Pediatrics Hypertension

1. SYSTEMIC HYPERTENSION
Dr.Chaithrashree R
Senior Resident
Dept of Paediatrics

2. Contents
• Systemic hypertension
• Peripheral Vascular Diseases
Kawasaki Disease
Arteriovenous fistulas
GACI
Arterial tortuosity

3. SYSTEMIC HYPERTENSION

5. • White coat HTN: BP >95th centile when
measured in clinic setting but <90th centile when
measured outside clinic environment.
• Masked HTN: BP normal in clinic setting but
in hypertensive range when measured outside
clinic environment as detected on ABPM.

6. • Hypertensive urgency: raised BP without
end-organ damage or symptoms, such as
headache, nausea or blurred vision.
• Hypertensive emergency: raised BP along
with the presence of end-organ damage, such as
encephalopathy, seizures, CHF, AKI,papilledema
or pulmonary edema.

7. • The preferred method is by auscultation using a
sphygmomanometer (BP) cuff appropriate for the
size of the child's arm.

8. • BP should be measured with the child in the seated
position after a period of quiet for at least 5 min,
and it is recommended that the BP is checked 3
times, averaging the results.
• Elevated readings should be confirmed on repeat
visits before determining that a child is
hypertensive.

9. • Palpation is useful for rapid assessment of SBP,
although the palpated BP is generally about 10
mm Hg lower than that obtained by auscultation
• Oscillometric techniques are used frequently in
infants and young children, but they are
susceptible to artifacts and are best for
measuring mean arterial pressure (MAP).

10. Ambulatory Blood Pressure Monitoring
(ABPM)
• The patient wears a device that records BP every
20-30 min, throughout a 24 hr period, during
usual daily activities, including sleep.
• The cuff should be placed on the patient's
nondominant arm.
• This monitoring allows calculation of the mean
daytime BP, sleep BP, and mean BP over 24 hr.
• normal if there is a decrease in nocturnal BP of
>10% from awake values.

12. • Blood pressure is the product of cardiac output
(CO) and peripheral vascular resistance (PVR).
BP= CO*PVR
• When hypertension is the result of another
disease process, it is referred to as secondary
hypertension.
• When no identifiable cause can be found, it is
referred to as primary hypertension.

13. Prevalence:
• In infants and young children
o<1%
osecondary hypertension
oSevere and symptomatic hypertension
• In older school-age children and adolescents,
oPrimary hypertension
oin parallel with the obesity epidemic

14. Etiology
• Secondary causes
Renal/renovascular
Cardiac (coarctation of aorta)
Endocrine
Exposure to lead, cadmium, mercury, etc.,
Drugs- oral contraceptives, corticosteroids, CNS
stimulants

15. Renal/ Renovascular causes:
• Renal parenchymal ( 34-76% )
• Renovasular ( 12-13% )
Aortic coarctation
• At the level of aortic isthmus
Repaired aortic coarctation ( 17-77%)
• Abdominal aortic obstruction in syndromes like
NF, Turners, Williams, Alagille and Takayasu
arteritis

16. Etiology of persistent hypertension

17. Monogenic hypertension

18. Diagnosis

19. Investigations:

20. LVH and ECHO:
LVH in 30-40% of HTN
ECHO to be done at the start of Pharmacologic
treatment of HTN

21. Prevention
• Public health, population-based approaches to
prevention of primary hypertension in both adults
and children includes
• reduction in obesity,
• reduced sodium intake,
• avoidance of tobacco intake, and
• an increase in physical activity through school-
and community-based programs.

22. The DASH (Dietary Approaches to Stop
Hypertension) diet has been suggested as a
nutritional approach to prevent or even treat
hypertension
• The diet focuses on lowering sodium intake and
increasing potassium-, calcium-, and magnesium-
containing foods, such as 6-8 servings of whole
grains, 4-5 servings of fruits, and 4-5 servings of
vegetables per day and low-fat dairy foods.
• DASH diet recommends up to 1500 mg of sodium
per day.

23. Treatment
• lifestyle modification with dietary changes
and regular exercise(30-60 min on most days),
reduction of sedentary activities<2hr/day.

24. • Pharmacologic treatment:
• Atleast 6 months of lifestyle changes
• Symptomatic HTN
• Stage 2 HTN without modifiable risk factor
• comorbidities (DM, CKD)

25. Treatment goals
• < 90th percentile/ <130/80mm Hg in adolescents
>13yr
• CKD with HTN, 24hr MAP<50th percentile by
ABPM

26. Anti-Hypertensive drugs
• Aldosterone receptor antagonists:
Eplerenone, Spironolactone
• ACE inhibitors:
Captopril, Enalapril, Fosinopril, Ramipril
• Angiotensin receptor blockers:
Candesartan, Losartan, Valsartan, Olmesartan
• Beta blockers:
Atenolol, Metoprolol, Propranolol
• α+β blockers:
Carvedilol, Labetalol

27. • Calcium channel blockers:
Amlodipine, Felodipine, Nifedipine
• Central α- agonist: Clonidine
• Vasodilators: Hydralazine, Minoxidil
• Diuretics:
Furosemide, Hydrochlorthiazide, Chlorthalidone

28. • First line anti-HTN drugs:
• ACE/ARBs
• Long acting CCBs
• Thiazide diuretic
• In CKD or Diabetes: ACEI/ARB

29. Approach to anti-HTN therapy

30. Severe hypertension/accelerated
HTN/Hypertensive crisiss
• BP 5-10 mm Hg above the 99th centile or
DBP>110 mmHg are considered ‘severe’.
• likely to manifest clinical features of end organ
involvement and need urgent attention

31. Management of Severe Hypertension
• For patients with acute severe hypertension and
life-threatening symptoms, ICU admission and IV
drug infusion is indicated so that decrease in BP
can be carefully monitored and titrated .
• Arterial lines should be used for continuous BP
monitoring.

32. • Because too rapid a reduction in BP may
interfere with adequate organ perfusion, a
stepwise reduction in pressure should be
planned.
• BP should be reduced by no more than 25% of
the planned reduction over the 1st 8 hr, with a
gradual normalization of BPs over next 24-48 hr.
• The target blood pressure level is the 95th centile
of the systolic value for the age and sex.

34. Measurement of BP
• annually, in all children older than 3 years who
seek medical consultation.
• Children <3 years with any of the following risk
factors,
H/o prematurity, VLBW babies
CHD
Recurrent UTI,hematuria or proteinuria
K/C/O renal disease or urologic malformation

35. Family h/o congenital renal disease
solid organ transplantation
malignancy or bone marrow transplant
treatment with drugs known to raise BP
illnesses a/w HTN (neurofibromatosis, tuberous
sclerosis)
evidence of raised ICP

36. Follow-up :
• When on only lifestyle modification, every 3-6
months
• When on antihypertensive drugs, till goal BP is
reached every 4-6 weeks, f/b once in 3-4 months
• Atleast once a year ABPM in CKD to assess
masked hypertension

37. References
• Nelson Textbook of Pediatrics-21st edition
• Textbook of Pediatric Nephrology- Arvind Bagga
• 2017 AAP guidelines for childhood hypertension