diagnosing hypertension in children work up for increased blood pressure guide line for controling hypertension in pediatrics treatment of hypertension hypertensive crisis/emergency

2. By
DrTanveer alam khan

3.  What is hypertension
 How to diagnose hypertension in children
 Measuring BP in children
 Learning normal BP range for children
 Causes of hypertension in children
 Evaluating the cause
 Management

4. NORMAL BLOOD PRESSURE is defined as a systolic and diastolic blood pressure
below the 90th percentile for gender, age and height percentile
PRE-HYPERTENSION is defined as the 90th percentile to less than 95th percentile or
if BP greater than 120/80 even if below the 90th percentile (up to below the 95th
percentile).
STAGE 1 HYPERTENSION is defined as a blood pressure between the 95th percentile
and the 99th percentile plus 5mmHg.
STAGE 2 HYPERTENSION is defined as a blood pressure above the 99th percentile
plus 5mmHg.
WHITE COAT” HYPERTENSION is defined in a patient with blood pressure above
the 95th percentile in the physician’s office or clinic, who is normotensive outside the
clinical setting.

5.  Children >3Years must check BP
 Children <3 years who have congenital heart
defect/renal disease/malignancies ,recurrent
Uti ,solid organ transplant, raised icp.
 The preferred method ?.
 Appropriate to the size of cuff ?
 Repeated elevated BP must be confirmed
 Ambulatory BP monitoring (ABPM)

6.  Normally, BP is 10–20 mmHg higher in the legs than the
arms.
 The blood pressure must be obtained on three separate
occasions. If the systolic and diastolic blood pressure
falls into different categories, classify by the higher
category.
 Child should be calm resting on his/her back for 5 min
touching feets on ground
 Measures obtained by oscillometric devices that exceed
the 90th percentile should be repeated by auscultation
in all limbs preferably
 Different charts are designed for boys /girls in pediatric

10. (Year) Percentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64
90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78
95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82
99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90
Boys SBP, mmHg
Percentile Height
DBP, mmHg
Percentile Height

13. Must begin with:
 Thorough history (including hx of sleep disorder)
 Physical examination
 Laboratory evaluation
 Assessment of cardiovascular risk factors:
overweight
low plasma HDL cholesterol
high plasma triglycerides
abnormal glucose tolerance

14. Basic:
 Serum chemistries, BUN, Cr, PRA, Aldosterone level
 CBC
 Urinalysis and Urine culture
 Renal ultrasound with doppler
Evaluation for comorbidity:
 Fasting Lipid profile
 Fasting glucose
 Drug screen (if hx of drug use)
 Polysomnography (if hx of sleep disorder)
Evaluation for end-organ damage:
 Echocardiogram
 Retinal exam

16.  24hr ABPM (white coat /masked HTN)
 Reno vascular imaging
-Renal scan
-Duplex Doppler flow studies
-MRA, CTA
-Arteriogram
 Other labs
- Urine forVma
-Plasma and urine metanephrines
-Plasma and urine steroids

17. Classification of
Hypertension
Therapy Recommendations
Normal Encourage healthy diet, sleep, & physical activity
Recheck on next visit
Prehypertension Physical activity & diet management; No medication
unless compelling indications such as CKD, DM, HF or
LVH exist
Stage 1 Hypertension Physical activity & diet management; Initiate therapy if
indicated as above + Symptomatic hypertension +
Persistent hypertension despite
nonpharmacologic measures
Stage 2 Hypertension Physical activity & diet management; Initiate therapy

18.  Weight reduction
Dietary modifications:
consumption of more fruits, vegetables, fiber, nonfat diary,
reduced sodium intake (1.2g/day in younger kids and 1.5g/day
in older kids)

19. Indications:
1. Symptomatic hypertension
2. Secondary hypertension
3. Target-organ damage
4. Poor response to non pharmacologic therapy
5. Diabetes mellitus
 Goal is to reduce BP <95th percentile (<90th percentile if
concurrent conditions or LVH present)
 Treat severe symptomatic BP with IV antihypertensives

20. Class of Drugs Patients’ Characteristics
ACE-Is/ARBs First-line therapy
CCBs First-line therapy
(recommended >6years)
Diuretics Adjunct second-line drug
β–Blocker controversial in diabetes

23.  Machanism of action
 prevents conversion of angiotensin I to angiotensin II, which leads to an increase
in plasma renin activity and a reduction in aldosterone secretion
 Characteristic:
Renal insufficiency (unilateral renovascular hypertension, renal parenchymal
disease, renal proteinuria)
Congestive heart failure
Diabetes
Hyperlipidemia
 Comments:
 Monitor serum potassium and SCr
 Cough and angioedema
 May require a dosing adjustment in renal impairment

24.  Mechanism of action
 angiotensin II receptor antagonist blocks the vasoconstrictor and
aldosterone-secreting effects of anigotensin II
 Characteristic :
 same as ACE-I
 Coments:
 Less cough/ angioedema
• Monitor K & s-cr
• Less studies then ACE I in pediatrics

25.  mode of action:
 decrease intracellular calcium concentrations and results in dilation of
peripheral arterioles
 Characteristics:
 Emergency hypertension (nifedipine)
 Diabetes
 Chronic obstructive lung disease
 Broncho-pulmonary dysplasia
 Gout
 Hyperlipidemia
 PeripheralVascular Disease
 RenalTransplant (cyclosporine-induced)
Coments:
edema, arrhythmias, headache, fatigue, dizziness, flushing
May need adjustment in hepatic impairment

26.  Admit to the ICU!
 Goal is to safely lower BP
 Use titratable short-acting IV antihypertensive for BP
management
 Reduce BP by 25% of goal reduction in first 2 hrs and
then down to normal in next 3-4 days