1. Evaluation and management of hypertension in children
Dr. Nariman Fahmi

2. 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

3. 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

4. Hypertension Definitions
Normal BP: Both systolic and diastolic BP < 90th % for age, gender, and height

5. What does this percentile mean?2
Normal
<90th
Prehypertension
90-<95th or if >120-80
Stage 1 hypertension
95th-99th plus 5 mm Hg
Stage 2 hypertension
>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

6. 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.

7. Measurement of BP in Pediatrics
Main source of error – Using wrong cuff size
Small cuff- overestimates BP
Large cuff- underestimates BP

8. HTN Etiology by Age
Acta Paediatr (3):244-6 8

9. Conditions associated with hypertension in children

10. RENAL 1.Multicystic dysplastic kidney 2.Chronic pyelonephritis
3.reflux nephropathy

11. 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

12. ENDOCRINE Hyperthyroidism Hyperparathyroidism
Congential adrenal hyperplasia (11β-hydroxylase and 17-hydroxylase defect)
Cushing syndrome
Primary aldosteronism

13. CENTRAL NERVOUS SYSTEM
Intracranial mass
Hemorrhage

14. Pediatric Symptoms
Hypertension is often thought of as a silent disease because typically there have not been any classic symptoms

15. 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
seizures may occur in hypertensive encephalopathy which suggested by the presence of vomiting, temperature elevation, ataxia, stupor, and seizures

16. 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.

18. 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

19. 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

20. 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
frusemide→hypokalemia, hyperglycemia
thiazidehypokalemia, rash, hyperglycemia
spironalactone ----hyperkalemia,gynaecomastia, rash

21. β-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 effects GIT disturbance, bradycardia, bronchospasm, sleep disturbance, depression

22. Direct vasodilators
ex,Hydralazine dose (0.2–0.6 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 0.53–10 mcg/kg/min
Monitor cyanide levels with prolonged (>72 hr) use or in
renal failure; or coadminister with sodium thiosulfate

23. Thank you