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HYPERTENSION in children : summarized


HYPERTENSION

Dr Nimrah Shehzadi

Defined as
           "Systolic and diastolic blood pressure that is > or =95th percentile  for age,sex and height on atleast 3 readings" , or systolic blood pressure of 130 mmHg in any child taken thrice.
Prehypertension :
        "Systolic or diastolic BP that are >90th percentile but <95th percentile"
Children to be evaluated :                                                                       
Every child >3 yr old
Child <3yr of age with the following risk risk factor: Hx
      prematurity
      Congenital heart disease
      Renal disease
      Solid organ transplant
      Cancer
      Drugs raising bp
       Neurofibromatosis
       Tuberous sclerosis
       Raised intracranial pressure
Etiology :
Renal abnormalities ( chronic glomerulonephritis,reflux obstuctive nephropathy,hemolytic uremic syndrome,polycystic or dysplastic renal diseases )
Vascular (coarctation of aorta ,renal artery stenosis,umbilical artery catherization,neurofibrosmatosis,renal vein thrombosis,vasculitis,
Endocrine (hyperthyroidism ,hyperparathyroidism,CAH,cushing syndrome,primary aldosteronism)
CNS (raised intracranial pressure due to intracranial mass,hemorrhage,brain injury)
Clinical manifestations :
Asymptomatic
Headache
vomiting
Dizziness
Epistaxis
Anorexia
Visual changes
Seizures
Hypertensive encephalopathy(headache,vomiting, temperature elevation,visual disturbances,ataxia,depressed level of consciousness,CT abnormalities,seizures)
Malignant hypertension (cardiac failue,pulmonary edema,renal dysfunction,Fits)
Hypertensive crisis : decreased vision(retinal hemorrhage)papilledema, encephalopathy(headache,seizures, depressed level of consciousness),heart failure,accelerated deterioration of renal function
Investigations:
Urine analysis/culture
S/E (sodium,potassium, phosphate,calcium)
Blood urea and serum Creatinine
Abdominal USG(renal )
Fasting BSL and lipid profile
Echocardiography(LVH,coarctation of aorta)
Total cholesterol and HDL, LDL  levels
Abdominal angiography (vascular lesions of renal artery)
Measurement of VMA in 24 hours urine
CT brain may be indicated.
Prevention: by avoidance of
Obesity
Elevated serum cholesterol levels
High dietary sodium intake
Sedentary lifestyle
Alcohol and tobacco use
TREATMENT
Non-Pharmacologic: Aerobic exercise, salt restriction,weight loss.
Pharmacologic treatment: it is indicated when there is target organ damage, diabetes mellitus , and persisten hypertension despite non-pharmacologic measures.
A single drug or a combination of two or more drugs can be used depending upon the situation, commonly used drugs are as follows,
ACE inhibitors (captopril)                                          0.3mg-0.5mg/kg/dose x tds
     
B-Receptor blocker (propranolol)                               0.025-0.1mg/kg/day x tds
Calcium Channel Blockers (nifedipine)                     0.2-0.5mg/kg/day xbd or qid

Diuretic  (furosemide)                                                                 0.5-2mg/kg/dose every 4-6 hourly

Vasodilators            
Hydralazine,                                                   0.25mg/kg/day
Nitropruside                                                    0.5-10 g/kg/min 1/v infusion

Management of hypertensive crises
The blood pressure should be reduced 1/3rd of total planned reduction during Ist 6 hour and remaining over 48-72 hours.
Give i/v hydralazine :
0.1 mg/kg/dose IV as infusion over 20 mins ( may need to be added 4 Hrly or 6 hrly )

Monitor B.P before giving the drug.
Consult seniors for further management.

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