Professional Documents
Culture Documents
+ + Definitions
Pediatric
Pediatrics Adults
Normal BP SBP or DBP <90th SBP <120
Hypertension
percentile for age DBP <80
Pre-hypertension SBP or DBP 90-95th SBP 120-139
percentile for age DBP 80-89
OR BP>120/80
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Estimated Incidence of Pediatric Methods of BP Evaluation
Hypertension (HTN)
Auscultatory measurements- sphygmomanometer and stethoscope
Basis for BP tables
35% Patient should sit quietly for 5 minutes with his or her back supported, feet on the
floor and right arm supported at heart level
30.0%
30% Cuff size should be at least 2/3 distance from acromion to olecranon
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Chart of Office versus ABPM Causes of Pediatric Hypertension
Office BP Measurement
Primary or Essential Hypertension
Normal High Most common form of HTN and is a diagnosis of exclusion
Common at all ages
Ambulatory BP Measurement
Secondary Hypertension
7% 3% For all age groups, renal parenchymal or renovascular causes together
account for ~60-90% of secondary causes
Sustained
Masked HTN More frequent in:
High HTN
Younger children
10% 25%
Children with a greater degree of BP increase at the time of initial
diagnosis
Blue= patients at healthy checkups
Green= patients referred for elevated BP
Portman 2005, Brady 2009
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+ Differential Diagnosis of +
Common Causes of HTN by Age
Secondary Causes of HTN
Infants Children Adolescents
Malignancy 3% Miscellaneous Obstructive Sleep Apnea, SNS
Wilms’ , Neuroblastoma, 5% abnormalities, intracranial 1-6 y 7-12 y
Pheochromocytoma pressure, Drugs/medications
Thrombosis of Renal artery Renal Essential HTN
Coarctation of renal artery or vein stenosis parenchymal
Aorta 2% disease Renal
Endocrine 5%
Congenital renal Renal parenchymal
Corticosteroid excess, anomalies parenchymal Renovascular disease
mineralocorticoid excess, disease abnormalities
thyroid disease, hypercalcemia Renal Coarctation of Endocrine causes
from hyperparathyroidism Parenchymal Aorta Wilms tumor Endocrine
80%
causes
Renovascular Acute and chronic
glomerulonephritis, Bronchopulmonary Neuroblastoma
10% Parenchymal scar, dysplasia Essential HTN
Renal artery stenosis in main Polycystic Kidney Coarctation of
or branched arteries, Disease, CKD
aorta
midaortic syndrome
Rodrigues-Cruz 2011
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Clinical and Laboratory Clinical and Laboratory
Assessment of Children with HTN Assessment of Children with HTN
Important History Elements:
Symptoms suggestive of endocrine etiology (weight loss, sweating, flushing Important Physical Exam Elements
etc.)
Four extremity pulses and BP
History of prematurity and/or placement of umbilical artery/vein catheter;
neonatal course; birth weight (all hypothesized to predict HTN) Moon facies, truncal obesity, buffalo hump
History of UTI Retinopathy
Symptoms of Obstructive Sleep Apnea Thyromegaly
Medications including steroids, decongestant/cold prep, OCP, NSAIDs, Skin lesions (café-au-lait spots, neurofibromas, adenoma
stimulants, βadrenergic agonists, EPO, cyclosporine/tacrolimus, tricyclic sebaceum, striae, hirsutism, butterfly rash, purpura)
anti-depressants, recent discontinuation of antihypertensive
Evidence of CHF
Nutritional Supplements
Abdominal mass, abdominal bruits
Family history of HTN, early cardiovascular or cerebrovascular events, ESRD
Edema
Diet (caffeine, salt intake)
Smoking/drinking/illicit drugs
Physical Activity
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Clinical and Laboratory Clinical and Laboratory
Assessment of Children with HTN Assessment of Children with HTN
Laboratory Evaluation:
Imaging:
Specific tests may vary by clinic location and patient population
Renal ultrasound with Doppler examination of the renal vasculature
To rule out renal disease and chronic pyelonephritis:
Echocardiography including measurement of LVMI
Basic metabolic panel (electrolytes, BUN, HCO3, creatinine)
Renal arteriography: severe HTN or failure to control BP with one drug
Urinalysis
Urine Culture
CBC to rule our anemia which could be consistent with CKD
Fasting lipids and glucose
Other Tests:
Thyroid function tests Retinal Exam: severe cases
Plasma renin activity: very young with Stage 1 and children with Stage 2 Assessment of catecholamines: United States NO versus Europe YES
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ECHO 17.0%
Urinalysis 3.0%
BUN/creatinine 0.0%
Management algorithm. AMC = Apparent mineralocorticoid excess; GRA = Glucocorticoid remedial aldosteronism; VMA =
0% 10% 20% 30% 40% 50% 60% 70% Vanillylmandelic acid.
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General Therapeutic Practice Guidelines for Pediatric
Recommendations for Pediatric HTN BP Monitoring
All healthy children ≥3 years of age and children younger
than 3 with certain comorbid conditions (e.g. prematurity,
low birth weight, kidney disease, congenital heart disease)
should have their BP measured at all physician visits
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Non-pharmacological Interventions Pharmacological Intervention:
Who Should Get Drugs?
Suggested for all patients with
The 2004 NHBPEP guidelines indicate pharmacological therapy in
prehypertension and hypertension
children with one or more of the following conditions:
Most patients with pediatric Symptomatic HTN (e.g. headache, seizures, changes in mental status,
primary HTN should have a trial of focal neurological complaints, visual disturbances, CV complaints)
non-pharmacologic management Stage 2 HTN
prior to starting drug treatment Stage 1 HTN (without any evidence of target-organ damage) that
persists despite a trial of 4-6 months of non-pharmacologic therapy
Loss of 10-15 lbs (4-7 kg) is
Hypertensive target-organ damage, most often LVH
sufficient to achieve a meaningful
reduction in BP Stage 1 HTN with diabetes mellitus or other CVD risk factors such as
dyslipidemia
Physical activity with increased HR Stage 1 HTN with family history of premature CVD
for 30-40 minutes, 3-4x/wk can Prehypertension in presence of comorbid conditions, such as chronic
lead to a demonstrable drop in BP kidney disease or diabetes mellitus
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+ + References
Prognosis
Baracco R, et al. Prediction of primary vs secondary hypertension in children. Off J of Amer Soc of HTN 2012; 14:316-321.
Brady TM, Feld LG. Pediatric approach to hypertension. Sem Neph 2009; 29:379-388.
There is very little data available on the natural history of Chobanian AV, et al. NHBPEP Coordinating Committee. 7th report of the Joint National Committee on prevention, detection, evaluation and treatment of
high blood pressure. Hypertension 2003; 42:1206-1252.
primary HTN in children so it is impossible to predict the long-
term outcomes of untreated HTN in children and adolescents Flynn JT. Pediatric hypertension update. Curr Opin Neph Hyperten 2010; 19:292-297.
Lurbe E, et al. Prevalence, persistence, and clinical significance of masked hypertension in youth. Hypertension 2005; 45: 493-498.
One small study in Iceland demonstrated a correlation between
childhood SBP and the development of coronary artery disease NHBPEP Working Group on High BP in Children and Adolescents. The 4th report on the diagnosis, evaluation, and treatment of high blood pressure in
children and adolescents. Pediatrics 2004; 114:555-576.
in adulthood
Portman RJ, et al. Pediatric hypertension: diagnosis, evaluation, management, and treatment for primary care physicians. Curr Probl Pediatr Adolesc
Health Care 2005; 8:262-294.
LVH occurs in ~33% of children and adolescents with mild, Rodrigues-Cruz E. (2011, December 9). Pediatric hypertension. Retrieved July 2012, http://emedicine.medscape.com/article/889877-overview
untreated HTN
Stabouli S, et al. White-coat and masked hypertension in children: association with target-organ damage. Pediatr Nephrol 2005; 20: 1151-1155.
Preventing end organ damage including vascular changes, Stergiou, et al. White-coat hypertension and masked hypertension in children. Blood Press Monit 2005; 10: 297-300.
cardiac damage and renal effects should be the goal of
treatment for pediatric hypertensive patients Trachtman H. Short- and long-term physiologic and pharmacologic control of blood pressure in pediatric patients. Integ Blood Press Contr 2011; 4:35-
44.
Urbina E, et al. Ambulatory BP monitoring in children and adolescents: recommendations for standard assessment. Hypertension 2008; 52: 433-451.
Wiesen J, et al. Evaluation of pediatric patients with mild-to-moderate hypertension: yield of diagnostic testing. Pediatric 2008; 122:e988-e993.
Flynn 2010, NHBPEP 2004