This document discusses hypertension in pediatrics. It defines different types and stages of hypertension based on blood pressure percentiles. Secondary hypertension is most common in infants and children and is usually caused by an underlying condition. Accurate blood pressure measurements should be taken routinely starting at age 3. Treatment involves identifying and managing the underlying cause, lifestyle changes like salt restriction, and medications like ACE inhibitors, ARBs, calcium channel blockers, and diuretics. Hypertensive emergencies require promptly but gradually lowering blood pressure over hours to days to prevent end organ damage, while hypertensive urgencies can be treated orally by lowering blood pressure over 1-2 days.

1. Dr. Amlendra yadav
Resident
Pediatric
Hypertension

2. Background
Adolescents may acquire primary or essential hypertension
In infants and younger children, systemic hypertension is uncommon, but
when present, it is usually indicative of an underlying disease process
(secondary hypertension).
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3. Cont.
Correlate with BP tables for age, height, and weight
Accurate blood pressure measurements should be part of the routine
annual physical examination of all children 3 yr or older.
A complete family history of hypertension should be elicited
Use appropriate cuff size for blood pressure (BP) measurement.
Width should be between 50-75% of the circumference of arm.
Cuff size for :- Infant – 2.5cm ; 1- 12 month – 5cm
1- 8 yrs – 9cm ; Older children – 12.5cm
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4. Definition
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• Pre-hypertension : Systolic or diastolic blood pressure 90th – 95th
percentile
• Hypertension : Systolic or diastolic blood pressure > 95th percentile
• Stage I hypertension : Systolic or diastolic blood pressure between 95th
percentile & 99th percentile + 5mmHg .
• Stage II hypertension : Systolic or diastolic blood pressure > 99th percentile
+ 5mmHg

5. Etiology and Pathophysiology
Many childhood diseases may be responsible for
both acute and chronic elevation of blood pressure
Secondary hypertension is most common in infants
and younger children
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6. Cont.
Hypertension in the newborn
is most often associated with:
1. umbilical artery catheterization
and
2. renal artery thrombosis
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7. Cont.
Hypertension during early childhood
may be due to :
1.renal disease
2.coarctation of the aorta
3. endocrine disorders
4.medications.
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In adolescents
essential hypertension becomes increasingly common

8. Cont.
In general, children and adolescents with essential hypertension
have blood pressure values at or only slightly above the 95th
percentile for age
The severity of hypertension is also helpful in distinguishing
secondary from primary hypertension
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9. Cont.
Renal and renovascular hypertension accounts for the majority of
children with secondary hypertension
A history of urinary tract infection is present in 25-50% of these
patients and is often related to an obstructive lesion of the urinary
tract
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10. Conditions Associated with Transient or Intermittent
Hypertension in Children
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11. • Acute postinfectious glomerulonephritis
• Anaphylactoid (Henoch-Schönlein) purpura with nephritis
• Hemolytic-uremic syndrome
• Acute tubular necrosis
• After renal transplantation (immediately and during episodes of rejection)
• After blood transfusion in patients with azotemia
Renal
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12. • Renal trauma
• Leukemic infiltration of the kidney
• Obstructive uropathy associated with Crohn disease
Cont.
• Hypervolemia
• After surgical procedures on the genitourinary tract
• Pyelonephritis
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13. Drugs and Poisons
• Cocaine
• Oral contraceptives
• Sympathomimetic agents
• Amphetamines
• Phencyclidine
• Corticosteroids and
adrenocorticotropic hormone
• Cyclosporine or sirolimus treatment
post-transplantation
• Licorice (glycyrrhizic acid)
• Lead, mercury, cadmium, thallium
• Antihypertensive withdrawal
(clonidine, methyldopa, propranolol)
• Vitamin D intoxication
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14. Central
and
Autonomic nervous system
• Increased intracranial pressure
• Guillain-Barré syndrome
• Burns
• Familial dysautonomia
• Stevens-Johnson syndrome
• Posterior fossa lesions
• Porphyria
• Poliomyelitis
• Encephalitis
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15. Miscellaneous
• Fractures of long bones
• Hypercalcemia
• After coarctation repair
• White cell transfusion
• Extracorporeal membrane oxygenation
• Chronic upper airway obstruction
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16. Conditions Associated with
Chronic Hypertension
in Children
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17. Renal
•Chronic pyelonephritis
•Chronic glomerulonephritis
•Hydronephrosis
•Congenital dysplastic kidney
•Multicystic kidney
•Solitary renal cyst
•Vesicoureteral reflux nephropathy
•Segmental hypoplasia (Ask- Upmark kidney)
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18. • Ureteral obstruction
• Renal tumors
• Renal trauma
• Rejection damage following transplantation
• Postirradiation damage
• Systemic lupus erythematosus (other connective tissue diseases
Cont.
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19. Vascular
• Coarctation of thoracic or abdominal aorta
• Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis,
aneurysm)
• Umbilical artery catheterization with thrombus formation
• Neurofibromatosis (intrinsic or extrinsic narrowing of vascular lumen)
• Renal vein thrombosis
• Vasculitis
• Arteriovenous shunt
• Williams- Beuren syndrome
• Moyamoya disease
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20. Endocrine
• Hyperthyroidism
• Hyperparathyroidism
• Congenital adrenal hyperplasia (11 β- hydroxylase and
17-hydroxylase defect)
• Cushing syndrome
• Primary aldosteronism
• Dexamethasone-suppressible hyperaldosteronism
• Pheochromocytoma
• Other neural crest tumors (neuroblastoma,
ganglioneuroblastoma, ganglioneuroma)
• Diabetic nephropathy
• Liddle syndrome
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21. Central Nervous
System
• Intracranial mass
• Hemorrhage
• Residual following brain injury
• Quadriplegia
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22. Acute
Hypertension
• Hypertensive urgency:
Significant elevation in BP without accompanying end-organ damage;
more common in children.
 Symptoms include headache, blurred vision, and nausea
• Hypertensive emergency:
Elevation of both systolic and diastolic BP with acute end-organ damage
(e.g., cerebral infarction or hemorrhage, pulmonary edema, renal failure,
hypertensive encephalopathy, or seizures)
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23. Clinical Features
• Mostly asymptomatic
• Presence of symptoms indicates end organ damage
• Symptoms attributed to hypertension include headache , nausea
, vomitting , diziness , irritability and epistaxis.
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24. Physical
examination
• Four-extremity BP
• Funduscopy (papilledema, hemorrhage, exudate)
• Visual acuity
• Thyroid examination
• Evidence for congestive heart failure (tachycardia, gallop rhythm,
hepatomegaly, edema)
• Abdominal examination (mass, bruit)
• Thorough neurologic examination
• Evidence of virilization, cushingoid effect
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25. Screening inestigation
• Complete blood count
• Blood urea nitrogen, creatinine , electrolytes, glucose , uric acid
• Lipid profile
• Urinalysis
• 24 hr urinary protein or spot albumin to creatinine ratio
• Chest radiograph
• Electrocardiogram
• Ultrasonography for kideneys , adrenals
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26. Screening for target organ damage
• Retinal fundus examination
• Urine spot protein to creatinine ratio
• Echocardiography
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27. Consider
• Renin level
• Toxicology screen
• Thyroid and adrenal testing
• Urine catecholamines
• Abdominal ultrasound
• Renal Doppler ultrasound
• Head CT
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28. Management
• Each patient must be appropriately evaluated . Efforts must be made to
determine the etiology of hypertension .
• Salt restriction : It is useful but difficult to implement in children .
Long term medication
1. Diuretics (thiazide group are commonly employed)
2. Beta – adrenergic antagonist
3. ACE inhibitors and Angiotensin receptor blockers
4. Calcium chanal blockers
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29. • Captopril 0.3 - 6 mg/kg/day , three divided doses
• Enalapril 0.1 – 0.6 mg/kg/day , single daily dose
• Lisinopril 0.06 – 0.6 mg/kg/day , single daily dose
• Losartan 0.7 – 1.4 mg/kg/day , single daily dose
• Amlodepine 0.05 – 0.5 mg/kg/day , once - twice daily doses
• Nifedipine 0.25 – 3 mg/kg/day , once – twice daily doses
• Atenelol 0.5 – 2 mg/kg/day , once – twice daily doses
• Metoprolol 1 – 6 , two divided doses
• Labetelol 1 – 40 mg/kg/day , two – three divided doses
• Clonidine 5 – 25 ug/kg/day , three – four divided doses
• Prazosin 0.05 – 0.5 mg/kg/day , two divided doses
• Hydralazine 1 – 8 mg/kg/day , four divided doses
• Frusemide 0.5 – 6 mg/kg/day , one – two doses
• Spironolactone 1 – 3 mg/kg/day , one – two doses
• Hydrochlorothiazide 1 – 3 mg/kg/day , once daily
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30. Management
Hypertensive emergency:
Goal:
Lower BP promptly but gradually to preserve cerebral autoregulation
(a) Mean arterial pressure (MAP) = 1/3 systolic + 2/3 diastolic BP
(b) Lower by 1/3 of planned MAP reduction over first 6 hours, then
(c) Lower by additional 1/3 over next 24–36 hours, then
(d) Lower final 1/3 over next 48 hours
After elevated ICP is ruled out, do not delay treatment because of further
diagnostic workup
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33. Hypertensive urgency:
Goal:
To lower MAP by 20% over 1 hour and return to baseline levels
over 24 to 48 hours
An oral route may be adequate.
(Use of sublingual nifedipine is not recommended, as a precipitous,
uncontrolled fall in BP may result.)
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