This document provides guidelines for screening and managing hypertension in children and adolescents. It defines hypertension as blood pressure above the 95th percentile for age, gender and height on 3 occasions. Secondary causes are more common in children and include conditions like renal disease, coarctation of aorta, and endocrine disorders. Treatment involves lifestyle modifications and medications, with the goal of reducing blood pressure below the 90th percentile. For hypertensive emergencies, the aim is to lower blood pressure more gradually to prevent end-organ damage.

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

9. BARORECEPTOR
REFLEX CONTROL


10. 

12. How should blood pressure be
measured in children?


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.

14. Choose the appropriate size cuff


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.

18. ETIOLOGY
COMMONEST CAUSES
Newborn Umbilical artery catheterization and
Renal artery thrombosis.
Childhood Renal disease, COA, endocrine
disorders or medications.
Adolescents. Essential hypertension becomes
increasingly common.

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

23. 

24. Acute Gromerulonephritis Oliguria, haematuria, mild proteinuria, oedema
Pyelonephritis Urinary tract infection, fever
Haemolytic Uraemic
Syndrome
AGE (bloody stool), weakness, irritability,
oliguria, oedema
Henoch-Schonlein purpura Palpable purpuric rash, abdominal pain,
haematochezia, periarticular swelling, scalp &
scrotal oedema, haematuria
SLE Arthritis, arthralgia, weight loss, fever, malaise,
malar rash, alopecia, oral ulcers, haematuria
Renal vein thrombosis Abdominal pain, history of umbilical
catheterization
Familial nephritis Frequent haematuria
Wilms tumour Abdominal mass, abd pain, fever,
microscopic/gross haematuria
Neuroblastoma Abdominal mass, fever, weight loss, limp, back
pain
Neufibromatosis Skin nodules, family history

25. Hyperthyroidism Tremor, anxiety, sweating, heat intolerance,
inability to concentrate, weight loss,
hyperactivity, neck mass
Pheochromocytoma Anxiety, tremor, sweating, headache, flushing,
nausea, vomiting, weight loss,
constipation/diarrhoea, Raynaud’s, chest pain,
polyuria/nocturia
Cushing syndrome Obesity, failure of long. growth, hirsutism,
weakness, acne, hyperpigmentation, history of
taking steroid
Congenital adrenal
hyperplasia
Ambiguous genitalia, virilization, precocious
puberty

26. 
 Complete blood count : anaemia(chronic renal disease)
 BUSE, Creatinine: Renal disease, hyperaldosteronism
(hyperkalemia)
 Urinalysis : proteinuria, haematuria
 24 hr urinary protein or spot albumin to creatinine ratio
 Urine culture& sensitivity: chronic pyelonephritis
 Chest radiograph : CoA
 Electrocardiogram : cardiac cause of HPT
 Ultrasonography for kidneys , adrenals : hydroneprosis,
PKD, Wilm’s tumour
26
SCREENING
INVESTIGATION
Aims;
Assessment for target organ damage
Assessment for aetiology
Assessment for other cardiovascular risk factors

27. 
 Retinal fundus examination
 Urine spot protein to creatinine ratio
 Echocardiography : LVH, LV function
27
SCREENING FOR
TARGET ORGAN
DAMAGE

28. 
 Renin level : plasma renin (high-renovascular; low-hyperaldosteronism)
 Toxicology screen
 Thyroid and adrenal testing :T3 T4, plasma aldosterone,
plasma catecholamines (pheochoromocytoma, neuroblastoma)
 Urine catecholamines
 Abdominal ultrasound : : Structure anomalies of kidney, renal
vasculature and tumours; renal scarring, renal asymmetry(r.
dysplasia, r. artery stenosis), extrarenal masses (neuroblastoma,
Wilms tumour)
 Renal Doppler ultrasound
 Brain CT scan
28
CONSIDER

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

32. 

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.

39. 
Management Algorithm of Systemic Hypertension