2. Rationale for identification and treatment
• Rationale for identification and treatment
• International Childhood Cardiovascular Cohort (130) Consortium was
initiated to link childhood cardiovascular risk factors to adults disease
• 1) Childhood BP, is strongly predictive of adult BP
• 2) LVH is independent risk factor for cardiovascular events
• 3) Microalbuminuria is a powerful predictor of both renal
insufficiency and cardiovascular morbidity and mortality in adults.
The prevalence of microalbuminuria among children diagnosed with
hypertension is estimated to be 20%.
3. Indian scenario
• Indian scenario
• The application of international reference to Indian children that
differ in various demographic factors, may not be valid
• Higher diastolic pressures for both sexes than international standard
across all age groups.
• Higher blood pressure values in Indian population are of considerable
public health significance.
4. • Prevalence:
• Various studies have found prevalence in range between 4.7 and
19.4%
• The combined prevalence increases by nearly five times, to around
30%, in adolescents who are obese
7. • Hypertensive crisis : subdivided into 2 : hypertensive urgency and
hypertensive emergency.
• Hypertensive urgency describes severe hypertension but without any
end organ damage but can be more gradually reduced within few
days to avoid serious sequelae.
• Hypertensive emergency describes severe hypertension with end
organ damage which has to be reduced within minutes to avoid life
threatening complications.
8. MEASUREMENT
• Quiet room for 3-5 min
• Appropriate bp cuff size
• Bell of stethoscope over the brachial artey
• Kortoff sounds
Done in : Secondary HTN , CKD or structural renal
abnormalities,T1DM and T2DM,Solid-organ
transplant , Obesity , OSAS ,Aortic coarctation
(repaired) , Genetic syndromes associated with
HTN (neurofibromatosis, Turner syndrome,
Williams syndrome, coarctation of the aorta)
10. Screening in a busy OPD
• Based on the 90th percentile BP for age and sex at the 5th percentile
of height.
• Which gives the values in the table a NPV of >99%.
11.
12. Differentiating Primary and Secondary HT
Secondary HTN
• Prepubertal
• Usually stage 2
• Diastolic / nocturnal
• May be positive
• Symptoms of underlying
disorder
Primary HTN
• Adolescents
• Usually stage 1
• Overweight/obese
• Positive family history
• Usually asymptomatic
15. Approach to hypertension
Those with severe htn have and evidence of end organ involvement and
very likely have an underlying etiology.
16. Evaluation of HTN in Children and Adolesc
• Must begin with:
• - Thorough history (including hx of sleep disorder)
• - Drugs
• - Family history of hypertension, CVD risks, renal and endocrine
disorders
• - Other risk factors like lack of physical activity, unhealthy diet,
smoking and alcohol use
• - Complete review of other systems like headache, vomiting, seizures,
altered mental status
17. Evaluation of HTN in Children and Adolescent
Physical examination:
• • Calculate BMI
• • BP in both arms and right leg
• • Look for presence of radiofemoral delay
• • Look for presence of abdominal bruit
• • Ambiguous genetalia
18. • Any symptoms of any end organ damage
• headache, weakness, fatigue, dizziness, stroke-to rule out
cerebrovascular disease
• Any history of blurred vision-rule out retinal disease
• Angina pectoris –coronary artery disease
• Dyspnea –to rule out congestive heart failure
• Any history of epistaxis
• Facial palsy
20. Signs to look in hypertension
• BMI - to rule out metabolic syndrome
• Tachycardia - to rule out pheochromocytoma Hyperthyroidism
Neuroblastoma
• R-F delay - coA
• Growth retardation - in chronic renal failure ,chronic kidney disease
• Thyromegaly - seen in hyperthyroid
• virilization ,ambiguous genitalia - to rule out congenital adrenal
hyperplasia
• Rashes - to rule out systemic lupus erythematosis ,vasculitis (Hsp)
Impetigo with acute nephritis
21. • any genetic conditions - neurofibromatosis ,VHL , Williams syndrome ,Turner syndrome
• on auscultation - bruits heard over great vessels - Arteritis / arteriopathy
• any rub - rule out pericardial effusion secondary to cardiac disease
• palpable kidneys - seen in poly cystic kidney disease ,hydronephrosis ,multicystic
dysplastic kidney
• abdominal mass - in Wilms Tumor ,neuroblastoma ,pheochromocytoma
• epigastric /abdominal bruit - seen in coarctation of abdominal aorta , renal artery
stenosis
• Hepatosplenomegaly - seen in Autosomal recessive poly cystic kidney disease
• evidence of any 7 nerve palsy - to rule out focal neurological deficit
22. ESSENTIAL HYPERTENSION
• More common in older school age children and adolesents
• Patient are often overweight with strong family history of
hypertension
• Risk factors-diet –salt intake ,sleep problems and
• Obesity, genetic alteration in calcium and sodium transport
RAAS and sympathetic system over activity
Obese children -3 fold risk for htn compared with non obese children
27. Non Pharmacologic Therapy
• Recommended for all pts with HT
• • Wt reduction in obese pts.
• • Regular exercise
• • Dietary modification
• • Stress reduction
• • Preventing dyslipidemia, avoiding smoking, alchohol, caffeine,
energy drinks
28. Pharmacologic therapy
• INDICATIONS :
• Symptomatic HTN
• •Stage 2 HTN.
• •Stage 1 HTN without any evidence of end-organ damage and that
persists despite a trial of four to six months of non-pharmacologic
therapy.
• Hypertensive end-organ damage
• •Any stage of HTN or high BP for patients with chronic kidney disease
(CKD).
• Any stage of HTN for patients with DM
29. Choice of initial drug
• • Underlying cause of HTN
• • Concurrent disorders
• • And the preference and experience of the responsible clinician
30. • Primary HTN
• • ACE inhibitor or ARB-except for sexually active females.
• • If the target BP goal is not met with the maximum allowable dose of the
initial medication (ACE inhibitor or ARB), add a thiazide diuretic to the drug
regimen.
• For sexually active females -CCB be used as the initial antihypertensive
agent
• Renovascular Disease-CCB be used as the initial antihypertensive agent
• CKD/DM-ACE inhibitors be used as the initial antihypertensive agent ARBs
are a reasonable alternative.
31. DRUGS
Drug Class Initial dose Max dose Dosing
interval
s
ADR/contraindications Monitoring
Captopril ,
Enalapril
ACE inhibitors Infants :
0.05m/k/dose
Children :
0.5m/k/dose
6mkd OD -QID Cough, C/I in B/L renal
artery stenosis
Olmesartan ARB <35kg : 10mg 20 mg OD Less cough than ACE-
headache,
dizziness,hyperkalemia
Potassium
levels,AKI fetal
toxicity
Chlorthiazide Thiazide
diuretics
10mkd 20mkd Od-BD Dizziness,
Hypokalaemia,cardiac
dysarrythmias,
cholestatic jaundice ,
pancreatitis
Potassium
levels,cardiac
dysarrythmias,
cholestatic
jaundice ,
pancreatitis
32. Drugs
DRUG Class Initial dose Max dose Dosing
interval
ADR/ c/i Monitoring
Hydrochlorthi
azide
Thiazide
diuretics
1mkd 2mkd OD-BD
Amlodipine CCB 1-5yrs: 0-1mkd
>6yrs: 2.5mkd
0.6mkd
10mg
OD Flushing,
Headache,
peripheral ankle
edema
Nifedepine CCB 0.2-0.5mkd 3mkd OD-BD Unpredicatble and
uncontrolled fall in
BP
35. Target BP-AAP 2017 guidelines
• • Below the 90th percentile or <120/80 in adolescents (13 years or
older)
• • CKD -goal of mean arterial BP <50th percentile based on 24-hour
ambulatory blood pressure monitoring (ABPM)
36. Conclusion
• • Hypertension and obesity in children are increasing in an upward
trend
• • It is imperative that pediatric hypertension is recognized and
treated
• • It is advisable to measure blood pressure at every visit with the
appropriate technique, use the gender, age, and height specific blood
pressure table
• • It is important to encourage healthy lifestyles in all children and
adolescents and help institute lifestyle changes for weight reduction
in overweight children
