Evaluation and management of hypertension in children
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Transcript of Evaluation and management of hypertension in children
Evaluation and management of hypertension in children
Dr. Nariman Fahmi Objectives Why Hypertension is important in
Pediatrics.
Definition ,classifications ,causes and the association Between
Childhood Obesity and Hypertension. How to Evaluate and Manage
Hypertension in Your Practice Complications of Hypertension:
End-Organ Damage
Hemorrhage, Stroke LVH, CHD, CHF Complications of
Hypertension:End-Organ Damage Hypertension is an important
contributing risk factor for end-organ damage and for the
development of cardiovascular and other diseases, including
retinopathy, peripheral vascular disease, stroke, coronary heart
disease, heart failure, cardiac disease, renal failure, and
proteinuria. Blood pressure reduction has been shown to decrease
the rate of stroke, myocardial infarction, end-stage renal disease,
and proteinuria. Reference: Chobanian AV, Bakris GL, Black HR, et
al, for the National High Blood Pressure Education Program
Coordinating Committee. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure: the JNC 7 report. JAMA. 2003;289: Peripheral
Vascular Disease Renal Failure, Proteinuria Retinopathy CHD =
coronary heart disease CHF = congestive heart failure LVH = left
ventricular hypertrophy Hypertension Online Chobanian AV, et al.
JAMA. 2003;289: 3 Hypertension Definitions
Normal BP: Both systolic and diastolic BP < 90th % for age,
gender, and height What does this percentile mean?2
Normal 99th plus 5 mm Hg > Than 95th percentile should be
staged.If stage 1 (95-99th).BP should be repeated on 2 more
occasions.If hypertension is confirmed proceed with evaluation.If
stage 2 (>99th) prompt referral if symptomatic immediate
referral. 5 Measuring BP in Children
Choose appropriate cuff for body size (not just age). Child should
be quiet and calm for 3-5 minutes prior to measurement. Cuff or
stethoscope bell should be at heart level. Record BP 2-3 times and
take the average for the best estimate. Measurement of BP in
Pediatrics
Main source of error Using wrong cuff size Small cuff-
overestimates BP Large cuff- underestimates BP HTN Etiology by Age
Acta Paediatr (3):244-6 8 Conditions associated with hypertension
in children RENAL 1.Multicystic dysplastic kidney 2.Chronic
pyelonephritis
3.reflux nephropathy VASCULAR Coarctation of thoracic or abdominal
aorta
Renal artery lesions (stenosis, fibro muscular dysplasia,
thrombosis, aneurysm) Umbilical artery catheterization with
thrombus formation Neurofibromatosis (intrinsic or extrinsic
narrowing for vascular lumen) Renal vein thrombosis Vasculitis
ENDOCRINE Hyperthyroidism Hyperparathyroidism
Congential adrenal hyperplasia (11-hydroxylase and 17-hydroxylase
defect) Cushing syndrome Primary aldosteronism CENTRAL NERVOUS
SYSTEM
Intracranial mass Hemorrhage Pediatric Symptoms Hypertension is
often thought of as a silent disease because typically there have
not been any classic symptoms unless the pressure has been rising
rapidly, HPT
unless the pressure has been rising rapidly, HPT. does not produce
symptoms Headache Dizziness Epistaxis Anorexia visual changes
seizuresmay occur in hypertensive encephalopathy which suggested by
the presence of vomiting, temperature elevation, ataxia, stupor,
and seizures Therapeutic Lifestyle Changes
If obese, make a goal to gradually get BMI < 85% Set realistic,
achievable, pace of weight loss. Exercise: Moderate to vigorous
aerobic activity for 40 min, 3-5 days/week Diet: Avoid sugary
foods/drinks and saturated fats. Less salt. Eat fruit, vegetables,
lean meats and whole grains. 50/50 plate Involve the whole family
as partners. Hyperkalemia, neutropenia, dry cough, rash
Angiotensin converting enzyme inhibitor(ACEI ) (ex.
Captopril,enalapril,lisinopril) Block the conversion of angiotensin
I to II (potent vasoconstrictor) 0.5-2 mg/kg/day every 8 hours Side
effect : Hyperkalemia, neutropenia, dry cough, rash Ca channel
blockers (ex:Nifedipine ,amlodipine) Interfere with calicum ion
influx into the vascular smooth muscle cells lead to vasodilatation
(dose of nifedipine mg/kg/dose every 4-6 hours) Side effect
:odema,Headache, dizziness, tachycardia, hypotension Increase water
and salt excretion
Diuretics ex.Furosemide,Thiazide ,Spironolactone Increase water and
salt excretion Furosemide mg/kg/dose 2x Thiazide mg/kg/dose
Spironolactone 1-3 mg/kg/dose by Side effect frusemidehypokalemia,
hyperglycemia thiazidehypokalemia, rash, hyperglycemia
spironalactone ----hyperkalemia,gynaecomastia, rash -adrenergic
antagonists (ex.Propranolol,atenolol,metoprolol)
Block B receptors ,Reduce the heart rate and cardiac output
maximally during exercise Dose (0.5-2 mg/kg/day every 6-12 hours)
Side effectsGIT disturbance, bradycardia, bronchospasm, sleep
disturbance, depression Direct vasodilators ex,Hydralazine dose
(0.20.6 mg/kg/doseShould be given every 4 hours when given iv
bolus). Side effects SLE like picture, lymphadenopathy, fever,
arthritis ,headache, dizziness, confusion Sodium nitoprusside IV
infusion 0.5310 mcg/kg/min Monitor cyanide levels withprolonged
(>72 hr) use or in renal failure; or coadministerwith sodium
thiosulfate Thank you