blood pressure between 50 – 95 % for Weight

50

Quiz 6. Normal Blood Pressure in a 5 year old child is defined as

A. The blood pressure less than 90% for Height

B. The blood pressure less than 95% for Height & Weight

C. The blood pressure less than 90% for Height & Weight

D. The blood pressure less than 100/60 for Height & Weight

E. The blood pressure between 50 – 95 % for Weight

51

Quiz 7. True or False Statements

1. BP > 95% in clinic and < 90% at home = White coat syndrome

a. True b. False

2. BP > 75 % but < 95 % = Prehypertension

a. True b. False

3. BP > 99% + 5 = Stage II Hypertension

a. True b. False

4. BP > 90% but < 99 % = Stage I Hypertension

a. True b. False 52

Quiz 7. True or False Statements

1. BP > 95% in clinic and < 90% at home = White coat syndrome

a. True b. False

2. BP > 75 % but < 95 % = Prehypertension

a. True b. False

3. BP > 99% + 5 = Stage II Hypertension

a. True b. False

4. BP > 90% but < 99 % = Stage I Hypertension

a. True b. False 53

Education

Pediatric hypertension