Management of

Hypertension in Children
Carlos A. Delgado, M.D.FAAP
Div. Pediatric Emergency Medicine
Emory University School of Medicine
CHOA

Enregistrement de la pression artrielle l'aide d'un capteur

introduit dans l'aorte: premire mthode historique de mesure
de la pression artrielle (1732, Stephen Hales).

The Sphygmomanometer - Riva Rocci's instrument

Marey's wrist sphygmograph, c.

1857.

Dudgeon's wrist sphygmograph, c.

1890

The Korotkoff sounds

Objectives
Recall key elements necessary for
the diagnosis and management of
hypertension in children.
Discuss various pharmacological
treatment options for the
management of hypertensive
urgencies and emergencies

Hypertension basics

Primary hypertension:
Significant health problem, with overweight/obesity
being a major contributor to much of the prehypertension and stage1 hypertension.
Body mass index (BMI) should be calculated and
plotted on the CDC growth curves in pediatric
patients.
The prevalence of hypertension increases with
increased BMI; hypertension is present in about 30
percent of those with BMI above the 95th percentile.

Prevalence
Estimated at 1-2 % with an increase in
primary hypertension likely due to the
rising trend towards childhood obesity
Overweight prevalence is aprox 20%

31% Hispanics
22% African American
15% White
11% Asian

Prevalence of Elevated
Blood Pressure

Hispanics 25%
African American 19.5%
White 9.5%
Asian 4.5%

Prevalence of Hypertension
Compared to BMI

Pediatrics 113;3;475-482;March 2004

Definitions
Hypertensive Emergency is a severely elevated
blood pressure with evidence of target organ
injury- most commonly the CNS system,
kidneys, or cardiovascular system.
Hypertensive Urgency is a severely elevated
blood pressure with no evidence of secondary
organ damage but if left untreated will
imminently result in target organ injury.

How to measure a blood

pressure
Patient resting in seated position right arm at
the level of the heart.
Blood pressure cuff:
The width of the inflatable bladder should be at least
40% of the arm circumference at a point midway
between the acromion process and the olecranon
Cuff too large BP artificially low
Cuff too small BP artificially high

Abnormal BP should be verified by auscultation

with a sphygmomanometer.

Pediatric hypertension
1987/2004 Task Force on Blood Pressure
Control in Children Hypertension: is
the average systolic and/or diastolic
blood pressure persistently above the 95 th
percentile.
Severe hypertension that above the 99 th
percentile.

Pediatric hypertension
The blood pressure must be obtained on three separate occasions. If the systolic and diastolic
blood pressure falls into different categories, classify by the higher category.
- NORMAL BLOOD PRESSURE is defined as a systolic and diastolic blood pressure below
the 90th percentile for gender, age and height percentile (utilizing the Center for Disease
Control (CDC) growth curves).
-PRE-HYPERTENSION is defined as the 90th percentile to less than 95th percentile or if BP
greater than 120/80 even if below the 90th percentile (up to below the 95th percentile).
- STAGE 1 HYPERTENSION is defined as a blood pressure between the 95th percentile and
the 99th percentile plus 5mmHg.
-STAGE 2 HYPERTENSION is defined as a blood pressure above the 99th percentile plus
5mmHg.
-WHITE COAT HYPERTENSION is defined in a patient with blood pressure above the
95th percentile in the physicians office or clinic, who is normotensive outside the clinical
setting.
* 1987/2004 Task Force on Blood Pressure Control in Children

Hypertension
Systolic BP elevation is an important factor in the
morbidity of hypertension in children and adults
Mild to moderate BP elevation is associated with
increased left ventricular mass
Elevation of systolic BP is more closely related with
LV morphology
Among hypertensive pts prevalence on LVH
ranges from 30-70%
Treatment of hypertension should be directed to
normalization of systolic BP

Hypertension management

The indications for antihypertensive drug therapy:

secondary hypertension and
insufficient response to lifestyle modification.

Pharmacological therapy should be initiated with

a single drug.

Acceptable classes for use in children include ACE

inhibitors, angiotensin receptor blockers, betablockers, calcium channel blockers and diuretics.

BP Goal
The goal for antihypertensive treatment in
children should be reduction of BP to below the
95th percentile unless concurrent conditions
are present, in which case BP should be lowered
to below the 90th percentile.

Hypertensive Emergencies
Usually accompanied by signs of
hypertensive encephalopathy and
typically causing seizures.
Should be treated with intravenous
antihypertensive that can produce a
controlled reduction in BP aiming to :
decrease the BP by < 25% over 1st 8 hours
and normalizing the BP over 26 to 48hrs.

Hypertensive Urgencies
Less serious symptoms such as:
headache,
vomiting

Can be treated by either intravenous or

oral antihypertensives

Common causes of
hypertension
in
children
Age group
Cause
Newborns

Renal vessel thrombosis

Renal artery stenosis
Congenital renal anomalies
Coartation of the aorta

Early Childhood 1-6 yrs

Renal parenchymal disease

Renovascular disease
Coartation of the aorta

School age 6- 10 yrs

Renal parenchymal disease

Renovascular disease
Essential hypertension

Adolescence

Essential hypertension
Renal parenchymal disease
Renovascular disease
Drugs

* Pheochromocytoma and Cushing Disease should be considered in all age

Clinical Assessment
History
Prior history of HTN
Abrupt withdrawal of meds

Symptoms
Visual changes, CNS disturbance, renal disease,CV
compromise
Flushing, tachycardia, weight changes,

Umbilical vessel catheterization, GU anomalies,

recent head injury, medication use, drugs of abuse
Family history of hypertension or stroke

Physical examination

Vital signs , pulse oximetry

4 limb blood pressures
Accurate weight
Fundoscopic examination
Neurologic examination including mental
status
Cardiovascular examination
Renal artery bruits, edema, growth failure

Ancillary investigations

CXR
EKG
CT head
UA and serum BUN and creatinine
CBC to r/o HUS or anemia
Renal ultrasound
Plasma renin
MRA/Duplex Doppler flow studies/3-D CT

Management
Persistent mild to moderate BP elevation:
Close follow up with outpatient evaluation
and management.

Management
BP should be reduced no more than 25%
in the first 2 hours, then reduced
gradually over the next 3-4 days.
IV route for medication administration is
preferred- better titration and
predictable absorption.

Drugs

Sodium Nitroprusside
Labetalol
Metoprolol
Nicardipine
Esmolol
Hydralazine
Fenoldopam
Nifedipine
Lisinopril
Amlodipine

Sodium Nitroprusside

Arterial and venous vasodilator

No chronotropic or inotropic effects
Extremely short half-life
Easily titrated to effect
Dose: 0.3-0.5 micrograms/kg/min.
Maximum 8 mcg/kg/min
Most patients will respond at rates of 3
mcg/kg/min

Sodium Nitroprusside
Its rapid vasodilatory effects cause reflex
stimulation of sympathetic nervous
system resulting in tachycardia
Long term therapy( > 24hrs) may lead to
accumulation of cyanide and thiocyanate.

Fenoldopam( Corlopam
)
Fenoldopam is a selective dopamine agonist
In both an oral and parenteral form, the drug causes
peripheral vasodilatation by stimulating dopamine-1
adrenergic receptors.
Intravenous fenoldopam may provide advantages
over sodium nitroprusside because it can induce both
a diuresis and natriuresis, is not light sensitive, and is
not associated with cyanide toxicity.
There is no evidence for rebound hypertension after
discontinuation of fenoldopam infusion.

Fenoldopam
Selective dopamine agonist causing
vasodilatation of the renal, coronary, cerebral
and splacnic vasculature reducing MAP.
Successful controlled hypotension in spinal
fusion and in PICU
Peak effect in 5-15 minutes
Infusion 0.1-2 g/kg/min
Side effects: reflex tachycardia, Increased ICP
and IOP

Labetalol

Both and sympathetic blocker

May be safer that sodium nitroprusside
Reduces vascular resistance
Difficult to titrate due to long half life
Continuous infusion or bolus
Infusion- 0.2 to 3 mg/kg/hr
Intermittent bolus 0.2- 1 mg/kg
Efficacious in those with renal disease
Caution: asthma,CHF, diabetes

Metoprolol (TOPROL-XL )
1- selective blocker
Doses: 0.2 mg/kg "low," 1.0 mg/kg "medium,"
or 2.0 mg/kg "high")
The most common adverse events:
Headache 11.7%
upper respiratory tract infection 6.8%
dizziness 4.2% and cough 2.5%

Esmolol ( Breviblock )

Ultrashort cardioselective - adrenergic blocking

agent
Primary use in the perioperative management of
tachycardia and hypertension in patients at risk
of developing hemodynamically-induced
myocardial ischemia.
Infusion: loading 100-500 g/kg followed by
infusion of 50-300 g/kg/min
Caution in asthmatics, bradycardia, and CHF

Nicardipine (Cardene )

Calcium channel blocker

Blocks movement of Ca+ across vascular smooth
muscle decreasing preventing contraction total
vascular resistance.
Advantages: Lack of decreased cardiac output and
limited effects on chronotropic and inotropic
effects on the heart.
Can be given IV
Rare hypotensive episodes
Limited experience in children

Nicardipine
Dose: 0.5 1 g/kg/min to max of 3
g/kg/min
Infusion should be increased every 3-5
minutes to desired effect
Fast onset of action
Adverse effects: increased ICP, headache
nausea, hypotension
Cimetidine increases effects

Hydralazine
Potent arterial vasodilator to reduce
systemic BP
Onset of action is 5-30 mins
Duration of action 4-12 hrs
Dose: 0.1-0.5 mg/kg/dose max 20 mg
every 4-6 hr
Losing popularity

Nifedipine
Reported adverse cardiac and neurologic
sequelae due to hypotension in adults
Reported rebound hypertension causing adverse
neurologic events in children associated with the
use of short acting nifedipine. Calcium channel
blocker- decrease peripheral vascular resistance
Dose 0.25mg/kg
Blaszac study J Peds 2001- no significant complications

Nifedipine
Sublingual or orally best absorption is to
bite and swallow
Recommended oral administration to be
limited to hypertensive urgencies

Lisinopril (Zestril)
Lisinopril is ACE inhibitor.
It is used to treat mild to severe high
blood pressure as well as congestive heart
failure. Lisinopril is given as a tablet.
Side effects
Dizziness
Rash
Dry cough

Lisinopril(Zestril)
For people not on diuretics, the initial starting
dose is usually 10 milligrams, taken 1 time a
day. The long-term dosage usually ranges from
20 to 40 milligrams a day, taken in a single dose.
Diuretic use should, if possible, be stopped
before using lisinopril.
Renal disease needs dose adjustments,
depending on kidney function

Lisinopril(Zestril)
Dose is 0.07 milligrams per day up to a total of
5 milligrams per day.
Zestril is not recommended in children younger
than 6 years old or in children with poor kidney
function.

Amlodipine
( Norvasc )
Amlodipine is a calcium channel blockers.
Amlodipine - tablet to take by mouth. It is usually taken once a
day
Amlodipine may cause side effects.
swelling of the hands, feet, ankles, or lower legs
headache
upset stomach
stomach pain
dizziness or lightheadedness
drowsiness
excessive tiredness
flushing (feeling of warmth)

Amlodipine
( Norvasc )
Dose: 0.05 0.1 mg/kg/day once daily
increase to effect
Usual target dose is 0.2-0.25 mg/kg/day
Younger children may require 0.3-0.4
mg/kg/day
Titrate over 1-2 week period

Diuretics
No longer 1st line recommendation of
chronic pediatric hypertension
Furosemide
Spirinolactone

When to refer to
specialist
Blood pressure values greater than 95% for
gender , age, height on three different occasions.
One or more risks factors of cardiovascular
disease

Obesity
Diabetes
High blood lipids
Family hx. of stroke, cardiovascular disease
Failed pharmacological management

So which drugs should I

use?
Labetalol for initial bolus, it alone
may control BP, may require
rebolusing
Nicardipine if placing on a drip. Use
on neonates is not recommended
due to immature function of
sarcoplasmic reticulum.
If using PO: Norvasc or Labetalol

Classification of Hypertension in Children and Adolescents With Measurement

Frequency and Therapy Recommendations