The document discusses hypertension in children, categorizing it into primary and secondary types and outlining diagnosis, classification, and management strategies. It emphasizes the importance of regular blood pressure checks for children over three years old and specific risk factors that warrant monitoring in younger children. Treatment recommendations include lifestyle changes, pharmacologic therapies for varying stages of hypertension, and the importance of accurate blood pressure measurement techniques.

1. RVS Chaitanya koppala

2. INTRODUCTIONINTRODUCTION
Hypertension is a silent killer. It can be a primary diseaseHypertension is a silent killer. It can be a primary disease
(essential hypertension) or due to some underlying(essential hypertension) or due to some underlying
disease process (secondary hypertension) (moredisease process (secondary hypertension) (more
common in pediatric population)common in pediatric population)
Blood pressureBlood pressure
= systemic vascular resistance= systemic vascular resistance χχ cardiac output.cardiac output.
Factors increasing either of the two can increase BP.Factors increasing either of the two can increase BP.

3. DEFINITIONDEFINITION
Hypertension is defined as averageHypertension is defined as average
SBP and/or diastolic BP that isSBP and/or diastolic BP that is ≥≥ 95th95th
percentile for gender , age and heightpercentile for gender , age and height
on 3 or more occasions.on 3 or more occasions.

4. CLASSIFICATION OF HYPERTENSIONCLASSIFICATION OF HYPERTENSION
NormalNormal <90<90thth
percentile of SBP and /or DBPpercentile of SBP and /or DBP
for the age gender and heightfor the age gender and height
PrehypertensionPrehypertension 9090thth
to <95to <95thth
percentile or if BPpercentile or if BP
exceeds 120/80 even if <90thexceeds 120/80 even if <90th
percentile upto 95th percentilepercentile upto 95th percentile
Stage 1 hypertensionStage 1 hypertension 9595thth
to 99to 99thth
percentile + 5mm Hgpercentile + 5mm Hg
Stage 2 hypertensionStage 2 hypertension >99percentile + 5mm Hg>99percentile + 5mm Hg

5. White-coat hypertensionWhite-coat hypertension—A patient with—A patient with
BP levels above the 95th percentile in aBP levels above the 95th percentile in a
physician’s office or clinic who isphysician’s office or clinic who is
normotensive outside a clinical setting.normotensive outside a clinical setting.
(Ambulatory BP monitoring is usually(Ambulatory BP monitoring is usually
required to make this diagnosis.)required to make this diagnosis.)

6. Which children should get their bloodWhich children should get their blood
pressure checked?pressure checked?
All children 3 years of age and olderAll children 3 years of age and older
should have their blood pressure measuredshould have their blood pressure measured
at all health care encounters, including bothat all health care encounters, including both
well child care and acute care or sick visits.well child care and acute care or sick visits.

7. Certain childrenCertain children younger than 3 withyounger than 3 with coco
morbid conditions:-morbid conditions:-
prematurityprematurity
History of low birth weight or neonatal intensiveHistory of low birth weight or neonatal intensive
care unit (NICU) staycare unit (NICU) stay
Presence of congenital heart disease, kidneyPresence of congenital heart disease, kidney
disease,disease,
or genitourinary abnormalityor genitourinary abnormality
Family history of congenital kidney diseaseFamily history of congenital kidney disease
Recurrent urinary tract infection (UTI),Recurrent urinary tract infection (UTI),
hematuria, proteinuriahematuria, proteinuria

8. Transplant of solid organ or bone marrowTransplant of solid organ or bone marrow
MalignancyMalignancy
Taking medications known to increase bloodTaking medications known to increase blood
pressure (steroids, decongestants, nonsteroidalpressure (steroids, decongestants, nonsteroidal
anti-inflammatory drugs [NSAIDs], beta-anti-inflammatory drugs [NSAIDs], beta-
adrenergic agonists)adrenergic agonists)
Presence of systemic illness associated withPresence of systemic illness associated with
hypertension (neurofibromatosis, tuberoushypertension (neurofibromatosis, tuberous
sclerosis)sclerosis)
Evidence of increased intracranial pressureEvidence of increased intracranial pressure

9. How should blood pressure be
measured in children?

10. Choose the appropriate size cuffChoose the appropriate size cuff

11. METHODSMETHODS
Palpatory MethodPalpatory Method BP recording is 10 mm Hg lessBP recording is 10 mm Hg less
than that obtained by auscultatorythan that obtained by auscultatory
method .method .
Auscultatory MethodAuscultatory Method Preferred method. BP tables arePreferred method. BP tables are
based on it.based on it.
Doppler StudyDoppler Study Non invasive procedureNon invasive procedure
Oscillometric MethodOscillometric Method Better to record mean BP. UsefulBetter to record mean BP. Useful
in infants and young children. BPin infants and young children. BP
> 90th percentile should be> 90th percentile should be
rechecked by auscultatoryrechecked by auscultatory
method.method.
Flush MethodFlush Method Used in newborns. Only SBP canUsed in newborns. Only SBP can
be recorded.be recorded.
Ambulatory Blood
Pressure Monitoring
White-coat hypertension
Target-organ injury risk

12. POINTS TO BE REMEMBEREDPOINTS TO BE REMEMBERED
BP should be recorded in all 4 limbs.BP should be recorded in all 4 limbs.
Cuff should not be applied too tight (lowCuff should not be applied too tight (low
BP recording) or too loose (high BPBP recording) or too loose (high BP
recording).recording).
BP monitoring subsequently should beBP monitoring subsequently should be
taken in the same limb and position.taken in the same limb and position.
Normally the BP is 10-20mm Hg higher inNormally the BP is 10-20mm Hg higher in
lower limbs compared to the upper limbs.lower limbs compared to the upper limbs.

13. ETIOLOGYETIOLOGY
COMMONEST CAUSESCOMMONEST CAUSES
NewbornNewborn Umbilical artery catheterization andUmbilical artery catheterization and
Renal artery thrombosis.Renal artery thrombosis.
ChildhoodChildhood Renal disease, COA, endocrineRenal disease, COA, endocrine
disorders or medications.disorders or medications.
Adolescents.Adolescents. Essential hypertension becomesEssential hypertension becomes
increasingly common.increasingly common.

14. Renal CausesRenal Causes Renal Parenchymal diseases (78%)Renal Parenchymal diseases (78%)
Renal vascular diseases (12%)Renal vascular diseases (12%)
CardiovascularCardiovascular CoA(2%)CoA(2%)
Condition with large stroke volume (PDA, AV fistula)Condition with large stroke volume (PDA, AV fistula)
EndocrineEndocrine HyperthyroidismHyperthyroidism
Excessive Catecholamine levels (Pheochromocytoma)Excessive Catecholamine levels (Pheochromocytoma)
Adrenal dysfunction (CAH 11Adrenal dysfunction (CAH 11ββ, 17, 17 αα hydroxylasehydroxylase
deficiency)deficiency)
Hyperaldosteronism (Conn's Syndrome, Renin ProducingHyperaldosteronism (Conn's Syndrome, Renin Producing
Tumors)Tumors)
HyperparathyroidismHyperparathyroidism
NeurogenicNeurogenic Raised ICT, Poliomyelitis, LGB.Raised ICT, Poliomyelitis, LGB.
Drugs and ChemicalDrugs and Chemical Sympathomimetic drugs , Amphetamines, Steroids, OCP,Sympathomimetic drugs , Amphetamines, Steroids, OCP,
Heavy matal poising (Hg, Lead), Cocaine, CyclosporineHeavy matal poising (Hg, Lead), Cocaine, Cyclosporine
MiscellaneousMiscellaneous Hypercalcemia, After Coarctation repair, Pre eclampsiaHypercalcemia, After Coarctation repair, Pre eclampsia
etc.etc.
CAUSES OF HYPERTENSION IN PEDIATRIC POPULATIONCAUSES OF HYPERTENSION IN PEDIATRIC POPULATION

15. CLINICAL MANIFESTATION OFCLINICAL MANIFESTATION OF
HYPERTENSIONHYPERTENSION
Many children with mild hypertension areMany children with mild hypertension are
asymptomatic and hypertension isasymptomatic and hypertension is
diagnosed as a result of routine BPdiagnosed as a result of routine BP
measurement.measurement.
Severe hypertension may be symptomaticSevere hypertension may be symptomatic
like headache, dizziness, nausea,like headache, dizziness, nausea,
vomiting, irritability, personality changes.vomiting, irritability, personality changes.
Occasionally with complications likeOccasionally with complications like
neurological, CHF, Renal dysfunction,neurological, CHF, Renal dysfunction,
Stroke.Stroke.

16. APPROACH TO A PATIENTAPPROACH TO A PATIENT
HISTORYHISTORY
Present and Post HistoryPresent and Post History
– Neonatal - prematurity, BPD, umbilical artery catheterization .Neonatal - prematurity, BPD, umbilical artery catheterization .
– Cardiovascular- History of CoA or surgery for it, history of palpitationCardiovascular- History of CoA or surgery for it, history of palpitation
, Headache, excessive sweating (excessive catecholamine levels)., Headache, excessive sweating (excessive catecholamine levels).
– Renal- History of obstructive uropathy, UTI, radiation, trauma orRenal- History of obstructive uropathy, UTI, radiation, trauma or
surgery to kidney area.surgery to kidney area.
– Endocrine- weakness, fiushing, weight loss, muscle crampsEndocrine- weakness, fiushing, weight loss, muscle cramps
(hyperaldosteronism). Constipation(hyperaldosteronism). Constipation
– Medication/Drugs - Corticosteroids, amphetamines, coldMedication/Drugs - Corticosteroids, amphetamines, cold
medications, antiasthamatic drugs, OCP, cyclosporine/tacrolimus,medications, antiasthamatic drugs, OCP, cyclosporine/tacrolimus,
cocaine.NSAIDs Stimulant medications (eg, dexedrine,cocaine.NSAIDs Stimulant medications (eg, dexedrine,
methylphenidate) Beta-adrenergic agonists (eg, theophylline)methylphenidate) Beta-adrenergic agonists (eg, theophylline)
,Erythropoietin, Tricyclic antidepressants, Recent abrupt,Erythropoietin, Tricyclic antidepressants, Recent abrupt
discontinuation of antihypertensivesdiscontinuation of antihypertensives

17. – Habits - Smoking/drinking/Habits - Smoking/drinking/
illicit drugs (eg,illicit drugs (eg,
tobacco,ethanol,amphetamines,cocaine,phencyclidine,tobacco,ethanol,amphetamines,cocaine,phencyclidine,
– Symptoms of obstructive sleep apnea (ie, difficultySymptoms of obstructive sleep apnea (ie, difficulty
falling asleep,falling asleep,
• multiple nighttime awakenings, snoring, daytimemultiple nighttime awakenings, snoring, daytime
somnolencesomnolence
- Diet (caffeine, salt intake- Diet (caffeine, salt intake))
Family HistoryFamily History
– Essential hypertension , atherosclerotic heart disease, stroke.Essential hypertension , atherosclerotic heart disease, stroke.
– Familial or hereditary renal disease (PKD etc.)Familial or hereditary renal disease (PKD etc.)

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

19. ROUTINE LABORATORY TESTSROUTINE LABORATORY TESTS
Initial laboratory tests should be directedInitial laboratory tests should be directed
toward detecting renal parenchymaltoward detecting renal parenchymal
disease, renovascular disease, thereforedisease, renovascular disease, therefore
should include urinalysis; urine culture;should include urinalysis; urine culture;
serum electrolyte, blood urea nitrogen,serum electrolyte, blood urea nitrogen,
creatinine, and uric acid levels; ECG;creatinine, and uric acid levels; ECG;
chest X-ray studies; and possibly echo.chest X-ray studies; and possibly echo.

20. Classification of Hypertension in ChildrenClassification of Hypertension in Children
and Adolescents:and Adolescents:
Therapy RecommendationsTherapy Recommendations
All patients to receive Therapeutic Life-style Changes (TLC)All patients to receive Therapeutic Life-style Changes (TLC)
Pharmacologic TherapyPharmacologic Therapy
NormalNormal NoneNone
PrehypertensionPrehypertension Do not initiate therapy unless there areDo not initiate therapy unless there are
compelling indications such as chronic kidneycompelling indications such as chronic kidney
disease (CKD), diabetes mellitus, heart failure,disease (CKD), diabetes mellitus, heart failure,
left ventricular hypertrophy (LVH).left ventricular hypertrophy (LVH).
Stage 1 hypertensionStage 1 hypertension Initiate therapy based on indications forInitiate therapy based on indications for
antihypertensive drug therapy or if there areantihypertensive drug therapy or if there are
compelling indications as above.compelling indications as above.
Stage 2 hypertensionStage 2 hypertension Initiate therapy.Initiate therapy.

21. MANAGEMENTMANAGEMENT
Prehypertension orPrehypertension or
asymptomatic, Stage 1 Primary HTNasymptomatic, Stage 1 Primary HTN
( who do not have evidence of end-organ damage( who do not have evidence of end-organ damage
or diabetes )or diabetes )
Lifestyle modificationsLifestyle modifications
(Non-pharmacologic interventions)(Non-pharmacologic interventions)
re-evaluated in six monthsre-evaluated in six months
Not controlledNot controlled

22. Non pharmacologic interventions-Non pharmacologic interventions-
Weight reduction.Weight reduction.
Low salt intake*.Low salt intake*.
Regular aerobic exercise.Regular aerobic exercise.
Dietary Approaches- fresh vegetables, fruits, andDietary Approaches- fresh vegetables, fruits, and
low-fat dairylow-fat dairy
Avoidance of smoking.Avoidance of smoking.

23. CLASSIFICATION OF DRUGSCLASSIFICATION OF DRUGS
ACE inhibitorsACE inhibitors Captropil, EnalaprilCaptropil, Enalapril
Angiotensin AT 1, antagonistsAngiotensin AT 1, antagonists LosartanLosartan
Calcium channel blockersCalcium channel blockers Nifedipine, Verapamil.Nifedipine, Verapamil.
DiureticsDiuretics Hydrochlorthizide, Furosemide,Hydrochlorthizide, Furosemide,
SpironolactoneSpironolactone
ββ adrenergic blockersadrenergic blockers PropranololPropranolol
αα++ββ adrenergic blockersadrenergic blockers LabetalolLabetalol
αα adrenergic blockersadrenergic blockers PrazosinPrazosin
Central sympatholyticsCentral sympatholytics ClonidineClonidine
VasodilatorsVasodilators Arterial (Hydralazine, Minoxidil),Arterial (Hydralazine, Minoxidil),
Mixed (Sodium nitropruside)Mixed (Sodium nitropruside)

24. Indications for antihypertensiveIndications for antihypertensive
drug therapydrug therapy
Symptomatic hypertensionSymptomatic hypertension
Secondary hypertensionSecondary hypertension
Hypertensive target organ damageHypertensive target organ damage
Diabetes( types 1 & 2)Diabetes( types 1 & 2)
Persistent hypertension despitePersistent hypertension despite
nonpharmacologic measuresnonpharmacologic measures

25. Goals of antihypertensiveGoals of antihypertensive
therapytherapy
Reduction of BP to < 95Reduction of BP to < 95thth
percentilepercentile
without any concurrent conditions .without any concurrent conditions .
Reduction of BP to <90Reduction of BP to <90thth
percentile withpercentile with
concurrent conditionsconcurrent conditions
(eg.Hyperlipidemia ,End organ damage,(eg.Hyperlipidemia ,End organ damage,
Obesity, CKD Complications etc)Obesity, CKD Complications etc)

26. How should I treat?How should I treat?
Step-1Step-1 - Starting with a single antihypertensive in- Starting with a single antihypertensive in
small dose and proceeding to full dose .small dose and proceeding to full dose .
Step-2Step-2 - If it produce no clinical improvement, a- If it produce no clinical improvement, a
second antihyprtensive drug should be added orsecond antihyprtensive drug should be added or
substituted.substituted.
initial antihypertensive therapyinitial antihypertensive therapy
a Calcium channel blocker (CCB) or ana Calcium channel blocker (CCB) or an
Angiotensin converting enzyme (ACE) inhibitor,Angiotensin converting enzyme (ACE) inhibitor,
unless there is a compelling reason to use anunless there is a compelling reason to use an
agent from another classagent from another class

28. COMBINATION THERAPYCOMBINATION THERAPY
SYNERGISTIC COMBINATIONS.SYNERGISTIC COMBINATIONS.
Drugs increasing reninDrugs increasing renin
activity+ Drugs decreasingactivity+ Drugs decreasing
renin activityrenin activity
ACE inhibitors , DiureticsACE inhibitors , Diuretics
++
ββ blockersblockers
Sympathic inhibitors andSympathic inhibitors and
vasodilators cause fluidvasodilators cause fluid
retention. Add diureticsretention. Add diuretics
ββ blockers + Thiazide,blockers + Thiazide,
LasixLasix
ACE inhibitors + DiureticsACE inhibitors + Diuretics Envas + Thiazide, LasixEnvas + Thiazide, Lasix
αα Blocker +Blocker + ββ blockerblocker Prazosin + PropranololPrazosin + Propranolol

29. COMBINATIONS TO BE AVOIDEDCOMBINATIONS TO BE AVOIDED
αα oror ββ blocker + clonidine (antagonism)blocker + clonidine (antagonism)
ββ blocker + CCB (marked bradycardia/ AVblocker + CCB (marked bradycardia/ AV
block).block).
Any 2 drugs of same class.Any 2 drugs of same class.

30. SECONDARY HYPERTENSIONSECONDARY HYPERTENSION
Treatment should be aimed at removing theTreatment should be aimed at removing the
cause of hypertension whenever possible.cause of hypertension whenever possible.
Curable forms of HypertensionCurable forms of Hypertension
RenalRenal Unilateral kidney disease (Nephritis,Unilateral kidney disease (Nephritis,
Pyelonephritis, hydronephrosis)Pyelonephritis, hydronephrosis)
CardiovascularCardiovascular CoA, Renal artery stenosis, thrombosis.CoA, Renal artery stenosis, thrombosis.
AdrenalAdrenal Pheochromocytoma, Neuroblastoma,Pheochromocytoma, Neuroblastoma,
hyperaldosteronismhyperaldosteronism
MiscellaneousMiscellaneous Drugs/ OCP etc.Drugs/ OCP etc.

31. Management Algorithm of Systemic Hypertension

32. CONCLUSIONSCONCLUSIONS
Hypertension is a silent killer. All children >3Hypertension is a silent killer. All children >3
years of age attending OPDs should have theiryears of age attending OPDs should have their
BP recorded (Special circumstances in childrenBP recorded (Special circumstances in children
< 3 years).< 3 years).
Thorough history and physical examinationThorough history and physical examination
followed by relevant investigations can clinch thefollowed by relevant investigations can clinch the
cause of hypertension.cause of hypertension.
Hypertension is a curable disease.Hypertension is a curable disease.