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Hypertension in Childhood: Diagnosis & Management

Hypertension in Childhood: Diagnosis & Management. Measuring BP in Children. Children >3 years old Preferred method: Auscultation with appropriate size cuff BP tables include 50 th , 90 th , 95 th , and 99 th percentiles by gender, age, and height (compiled by NHBPEP Task Forces)

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Hypertension in Childhood: Diagnosis & Management

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  1. Hypertension in Childhood: Diagnosis & Management

  2. Measuring BP inChildren • Children >3 years old • Preferred method: Auscultation with appropriate size cuff • BP tables include 50th, 90th, 95th, and 99th percentiles by gender, age, and height (compiled by NHBPEP Task Forces) • Confirm an elevated BP on at least 2 additional visits • Consider ABPM (portable 24hr BP device) in evaluating “white-coat” HTN, episodic HTN, CRD, DM, autonomic HTN, etc.

  3. Measuring BP in Children < 3 years • Hx of prematurity, very low BW, neonatal complication, NICU • Congenital heart disease • Recurrent URIs, hematuria, or proteinuria • Known renal disease or urologic malformations • FHx of congenital renal disease • Solid-organ transplant • Malignancy or bone marrow transplant • Treatment with drugs know to raise BP • Other systemic illnesses associated with HTN (neurofibramatosis, tuberous sclerosis, etc.) • Evidence of elevated intracranial pressure

  4. The Right Cuff

  5. CLASSIFICATION NORMAL: < 90th percentile PREHYPERTENSION Average SBP or DBP that are > 90th to < 95th percentile <OR> if BP >120/80 HYPERTENSION Average SBP and/or DBP that is > 95th for age, gender, and height on 3 separate occasions Stage I HTN: 95th-99th percentile + 5mm Hg Stage II HTN: > 99th percentile + 5mm Hg

  6. Causes of HTNin Children PRE-ADOLESCENCE ADOLESCENCE Primary hypertension 15%–30% 85%–95% Secondary hypertension 70%–85% 5%–15% Renal parenchymal disease 60%–70%  Coarctation of the aorta 10%–20%   Renovascular 5%–10%  Reflux nephropathy 5%–10%  Endocrine disorder 3%–5%  Tumors 1%–5%  Other causes 1%–5% 

  7. H I S T O R Y OSA

  8. P H Y S I C A L

  9. LABORATORY EVALUATION SCREENING TESTS UA and culture Electrolytes, Ca2+, Phos BUN/Cr, Uric Acid Lipids CBC with differential

  10. LABS cont’d . . . SPECIFIC TESTS Fasting insulin & glucose 24-hr urine protein and Cr Urine and serum catecholamines Hormone levels (thyroid, adrenal) ECHO RUS

  11. Labs cont’d . . . SPECIALIZED TESTS Plasma Renin activity and 24-hr urine Na RUS with Doppler of renal arteries Captopril Challenge Renal angiography with renal vein renins MRA Captopril renal scan Ambulatory blood pressure monitoring Renal biopsy

  12. MANAGEMENT • Educate • Incorporate patient AND family • Nonpharmacologic measures – Therapeutic LifestyleChanges • Antihypertensive Meds • Monitor for side effects and treatment response

  13. OVERVIEW NORMAL encourage healthy diet/sleep/exercise PRE-HTN Re-check in 6months TLC STAGE I Re-check 1-2wks - sooner if sx TLC. Initiate pharm tx if indicated STAGE II Evaluate within 1wk, immediately if patient with sx TLC + pharmacological tx.

  14. Therapeutic Lifestyle Changes Diet + Exercise = . . . • Weight loss in obese children results in reduction of both systolic and diastolic BP • Sustained aerobic exercise has a blood-pressure lowering effect in both normotensive and hypertensive persons • Whether excessive Na causes hypertension is still under debate; nonetheless, hypertensive persons benefit from reduction in their Na intake. • Let’s hear it for DASH (Dietary Approaches to Stop Hypertension)!!

  15. To Give or Not To Give ...MEDS…When to initiate pharmacological therapy • Symptomatic HTN • Stage II HTN • Stage I HTN refractory to nonpharmacologic therapy. • Target-organ damage (LVH, retinopathy, micoralbuminuria) • Stage I hypertension in patients with diabetes mellitus • CONSIDER if child has additional cardiovascular risks –dyslipidemia, smoking, obesity, family hx, etc.

  16. Choosing an Antihypertensive • “Pediatric clinical trials of antihypertensive drugs have focused only on their ability to lower BP and have not compared the effects of these drugs on clinical endpoints.” (NHBPEP Task Force) • Physician preference • Some diuretics and B-Blockers - long hx of safety/efficacy • Newer classes: ACEI, CCB, ARBs studied short term – safe and well tolerated • Antihypertensives specific to underlying condition or concurrent medical conditions (ACEI in DM, CCB or BB in child with migraines)

  17. Principles of Pharmacotherapy #1 Nonpharmacologic measures should be incorporated into every hypertensive child’s treatment plan #2 Drug therapy should be designed to MAXIMIZE compliance and minimize adverse effects #3 Stepped Care Approach #4 Step Down Therapy

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