HTN

Dr. Nariman Fahmi

Evaluation and management of hypertension in children

Objectives

Why Hypertension is important in Pediatrics. Definition ,classifications ,causes and the association Between Childhood Obesity and Hypertension. How to Evaluate and Manage Hypertension in Your Practice

Complications of Hypertension:End-Organ Damage

Chobanian AV, et al. JAMA. 2003;289:2560-2572.
Peripheral Vascular Disease
Renal Failure, Proteinuria
LVH, CHD, CHF
Hemorrhage, Stroke
Retinopathy
CHD = coronary heart disease CHF = congestive heart failure LVH = left ventricular hypertrophy
Hypertension
Hypertension Online www.hypertension.org

Hypertension Definitions

Normal BP: Both systolic and diastolic BP < 90th % for age, gender, and height

What does this percentile mean?2

Normal
<90th
Prehypertension
90-<95th or if >120-80
Stage 1 hypertension
95th-99th plus 5 mm Hg
Stage 2 hypertension
>99th plus 5 mm Hg

Measuring BP in Children

Choose appropriate cuff for body size (not just age). Child should be quiet and calm for 3-5 minutes prior to measurement. Cuff or stethoscope bell should be at heart level. Record BP 2-3 times and take the average for the best estimate.

Measurement of BP in Pediatrics

Main source of error – Using wrong cuff sizeSmall cuff- overestimates BP Large cuff- underestimates BP

HTN Etiology by Age

Acta Paediatr 1992 81(3):244-6

Conditions associated with hypertension in children

RENAL 1.Multicystic dysplastic kidney 2.Chronic pyelonephritis 3.reflux nephropathy

VASCULAR

Coarctation of thoracic or abdominal aorta Renal artery lesions (stenosis, fibro muscular dysplasia, thrombosis, aneurysm) Umbilical artery catheterization with thrombus formation Neurofibromatosis (intrinsic or extrinsic narrowing for vascular lumen) Renal vein thrombosis Vasculitis


ENDOCRINEHyperthyroidismHyperparathyroidismCongential adrenal hyperplasia (11β-hydroxylase and 17-hydroxylase defect)Cushing syndromePrimary aldosteronism



CENTRAL NERVOUS SYSTEM Intracranial mass Hemorrhage

Pediatric Symptoms

Hypertension is often thought of as a silent disease because typically there have not been any classic symptoms


unless the pressure has been rising rapidly, HPT. does not produce symptoms Headache Dizziness Epistaxis Anorexia visual changes seizures may occur in hypertensive encephalopathy which suggested by the presence of vomiting, temperature elevation, ataxia, stupor, and seizures

Therapeutic Lifestyle Changes

If obese, make a goal to gradually get BMI < 85% Set realistic, achievable, pace of weight loss. Exercise: Moderate to vigorous aerobic activity for 40 min, 3-5 days/week Diet: Avoid sugary foods/drinks and saturated fats. Less salt. Eat fruit, vegetables, lean meats and whole grains. 50/50 plate Involve the whole family as partners.


Angiotensin converting enzyme inhibitor (ACEI ) (ex. Captopril,enalapril,lisinopril) Block the conversion of angiotensin I to II (potent vasoconstrictor) 0.5-2 mg/kg/day every 8 hours Side effect : Hyperkalemia, neutropenia, dry cough, rash


Ca channel blockers (ex:Nifedipine ,amlodipine) Interfere with calicum ion influx into the vascular smooth muscle cells lead to vasodilatation (dose of nifedipine 0.25-0.5 mg/kg/dose every 4-6 hours) Side effect :odema,Headache, dizziness, tachycardia, hypotension



Diuretics ex.Furosemide,Thiazide ,SpironolactoneIncrease water and salt excretionFurosemide …….. 0.5-2 mg/kg/dose 2x Thiazide …….. 5-10 mg/kg/dose Spironolactone …… 1-3 mg/kg/dose by Side effectfrusemide→hypokalemia, hyperglycemia thiazidehypokalemia, rash, hyperglycemia spironalactone ----hyperkalemia,gynaecomastia, rash


β-adrenergic antagonists (ex.Propranolol,atenolol,metoprolol)Block B receptors ,Reduce the heart rate and cardiac output maximally during exerciseDose (0.5-2 mg/kg/day every 6-12 hours)Side effects GIT disturbance, bradycardia, bronchospasm, sleep disturbance, depression


Direct vasodilatorsex,Hydralazine dose (0.2–0.6 mg/kg/doseShould be given every 4 hours when given iv bolus). Side effects SLE like picture, lymphadenopathy, fever, arthritis ,headache, dizziness, confusion Sodium nitoprusside IV infusion 0.53–10 mcg/kg/min Monitor cyanide levels with prolonged (>72 hr) use or inrenal failure; or coadminister with sodium thiosulfate

Thank you