Hypertension in pediatric has been increased around the world. there is a lot of factors plays a role in this increased. Here, we described the AAP 2017 protocol for pediatric

1. The Silent Killer
AAP 2017
Dr. Leen Doya
Department of pediatric
Tishreen university

2. Is there hypertension in
children?

3. Before 1977
• no accepted
normative
data.
1977
• 1st Task Force
Report
(3 sources).
• Normative
data for
children.
• Defined HTN
>95th
percentile for
age & gender.
1987
• 2nd Task Force
Report
(9 sources).
• Additional
data for over
60,000
children.
1996
• Task Force
Update
• Incorporated
height in the
BP norms.
2004
• Fourth
Working
Group
Report.

4. AAP Clinical Practice Guidelines
(CPG)
2017

5. Four Clinical Questions
1. Does my patient have hypertension?
2. Why does my patient have hypertension?
3. Is there any evidence of target organ
damage?
4. Are there any other modifiable risk factors
for CVD?

6. INTRODUCTION
 childhood hypertension (HTN) since 2017 :
 clinical HTN in children is ≈3.5%.
 10%–11% have elevated BP.
 Increase due to obesity and overweight
(25%).
 Up to 30% of newly diagnosed significant
target organ damage, particularly cardiac.

8. Definition of Hypertension in Neonates
and Infants (0–1 year)
 Normal blood pressure values depend on the infant’s
gestational age, postnatal age, and birth weight.
 Hypertension is commonly defined as a BP >2
standard deviations above normal values for age
and weight.

9. Definition of Hypertension
(1–18 years)
 Normal BP:
BP (<90th ) percentile for age, sex, and height.
or (<120/ 80) mm Hg for (≥13 yr) .
 Elevated BP:
BP(90th - 95th)percentile or(120/80)mmHg. (which lower)
or BP (120/80- 129/<80) mm Hg for (≥13 yr).
 Hypertension: (at 3 different visits)
BP (>95th ) percentile .
or ( ≥130/80) mm Hg for (≥13 yr ).
Obtain multiple measurements over time before
diagnosing HTN.

10. Definition of Hypertension
(1–18 years)
 Hypertensive-level BP is staged :
 Stage 1 hypertension:
BP (90th - 95th) percentile(+12)mmHg or
(130-139/80-89) mmHg ( which lower).
or (130-139/80-89) mm Hg (≥13 yr) .
 Stage 2 hypertension:
BP (≥95th) percentile (+12 mmHg) or (≥140/90mmHg)
(which lower).
or (≥ 140/90 )mm Hg (≥13 yr).

11. Definition of Hypertension
(1–18 years)
 White Coat Hypertension (WCH):
BP (> 95th) percentile in the physician’s office,
normotensive in outside environment.
 Masked Hypertension (MH) :
Normal BP in the physician’s office, but high
at home.

12.  Most children are asymptomatic and diagnosed as a
result of routine BP measurment .
 begin BP measurement at age 3.
 children should have BP measured if they have:
1. obesity.
2. taking medications known to increase BP.
3. renal disease.
4. history of aortic arch obstruction or coarctation.
5. diabetes.
Blood Pressure Measurement Frequency

13. Children younger than 3 years should
have BP measured
 (˂32 week ) or VLBW, small for gestation age.
 Congenital heart disease.
 Renal disease or urologic malformation .
 Family history of congenital renal disease .
 Solid-organ transplant.
 Malignancy or bone marrow transplant.
 Treatment with drugs known to raise BP.
 Other illnesses (e.g., neurofibromatosis, TSC, SCD…etc )
 Evidence of increased ICP.

14. Blood pressure monitor

15. Ambulatory Blood Pressure
Monitoring
The patient wears a device that records BP every
20-30 min, throughout a 24 hr period, during
usual daily activities.

16. Ambulatory Blood Pressure
Monitoring
children with elevated BP for
≥1 year .
Stage 1 HTN ( 3 visits).
evaluating effectiveness of
antihypertensive therapy.
Frequency of (WCH), (MH).
high-risk : CKD,T1DM, aortic
coarctation ,severe obesity.

17. Etiology of Hypertension
Primary Hypertension:(essential)
 Characteristics include:
 ≥6 years of age.
 positive family history of HTN.
 obesity/overweight. (~25%)
 Systolic HTN predictive of primary HTN.

18. Secondary Hypertension
 Renal/Renovascular :( children <6 years of age )
 Renal parenchymal (34–76%), Renovascular (12%).
 Aortic Coarctation:( 17-77%) .
 Endocrine : Hyperthyroidism , CAH , Cushing syndrome…
 Medication related: Corticosteroids , Vitamin D
intoxication……etc
 CNS : mass , hemorrhage , trauma……
 Diastolic HTN predictive of secondary cause.

19. Patient Evaluation
Patient Population Screening Tests
All patients Urinalysis.
Chemistry panel ( electrolytes, blood
urea , cr )
lipid profile .
renal ultrasonography (˂6 year with
abnormal renal function and urinalysis).
BMI ˃95th child or adolescent in
addition to the above
HbA1c .
AST , ALT.
Optional tests to be obtained on
the basis of history ,history
physical examination , and initial
study
fasting serum glucose
TSH
Drug screen
Sleep study
CBC ( with growth delay or abnormal
renal function)

20. Patient Evaluation
 History and Physical examination :
Dizziness , headache , heart palpitation ,Epistaxis, short
breath , anger , flushing, visual problems , fatigue , seizures
, confusion, sore knee , raised Temp , …..

21. Patient Evaluation
 Radiology:
Doppler Renal Ultrasound ,Reno
vascular imaging ……
 Echocardiography :
recommended echocardiography
at time of diagnosis of HTN.
 Repeat echocardiography to
monitor patients with LVH or
abnormal left ventricular
function.

22. Management on Basis of Office
Blood Pressure

23. Normal Blood Pressure
BP is normal, no additional action is needed.
Give standard lifestyle recommendations
(nutrition, sleep, physical activity).
Recheck BP at next routine visit.

24. If patient is symptomatic or BP is >30 mm Hg
above the 95th percentile (or >180/120 in an
adolescent ) , refer for emergency care.

25. BP is elevated
Lifestyle recommendations
BP is still elevated
Check upper and lower extremity BP
.
If BP is still elevated after
12 months
1. ABPM .
2. Diagnostic evaluation.
3.Consider subspecialty referral.
6
months
6
months
If BP normalizes at any point, return to annual
screening
Elevated
Blood
Pressure

26. Stage 1 Hypertension
in 1–2
weeks
• BP is Stage 1 HTN is asymptomatic:
• Lifestyle recommendations.
3 months
• BP is still Stage 1 HTN:
• Check upper and lower extremity BP
After 3
visits
• If BP is still Stage 1 HTN :
• ABPM .
• Diagnostic evaluation.
• Consider subspecialty referral and Initiate
treatment .

27. Stage 2 HTN
BP is Stage 2 HTN is
asymptomatic:
1. Check upper and lower
extremity BP.
2. Lifestyle
recommendations .
3. referred to
subspecialty care within
1 week .
1 week
If BP still Stage 2 HTN level
1. ABPM.
2. Initiate treatment.
3. subspecialty referral
within 1 week

28. Overall Treatment Goals
 Achieve a BP level that :
 Reduces risk for target organ damage.
 Reduces risk for hypertension-related cardiovascular
disease in adulthood
 Treatment goal :
 ˂ 90th percentile in younger children .
 ˂ 130/80 ( ≥13 yr).

29. Lifestyle Modifications
At the time of diagnosis clinicians should
provide advice on the DASH (Dietary
Approaches to Stop Hypertension diet) : High in
fruits , vegetables , low- fat milk products ,
whole grains , fish, poultry , nuts , and lean red
meat.

30. Lifestyle Modifications
Sodium Restriction :
 4-8 year olds – 1.2 g/day
 > 8 years – 1.5 g/day
moderate to vigorous physical activity at least 3 to
5 days per week (30–60 min per session).
Weigh loss.
Stress reduction

31. Medical Therapy
 Prescribe antihypertensive medications if:
1. Patient has failed at least 6 months of lifestyle
change.
2. Symptomatic HTN.
3. Stage 2 HTN without clearly modifiable risk factor
(e.g. obesity).
4. Any stage of HTN associated with CKD or DM.

32. 1st line agents may include :
(ACEI) or (ARB) , Long-acting calcium channel
blocker, Thiazide diuretic .
 B – blockers not recommended as initial
treatment .
In CKD , proteinuria or diabetes : ACE inhibitor
or ARB.
 Single agent preferred.

33. Medical Therapy
treated with lifestyle change only should be
seen every 3–6 months .
treated with antihypertensive medications
should be seen every 4–6 weeks for dose until
goal BP is reached, then every 3–4 months.
Evaluate control with ABOM.
Second agent can be added and titrated as
needed.