power point presentation of Clinical evaluation of strabismus
Child with hypertension
2. OBJECTIVES
Identify children and adolescents for whom
hypertension screening is appropriate
Implement an initial workup for pediatric
hypertension
Develop treatment plans for children with
essential or secondary hypertension
3. BACKGROUND
Hypertensive children
Usually asymptomatic
HOWEVER already manifest evidence of target organ
damage
Left ventricular hypertrophy ( up to 40%)
Increased carotid intima-media thickness
Children with BP > 90th percentile have a 2.4-fold greater
risk having hypertension as adults
4. PREVALENCE OF HYPERTENSION
IN CHILDREN
Systemic hypertension is uncommon (<1%)
If present often indicative of an underlying disease
process
SEVERE and SYMPTOMATIC HYPERTENSION in
children is usually due to SECONDARY
HYPERTENSION
Prevalence of primary essential hypertension has
increased, mostly in older school age and adolescents
5. DEFINITION
Hypertension is defined as average SBP and/or
diastolic BP that is 95th percentile for gender , age
and height on 3 or more occasions.
6.
Normal Blood Pressure : < 90th percentile for age,
gender and height.
Pre-hypertension : SBP and/or DBP >90th percentile
but less than 95th percentile for
age, gender and height.
For age >12years, BP >120/80 regardless of 90th percentile
considered pre-hypertension
Hypertension : SBP and/or DBP >95th percentile
for age, gender and height
Stage 1: 95th – 99th percentile + 5 mmHg
Stage 2: > 99th percentile + 5 mmHg
6
CLASSIFICATION OF
HYPERTENSION
7.
Hypertensive urgency:
Significant elevation in BP without accompanying end-organ
damage; more common in children.
(180 or higher for your systolic pressure or 110 or higher for
your diastolic pressure)
Symptoms include headache, blurred vision, and nausea
Hypertensive emergency:
Elevation of both systolic and diastolic BP
(exceeding 180 systolic or 120 diastolic)
with acute end-organ damage (e.g., cerebral infarction or
hemorrhage, pulmonary edema, renal failure, hypertensive
encephalopathy, or seizures)
7
HYPERTENSIVE CRISIS
8. BLOOD PRESSURE
REGULATIONS
Short term mechanisms
Baroreceptors (low pressure & high pressure)
Hormonal
Noradrenaline-adrenaline system
Renin-angiotensin-aldosterone system
Vasopressin system
Long term mechanisms
Renal body fluid pressure control system
13.
The child should be calm and free of anxiety
The child should have been sitting quietly for 5 minutes.
The child should be sitting with back supported, both feet
on the floor and right cubital fossa supported at heart
level.
Choose the appropriate cuff size:
The cuff width should cover ~70% of the distance
between the acromion and the olecranon .
The cuff bladder length should be 80 to 100% of the arm
circumference, and the cuff bladder width should be at
least 40% of the arm circumference at the midpoint of the
acromion-olecranon distance.
15. Recommended Dimensions
for Blood Pressure Cuff Bladders
Maximum Arm
Age Range Width (cm) Length (cm) Circumference (cm)*
Newborn 4 8 10
Infant 6 12 15
Child 9 18 22
Small adult 10 24 26
Adult 13 30 34
Large adult 16 38 44
Thigh 20 42 52
*Calculated so that the largest arm would still allow the bladder to
encircle the arm by at least 80 percent.
16. METHODS
Palpatory Method BP recording is 10 mm Hg less
than that obtained by auscultatory
method .
Auscultatory Method Preferred method. BP tables are
based on it.
Doppler Study Non invasive procedure
Oscillometric Method Better to record mean BP. Useful in
infants and young children. BP >
90th percentile should be
rechecked by auscultatory method.
Flush Method Used in newborns. Only SBP can
be recorded.
Ambulatory Blood
Pressure Monitoring
White-coat hypertension
Target-organ injury risk
17. POINTS TO BE
REMEMBERED
BP should be recorded in all 4 limbs.
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.
19. DEVELOPING A DIFFERENTIAL . . .
“M.O.N.S.T.E.R.”:
A simple pneumonic to start the thinking process
19
20. CAUSES OF HYPERTENSION IN PEDIATRIC POPULATION
Renal Causes Renal Parenchymal diseases (78%)
Renal vascular diseases (12%)
Cardiovascular CoA(2%)
Condition with large stroke volume (PDA, AV fistula)
Endocrine Hyperthyroidism
Excessive Catecholamine levels (Pheochromocytoma)
Adrenal dysfunction (CAH 11b, 17 a hydroxylase
deficiency)
Hyperaldosteronism (Conn's Syndrome, Renin
Producing Tumors)
Hyperparathyroidism
Neurogenic Raised ICT, Poliomyelitis,GBS, encephalitis
Drugs and Chemical Sympathomimetic drugs , Amphetamines, Steroids,
OCP, Heavy matal poising (Hg, Lead), Cocaine,
Cyclosporine
Miscellaneous Hypercalcemia, After Coarctation repair, fractures
of long bone,Pre eclampsia etc.
21. Obesity-- for each one unit increase in BMI
z-score, children 8 to 17 years of age have been shown to
have twice the risk of having a BP greater than the 95th
percentile.1
22. CLINICAL
MANIFESTATIONS
Usually asymptomatic
Mild to moderate obesity
Clinical manifestation of the underlying disease
Headache, dizziness, epistaxis, anorexia, visual
changes, seizures
Hypertensive encephalopathy : vomiting, temperature
elevation, ataxia, stupor, seizures
29.
NON PHARMACOLOGICAL
Recommended in all children with prehypertension and
hypertension
Weight management: reduction in obese children and
maintenance in normal weight
Lifestyle modifications
Diet modification (reduce salt intake, low fat diet).
Note that those with severe HTN should avoid very
strenuous exercises including weight lifting and high
intensity sports, until evaluations clears an individual for
participation
Some exercises can result in a brisk increase in BP that may
result in significant adverse consequences
29
Management
30. GOALS OF
ANTIHYPERTENSIVE
THERAPY
Reduction of BP to < 95th percentile without any
concurrent conditions .
Reduction of BP to <90th percentile with concurrent
conditions (eg.Hyperlipidemia ,End organ damage,
Obesity, CKD Complications etc)
31.
Pharmacologic
1. Hypertension but asymptomatic :
Bed rest.
Re-check BP ½ hour later.
Monitor BP hourly x 4 hours then 4 hourly until stable.
Oral nifedipine 0.25-0.5mg/kg if necessary 4 hourly basis.
Consider regular oral nifedipine (6-8 hourly) if BP
persistently high.
Add frusemide 1mg/kg/dose if BP still not well controlled.
Other anti-hypertensive if BP still not well controlled :
Captopril 0.1-0.5 mg/kg 8 hourly.
Metoprolol 1-4 mg/kg 12 hourly
33.
2.Long standing/poorly controlled hypertension:
Combination of antihypertensives.
Different sites or mechanism of action.
Compliance.
34. COMBINATION
THERAPY
SYNERGISTIC
COMBINATIONS.
Drugs increasing renin
activity+ Drugs decreasing
renin activity
ACE inhibitors , Diuretics
+
b blockers
Sympathic inhibitors and
vasodilators cause fluid
retention. Add diuretics
b blockers + Thiazide,
Lasix ( furosemide)
ACE inhibitors + Diuretics Enalapril (Envas) +
Thiazide, Lasix
a Blocker + b blocker Prazosin + Propranolol
35. COMBINATIONS TO
BE AVOIDED
a or b blocker + clonidine (antagonism)
b blocker + CCB (marked bradycardia/ AV block).
Any 2 drugs of same class.
36. Hypertensive crisis
Severe symptomatic hypertension with BP well above
99th percentile .
Hypertensive emergencies(encepalopathy,chf)
controlled reduction in BP
25% in first 8hrs
then gradually normalising BP 75% within 48 hours. .
37. EMERGENCIES
Nifedipine
0.25-0.5 mg/kg/dose oral.
May be repeated twice if no response.
Sodium nitroprusside
Need to be given in ICU setting.
0.5-1.0 mcg/kg/min IV infusion.
May be increased to 8.0 mcg/kg/min maximum.
Caution in renal and liver failure.
Labetolol
0.2-1.0 mg/kg/dose repeated IV boluses
0.25-2.0 mg/kg/hour IV infusion
Hydralazine
0.2-0.4 mg/kg/dose IV bolus.
May be repeated twice if no response.
38. SECONDARY
HYPERTENSION
Treatment should be aimed at removing the cause of
hypertension whenever possible.
Curable forms of Hypertension
Renal Unilateral kidney disease (Nephritis,
Pyelonephritis, hydronephrosis)
Cardiovascular CoA, Renal artery stenosis, thrombosis.
Adrenal Pheochromocytoma, Neuroblastoma,
hyperaldosteronism
Miscellaneous Drugs/ OCP etc.