powerpoint presentation

1. Welcome to the seminar on
CHILDHOOD
HYPERTENSION
Presented byPresented by
•Dr Writtika Majumdar, DCH student.Dr Writtika Majumdar, DCH student.
•Dr Md. Ashik Kamal Alvee, MD student.Dr Md. Ashik Kamal Alvee, MD student.
Paediatrics department, DMCH.Paediatrics department, DMCH.

2. Objectives
• Hypertension and its classification
• Prevalence of Hypertension in childhood
• Common causes of Hypertension
• Who are the candidates of screening for Hypertension
• Methods of measurement of BP
• Approach to a hypertensive child
• Management and prevention

3. Hypertension
• Hypertension is defined as average Systolic BP
and/or diastolic BP that is ≥ 95th percentile for age ,
sex and height on 3 or more occasions.
• It can be a primary disease (essential hypertension)
or due to some underlying disease process
(secondary hypertension).

4. • In infant and young children :
< 1% ( Secondary hypertension)
• Older school age children and adolescents :
- primary essential hypertension
- increased in prevalence is in parallel with the obesity
Prevalenc
e

5. The lateral pressure exerted by the moving column of
blood on the vessel wall
Blood pressure(BP) = Cardiac output x Total
peripheral resistance
Blood pressure
Physiology of blood pressure

6. Blood Pressure Regulation
1.Short term regulation of BP:1.Short term regulation of BP: (occurs within seconds)(occurs within seconds)
A) Baroreceptor feedback mechanismA) Baroreceptor feedback mechanism
B) Chemoreceptor feedback mechanismB) Chemoreceptor feedback mechanism
C) CNS ischemic mechanismC) CNS ischemic mechanism

7. Blood Pressure Regulation(cont..)
2. Intermediate term regulation of BP:2. Intermediate term regulation of BP: (occurs within minutes)(occurs within minutes)
A) Renin-Angiotensin vasoconstrictor mechanismA) Renin-Angiotensin vasoconstrictor mechanism
B) Capillary fluid shift mechanismB) Capillary fluid shift mechanism
C) Stress relaxation change in vasculatureC) Stress relaxation change in vasculature
3. Long term regulation of BP:3. Long term regulation of BP:
A) Renal body fluid mechanismA) Renal body fluid mechanism
B) Renin-Angiotensin-Aldosterone mechanismB) Renin-Angiotensin-Aldosterone mechanism

11. When these physiological auto-regulations fail
This causes HYPERTENSION

12. Classification of hypertension
Type
Normal <90th
percentile of SBP and /or DBP
for the age, gender and height
Prehypertension 90th
to <95th
percentile
Stage 1 Hypertension 95th
to 99th
percentile + 5mm Hg
Stage 2 Hypertension >99percentile + 5mm Hg
Ref. Marc B. Lande; Systemic Hypertension; Kliegman, Stanton, St Geme, Schor ed. Nelson
Textbook of Pediatrics; 1st
South Asian edition; India; Elsevier; 2016 : pg-2294-2295

15. White-coat hypertension
A patient with BP levels above the 95th percentile
in a physician’s office or clinic who is normotensive
outside a clinical setting. (Ambulatory BP
monitoring is usually required to make this
diagnosis.)

16. Etiology

17. Commonest causes
Newborn Umbilical artery catheterization
Renal artery thrombosis.
Childhood Renal disease, Coarctation of
aorta, endocrine disorders or
medications.
Adolescents Essential hypertension becomes
increasingly common.

18. Conditions associated with chronic
hypertension in children
Renal Chronic pyelonephrits
Chronic glomerulonephritis
Hydronephrosis
Polycystic kidney
Vesicoureteral reflux nephropathy
Renal tumor
Connective tissue disorder i.e. SLE

19. Cont…
Vascular Coarctation of aorta
Renal artery disease (stenosis , thrombosis)
Renal vein thrombosis
Vasculitis
Neurofibromatosis
CNS Intracranial mass
Hemorrhage

20. Cont…
Endocrine Hyperthyroidism
Hyperparathyroidism
Congenital adrenal hyperplasia
Cushing syndrome
Primary hyperaldosteronism
Pheochromocytoma
Neuroblastoma

21. Conditions Associated with Transient
or Intermittent Hypertension in
ChildrenRenal Acute post infectious glomerulonephritis
Henoch Schonlein Purpura nephritis
Hemolytic uremic syndrome
Acute tubular necrosis
After renal transplant
Hypervolemia
Obstructive uropathy

22. Cont…
Drugs and Poisons Corticosteroids
Amphetamines
Cocaine
Oral Contraceptive Pills
Heavy metal ( lead, mercury, cadmium,
thallium )
Vitamin D intoxication

23. Cont…
Central Nervous
System
&
Peripheral
Nervous System
Raised Intracranial Pressure
Guillain Barre Syndrome
Burns
Stevens – Johnson syndrome
Posterior fossa lesions
Poliomyelitis
Encephalitis

24. Cont…
Miscellaneous Hypercalcaemia
After coarctation repair
Fracture of long bone
Chronic upper airway obstruction

26. All children 3 years of age and older should have
their blood pressure measured at all health care
encounters, including both healthy and sick child.
Ref. Marc B. Lande; Systemic Hypertension; Kliegman, Stanton, St Geme, Schor ed. Nelson
Textbook of Pediatrics; 1st
South Asian edition; India; Elsevier; 2016 : pg-2295

27. Cont…
Certain children younger than 3 years with co morbid
conditions:-
• History of prematurity
• History of low birth weight or neonatal intensive
care unit (NICU) stay
• Presence of congenital heart disease, kidney disease,
or genitourinary abnormality

28. Cont…
• Solid organ transplant
• Cancer
• Treatment with drugs known to raise BP
• Other diseases associated with hypertension
(neurofibromatosis, tuberous sclerosis)
• Evidence of raised intracranial pressure
Ref. Marc B. Lande; Systemic Hypertension; Kliegman, Stanton, St Geme, Schor ed. Nelson
Textbook of Pediatrics; 1st
South Asian edition; India; Elsevier; 2016 : pg-2295

29. Methods of measurement of
blood pressure

30. Measurement of blood pressure
cont.
The child should be
- calm and free of anxiety
- sitting quietly for 5 minutes
- back supported
- right cubital fossa supported at heart level

32. Choosing the appropriate cuff
size:
• An appropriate sized cuff has an inflatable bladder
that is at least 40% of the arm circumference at the
midpoint of the acromion-olecranon distance.
• The inflatable bladder should cover at least two
thirds of the upper arm length and 80%-100% of its
circumference
Ref. Marc B. Lande; Systemic Hypertension; Kliegman, Stanton, St Geme, Schor ed. Nelson
Textbook of Pediatrics; 1st
South Asian edition; India; Elsevier; 2016 : pg-2295

33. Choose the appropriate size cuff

35. METHODS
1.Auscultatory Method
2.Palpatory Method
3.Oscillometric Method
4.Ambulatory Blood Pressure Monitoring

36. Digital sphygmomanometer Mercury sphygmomanometer
Ambulatory BP monitor

37. Child sittedChild sitted
quietly withquietly with
back restedback rested

38. BP is first
measured by
palpatory
method
palpating the
radial artery .
The arm must
be rested at the
heart level.

39. Then we deflate the calf
and Brachial artery is
palpated.

40. Then the BP is measured by
auscultatory method.

41. Graph showing
oscillometric measurement
of BP

42. Points to be
remembered
•Cuff should not be applied too tight (low BP recording)
or too loose (high BP recording).
• BP monitoring subsequently should be taken in the
same limb and position.
• Normally the BP is 10-20mm Hg higher in lower limbs
compared to the upper limbs.

43. Clinical
manifestations

44. • Asymptomatic.
• In severe hypertension
- headache, dizziness,
- nausea, vomiting,
- irritability, personality changes.
• Occasionally with complications like
- Neurological
- CHF
- Renal dysfunction
- Stroke

45. Clinical manifestations of
hypertension

46. Hypertensive Crisis:
• Hypertensive emergency
• Hypertensive urgency
• Accelerated malignant hypertension
• Hypertensive encephalopathy
Ref. Park Myung K; Systemic Hypertension; Park Myung K ed. Park’s Pediatric
Cardiology for practitioners; 6th
edition; India; RELX India Pvt. Ltd.; 2016; Pg- 481

47. Hypertensive urgency:
• Systolic BP as high as 180 mm of Hg
• Diastolic BP as high as110 mm of Hg
•No accompanying end organ damage.
• Headache, blurred vision and nausea may be
present

48. Hypertensive emergency
This may manifest with acute end organ damage. i.e. -
• Decreased vision ( retinal hemorrhage of hypertensive
retinopathy) and papilloedema,
• Encephalopathy (headache, seizure, decreased level
of consciousness, visual disturbance etc)
• Heart failure or
• Accelerated deterioration of renal function

49. Accelerated malignant hypertension:
• Papilledema , hemorrhage and exudation present
on ophthalmoscopic examination
• Markedly elevation of BP in which diastolic pressure
is usually above 140 mm Hg

50. Hypertensive encephalopathy
• It is suggested by the presence of
- headache and vomiting,
- temperature elevation,
- visual disturbance,
- ataxia,
- depressed level of conciousness and
- seizures.
• There is associated CT scan/MRI abnormalities.

51. MRI of brain show bilateral occipital high signal intensity
suggestive of posterior reversible encephalopathy syndrome.

52. Approach to a patient
With
Hypertension

53. History
Present and Past History
• Neonatal - prematurity, umbilical artery catheterization
• Cardiovascular- History of Coarctation of aorta or
surgery for it, history of palpitation, Headache, excessive
sweating (excessive catecholamine levels).
• Renal- History of obstructive uropathy, UTI, radiation,
trauma or surgery to kidney area.

54. • Endocrine- weakness, flushing, weight loss, muscle
cramps (hyperaldosteronism), constipation
• Medication/Drugs - Corticosteroids, amphetamines,
antiasthamatic drugs, OCP, cyclosporine/tacrolimus,
cocaine, NSAIDs, Stimulant medications, Beta-adrenergic
agonists (eg, theophylline) ,Erythropoietin, Tricyclic
antidepressants, antihypertensives withdrawal.
Cont…

55. • Habits - Smoking / drinking / illicit drugs (eg: ethanol,
amphetamines, cocaine , phencyclidine)
• Symptoms of obstructive sleep apnea (difficulty
falling asleep, multiple night time awakenings, snoring,
daytime somnolence)
• Diet -caffeine, excessive salt intake
Cont…

56. Cont…
Family History
• Essential hypertension
• Atherosclerotic heart disease
• Stroke.
• Familial or hereditary renal disease (PKD etc.)

57. PHYSICAL EXAMINATION
• Accurate measurement of BP.
• Complete careful physical examination to assess the
underlying etiology
GENERAL
• Pale mucous membranes, oedema , growth retardation
(Chronic Renal disease)
• Moon facies , truncal obesity, buffalo hump (Cushing
syndrome)

58. Cont…
• Webbing of neck, low hairline, widespread nipple (Turner
syndrome)
• Bounding peripheral pulses (Patent Ductus Arteriosus,
Aortic regurgitation)
• Weak or absent femoral pulses or BP differential between
arms and legs (Coarctation of aorta)
• Virilization-Congenital adrenal hyperplasia
• Thinness- Pheochromocytoma, Hyperthyroidism

59. Cont…
• Eyes- Extraocular muscle palsy, Fundal changes, Proptosis
• Head & Neck-Goiter (Thyroid Disease) , Adenotonsillar
hypertrophy (Sleep disordered breathing)
• Signs of meningeal irritation (CNS Infections, encephalopathy)
• Skin Survey – Café-au-lait spots, ash-leaf spot,
neurofibromas, striae, hirsutism, butterfly rash, acanthosis
nigricans, needle tracks

60. Skin findings that may give some clues in a HypertensiveSkin findings that may give some clues in a Hypertensive
patientpatient
AcanthosisAcanthosis
nigricans innigricans in
cushingcushing
syndromesyndrome
Butterfly
rash in SLE
Café-au-lait spots in
neurofibromatosis
Ash- leaf spots inAsh- leaf spots in
Tuberous sclerosisTuberous sclerosis

61. Systemic
ExaminationCVS :
• Absent or Diminished femoral pulses, low leg pressure
relative to arm pressure (Coarctation of aorta)
• Heart size, rate, rhythm, murmurs, resp difficulty,
hepatomegaly (Coarctation of aorta ,Congestive Heart
Failure)
• Bruits over great vessels (Arteritis or arteriopathy)

62. Respiratory System: Features of pulmonary oedema
(Congenital heart failure)
Neurological sign : Neurological deficits due to chronic or
severe acute hypertension with stroke.
Cont…

63. Abdomen
•Abdominal mass (Wilms tumor, neuroblastoma,
pheochromocytoma)
•Palpable kidneys (Polycystic kidney disease,
hydronephrosis, multicystic dysplastic kidney, mass)
•Tenderness over kidney (renal infection)
•Abdominal bruits (Renal Vascular Disease)
•Ambiguous genitalia (Congenital adrenal hyperplasia)
Cont…

64. Complications of
hypertension

66. InvestigationsInvestigations

67. Documented HypertensionDocumented Hypertension
Gradient between upper and lower limb Blood pressureGradient between upper and lower limb Blood pressure
Yes NoYes No
Coarctation of aorta Abnormal urinalysisCoarctation of aorta Abnormal urinalysis
YesYes
NoNo
Predominantly WBC Predominantly RBCPredominantly WBC Predominantly RBC
Reflux nephritis Post infectious nephritis RenovascularReflux nephritis Post infectious nephritis Renovascular
Recurrent UTI Lupus nephritis lesionRecurrent UTI Lupus nephritis lesion
Renal anomaly HSPRenal anomaly HSP
and infection Nephrocalcinosis Essential HTNand infection Nephrocalcinosis Essential HTN
NephrolithiasisNephrolithiasis
Renal vein thrombosis EndocrineRenal vein thrombosis Endocrine
ThromboembolismThromboembolism
TumorTumor
Algorithm: Initial diagnostic approach in the evaluation of hypertensionAlgorithm: Initial diagnostic approach in the evaluation of hypertension
Ref. Marc B. Lande; Systemic Hypertension; Kliegman, Stanton, St Geme, Schor ed. Nelson
Textbook of Pediatrics; 1st
South Asian edition; India; Elsevier; 2016 : pg-2298

68. Blood Significance
Complete blood count Anemia (Chronic kidney disease)
S. electrolyte
Hypokalaemia (Hyperaldosteronism,
Congenital adrenal hyperplasia, Renin
producing tumor)
Hyperkalaemia ( Chronic kidney disease)
Blood glucose level Congenital adrenal hyperplasia, Diabetes
mellitus
BUN, S. creatinine,
Uric acid
Renal Parenchymal disease

69. Blood significance
Plasma Renin
Activity
High Renin- Reno vascular HTN,Renin
Producing Tumor
Low Renin-Congenital adrenal hyperplasia,
Primary Hyperldosteronism
Serum C3,C4 Acute glomerulonephritis, Systemic lupus
erythematosus
Serum cortisol
level
Cushing syndrome

70. LimitationsLimitations
Urine investigation Significance
Urine R/E, Urine C/S Renal Parenchymal Disease
24 hr urine collection for
catecholamine and
vanilyl mandelic acid
Pheochromocytoma,
Neuroblastoma
24 hr urine test for free
cortisol
Cushing syndrome

71. Others Significance
ECG, Chest X-ray Cardiac Cause of HTN &
baseline function
USG, CT scan, MRI of the
abdomen
Abdominal Tumour
Abdominal aortogram Coarctation of abdominal
aorta
Isotope scintigraphy (Renogram)
Magnetic resonance angiography
Duplex Doppler flow study
CT angiography
Reno vascular
Hypertension

72. Evaluating for target organ damage
• Echocardiography- Left ventricular hypertrophyEchocardiography- Left ventricular hypertrophy
• CT scan/MRI of brain- intracranial hemorrhage,CT scan/MRI of brain- intracranial hemorrhage,
hypertensive encephalopathyhypertensive encephalopathy
• Fundoscopic examination- features of hypertensiveFundoscopic examination- features of hypertensive
retinopathyretinopathy
• Various urinary, hematological, imagingVarious urinary, hematological, imaging
investigations- renal damageinvestigations- renal damage

73. Screening for co-morbidities
• Fasting lipid profileFasting lipid profile
• Fasting and random blood sugarFasting and random blood sugar

74. Grades of hypertensive retinopathy
Grade 1Grade 1-- increased arteriolar thickening andincreased arteriolar thickening and
tortiousitytortiousity
Grade 2Grade 2-- grade1+ venous constriction at arteiolargrade1+ venous constriction at arteiolar
crossing/ arteriovenous nippingcrossing/ arteriovenous nipping
Grade 3Grade 3-- grade 2+ evidence of retinal hemorrhagegrade 2+ evidence of retinal hemorrhage
(flame shaped hemorrhage, cotton wool spot)(flame shaped hemorrhage, cotton wool spot)
Grade 4-Grade 4- grade 3+ papilloedemagrade 3+ papilloedema

75. Normal retina on fundoscopic examinationNormal retina on fundoscopic examination

76. Grade 1 Grade 2
Grade 3 Grade 4

77. Management ofManagement of
childhood hypertensionchildhood hypertension

78. Goal of anti-hypertensiveGoal of anti-hypertensive
therapytherapy
• Reduction of BP below 95th
percentile
• Reduction of BP below 90th
percentile.(In case
of CKD, diabetes, hyperlipidemia target-organ
damage)

79. Algorithm:Algorithm:Management algorithm of childhoodManagement algorithm of childhood
hypertensionhypertensionRef. Marc B. Lande; Systemic Hypertension;Nelson Textbook of Pediatrics; 1st
South Asian edition;Elsevier; 2016 : pg-2295

80. Algorithm:Algorithm:Management algorithm of childhoodManagement algorithm of childhood
hypertension(Contd…)hypertension(Contd…)Ref. Marc B. Lande; Systemic Hypertension;Nelson Textbook of Pediatrics; 1st
South Asian edition;Elsevier; 2016 : pg-2295

81. Algorithm:Algorithm:Management algorithm of childhoodManagement algorithm of childhood
hypertension(Contd…)hypertension(Contd…)Ref. Marc B. Lande; Systemic Hypertension;Nelson Textbook of Pediatrics; 1st
South Asian edition;Elsevier; 2016 : pg-2295

82. Therapeutic lifestyle modification
Mainstay of treatment in children with mild HTNMainstay of treatment in children with mild HTN
It includesIt includes
•Dietary changes:Dietary changes: Fresh food and vegetable,Fresh food and vegetable,
fiber, non fat dairy and reduced sodium)fiber, non fat dairy and reduced sodium)
•Regular aerobic exercise:Regular aerobic exercise: 30-6030-60
minutes on most days of the weekminutes on most days of the week
•Weight loss:Weight loss: In obese patientsIn obese patients

83. Indication for drug therapy
in hypertension
• Symptomatic hypertension
• Secondary hypertension
• Hypertensive target organ damage
• Diabetes( types 1 & 2)
• Persistent hypertension despite
nonpharmacologic measures

84. Anti-hypertensive drugs

85. Contd.

86. Step 1
Step 2
Step 3
Step 4
Begin with the recommended initial dose of desiredBegin with the recommended initial dose of desired
medicationmedication
Increase dose until desired BP target is reached orIncrease dose until desired BP target is reached or
maximum dose is reachedmaximum dose is reached
Add a second medication. Proceed to highestAdd a second medication. Proceed to highest
recommended dose if necessary.recommended dose if necessary.
Add a third antihypertensive of different Class, ORAdd a third antihypertensive of different Class, OR
Consult a physician experienced in treatingConsult a physician experienced in treating
childhood hypertension.childhood hypertension.
Algorithm: Stepped care management of hypertension
Ref. Marc B. Lande; Systemic Hypertension;Nelson Textbook of Pediatrics; 1st
South Asian edition;Elsevier; 2016 : pg-2295

87. Management of hypertensive
crisis
Drug of choice: Labetalol, Nicardipine, Na nitroprusside
Hypertensive emergency: I/V administration is preferred.
Hypertensive urgency: Oral or I/V drug.
Stepwise reduction of Blood pressure:
10% reduction in first hour.
15% more reduction in the next 3-12 hours

88. Antihypertensives used in severe
hypertension
Ref. Marc B. Lande; Systemic Hypertension; Kliegman, Stanton, St Geme, Schor ed. Nelson Textbook of Pediatrics; 1st
South
Asian edition; India; Elsevier; 2016 : pg-2303

89. Contd
Ref. Marc B. Lande; Systemic Hypertension; Kliegman, Stanton, St Geme, Schor ed. Nelson
Textbook of Pediatrics; 1st
South Asian edition; India; Elsevier; 2016 : pg-2303

90. • Acute glomerulonephritis
Diuretics,Calcium channel blocker, ACE inhibitor
• Migraine headache
β blocker/ Ca channel blocker
• Acute kidney injury
Diuretics, Calcium channel blocker
Drug preferences

91. Contd.
• Chronic kidney disease
Thiazide diuretics (When GFR is normal),ACE
inhibitor, Angiotensin receptor blocker
• Heart failure
Diuretics, ACE inhibitor, Angiotensin receptor blocker
• Diabetes mellitus
ACE inhibitor, Angiotensin receptor blocker

92. • ß blocker
Diabetes mellitus, Heart failure, Asthma.
• ACE inhibitor/ Angiotensin receptor blocker
Bilateral renal arterial stenosis, acute renal failure,
Hyperkalaemia
• Calcium channel blocker
Heart failure
Drugs to be avoided in situations

93. •α or ß blocker + clonidine
•ß blocker + CCB (marked bradycardia/ AV block).
•Any 2 drugs of same class.
Drug combinations to be avoided

94. Secondary hypertension
Management is aimed at treating the cause.
Organ/System Disease
Renal Glomeruloephritis, Pyelonephritis,
hydronephrosis, Wilm’s tumor
Cardiovascular Coarctation of aorta, Renal artery aneurysm
(stenosis, thrombosis, aneurysm)
Adrenal Pheochromocytoma, Neuroblastoma,
hyperaldosteronism, Cushing syndrome
Others Drug therapy

95. Prevention of primary childhood
hypertension
A part of Prevention of co-mobidities like cardiovascular
disease and stroke. It includes
•Reduction of obesity
•Reduction of salt intake
•Increase physical activity

96. Conclusions
Early detection and management of hypertension is
essential for preventing many life threatening
situations.
World Hypertension Day (WHD) was on May 17, 2018.
The theme for World Hypertension Day is Know Your
Numbers with a goal of increasing high blood pressure
(BP) awareness in all populations around the world.

97. In honor of WHD 2017, Niagara Falls was lit up redIn honor of WHD 2017, Niagara Falls was lit up red
and blue for 15 minutes to help spread awareness!and blue for 15 minutes to help spread awareness!