Arterial hypertension in

children

Dr. Eliza Cinteza

AH in children – practical
approach

 What is it AH in children?
 Is it important?
 How should we measure?
 What should we look for?
 When should we treat? And how?
>140/90 mmHg

>95th percentile for

age, sex and
height
Definition
 AH - SBP and / or DBP> 95th percentile for
age, sex and height at measurements on 3
different occasions.

 Prehypertension - SBP or DBP between

percentiles 90-95.

 Adolescents with BP 120/80 mm Hg will be

considered prehypertension.
 Staging of hypertension in children

DIAGNOSE Percentile SBP/DBP

NORMAL <90th perc

PREHYPERTENSION 90th →95th or

ELEVATED BLOOD BP>120/80 mmHg
PRESSURE
AH ST I 95th → 95th perc + 12 mmHg

AH ST II ➢ > 95th perc + 12 mmHg

>140/90 mmHg

>95th percentile for

age, sex and
height
EXEMPLE
STEP 1

Ex: M, 10 years old, TA

125/80 mmHg

What is the height?

 Ex: M, 10 years
old, TA 125/80
mmHg

 What is the height?

 130 cm
Percentile CDC for height
STEP 2

PERCENTILA 10

http://www.cdc.gov/growthcharts.
 Percentile
AAP –BP
STEP 3
BP 125/80 mmHg

National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth
report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004; 114
(Suppl 2):555-76
>140/90 mmHg

>95th percentile for age, sex

and height

 Ex: M, 10 years old, TA

125/80 mmHg

➢ 99th SBP and

➢ > 95th DBP
>140/90 mmHg

>95th percentile for age, sex and

height

 Ex: M, 10 years old, TA

125/80 mmHg

➢ RESPONSE: WE DON’T KNOW

>140/90 mmHg >95th percentile for age,
sex and height

 Ex: M, 10 years old,

TA 125/80 mmHg

➢ >95th percentile

Minimum 3 measurements
AH in children – practical
approach

 What is it AH in children?
 Is it important?
 How should we measure?
 What should we look for?
 When should we treat? And how?
Prevalence of hypertension in
children: 5%

HU7,5/1,1%
YU 0,93%
SUA4,5% RO3,3%
ES7,6% IT4,2%
IL3,2%
TN11,2% IR6,15/3,4% CN9,13%
PK12,2-15,8/8,7%
IN 0,46%

BR6,5% ZA 4,4-9,1/3,8-6%
 AAP recommendations - BP should be
measured every medical visit after 3
years of age at least once a year.

 Before three years in some cases

Indications for ABP measurements

 > 3 years – every medical check-up

 < 3 years – in special cases:
◼ Affections from neonatal period,
◼ Congenital cardiac malformations,
◼ Renal affections or family history of familial
renal disease,
◼ Intracranial hypertension,
◼ transplant,
◼ malignancy,
◼ Treatment with drugs that increase the BP,
◼ Other systemic diseases asociated with AHT
(neurofibromatosis, tuberose sclerosis, etc).
AH in children – practical
approach

 What is it AH in children?
 Is it important?
 How should we measure?
 What should we look for?
 When should we treat? And how?
 Recommendations of BP
measurement in children
 PREVIOUSLY: -RELAXATION, recreation min 5'.

 NOT: food, drink exciting min 30 min prior

 POSITION: seated with the arm supported at

heart level, REST min 5'

 WIDTH cuff - 40% of the arm length and 80-

100% of the circumference

 Stethoscope: a brachial
K1 and K5 (appearance and disappearance)
BOTH ARMS
3 measurements x 3. Attention tachycardia.
Recommended dimensions for
cuff tensiometer
AH in children – practical
approach

 What is it AH in children?
 Is it important?
 How should we measure?
 What should we look for?
 When should we treat? And how?
Anamnesis
 Family history of Essential AH

 History of chronic renal disease, transplant

 Other issues considered risk factors: low birth

weight, malnutrition, smoking in adolescents,
excessive consumption of energy drinks, sleep
apnea syndrome

 Medication: sympathomimetic, oral contraceptives,

steroids

 Cocaine
Symptomatology

 nonspecific

 headache, vertigo, dizziness,

epistaxis, faintness, visual
disturbances, tinnitus, etc.
Particular Aspects
Management

DGN BP measurement

PREHYPERTENSION Measure BP in 6 months

AH STD I •X 2, in 1-2 weeks

•investig

AH STD II •Confirmation in 1 week

•investig
The most common causes of
hypertension by age
Age Causes
Neonate Thrombosis/stenosis of the renal artery, kidney
malformations, Co Ao, bronchopulmonary dysplasia

Infant-6ys renal parenchymal disease, coarctation of the aorta,

renal artery stenosis

6-10 ys renal parenchymal disease, renal artery stenosis,

essential HT

Adolescent renal parenchymal disease, essential HT, obesity

Renal AHT
 Can be estimated at 3 - 30% AHT in
adult, and between ½ - 2/3 in
children, being the most frequent
secondary AHT.
 There are 2 forms:
◼ renoparenchimal AHT
◼ renovascular AHT
Renoparenchimal AHT

 Renoparenchimal AHT
◼ In acute and chronic nephropathy
◼ There is a good corelation between volemy and
ABP, the diminished or absence of the plasmatic
renin and high total peripheral resistence.
◼ The most frequent renoparenchimal AHT are due
to:
 Acute or chronic glomerulonephrites
 Chronic atrophic pielonephrites,
 Renal polycystic disease
 Hydronephrosis
 Wilms and juxtaglomerular cell tumors
(hemangiopericitom)
 Collagen diseases and others
 Renovascular AHT
 1-2 % in all AHT in adult. ↑in children
 Low renal irigation due to the stenosis,
trombosis, oclusion or compresive tumor at
the renal artery, ↑ plasmatic renin,
hipovolemy and high neurogen activity.
 Renovascular AHT in children:
◼ Fibromuscular dysplasia, predominant in
female, at the 1/3 median or distal.
◼ In Recklinghausen neurofibromatosis with AH –
stenosis due to focal proliferation, predominant
intimal, at the renal and intrarenal artery.
Endocrine AHT
 Feocromocitoma
 Primary hyperaldosteronism (Conn
disease)
 Suprarenalian enzymatic deficits
 Hipercorticism
 Hiper and hipothyroidism
 Hiperparathyroidism
 Primary reninism
Feocromocitoma
 Neuroectodermal tumor
 With paroxistic high release of
cathecolamines
 In children – more frequent permanent
AHT and not intermittent
 Variable clinical manifestations:
◼ norepinefrins, most frequent- α adrenergic
manifestations (SHT,DHT, tahicardia),
◼ epinefrins- β adrenergic manifestations (SHT,
tahicardia, hipermetabolism, hiperglicemia,
anxiety, sometimes hypotension)
◼ dopamin, very rare, with normal or even low
ABP, tahicardia, diarhea, poliuria and nausea.
Cardiovascular AHT

Aortic coarctation = variable stenosis

of the aortic arch with the eccentric
lumen.
There are 2 types:
◼ Postductal or adult type, the most
frequent, with tight stenosis under the
arterial channel origin
◼ Preductal or infantil type, between the
subclavicular artery and arterial channel.
This type is frequent associated with
severe cardiovascular anomalies.
Investigations
 Basic tests:

◼ blood count,

◼ urea and serum

◼ creatinine,

◼ Urine,

◼ ENT examination,

◼ Chest X rays,

◼ ECG

◼ Ophtalmology examination

◼ Metab carbohydrate, lipid,

◼ ionogram serum, and urine possibly

◼ urine culture
Investigations
 Specific tests

◼ cardiac ultrasound,

◼ abdominal and renal Doppler aa ultrasound,

◼ arteriography,

◼ Hormonal Dosage: thyroid, plasma renin, plasma

aldosterone, urinary ionogram, cortisol levels, urinary
free cortisol, dexamethasone suppression test, serum
or urinary catecholamine dosage (Vanil mandelic
acid),
◼ Computed Tomography
AH in children – practical
approach

 What is it AH in children?
 Is it important?
 How should we measure?
 What should we look for?
 When should we treat? And how?
 HTA la copil - management
DGN BP measure General Therapy Medication

PRE- Measurement of •Manag Weight •If there is

AH BP in 6 months •Manag physical association with cr
activity and diet renal disease,
diabetyes, HF, LVH
AH STD I •X 2, in 1-2 IF – AH is
weeks ID simptomatic,
•investig secondary,
persistent
diabetes, target
organs implied
AH STD •in 1 week ID YES
II •investig
1.Care este greutatea?
2. Care este IMC?
3. Care este percentila corespunzatoare acestui IMC?
 >140/90 mmHg

>95th percentile for age, sex

and height

 Ex: M, 10 years old, TA

125/80 mmHg

➢ 99th SBP and

➢ > 95th DBP
1. Which is the weight? 1. 40.5 kg
2. Which is the BMI? 2. 24 kg/m2
3. Which is the corresponding percentile for the BMI? 3. ???
STEP 6
>95th - obesity
Nonpharmacologic treatment
 Lifestyle changes

 Weight loss - reductions in BP values 8-12 mmHg, 10% lower

BMI

 Regular physical activity

YES: dynamic or aerobic exercise
NO: static exercise

 Changes in diet

Sodium
Diet
Breast feeding
Indications for treatment
ST I

 Symptomatic hypertension
 Secondary hypertension
 Hypertension with target organ
damage
 Association of type 1 or 2 diabetes

 AH despite persistent non-

pharmacological measures
Antihypertensive medication
 Initiation - an antihypertensive at
minimum recommended dose,
preferably angiotensin converting
enzyme inhibitor (ACEI)
 ACEI (captopril, enalapril) - obesity
associated with AH
 Calcium channel blockers
 Thiazides diuretics
Antihypertensive medication

 “step-up” therapy
 Associations
 After achieving BP control -
measuring 6 months is a
candidate for "step down"
 Specific treatment
Pharmacological treatment (1)

One drug at minimum dose

 β adrenergic non-/selectiv antagonist
◼ propranololul (1-4 mg/kg/day)
◼ metoprololul (1-6 mg/kg/day)
 IECA
◼ captopril,0,3-6 mg/kg/day,
◼ enalapril-0,1-0,5 mg/kg/day,
 Calcium channels blockers
◼ nifedipin SR 0,25-3 mg/kg/day
Pharmacological treatment (2)
 Then the “step up” therapy
 In 2 weeks the BP – not controlled
◼ The second antihypertensive drug
 If the second drug is not enough
◼ The third even the fourth drug
 Diuretics can be associated: clorotiazid (20-30
mg/kg/day), hidroclorotiazid, 1-3 mg/kg/day,
spironolactona (1-3 mg/kg/day), furosemidul
(0,5-6 mg/kg/dose).
 Other classes of antihypertensive drugs can
be used now in children: blocker of the
angiotensin II receptors, losartan (0,7-1,4
mg/kg/day), irbesartan
 After stabilization ABP must be measured at 6
months and the „step down” can be tried.
Treatment of the emergency
hypertension

 Admitted
 DABP ≥120 mmHg.
 ABP must be reduced with 20-25% in first 8
hours, then ↓ gradualy, in weeks.
 Can be used the 2 ways
◼ parenteral or
◼ oral – calcium channel blockers, nifedipin, 0,2-0,5
mg/kg/dose (10 mg/dose)
 Parenteral:
◼ labetalol, in bolus 0,2-1 mg/kg/dose in 2 minutes
or in pev, 0,4-3 mg/kg/h
◼ Associated, if necessary, with sodiu nitroprusiat,
0,3-10 μg/kg/min in pev
◼ Others.