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.