paediatrics

1. PROTOCOL
PEDIATRIC HYPERTENSION
DR.T.V.SURESH BABU

2. • History
• Definition of Hypertension
• Etiology
• Pathophysiology
• Evaluation
• Treatment
• Hypertensive crisis

3. Blood pressure : –
The pressure exerted by circulating blood on arterial vessel
wall during cardiac contraction and relaxation which is
represented as systolic and diastolic BP respectively

4. • Childhood hypertension
has become a significant public health problem
due to increased prevalence in obesity in recent decades.
• Causes increased mortality and morbidity in childhood,
• Precedes adult hypertension
• Causes increased cardiovascular events in adulthood

5. History
• Stephen Hales was the first to quantitatively
measure blood pressure
• By inserting a tube into a blood vessel of a
horse
• Allowing the blood to rise up the tube

6. History
• Samuel Siegfried Karl von Basch
first noninvasive BP recording
SPHYGMOMANOMETER
• Riva Rocci – invented mercury manometer

7. Guidelines
• Task force report on High Blood pressure in Children and Adolescent - 1987
• The Fourth report in 2004 on the diagnosis, evaluation and treatment of high
blood pressure in children and adolescent by NHBPEP – National High Blood
Pressure Education Program working group
• Clinical practice guidelines by AAP (American Academy of Pediatrics) 2017
update

8. Definitions – AAP 2017 update
Children < 13 years Children > 13 years
Normal BP SBP and DBP < 90th centile BP <120/80mmHg
Elevated BP SBP and/or DBP 90th – 95th centile SBP : 120-129, DBP < 80mmHg
Stage 1 HTN SBP and/or DBP > 95th centile to 95th
percentile + 12 mmHg
BP : 130-139/80-89 mmHg
Stage 2 HTN SBP and/or DBP > 95th centile + 12mmHg BP > 140/90 mmHg
OTHER TERMS
White coat
hypertension
BP > 95th centile when measured in clinic setting
BP < 90th centile when measured outside clinical setting
Masked
Hypertension
BP normal in clinical setting
BP > 95th centile when measured outside the clinical setting
MORE THAN 3 OCCASIONS

10. General Rule in OPD
• Bp is high if
• >110/70 in children <5yrs
• >120/80 in children 5-10yrs
• >130/80 in children >10yrs
• Neonatal hypertension >90/60 at birth

11. BP Formulas(Applicable for 1yr and above
• 95th Centile = 100 + (age x 3)
70 + (age x 1.5)
• 50th Centile = 90 + (age x 2)
60 + (age x 2)

12. Secondary hypertension likely!
• Symptomatic hypertension
• Stage 2 hypertension
• Younger age
• High diastolic pressure

13. Hypertensive urgency Hypertensive emergency
• Raised blood pressure with symptoms but
without end organ damage
• Eg - headache, nausea or blurred vision
• Raised blood pressure along with presence
of end organ damage
• Eg – encephalopathy, seizure, congestive
heart failure, acute kidney injury,
papilledema, pulmonary edema

14. Burden of disease
• The reported prevalence of pediatric hypertension is approximately 4%,
although the true prevalence may be underestimated
• Increasing prevalence due to obesity pandemic

15. • 64 studies
• The prevalence was
• 7% for hypertension
• 4% for sustained hypertension
• 10% for prehypertension
• Urban children had a higher prevalence of hypertension as compared to their rural counterparts.
• Children with obesity had a significantly high prevalence of hypertension (29%) than normal-
weight children (7%).

16. • BP at any given moment is determined by complex interaction of various
physiologic mechanisms that regulate cardiac output, vascular tone,
quantity and distribution of blood volume.
• High BP can be idiopathic or due to disturbance of any of these regulatory
factors

17. Etiology
• Primary
• Primary hypertension is the most common type of hypertension in older children.
• Secondary
• With an identifiable underlying cause
• Remains the most frequent etiology of high BP in infants and young children
• Renal – parenchymal 34-79% /renovascular12-13%
• Cardiac
• Endocrine
• Drugs
• Pulmonary

18. Primary hypertension
• Older school age children (6 years and above) and adolescent
• Overweight/obese
• Family history of hypertension
• Isolated systolic hypertension ---- primary hypertension

19. • Chronic hypertension
• Acute/intermittent hypertension

20. Causes of persistent hypertension by age
Newborn Childhood Adolescence
Umbilical artery catheterisation Renal parenchymal disease Primary hypertension
Renal vein thrombosis Renovascular disease Renal parenchymal disease
Coarctation of aorta CoA Renovascular disease
Renal artery stenosis Endocrine causes Endocrine causes
BPD Primary hypertension

21. Conditions associated with chronic hypertension
Renal
• Recurrent pyelonephritis
• Chronic glomerulonephritis
• Congenital dysplastic kidney
• Polycystic kidney disease
• Vesico ureteric Reflux
• Renal tumours
• Renal trauma
Vascular
• CoA
• Renal artery lesion – stenosis, fibromuscular
dysplasia, thrombosis
• UAC
• Neurofibromatosis
• Renal vein thrombosis
• Vasculitis – PAN, Takayasu arteritis
• Moyamoya disease

22. Endocrine
• Hyperthyroidism
• CAH (11beta-hydroxylase)
• Cushing’s syndrome
• Primary hyperaldosteronism
• Pheochromocytoma
• Neural crest tumours –
• Neuroblastoma
• ganglioneuroblastoma
• Liddle syndrome
• Gordon syndrome
CNS causes
• Intracranial mass
• Hemorrhage
• Dysautonomia
• Sleep disordered breathing

23. Causes of transient / intermittent hypertension
Causes
Renal Acute post infectious glomerulonephritis
HSP nephritis
HUS
AKI
Pyelonephritis
Renal trauma
Drugs and poison Cocaine
OCP
Aphetamines
Steroids
Vitamin D intoxication
Central / Autonomic NS Raised ICP
Guillain-Barre syndrome
Steven Johnson syndrome
Encephalitis
Miscellaneous Pain, anxiety
Hypercalcemia
ECMO

24. Measurement of blood pressure in pediatrics
• According to clinical practice guidelines by AAP 2017
• All children > 3 year : Annual BP
• Obesity, CKD, diabetes : BP every visit
• Selected children < 3 years :
• Prematurity
• CHD
• Renal disease
• Solid organ transplant
• Cancer
• Other diseases – neurofibramatosis, tuberous sclerosis
BP every visit

25. Methods of measurement
• Auscultatory method
• Oscillometric method
• Ambulatory BP measurement
• Flush method

26. Auscultatory method
• Mercury sphygmomanometer
• Aneroid sphygmomanometer

27. ABPM
• Records BP every 20-30min
• Throughout 24 hour
• During daily activities and sleep
• Nocturnal dip : decrease in BP > 10% from
awake value
• Uses :
• Effectiveness of antihypertensive therapy
• Masked hypertension
• White coat hypertension
• BP patterns in high risk cases – CKD, solid organ
transplant, severe obesity

28. Non dominant limb

29. BP cuff

32. Invasive BP monitoring
• Continuous invasive arterial pressure measurement by a pressure transducer is
the gold standard in sick children and extremes of blood pressure.

33. Pathophysiology

34. Genetic factors Environmental factors
Defect in renal sodium
hemostasis
Defects in vascular
smooth muscle
structure
Functional
vasoconstriction
Increased cardiac
output
Increased peripheral
vascular resistance
HYPERTENSION
Inadequate Na excretion
Increased plasma volume Vascular reactivity Vascular wall thickness

35. Evaluation
HISTORY CLINICAL EXAMINATION LABORATORY TESTS

36. Clinical evaluation of a confirmed case of hypertension
Evaluation for target organ damage
Evaluation for co morbidities
Evaluation of identifiable cause

37. HISTORY
• Age of child
• Antenatal/natal/post natal – LBW, Prematurity, Antenatally detected
renal anomalies
• Family history – Hypertension
• Personal history – sleep disordered breathing, smoking ( passive )

38. Physical examination
Vital signs
Tachycardia Hyperthyroidism
Pheochromocytoma
Neuroblastoma
Decreased lower limb pulses Coarctation of aorta

39. Physical examination
Finding Possible etiology
Eyes Retinal changes Severe hypertension
Ear/nose/throat Adenotonsillar hypertrophy Sleep disordered breathing
Height/weight Growth retardation
Obesity
Truncal obesity
Chronic renal failure
Primary hypertension
Cushing syndrome, insulin resistance
Head and neck Moon facies
Elfin facies
Webbed neck
Thyromegaly
Cushing syndrome
Williams syndrome
Turner syndrome
hyperthyroidism

40. Physical examination
Finding Possible etiology
Skin Pallor, flushing, diaphoresis
Acne, hirsuitism
Café au lait macules
Adenoma sebaceum
Malar rash
Acanthosis nigricans
Needle tracks
Pheochromocytoma
Cushing syndrome
Neurofibromatosis
Tuberous sclerosis
SLE
Type 2 diabetes mellitus
Drugs abuse
Chest Wide spaced nipple
Murmur
Turner syndrome
Coarctation of aorta
Abdomen Mass
Flank bruit
Palpable kidney
Wilms tuour, neuroblastoma, pheochromocytoma
Renal artery stenosis
PCKD, Multicystic dysplastic kidneys

41. Physical examination
Finding Possible etiology
Genitalia Ambiguous/virilised Adrenal hyperplasia
Extremities Joint swelling
Muscle weakness
SLE
Hyperaldosteronism

42. BUN/creatine/electrolytes – renal disease
CBC –
• Anemia – CKD
Renal USG –
• Congenital anomaly
• Renal scar
Laboratory investigation

43. Evaluation of co morbidities
Fasting lipid profile
Fasting glucose
Drug screen
Polysomnography

44. Evaluation
of target
organ
damage
ECG
Echocardiogram - LVH
Retinal examination

45. LVH
• Upto 40% of children with HTN
• Definition:
• LV mass >51g/m2
• LV mass > 115g/BSA for boys
• LV mass > 95g/BSA for girls

46. Further evaluation
Plasma renin determination
Renovascular imaging :
• Isotopic scintingraphy (renal scan)
• MR angiography
• Doppler scan
• 3D CT
• Arteriography - DSA
Plasma and urine catecholamines

47. Treatment
Correction of underlying cause
Non Pharmacotherapy
Pharmacotherapy

48. Goals
Goal-to achieve BP less than 90th centile
Less than 130/80 in greater than 13 year old
Prevent end organ damage
Prevent accelerated cardiovascular disease

49. MANAGEMENT
Education
Involve parents and child
Non-phramacologic measures
• Therapeutic Lifestyle Changes
Antihypertensive medications
Monitor for Side effects and treatment response

50. Therapeutic Lifestyle Changes
Weight reduction
• Decreases BP
• Decreases dyslipidemia
• Decreases insulin
resistance
Regular physical activity
• Sedentary activities < 2
hours per day
• Physical activities 30-60
minutes per day
• Competitive sports is
limited for uncontrolled
stage II hypertension.
• AT LEAST 60 mins of
physical activity 3 times a
week
Dietary modifications
• Fresh vegetables, fresh
fruits, fiber,
• Reduction of fat,
reduction of salt.
• Other recommendations
are Ca, Mg, K, folic acid,
unsaturated fat, and fiber.
Family based intervention
• Interventions to improve
sleep quality.

51. Treatment modalities -The DASH Diet
Dietary approaches to stop hypertension (DASH)
The DASH diet features
• High intake of whole grains, fruits, vegetables, legumes, and nuts;
• Moderate intake of low-fat dairy
• Low intake of sweets and red meats.
Combines many nutrients that have been shown to help reduce blood pressure.
• Calcium, potassium, magnesium, protein and fiber
• Lower total fat and saturated fat.

52. DASH DIET
Increased
K, Mg, Ca
Low
sodium
6-8
servings
of whole
grains
4-5
servings
of fruits
and veg
Low
fat
diary

54. Pharmacological agents

55. Antihypertensives
ACE inhibitors
ARBs
CCB Diuretics
Betablockers
Aldosterone
antagonist

56. Indications for antihypertensive therapy
• Secondary hypertension
• Hypertension with target organ damage
• Coexisting Diabetes mellitus TYPE I and II
• Patient symptomatic after 6 month life style modification
• Persistent hypertension despite non pharmacologic methods
• Stage 2 HTN without a modifiable risk factor

57. PHARMACOTHERAPY
• Start as monotherapy with the lowest dose
• Then titrate dose or add second drug every 2-4 week until goal BP achieved

58. Choice of antihypertensive
• ACEI and ARBs : The first line in DM and renal proteinuric disease, but
both are teratogenic
• Beta blocker - not preferred as first line

59. Stepped up care approach to antihypertensive therapy

60. Starting Dose Maximum Dose
Aldosterone receptor
antagonists
Eplerenone 25mg per day OD or BD 100 mg/day
Spironolactone 1mg/kg/day OD or BD 3.3 mg/kg/day up to 100 mg/day
ACE inhibitors
Benazepril 0.2-10 mg/kg/day OD or BD 0.6 mg/kg/day up to 40 mg/day
Captopril 0.5mg/kg/dose TID 6 mg/kg/day up to 450 mg/day
Enalapril 0.08mg/kg/day OD 0.6 mg/kg/day up to 40 mg/day
Fosinopril 0.1-10 mg/kg/day OD 0.6 mg/kg/day up to40 mg/day
Lisinopril 0.07-5 mg/kg/day OD 0.6 mg/kg/day up to40 mg/day
Quinapril 5-10mg/day OD 80 mg/day
Ramipril 1.6 mg/m2/day OD 6 mg/m2 /day up to 10 mg/day

61. Angiotensin receptor
blockers
Starting dose Maximum Dose
Candesartan 1-6 yr: 0.2 mg/kg/day
6-17 yr:
<50 kg 4-8 mg qd
>50 kg 8-16 mg qd
1-6 yr: 0.4 mg/kg up to 4 mg/day
6-17 yr:
<50 kg: 16 mg qd
>50 kg: 32 mg qd
Losartan † 0.75 mg/kg/day up to 50 mg/day 1.4 mg/kg/day up to 100 mg/day
Olmesartan 20 to <35 kg 10 mg qd;
≥35 kg 20 mg qd
20 to <35 kg: 20 mg qd
≥35 kg: 40 mg qd
Valsartan 6-17 yr: 1.3 mg/kg/day up to 40
mg/day
6-17 yr: 2.7 mg/kg/day up to 160 mg/day

62. Starting dose Maximum Dose
β-adrenergic antagonists
Atenolol 0.5-1 mg/kg/day qd-bid 2 mg/kg/day up to 100mg/day
Bisoprolol/HCTZ 2.5/6.25 mg/day qd 10/6.25 mg/day
Metoprolol 1-2 mg/kg/day bid 6 mg/kg/day up to 200mg/day
Propranolol 1 mg/kg/day bid-tid 8 mg/kg/day up to 640mg/day
Calcium Channel Blocker
Amlodipine- 1-5 year-0.1mg/kg/day
more than 6 year 2.5mg
1-5 yr: 0.6 mg/kg/day up to 5mg/day
≥6 yr: 10 mg/day
Felodipine- 2.5 mg/day OD 10 mg/day
Isradipine- 0.050.15mg/kg/dose TID/QID 0.6 mg/kg/day up to 10 mg/day
Nifidipine ER 0.2-0.5 mg/kg/day OD /BD 3 mg/kg/day up to 120 mg/day

63. Diuretics Starting dose Maximum Dose
Amiloride 5-10 mg/day qd 20 mg/day
Chlorthalidone 0.3 mg/kg/day qd 2 mg/kg/day up to 50
mg/day
Chlorothiazide 10 mg/kg/day bid 20 mg/kg/day up to
375 mg/day
Furosemide 0.5-2.0 mg/kg/dose qd-bid 6 mg/kg/day
HCTZ 0.5-1 mg/kg/day qd 3 mg/kg/day up to
37.5 mg/day

68. Goals of treatment
BP
< 90th centile
<130/80mmHg
ABPM 24hr
< 50th centile
For children with
CKD

69. Resistant hypertension
Persistence of hypertension despite 3 or more antihypertensice drugs
at the highest dose

70. Prevention
• Obesity reduction
• Reduce sodium intake
• Avoidance of tobacco
• Increase physical activity
• Diet : DASH

71. Hypertensive emergency
• Raised blood pressure along with presence of end organ damage
• Eg – encephalopathy, seizure, congestive heart failure, acute kidney
injury, papilledema, pulmonary edema

73. Management of hypertensive emergency and urgency
• ICU care
• IV drug administration
• Arterial line for BP monitoring
• Drugs
• Labetolol
• Nicardipine
• Sodium nitroprusside
• Esmolol
• Hydralazine
• Stepwise reduction
• No more than 25%reduction in 1st 8hr
• Gradual normalisation in 24-48 hrs

74. DRUGS IN HYPERTENSIVE EMERGENCY
Esmolol
Beta adrenergic blocker
100 to 500 microgram/kg/mt Iv- infusion Very short acting
Constant infusion preferred
Cause profound bradycardia
Hydralazine
Direct vasodilator-
0.2-0.4 mg/kg/dose Iv or im Every 4hr when given iv bolus
Labetalol
Alpha and beta
adrenergic blocker
Bolus 0.2 to 1mg/kg/dose upto 40mg /dose
Infusion: 0.25-3.0 mg/kg/hr
IV bolus
Or infusion
Asthma and overt heart failure are relative
contraindication
Nicardipine
Calcium channel
blocker
30 microgram/kg up to 2mg per dose
Infusion 0.5-4microgram/kg/mt
Bolus
Or infusion
May cause reflex tachycardia
Sodium nitroprusside
Direct vasodilator
0.5-10microgram/kg/mt Iv
Infusion
Monitor cyanide level
• Prolonged use
• In renal failure
• Or co-administer with sodium thiosulfate

75. SUMMARY
• Prevalence of HTN in children are increasing
• Early identification and management prevent end stage renal disease
• AAP 2017 GUIDLINE HELP FOR COMPREHENSIVE EVALUATION AND
MANAGEMENT

79. THANK YOU