Post on 21-Oct-2020
Hypertension in Children
Prof. Dr. Farkhanda Hafeez
M.B.B.S, D.C.H, M.C.P.S, F.C.P.S (Pak), MCCEE (Canada)Consultant
Paediatric Nephrologist
Introduction
HTN a Global issue- Major risk for CVD
Currently affects 3-4% of children
Pre HTN more prevalent and affects 10-15% of youth
Children > Sec HTN
Primary inc - over last two decades- linked to Obesity
HTN is defined as average SBP and/or DBP that is ≥ 95th percentile for gender, age, and height on three or more separate occasions.
In children younger than 1 year of age, SBP has been used to define HTN.
National High Blood Pressure Education Program(NHBPEP) Working Group
Method:
Taken on three separate occasions in a controlled environment
Preferably in the right arm with the cubitalfossa at heart level when the patient is seated
Has rested quietly for 5 min
Avoided stimulant drugs, foods, or activities like video games.
The inflatable bladder of the cuff, not the entire cuff, should be an appropriate size for the patient.
The bladder width should be approximately 40 % of the arm circumference midway between the acromion and olecranon.
The length of the bladder should cover 80–100 % of the circumference of the arm without overlapping.
The bladder width-to-length ratio should be at least 1:2.
STAGING OF HTN
Factors Influencing Blood Pressure
Age Birth Weight Gender Prematurity Height
Breast Feeding Obesity /Uric Acid Nephron Number Physical Activity Salt intake
Race and Ethnicity Family History Environment Genetics Sleep-Disordered Breathing Epigenetics Emotional/Mental stress
Primary Hypertension
For those hypertensive individuals without underlying secondary causes.
uncommon, accounting for less than25 % of hypertensive children (1990)
Recently up to 90% in US.
Many children develop PH as manifestation of obesity.
Primary HTN is a multifactorial disorder
Primary HTN
Causes of Secondary HTN :Renal
Poor Urinary Stream
Polyuria / Polydipsia
Resp. Distress
Growth failure
Bony Deformities
Unexplained pallor
Abdominal Pain/
Passage of Gravel
Swelling/ Rash/ Jt pain
Oligo/Polyhydramnios
Inherited Causes (Monogenic)
Hypertension in Dialysis Patients
Hypertension After Renal Transplantation
Coarctation of the Aorta
Vasculitis
Endocrine Diseases
Hypertension in Pulmonary Diseases
(BPD, Sleep Apnea)
Hypertension in Neurologic Disorders
Drug-induced hypertension
Neonatal HTN:
Incidence 1.3-2%
( Flush, osillometer, Intra arterial Transducer)
B. P > 95%tile on three separate occasions
Renal thromboemboli sec to Umbilical vascular access, PCKD.
Right to Left shunts (VSD, PDA), Co-arctation
Acute cortical Necrosis (Birth Asphyxia, Sepsis)
Circulatory Shock ( RVT, AKI)
BPD ( Na & Water Retention)
ICH, Iatrogenic, Pain
Evaluation
FMD / NF1 / Takayasu William Turner
Management of HTN
Goals of Therapy
In asymptomatic children, the NHBPEP recommends achieving the target BP of:
Non-pharmacologic & Lifestyle Measures :pre-hypertension or stage 1 HTN.
Pharmacologic Therapy Stage I HTN (95th–99th percentile plus 5 mmHg)
who are unresponsive to changes in lifestyle Stage II HTN: (>99th percentile plus 5 mmHg). Symptomatic HTN: including headaches, changes
in mental process or consciousness , or irritability. Secondary HTN. Evidence that the high BP is causing end-organ
damage
Pharmacotherapy
primary Secondary
ARB/ACEI
P.H & TachycardiaNon cardio-selective β Blockers
(Carvedilol)
Obese & Metabolic syndβ Blocker/vasodilator
(Nebivolol)
CarbenoxoloneBlocks 11 β HSD1 which converts
inactive Glucocorticoids - Cortisol
GN : Diuretics ± CCB
CKD:ARBs/ACEI ± Diuretics
(Ramipril)
Combination of ACEI+ CCB
(Benazopril+Amlodipine)
Avoid Thiazide diuretics if GFR< 30 / Cr > 1.5mg/dl
RAS bilateral/ unilateral with solitary kidney- ARB Contraindicated
Neonates
> 99%tile 95-99%tile
Short acting I.V to reduce B.P< 95%tile
CCB ( Nicardipine)
β Blockers ( labetalol, Esmalol)
Na Nitropruside
Not able to Absorb:
Hydralazine / Labetalolbolus
Who can absorb:
Short acting CCB-Isradipine
Long ActingCCB – less suitable
Avoid ACEI & β Blockers
Prevention
Children ≥ 3 years have their B.P checked at every clinic visit.
Awareness about prevalence of HTN in association with obesity.
Information on dietary and life style modification.
Improvement in prenatal & natal care.
Early detection of Sec HTN.
Timely management to prevent end organ damage.
Sequelae of HTN
LVH
Non dipping & M.H - inc LVMI & PreHTN
Inc cIMT - Measure of atherosclerosis
Retinal arteriolar narrowing
Microalbuminuria even nephrotic range
Sys. HTN predictor of progression of CRI
Arterial stiffness
Cognitive impairment