pediatric Hypertension definition, classification, etiology, management (investigation and treatments guidelines)

1. HYPERTENSION
DR. PRAVEEN UNKI

2. Prehypertension Average SBP or diastolic BP that are
≥90th percentile but <95th percentile
Defn: The Fourth report defined hypertension as average
systolic blood pressure (SBP) and/or diastolic BP that is
≥95th percentile for age, sex, and height on ≥3 occasions.
Stage 1 Hypertension: BP between the 95th and 99th
percentile plus 5 mm hg.
Stage 2 Hypertension: BP above the 99th percentile
Plus 5 mm hg.
Careful attention to cuff size is necessary to avoid over
diagnosis, as a cuff that is too short or narrow artificially
increases BP readings.
The inflatable bladder should cover at least two thirds of the
upper arm length and 80-100% of its circumference.

4. Hypertensive Crisis-
An elevation in Blood pressure to a level that has the potential to cause
end organ
damage
1. Hypertensive emergency – immediate and ongoing evidence of end
organ damage
Ex- Hypertensive encephalopathy, Stroke, Retinal hemorrhage,
Myocardial ischaemia or infarct, pulmonary edema

5. 2. Hypertensive Urgency- Less significant symptoms and no
target organ injury
Ex- Nausea and vomiting

6. Conditions under which children <3 years old should have
blood pressure measured:
• History of prematurity, very low birthweight, or other neonatal complication
requiring intensive care
• Congenital heart disease (repaired or nonrepaired)
• Recurrent urinary tract infections, hematuria, or proteinuria
• Known renal disease or urologic malformations
• Family history of congenital renal disease
• Solid organ transplant
• Malignancy or bone marrow transplant
• Treatment with drugs known to raise BP
• Other systemic illnesses associated with hypertension (neurofibromatosis,
tuberous sclerosis, etc.)
• Evidence of elevated intracranial pressure

7. Conditions associated with transient or intermittent hypertension:
Renal
 Acute postinfectious glomerulonephritis
 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
 Hypervolemia
 Pyelonephritis
 Renal trauma
 Leukemic infiltration of the kidney
 Obstructive uropathy associated with crohn disease

8. Drugs and poisons
Cocaine
Oral contraceptives
Sympathomimetic agents
Amphetamines
Phencyclidine
Corticosteroids and adrenocorticotropic hormone
Cyclosporine or sirolimus treatment posttransplantation
Licorice (glycyrrhizic acid)
Lead, mercury, cadmium, thallium
Antihypertensive withdrawal (clonidine, methyldopa, propranolol)
Vitamin D intoxication

9. Central and autonomic nervous system
Increased intracranial pressure
Guillain-barré syndrome
Burns
Familial dysautonomia
Stevens-johnson syndrome
Posterior fossa lesions
Porphyria
Poliomyelitis
Encephalitis
Spinal cord injury (autonomic storm)

10. Conditions associated with chronic hypertension in children:
Renal
• Chronic pyelonephritis/Chronic glomerulonephritis
• Hydronephrosis
• Congenital dysplastic kidney
• Multicystic kidney
• Solitary renal cyst
• Vesicoureteral reflux nephropathy
• Ureteral obstruction
• Renal tumors
• Renal trauma
• Rejection damage following transplantation
• Post-irradiation damage
• Systemic lupus erythematosus (other connective tissue diseases)

11. Endocrine
 Hyperthyroidism
 Hyperparathyroidism
 Congenital adrenal hyperplasia
 Cushing syndrome
 Primary aldosteronism
 Apparent mineralcorticoid excess
 Glucocorticoid remedial aldosteronism (familial aldosteronism type 1)
 Glucocorticoid resistance (chrousos syndrome)
 Pseudohypoaldosteronism type 2 (gordon syndrome)
 Pheochromocytoma
 Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma)
 Liddle syndrome
 Geller syndrome

12. 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 for vascular
Lumen)
Renal vein thrombosis
Vasculitis
Arteriovenous shunt
Williams-beuren syndrome
Moyamoya disease
Takayasu arteritis

13. Central nervous system
Intracranial mass
Hemorrhage
Residual following brain injury
Quadriplegia

14. Renovascular hypertension, account for approximately 90%
of secondary hypertension.

15. Antihypertensive therapy should be used in CKD to:
• Lower BP
• Reduce the risk of CVD, in patients with or without
hypertension
• Slow progression of kidney disease, in patients with or
without hypertension

16. Clinical manifestations:
Headache, vomiting, dizziness, epistaxis, anorexia, visual
changes, and
seizures
Temperature elevation, ataxia, depressed Level of
consciousness
Cardiac failure, pulmonary edema, and renal dysfunction
(malignant hypertension)
Decreased vision (retinal hemorrhages of hypertensive
retinopathy) and papilledema

17. Approach to a case of Hypertension:
A family history for early cardiovascular events should be
obtained.
Growth parameters should be determined to detect
evidence
Of chronic disease.
Bp should be obtained in all 4 extremities to detect
Coarctation (thoracic or abdominal) of the aorta

18. • Investigations:
CBC with PS
RFT
Electrolytes
Urinalysis
CXR
ECG
2DEcho
USG Abd

21. Management of Hypertension:

22. • Life style modification.
• Indications for antihypertensive drug therapy in children
include secondary hypertension and insufficient response
to lifestyle modifications
• Pharmacologic therapy, when indicated, should be
initiated with a single drug.
Acceptable drug classes for use in children include ACE
Inhibitors, Angiotensin Receptor blockers, beta-blockers,
calcium channel blockers, and diuretics.
• Severe, symptomatic hypertension ( Hypertensive
Crisis) should be treated with intravenous
antihypertensive drugs.

23. • "Preferred agents." Classes of antihypertensive agents that
have beneficial effects on progression of CKD or reducing CVD
risk, in addition to their antihypertensive effects
• Modifications to antihypertensive therapy should be considered
based on the level of proteinuria during treatment

24. Antihypertensive drugs for outpatient management of
hypertension:
ACE inhibitors Captopril
Enalapril
0.3-0.5mkd
0.08mkd
ARBs Losartan 0.7mkd
Αlpha and ß blocker Labetalol Initial: 1–3 mg/kg/day
Max: 10–12 mkd
Beta blocker Propranolol
Metoprolol
1-2mkd
1-2mkd
Calcium Cannel
blocker
Amlodipine
Extended release
nifedipine
2.5-5mg/d
0.25-0.5mkd
Max-3mkd
Central Alpha
agonists
Clonidine 0.2mg/d
Max-2.4mg/d

25. Peripheral Alpha
Antagonist
Prazosin 0.05-0.1mkd
Max-0.5mkd
Diuretics Furosemide
Spironolactone
0.5-2mkdo
Max-6mkd
1mkd
Vasodilator Hydralazine
Minoxidil
0.75mkd
0.2mkd

26. Management of severe hypertension(Hypertensive
Crisis):
MAP reduction
25%- 8-12hr
25%- 8-12hr
50%- 24hr
Esmolol 100-500mcg/kg/min
Hydralazine 0.2-0.6mkdo Every 4hrly
Labetalol Bolus-0.2-1 mkdo
Infusion- 0.25-3mg/kg/hr
Nicardipine 1-3mcg/kg/min
Sodium nitroprusside 0.53-1mcg/kg/min
(cyanide level if used >72hr)
Nitroglycerine 1-3mcg/kg/min
Monitor :
Sensorium
Pupillary reflex

29. Anti-Hypertensive
combination
Potential adverse effect
Beta blocker and calcium
channel antagonists
Bradycardia and heart block
Potassium sparing diuretics
and ACE inhibitors
Hyperkalemia
Potassium sparing diuretics
and ARBs
Hyperkalemia
Verapamil and Prazosin Decreased clearance of
Verapamil
Clonidine and Beta blocker Increased sensitivity of
clonidine withdrawal
Combinations of Antihypertensives to be used with Cauti

30. • The goal of therapy for hypertension should be to reduce BP below
the 95th percentile.
• Except in the presence of chronic kidney disease, diabetes, or target-
organ damage, when the goal should be to reduce bp to less than the
90th percentile.

31. References:
1)K/DOQI clinical practice guidelines on hypertension and
Antihypertensive agents in chronic kidney disease-2017
2) Nelson textbook of pediatrics
3)evaluation and management of hypertension –IP 2007
4)diagnosis, evaluation, and treatment of high blood
pressure in children and adolescents-the fourth report
2005
5) PICU protocol AIMS

32. THANK YOU