Hypertension in Childhood: Hypertension in Childhood: Diagnosis & ManagementDiagnosis & Management

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Measuring BP inMeasuring BP in ChildrenChildren

Children >3 years oldChildren >3 years old

Preferred method: Auscultation with appropriate size cuffPreferred method: Auscultation with appropriate size cuff

BP tables include 50BP tables include 50thth, 90, 90thth, 95, 95thth, and 99, and 99thth percentiles by percentiles by gender, age, and height gender, age, and height (compiled by NHBPEP Task Forces)

Confirm an elevated BP on at least 2 additional visitsConfirm an elevated BP on at least 2 additional visits

Consider ABPM (portable 24hr BP device) in evaluating Consider ABPM (portable 24hr BP device) in evaluating “white-coat” HTN, episodic HTN, CRD, DM, autonomic “white-coat” HTN, episodic HTN, CRD, DM, autonomic HTN, etc. HTN, etc.

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Hx of prematurity, very low BW, neonatal complication, NICUHx of prematurity, very low BW, neonatal complication, NICU

Congenital heart diseaseCongenital heart disease

Recurrent URIs, hematuria, or proteinuriaRecurrent URIs, hematuria, or proteinuria

Known renal disease or urologic malformationsKnown renal disease or urologic malformations

FHx of congenital renal diseaseFHx of congenital renal disease

Solid-organ transplantSolid-organ transplant

Malignancy or bone marrow transplantMalignancy or bone marrow transplant

Treatment with drugs know to raise BPTreatment with drugs know to raise BP

Other systemic illnesses associated with HTN Other systemic illnesses associated with HTN (neurofibramatosis, tuberous sclerosis, etc.)(neurofibramatosis, tuberous sclerosis, etc.)

Evidence of elevated intracranial pressureEvidence of elevated intracranial pressure

Measuring BP in Children < 3 yearsMeasuring BP in Children < 3 years

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The Right CuffThe Right Cuff

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CLASSIFICATIONCLASSIFICATIONNORMALNORMAL: : < 90th percentile

PREHYPERTENSION PREHYPERTENSION

Average SBP or DBP that are > 90th to < 95th

percentile <OR> if BP >120/80

HYPERTENSIONHYPERTENSION

Average SBP and/or DBP that is > 95th for age,

gender, and height on 3 separate occasions

Stage I HTNStage I HTN: 95th-99th percentile + 5mm Hg

Stage II HTNStage II HTN: > 99th percentile + 5mm Hg

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PRE-ADOLESCENCE PRE-ADOLESCENCE ADOLESCENCEADOLESCENCE

Primary hypertension 15%–30% Primary hypertension 15%–30% 85%–95%85%–95%

Secondary hypertension Secondary hypertension 70%–85%70%–85% 5%–15% 5%–15% Renal parenchymal disease 60%–70% Renal parenchymal disease 60%–70%  Coarctation of the aorta 10%–20%  Coarctation of the aorta 10%–20%   Renovascular 5%–10%  Renovascular 5%–10%  Reflux nephropathy 5%–10% Reflux nephropathy 5%–10%  Endocrine disorder 3%–5% Endocrine disorder 3%–5%  Tumors 1%–5% Tumors 1%–5%  Other causes 1%–5% Other causes 1%–5% 

Causes of HTNCauses of HTNin Childrenin Children

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HH

II

SS

TT

OO

RR

YYOSA

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PP

HH

YY

SS

II

CC

AA

LL

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LABORATORYLABORATORY

EVALUATIONEVALUATIONSCREENING TESTSSCREENING TESTS

UA and cultureUA and culture

Electrolytes, CaElectrolytes, Ca2+2+, Phos, Phos

BUN/Cr, Uric Acid BUN/Cr, Uric Acid

LipidsLipids

CBC with differentialCBC with differential

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LABS cont’d . . .LABS cont’d . . .

SPECIFIC TESTSSPECIFIC TESTS

Fasting insulin & glucoseFasting insulin & glucose

24-hr urine protein and Cr24-hr urine protein and Cr

Urine and serum catecholaminesUrine and serum catecholamines

Hormone levels (thyroid, adrenal)Hormone levels (thyroid, adrenal)

ECHOECHO

RUSRUS

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Labs cont’d . . .Labs cont’d . . .

SPECIALIZED TESTSSPECIALIZED TESTS

Plasma Renin activity and 24-hr urine NaPlasma Renin activity and 24-hr urine NaRUS with Doppler of renal arteriesRUS with Doppler of renal arteriesCaptopril ChallengeCaptopril ChallengeRenal angiography with renal vein reninsRenal angiography with renal vein reninsMRAMRACaptopril renal scanCaptopril renal scanAmbulatory blood pressure monitoringAmbulatory blood pressure monitoringRenal biopsyRenal biopsy

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MANAGEMENTMANAGEMENT EducateEducate

Incorporate patient AND familyIncorporate patient AND family

Nonpharmacologic measures – TNonpharmacologic measures – Therapeuticherapeutic L Lifestyleifestyle CChangeshanges

Antihypertensive MedsAntihypertensive Meds

Monitor for side effects and treatment responseMonitor for side effects and treatment response

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OVERVIEWOVERVIEW

NORMALNORMAL encourage healthy encourage healthy diet/sleep/exercisediet/sleep/exercise

PRE-HTNPRE-HTN Re-check in 6monthsRe-check in 6monthsTLCTLC

STAGE ISTAGE I Re-check 1-2wks - sooner if sxRe-check 1-2wks - sooner if sxTLCTLC. Initiate pharm tx if indicated. Initiate pharm tx if indicated

STAGE IISTAGE II Evaluate within 1wk, immediately Evaluate within 1wk, immediately if patient with sx if patient with sx TLC + pharmacological tx.TLC + pharmacological tx.

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TTherapeuticherapeutic L Lifestyleifestyle C Changeshanges Diet + Exercise = . . . Diet + Exercise = . . .

Weight loss in obese children results in reduction of both Weight loss in obese children results in reduction of both systolic and diastolic BPsystolic and diastolic BP

Sustained aerobic exercise has a blood-pressure lowering Sustained aerobic exercise has a blood-pressure lowering effect in both normotensive and hypertensive persons effect in both normotensive and hypertensive persons

Whether excessive Na causes hypertension is still under Whether excessive Na causes hypertension is still under debate; nonetheless, hypertensive persons benefit from debate; nonetheless, hypertensive persons benefit from reduction in their Na intake.reduction in their Na intake.

Let’s hear it for DASH (Dietary Approaches to Let’s hear it for DASH (Dietary Approaches to Stop Hypertension)!!Stop Hypertension)!!

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To Give or Not To Give ...MEDS…To Give or Not To Give ...MEDS… When to initiate pharmacological therapyWhen to initiate pharmacological therapy

Symptomatic HTNSymptomatic HTN

Stage II HTNStage II HTN

Stage I HTN refractory to nonpharmacologic therapy.Stage I HTN refractory to nonpharmacologic therapy.

Target-organ damage (LVH, retinopathy, micoralbuminuria)Target-organ damage (LVH, retinopathy, micoralbuminuria)

Stage I hypertension in patients with diabetes mellitusStage I hypertension in patients with diabetes mellitus

CONSIDER if child has additional cardiovascular risks –dyslipidemia, CONSIDER if child has additional cardiovascular risks –dyslipidemia, smoking, obesity, family hx, etc.smoking, obesity, family hx, etc.

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Choosing an Choosing an AntihypertensiveAntihypertensive

““Pediatric clinical trials of antihypertensive drugs have Pediatric clinical trials of antihypertensive drugs have focused only on their ability to lower BP and have not focused only on their ability to lower BP and have not compared the effects of these drugs on clinical endpoints.” compared the effects of these drugs on clinical endpoints.” (NHBPEP Task Force)(NHBPEP Task Force)

Physician preferencePhysician preference

Some diuretics and B-Blockers - long hx of safety/efficacy Some diuretics and B-Blockers - long hx of safety/efficacy

Newer classes: ACEI, CCB, ARBs studied short term – Newer classes: ACEI, CCB, ARBs studied short term – safe and well toleratedsafe and well tolerated

Antihypertensives specific to underlying condition or Antihypertensives specific to underlying condition or concurrent medical conditions (ACEI in DM, CCB or BB in concurrent medical conditions (ACEI in DM, CCB or BB in child with migraines)child with migraines)

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Principles of PharmacotherapyPrinciples of Pharmacotherapy

#1#1 Nonpharmacologic measures should be Nonpharmacologic measures should be incorporated into every hypertensive child’s incorporated into every hypertensive child’s treatment plantreatment plan

#2 #2 Drug therapy should be designed to Drug therapy should be designed to MAXIMIZEMAXIMIZE compliance and compliance and minimizeminimize adverse adverse

effectseffects

#3#3 Stepped Care ApproachStepped Care Approach

#4#4 Step Down TherapyStep Down Therapy