Hypertension in children and adolescents is increasing in prevalence. The actual prevalence of clinical hypertension is approximately 3.5%, while the prevalence of prehypertension is 2.2-3.5%. High blood pressure in childhood increases the risk of adult hypertension and metabolic syndrome. Both primary and secondary causes of hypertension can occur in children. Treatment involves lifestyle modifications like diet and exercise changes as well as pharmacological treatment with medications like ACE inhibitors, ARBs, or calcium channel blockers if lifestyle changes are not effective. The goals of treatment are to lower blood pressure below the 90th percentile or 130/80 mmHg to reduce future cardiovascular risks.

1. Hypertension in children and adolescents
Presenters :Dr Joyce Mwatonoka
:Dr Elita Nywage
Mmed Pediatrics and Child Health
1st Year

2. Introduction
• There has been an increase in the prevalence of childhood high BP
• High BP is consistently greater in boys (15%–19%) than in girls
(7% - 12%)
• The actual prevalence of clinical HTN in children and adolescents is
∼3.5%

3. Cont…
• The prevalence of persistently elevated BP (formerly termed
“prehypertension” including BP values from the 90th to 94th
percentiles or between 120/80 and 130/80 mm Hg in adolescents)
• Is also ∼2.2% to 3.5%, with higher rates among children and
adolescents who have overweight and obesity
• HTN rates are higher in children with certain chronic conditions,
including children with obesity, sleep-disordered breathing (SDB),
CKD, and those born preterm

4. Cont…
• Importance of Diagnosing HTN in Children and Adolescents -
elevated BP in childhood increases the risk for adult HTN and
metabolic syndrome
• Youth with higher BP levels in childhood are also more likely to have
persistent HTN as adults

5. • Normal blood pressure is SBP and DBP values <90th percentile (on
the basis of age, sex, and height percentiles)
• Preadolescent, “prehypertension” is SBP and/or DBP ≥90th
percentile and <95th percentile (on the basis of age, sex, and height
tables)
• Adolescents, “prehypertension” is BP ≥120/80 mm Hg to <95th
percentile, or ≥90th and <95th percentile, whichever was lower.
• HTN is the average clinic measured SBP and/or DBP ≥95th percentile
(on the basis of age, sex, and height percentiles)

7. Causes of hypertension
Primary causes - they are common than secondary causes
• Characteristics of children with primary HTN include
Older age (≥6 years)
Positive family history (in a parent and/or grandparent) of HTN 22
Overweight and/or obesity.
• DBP elevation appears to be more predictive of secondary HTN,
whereas systolic HTN appears to be more predictive of primary HTN

8. Secondary causes
1. Renal and/or Reno vascular
2. Cardiac, Including Aortic Coarctation
3. Endocrine HT
4. Environmental exposure most prominent are lead, cadmium,
mercury, and phthalates.
5. Neurofibromatosis
6. Medication related- common medications associated with a rise in
BP include oral contraceptives, central nervous system stimulants
and corticosteroids

9. DIAGNOSIS
• History; The various components of the history include the perinatal
history, past medical history, nutritional history, activity history, and
psychological history
• Physical Examination; A complete physical examination may provide
clues to potential secondary causes of HTN and assess possible
hypertensive end organ damage. The child’s height, weight, calculated
BMI, and percentiles for age should be determined. Poor growth may
detect an underlying a chronic illness
• Investigations

10. Treatment
• The overall goals for the treatment of HTN in children and
adolescents, including both primary and secondary HTN, include
achieving a BP level that not only reduces the risk for target organ
damage in childhood but also reduces the risk for HTN and related
CVD in adulthood. Several studies have shown that currently available
treatment
• An optimal BP level to be achieved with treatment of childhood HTN
is <90th percentile or <130/80mm Hg, whichever is lower

12. Lifestyle and non-pharmacologic Interventions
1. Diet
• The Dietary Approaches to Stop Hypertension (DASH)
• Include a diet that is high in fruits, vegetables, low fat milk products,
whole grains, fish, poultry, nuts, and lean red meats; it also includes a
limited intake of sugar and sweets along with reduced dietary sodium
• Diet high in olive oil

13. Cont…
2. Increased physical activities
3. Weight loss
4. Stress reduction
• DASH diet + Exercise (grade C, weak recommendation)

14. Pharmacological treatment
• For those who remain hypertensive despite lifestyle modification or
who have symptomatic HTN, stage 2 HTN without a clear modifiable
factor, or any stage of HTN ass/c CKD or DM
• Therapy should be initiated with a single medication at the low end of
the dosaging range
• The dose can be increased every 2 to 4 weeks until BP is controlled
• Drugs recommended; ACEI, ARB, long acting CCB or Thiazide
Diuretics

15. Cont…
• Other antihypertensive medications (eg, α-blockers, β-blockers,
combination α- and β-blockers, centrally acting agents, potassium-sparing
diuretics, and direct vasodilators) should be reserved for children who are
not responsive to 2 or more of the preferred agent
• In hypertensive children and adolescents who have failed lifestyle
modifications (particularly those who have LV hypertrophy, symptomatic
HTN, or stage 2 HTN without a clearly modifiable factor [eg, obesity]),
clinicians should initiate pharmacologic treatment with an ACE inhibitor,
ARB, long-acting calcium channel blocker, or thiazide diuretic (grade B,
moderate recommendation)
• In African-American children high dose ACEI or CCB/Thiazide diuretic
initially preferred

16. Cont…
• In children with HTN and CKD or proteinuria, an ACE inhibitor or ARB
is recommended as the initial antihypertensive agent unless there is
an absolute contraindication (grade B, strong recommendation)
• Children and adolescents with T1DM or T2DM should be evaluated
for HTN at each medical encounter and treated if BP is ≥95th
percentile or >130/80 mm Hg in adolescents ≥13 years of age (grade
C, moderate recommendation)
-Recommended drugs ACE inhibitors or ARB

17. Follow-up and monitoring
• Follow-up every 4-6 weeks
• If goal BP is reached, every 3-4 months
• Assess adherence to medication/lifestyle modification
• At home BP measurement (ABPM)
• Care transitioned to an appropriate adult care provider by 22 years of
age

18. Reference;
• American Academy of Pediatrics; Clinical Practice Guideline For
Screening and Management ff High Blood Pressure In Children And
Adolescents