Systemic hypertension is defined as high blood pressure measured on 3 occasions. It is important to properly measure blood pressure in children using the correct cuff size based on age and arm circumference. Common causes of hypertension in children include primary hypertension, renal disease, vascular abnormalities like coarctation of the aorta, and endocrine disorders. Clinical evaluation involves taking a thorough history and physical examination to identify risk factors and look for signs of end organ damage from high blood pressure.

1. SYSTEMIC HYPERTENSION

2. DEFINITION
 Blood pressure(BP)- tension exerted by blood against
arterial walls.
 BP - indicator of cardiac output(CO) & peripheral
vascular resistance(PVR)
 Increase in CO  increase in SBP
 Increase in PVR  increase in DBP

3. How should blood pressure be
measured in children?
 First, Child should be calm and free of anxiety
 Child should have been sitting or lying quietly for 5
minutes.
 Child should be sitting with back supported, both
feet on the floor and right cubital fossa supported at
heart level.

4. How should blood pressure be
measured in children?

5. Choose the appropriate cuff size:
 Cuff width  ~70% distance between acromion-
olecranon
 Cuff bladder width  40-50% of arm circumference
at midpoint of acromion-olecranon distance
 Cuff bladder length  80%-100% of arm
circumference

6. Choose the appropriate size cuff

7. 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.

8. 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.
Oscillometric Method Better to record mean BP. Useful in
infants and young children..
Flush Method Used in newborns. Only SBP can be
recorded.
Ambulatory Blood
Pressure Monitoring
To R/o White-coat hypertension

9. POINTS TO REMEMBER
 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, BP is 10-20mm Hg higher in lower limbs
compared to upper limbs.

10. Which children should get their blood
pressure checked?
 All children 3 years of age and older.
 Children < 3 years with co morbid conditions:-
 History of prematurity
 History of LBW or NICU stay
 Presence of congenital heart disease, kidney disease,
or genitourinary abnormality
 Family history of congenital kidney disease
 Recurrent UTI, hematuria, proteinuria

11.  Bone marrow or solid organ transplantation
 Malignancy
 H/O medications like Corticosteroids,
amphetamines, nasal decongestants, antiasthamatic
drugs, OCP, cyclosporine, cocaine, NSAIDs Stimulant
medications (dexedrine, methylphenidate), Beta-
adrenergic agonists (theophylline),Erythropoietin,
Tricyclic antidepressants, Recent abrupt
discontinuation of antihypertensives etc..
 Presence of systemic illness associated with
hypertension (neurofibromatosis, tuberous sclerosis)
 Evidence of raised ICT

12. Hypertension
Hypertension is defined as average SBP and/or diastolic
BP that is  95th percentile for gender , age and height
on 3 or more occasions.

17. STAGES OF HYPERTENSION
 Normal below 90th percentile of SBP and /or
DBP for the age, gender and height
 Prehypertension SBP or DBP more than or equal to
90th percentile but below 95th
percentile or BP between 120/80
mm Hg and 95th percentile
 Stage 1 hypertension SBP or DBP between 95th and 99th
percentile plus 5mm Hg
 Stage 2 hypertension SBP or DBP above 99th percentile
plus 5mm Hg

18. 1. Primary hypertension(Essential hypertension)-
• No identifiable cause
• Common in adults and in some adolescents
• Risk factors- Obesity (75%), heredity, diet and stress
2. Secondary hypertension-
• Occurs due to some underlying disease
• Common in infants and younger children
• Causes varies with age
3. White-coat hypertension—Patients with BP levels
above the 95th percentile in a physician’s office & is
normotensive outside.
TYPES OF HYPERTENSION

19. 4. Hypertensive Crisis
 Rapidly rising or high BP associated with neurological
manifestations, heart failure or pulmonary edema
Divided into 4 subgroups:-
•Hypertensive emergencies
•Hypertensive urgencies
•Accelerated malignant hypertension
•Hypertensive encephalopathy

20. PATHOGENESIS OF RENOVASCULAR
HYPERTENSION
Renin Angiotensin Aldosterone System(RAAS):-
• Angiotensin and aldosterone together influence arterial pressure
and cardiac output.
•Renin, a proteolytic enzyme is stored and released from
Juxtaglomerular (JG) cells associated with afferent arteriole
entering glomerulus.
•Renin release is stimulated by reduction in BP.
•Renin cleaves angiotensinogen produces angiotensin I.
•Angiotensin-converting enzyme(ACE) converts angiotensin I into
angiotensin II, which acts as a vasoconstrictor maintain adequate
blood pressure.
•Angiotensin II stimulates the adrenal gland to increase
aldosterone secretion which increases sodium resorption.

21. Renin Angiotensin Aldosterone System(RAAS)

22. Common Causes of Hypertension
Newborns
•Renal artery thrombosis
•Renal artery stenosis
•Congenital renal malformations
•Coarctation of aorta
•Bronchopulmonary dysplasia
1 month- 6yrs
•Renal artery stenosis
•Coarctation of aorta
•Renal parenchymal disease

23. 6yrs-10 yrs
•Renal parenchymal disease
•Renal artery stenosis
•Primary hypertension
 >10yrs
•Renal parenchymal disease
•Renal artery stenosis
•Primary hypertension

24. RENAL CAUSES:-
•Chronic pyelonephritis
•Chronic glomerulonephritis
•Hydronephrosis
•Congenital dysplastic kidney
•Multicystic kidney
•Solitary renal cyst
•Vesicoureteral reflux nephropathy
•Segmental hypoplasia
•Ureteral obstruction
•Renal tumors
•Renal trauma
VASCULAR CAUSES:-
•Coarctation of thoracic or abdominal aorta
•Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis,aneurysm)
Conditions Associated with Chronic
Hypertension in Children

25. •Umbilical artery catheterization with thrombus formation
•Neurofibromatosis
•Renal vein thrombosis
•Vasculitis
•Arteriovenous shunt
•Williams-Beuren syndrome
•Moyamoya disease
•Takayasu arteritis
ENDOCRINE CAUSES:-
•Hyperthyroidism
•Hyperparathyroidism
•Congenital adrenal hyperplasia (11β-hydroxylase and 17-hydroxylase defect)
•Cushing syndrome
•Primary aldosteronism
•Glucocorticoid remedial aldosteronism (familial aldosteronism type 1)
•Glucocorticoid resistance (Chrousos syndrome)
•Pseudohypoaldosteronism type 2 (Gordon syndrome)
•Pheochromocytoma

26. •Other neural crest tumors
(neuroblastoma,ganglioneuroblastoma,ganglioneuroma)
•Liddle syndrome
•Geller syndrome
CENTRAL NERVOUS SYSTEM CAUSES:-
•Intracranial mass
•Hemorrhage
•Residual following brain injury
•Quadriplegia

27. Conditions associated with Transient
hypertension
Renal
•Acute postinfectious glomerulonephritis
•Henoch-schonlein purpura with nephritis
•Hemolytic-uremic syndrome
•Acute tubular necrosis
•Pyelonephritis
•Leukemic infiltration of the kidney
•Obstuctive uropathy associated with crohn disease
Drugs and Poisons
•Corticosteroids and adrenocorticotropic hormone
•Cocaine
•Oral contraceptives
•Amphetamines
•Cyclosporine
•Vitamin D intoxication
•Antihypertensive drug withdrawal(clonidine, methyldopa, propranolol)

28. Central and Autonomic Nervous System
•Raised intracranial pressure
•Guillain-Barre syndrome
•Burns
•Stevens-Johnson syndrome
•Poterior fossa lesions
•Porphyria
•Poliomyelitis
•Spinal cord injury(autonomic storm)
Miscellaneous
•Pre-eclampsia
•Fractures of the long bones
•Hypercalcemia
•After coarctation repair
•Chronic upper airway obstruction

29. Causes of Renovascular Hypertension in Children
Fibromuscular dysplasia
Syndromic
•Neurofibromatosis type 1
•Williams syndome
•Tuberous sclerosis
•Marfan syndrome
Vasculitis
•Takayasu disease
•Polyarteritis nodosa
•Kawasaki disease
•Other systemic vasculitides
Extrinsic compression
•Neuroblastoma
•Wilms tumor
•Other tumors

30. Other causes
•Radiation
•Umbilical artery catheterization
•Trauma
•Congenital rubella syndrome

31. CLINICAL MANIFESTATION OF
HYPERTENSION
Most of the children with mild hypertension are
asymptomatic and hypertension is diagnosed as a result of
routine BP measurement.
Severe hypertension may be symptomatic like headache,
dizziness, nausea, vomiting, abdominal pain, epistaxis,
irritability, visual disturbance, personality changes.
Hypertensive crisis may presents with
Blurring of vision (retinal hemorrhages) or blindness
Papilledema
Encephalopathy (headache, seizures, altered sensorium)
Heart failure or Renal dysfunction

32.  Hypertensive encephalopathy( generalized or posterior
reversible encephalopathy syndrome) presents with
Vomiting
Rise in temperature
Seizures
Ataxia
Stupor
Complications : Neurological, Congestive heart failure,
Renal dysfunction and Stroke

33. Clinical Evaluation
HISTORY
• Present and Past History
– Neonatal - prematurity, Bronchopulmonary dysplasia, umbilical artery
catheterization
– Cardiovascular- History of Coarctation of aorta or surgery for it, history
of palpitation , Headache, excessive sweating (excessive
catecholamine levels)
– Renal- History of obstructive uropathy, Urinary tract infection,
radiation, renal trauma
– Endocrine- weakness, flushing, weight loss, muscle cramps
(hyperaldosteronism)
– H/o drug intake
– Habits - Smoking, drinking, tobacco, amphetamines, cocaine

34. – Symptoms of obstructive sleep apnea (ie. difficulty falling asleep,
multiple night time awakenings, snoring, daytime somnolence
– Diet (caffeine, salt intake)
• Family History
– Essential hypertension , atherosclerotic heart disease, stroke
– Familial or hereditary renal disease

35. PHYSICAL EXAMINATION
• Accurate measurement of BP in all four limbs
• Complete physical examination:-
– Delayed growth or short stature (renal disease)
– Bounding peripheral pulses (PDA)
– Weak or absent femoral pulses or BP differential between arms and legs
(CoA)
– Abdominal bruits (Renal Vascular Disease)
– Abdominal mass(Wilms tumor, neuroblastoma, pheochromocytoma)
– Palpable kidneys (Polycystic kidney disease, hydronephrosis, multicystic
dysplastic kidney, mass)

36. – Skin lesions (café au lait spots, neurofibromas, adenoma sebaceum,
striae, hirsutism, butterfly rash, Acanthrosis nigricans palpable purpura)
– Tenderness over kidney (renal infection).
– Ambiguous genitalia (CAH).
– Moon facies, truncal obesity, buffalo hump(Cushing syndrome)
– Thyromegaly, Proptosis, hyperdynamic circulation (Hyperthyroidism
– Signs of meningeal irritation, CNS Infections.
– Widely spaced nipples, Webbed neck (turner’s)

37. ROUTINE LABORATORY TESTS
 Initial investigations
• Urinalysis –R/O renal disease and chronic pyelonephritis,
mineralocorticoid excess states
• Urine culture
• Serum electrolyte
• Blood urea nitrogen(BUN), creatinine and uric acid levels
• ECG, Chest X-ray and Echocardiography- R/O CoA and Left Ventricular
Hypertrophy
• Renal Ultrasonography-R/O renal scar, congenital anomaly and disparate
renal size

38. Special Lab Investigations
Special investigations:-
•Renal vein plasma renin activity(PRA) – R/O unilateral renal parenchymal disease,
renovascular hypertension
•Abdominal aortogram – R/O renovascular disease, abdominal coarctation of
aorta, unilateral renal parenchymal disease, pheochromocytoma
•Aldosterone - R/O hyperaldosteronism, renovascular hypertension and renin
producing tumors
•24 hour urinary catecholamines and VMA – R/O pheochromocytoma and
neuroblastoma
•24 hour urinary 17-ketosteroid and 17-hydroxycorticosteroids – R/O cushing
syndrome and adrenogenital syndrome
•Intra-arterial digital subtraction angiography – R/O renovascular hypertension

40. Management
Prehypertension Do not initiate therapy unless there are compelling
indications such as chronic kidney disease (CKD),
diabetes mellitus, heart failure, left ventricular
hypertrophy (LVH).
Stage 1 hypertension Initiate therapy based on indications for
antihypertensive drug therapy or if there are
compelling indications as above.
Stage 2 hypertension Initiate antihypertensive drug therapy
Secondary hypertension Initiate antihypertensive drugs & Aim is to remove the
cause of hypertension
Hypertensive crisis Aggressive parenteral administration of
antihypertensive drugs is indicated

41. Management of Prehypertension
Prehypertension, Asymptomatic & Essential HTN ( who
do not have evidence of end-organ damage or diabetes )
Lifestyle modifications
Re-evaluated in six months
if not controlled
Start Antihypertensive drugs

42. Lifestyle modifications like:-
• Low salt intake*.
• Dietary Approaches- fresh vegetables, fruits, and low-fat
dairy.
• Avoidance of smoking & Weight reduction.
• Regular aerobic exercise for 30 to 45 minutes.
*Can start with recommending “no added salt” with ultimate goal of achieving the current recommendation
of 1.2 grams/day total for 4- to 8-year-olds and 1.5 grams/day for children 9 years and older

43. Indications for antihypertensive drug
therapy
• Symptomatic hypertension
• Secondary hypertension
• Hypertensive target organ damage
• Diabetes( type 1 & 2)
• Persistent hypertension despite non-pharmacologic
measures

44. 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)

45. Antihypertensive Drugs
ACE inhibitors Captropil, Enalapril
AT1 antagonists Losartan
Calcium channel blockers(CCBs) Nifedipine, Verapamil
Diuretics Hydrochlorthiazide, Furosemide,
Spironolactone
b adrenergic blockers Propranolol
a+b adrenergic blockers Labetalol
a adrenergic blockers Prazosin
Central sympatholytics Clonidine
Vasodilators Arterial (Hydralazine, Minoxidil),
Mixed (Sodium nitropruside)

47. How should I treat?
• Step-1 - Starting with a single antihypertensive in small
dose and proceeding to full dose .
• Step-2 - If it produce no clinical improvement, a second
antihyprtensive drug should be added or substituted.
• Initial antihypertensive therapy a Calcium channel
blocker (CCB) or an Angiotensin converting enzyme
(ACE) inhibitor, unless there is a contraindication.

48. Monitoring and follow-up
• There are no specific, published guidelines regarding
frequency of monitoring and follow-up after
initiation of therapy, but in the beginning it would be
reasonable to measure a child’s blood pressure at
least weekly and arrange for follow-up every three
months.
• Once the child has achieved target BP’s on a
medication regimen, clinic follow-up can be spaced
to every six months.

49. COMBINATION THERAPY
(SYNERGISTIC COMBINATIONS)
Drugs increasing renin
activity+ Drugs decreasing
renin activity
ACE inhibitors , Diuretics
+
Beta blockers
Sympathic inhibitors and
vasodilators cause fluid
retention. Add diuretics
Beta blockers + Thiazide,
Furosemide
ACE inhibitors + Diuretics Enalapril + Thiazide,
a Blocker + b blocker Prazosin + Propranolol

50. COMBINATIONS TO BE AVOIDED
• a or b blocker + clonidine (antagonism)
• b blocker + CCB (marked bradycardia / AV block)
• Any 2 drugs of same class

51. Management of Hypertensive Crisis
Aggressive parenteral administration of antihypertensive drugs is indicated to
lower BP.
1. Labetalol(a+b blocker) 0.2-3 mg/kg/hr IV infusion or nitroprusside(direct
vasodilator) 0.5-10 mg/kg/min IV infusion under BP monitoring is the
treatment of choice.
2. Nifedipine 0.2-0.5 mg/kg may be used orally every 4 to 6 hourly in severe
cases.
3. Furosemide(diuretic) 1mg/kg is given to initiate diuresis.
4. Seizures treated with IV infusion of midazolam, 0.1-0.3mg/kg or another
antiepileptics.
5. When BP controlled switch to oral antihypertensive drug.

52. SECONDARY HYPERTENSION
• Treatment should be aimed to remove the cause of
hypertension.
• Curable forms of Hypertension are:-
Renal Unilateral kidney disease (Nephritis,
Pyelonephritis, hydronephrosis)
Cardiovascular CoA, Renal artery stenosis, thrombosis.
Adrenal Pheochromocytoma, Neuroblastoma,
hyperaldosteronism
Miscellaneous Drugs/ OCP etc.