REMEMBER

  • Systemic hypertension when present, usually indicates the underlying disease.
  • Blood pressure(BP) that is consistently above the 95th percentile for age requires further evaluation
  • Checking BP should be part of the routine annual examination in children >3 years of age.

 

Classification

  • Normal BP < 90th centile for age and height

  • Pre-hypertension- 90th to 95th centile for age and height

  • Stage 1 Hypertension- 95th to 99th centile for age and height

  • Stage 2 Hypertension – Above > 99th centile for age and height

 

Conditions Associated with Transient or Intermittent Hypertension in Children

RENAL

  • Acute postinfectious glomerulonephritis

  • Henoch-Schönlein purpura 

  • Hemolytic-uremic syndrome

  • Acute tubular necrosis

  • After renal transplantation (immediately and during episodes of rejection)

  • Hypervolemia

  • After surgical procedures on the genitourinary tract

  • Pyelonephritis

  • Renal trauma

  • Leukemic infiltration of the kidney

  • Obstructive uropathy associated with Crohn disease

 

DRUGS/ MEDICATIONS –

  • Oral contraceptives

  • Sympathomimetic agents

  • Corticosteroids and adrenocorticotropic hormone

  • Antihypertensive withdrawal

  • Vitamin D intoxication

 

CENTRAL NERVOUS SYSTEM CAUSES –

  • Increased intracranial pressure

  • Guillain-Barré syndrome

  • Burns

  • Posterior fossa lesions

  • Porphyria

  • Encephalitis

 

OTHER CAUSES

  • Fractures

  • Chronic airway disease

  • Electrolyte imbalance- Hypercalcemia

 

EXAMINATION- Look out for below findings-

PHYSICAL EXAMINATION-

  • Height, weight, body mass index

 

Features suggestive of syndromes

  • Neurofibromatosis

  • Multiple endocrine neoplasia

  • Turner/ William/ Marfan/ Cushing/ hyperthyroidism/ congenital adrenal hyperplasia

 

 Cardiovascular examination

  • Pulse and BP (both arms and legs)

  • Bruits/murmurs – heart, abdomen, flanks, back, neck, head

  • Signs of left ventricular hypertrophy or cardiac failure

 

Abdomen Masses –

  • Wilms/ neuroblastoma/ pheochromocytoma/ cystic kidney disease/ obstructive uropathy

  • Hepatosplenomegaly

 

Neurological examination

Fundoscopy for hypertensive changes

 

BLOOD INVESTIGATIONS 

  • Full blood count

  • Renal functions and calcium

  • Fasting plasma glucose

  • Serum lipids

  • Fasting serum triglycerides

  • Plasma renin activity

  • Plasma aldosterone concentration

URINE TESTS-

  • Urinalysis (quantification of microalbuminuria and proteinuria)

  • Urine and plasma catecholamines or metanephrines

  • Urinary free cortisol/steroid analyses

  • Molecular genetic studies

OTHER TESTS-

More sophisticated tests that should await results of above screening

  • Chest Xray

  • ECG and echocardiography

  • Renal ultrasound/ Color Doppler

  • Renal vein renin measurements

  • Renal angiography

  • Computed tomography/ Magnetic resonance imaging

 

MANAGEMENT-

AIMS OF TREATMENT-

  • To reduce blood pressure < 95th percentile for age.

  • Both medical and lifestyle changes are important.

  • If lifestyle changes like weight reduction, reduction of salt intake, regular exercise don’t help, then medications are considered

 

bp

DRUG TREATMENT-

ARTERIAL VASODILATORS

  • Example- Hydralazine/ Sodium nitroprusside/ Minoxidil

ADRENERGIC ANTAGONISTS-

  • Example- Esmolol/ Phentolamine/ Prazosin/ Propranolol/ atenolol/ labetalol

RENIN ANGIOTENSIN INHIBITORS

  • Example- Captopril/ Enalapril

CALCIUM CHANNEL BLOCKERS

  • Example-Nifedipine/ Amlodipine

DIURETICS

  • Example- Furosemide/ Bumetanide

 

MEDICATIONS BASED ON CAUSE OF HYPERTENSION-

Refer local kidney guidelines before starting treatment.

If excessive activity of renin-angiotensin-aldosterone system

  • Beta-blockers (propranolol) for suppression of renin secretion,

  • ACE inhibitor (captopril or enalapril)

  • Aldosterone antagonist (spironolactone).

ACE inhibitors used in –

  • In high-renin hypertension (renovascular disease)

  • Excess angiotensin production (neonates -occlusion of renal vessel by thrombus)

Use ?-Adrenergic blocking agents like phentolamine, phenoxybenzamine in 

  • Neural crest tumours which cause high catecholamines.

Consider Beta blockers to –

  • Also control heart rate.

  • In essential hypertension.

  • In high-renin/ high cardiac output

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes:

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>