An Approach To Hypertension In Children
Dr. Dipti Devi*
MD (Ped) FISN (Ped Nephro) FIPNA (Ped Nephro) Asso Prof Pediatrics SMCH *
Introduction
The prevalence of hypertension (HTP) in children is increasing. Symptomatic HTP almost always reveal a cause after careful diagnostic evaluation. Overweight, male gender and positive family history are some of the risk factors for HTP in children. Early development of atherosclerosis does exist in children and may be associated with HTP. Mild HTP in older children and adolescent may lead to essential HTP in adults. So, detection of and early intervention is important to reduce long-term health risk.
Methods
A standardized method of blood pressure measurement is the most essential prerequisite of defining HTP. Auscultatory method is the gold standard of all methods with available normative data for sex, age and height. It consists of the following steps in succession:
  • A relaxed, comfortable child after at least 3-5 minutes rest.
  • Sitting position with right arm at the heart level.
  • An accurate mercury sphygmomanometer with appropriate cuff (length 80-100% and breadth 40% of arm circumference) applied snugly to the upper arm.
  • Mercury column is raised to 20-30 mm of Hg above the radial artery occlusion level.
  • Bladder is deflated 2-3 mm at a time.
  • Korotkoff sound I represents the systolic blood pressure and sound 5 represents the diastolic blood pressure.
  • The measurement is repeated 3 times and average is taken.
Definition

Normal - SBP and DBP < 90th percentile
Pre-hypertensive - SBP/DBP = 90th percentile or = 120/80 mm in adolescent
Hypertensive - SBP/DBP = 95th percentile
State 1 - SBP/DBP 95-99th percentile + 5 mm
State 2 - SBP/DBP = 99th percentile + 5 mm
Blood Pressure Values
Once the child is found to be hypertensive, it is repeated at least thrice next week to confirm. However, it is difficult to differentiate white coat HTP by this method. Ambulatory oscillometric blood pressure measurement differentiate true HTP from white coat HTP by absence of early morning dipping (10% reduction), average day and night measurement (15-30 minutes each) and persistence outside the doctor's clinic. In neonates, infants and uncooperative child, an automated oscillometric method or in a sick child, an invasive blood pressure monitoring following arterial catheterization may be required; but these measurements are not standardized against normative data as by auscultator method.
Causes of Hypertension

< 6 yrs Renal parenchymal, Renovascular
Endocrine
Coarctation of aorta
Essential
6-12 yrs Renal parenchymal
Essential
Renovascular
Endocrine
Coarctation of aorta
Drugs
12-18 yrs Essential
Drugs
Renal parenchymal
Endocrine
Coarctation of aorta
Family history parents usually have vague aches and pains and psychological problem.
Age it is seen in children between 4-14 years, mean age of onset being 5-10 years.
Evaluation
A detailed history, focused physical examination and investigations as required often reveal the cause of hypertension in children. The goal of evaluation is to identify the cause, co-morbid conditions and end organ damage.
Hypertensive urgency (blood pressure > 99th percentile) should be treated and blood pressure should be lowered to a safe level within 12-24 hrs. Hypertensive emergency (blood pressure > 99th percentile + end organ damage in the form of encephalopathy, LVH, CCF, MI, proteinuria or retinal vascular change) should be immediately referred to a higher center for prompt and adequate management.
Initial long-term management of stage I HTP should be with family centered lifestyle modifications as follows:

Low salt < 1.2 gm/d for 4-8 yrs old
< 1.5 gm/d for older
5-20 mm reduction / 10 kg wt loss
2-8 mm reduction
Food habits Low fat diary
Fresh fruit, vegetables
Increased Ca, K intake
8-14 mm reduction
Physical activity Regular daily exercise for 30 min 4-9 mm reduction
Indications of long term antihypertensive drugs are:
  Symptomatic HTP
Secondary HTP
End organ damage
Diabetic
Stage I HTP with failed life style modifications for 6 months
Stage 2 HTP


CCB and ACEI are the most commonly used drugs in children. The goal of therapy is to reduce blood pressure to < 95th percentile without co-morbid conditions and < 90th percentile with co-morbid conditions and to protect the end organs from long-term consequences of persistent HTP. It is recommended that blood pressure should be checked at each visit in a child of > 3 yrs of age. In children less than 3 yrs of age with PT, SFD, family history, increased ICP, CHD, CKD and drugs known to cause HTP, at least one blood pressure value should be available. Awareness of the physician is the key factor for diagnosis and management of hypertension in children especially in asymptomatic children.

Key message - Blood pressure assessment needs awareness of the attending physician to diagnose hypertension early and to prevent its short-term and long-term consequences.
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Devi D D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=39
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