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Childhood Hypertension

Childhood Hypertension. Hypertension Definition. Systolic or diasystolic systemic arterial blood pressure above normal for age. 5 to 10 mm Hg above 95 th % for weight and height for those in the 50 th %. Quick Formula for estimation of 95 th % BP: Under one year of age: 100/70

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Childhood Hypertension

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  1. Childhood Hypertension

  2. Hypertension Definition • Systolic or diasystolic systemic arterial blood pressure above normal for age. • 5 to 10 mm Hg above 95th % for weight and height for those in the 50th %. • Quick Formula for estimation of 95th% BP: • Under one year of age: 100/70 • Over one year of age: • Systolic BP: 100 + 2(Age) • Diasystolic BP: 70 + 1.5 (Age)

  3. The Fourth Task Force Report on Pediatric High Blood Pressure

  4. Correct Measurement • Blood Pressure Cuff • Length: 2/3rd of the arm from the olecronan to acromion. (2/3rd length of humerus) • Bladder (rubber bag) of the BP cuff needs to cover the entire circumference of the upper arm

  5. Infant Blood Pressure Readings • Infants (12 months and below) • Use a Doppler ultrasound device • BP cuff still needs to remain 2/3rd length of humerus and rubber bag needs to fit the circumference of arm. • No Leg Blood Pressure standards exist and DO NOT use • Leg Blood Pressure check only for checking Coarctation of aorta

  6. Please Note! ONE MOST COMMON CAUSES OF APPARENT HYPERTENSION IS ERRONEOUS MEASUREMENT FROM USING TOOSMALL A BLOOD PRESSURE CUFF!

  7. Childhood Hypertension Chart

  8. http://www.statcoder.com/growthcharts.htm

  9. Stage 2 Hypertension > 5 mm above 99%le Stage 1 Hypertension 95% to 5 mm above 99%le Pre-Hypertension 90-95% le Normal < 90% le

  10. Disease Prevalence in Childhood • Congenital heart disease 1% • Epilepsy 3-5% • ADHD 3-5% • Asthma 7% • Hypertension 4-5% • Obesity 18-25%

  11. Age-Related Hypertension • Neonate and Infants • Renal Artery Thrombosis • Umbilical venous and arterial catheter • Renal Malformations • Bronchopulmonary Dysplasia and Abdominal Surgeries • Coarctation of Aorta • Drugs • Increased Intracranial Pressure • Infections, bleeding and tumors

  12. Top Causes of Hypertension in the School Age Child Chronic UTIs Glomerular Disease Renovascular Disease Aortic Coarctation Essential Hypertension 78 % 12 % 2%

  13. Age-Related Hypertension • Adolescents • Essential Hypertension • Obesity • Illegal Drugs • Renal Parenchymal Disease • Renal Artery Stenosis • Birth Control Pills

  14. Zebras of Childhood Hypertension • Immobilization Syndrome: Prolonged bed rest and traction • Guillian-Barre Syndrome • Hypercalcemia • Acute intermittent porphyria • Mercury and Lead Poisoning • Cyclic Vomiting • Hypervitaminosis A or D • Neurofibromatosis

  15. Single Mutation Hypertension

  16. GENES

  17. Work Up: Hypertension • History • Family history of Hypertension • Drug Use and OTC medication • History of Urinary Infections: Reflux Nephropathy • Prescribed Medications • History of Lead Exposure • Weight Gain or loss • Symptoms of palpitations, sweating, headaches, heat intolerance, and nausea and vomiting

  18. Rule of Thumb #1 The Younger the Patient with Hypertension, the More Likely you’ll find a Cause

  19. Rule of Thumb #2 • The Higher the Blood Pressure, • the more likely there’s a cause

  20. Arm & Leg BPs B • What’s Normal? • A = B = C • A = B > C • A = B < C • A > B > C • What’s Normal? • A = B = C • A = B > C • A = B < C • A > B > C A C

  21. Eye Grounds

  22. Young Stage 1 or Stage 2 Renin Catecholamines Angiogram Urine Steroids + Teenager Stage 1 RFP Urinalysis Renal Ultrasound + Labs & Imaging Pre-Hypertension Lipids Fasting Glucose Echocardiogram Retinal Exam

  23. Pre-Hypertension Lipids Fasting Glucose Echocardiogram Retinal Exam LVH on an echocardiogram is the most common end-organ manifestation in pediatric hypertension Essential hypertension almost always occurs with other risk factors

  24. Teenager Stage 1 RFP Urinalysis Renal Ultrasound Quantitate any abnormal urine protein There’s no normal creatinine in pediatrics, but there is a normal GFR. Renal vessel doppler are of questionable value.

  25. Young Stage 1 or Stage 2 Renin Catecholamines Angiogram Urine Steroids Plasma renin is usually uninterpretable. Elevated urine catecholamines are usually transient and not subtle. Don’t bother with MRAs or nuclear scans; the gold standard is an angiogram.

  26. Ambulatory Blood Pressure Monitor

  27. Work Up: Hypertension • Physical Examination • Obesity • Steriod-Related: Buffalo Hump, Striae, virilization • Café-au-lait spots; elfin facies and mental retardation • Papilledema • Displaced Left ventricular Apex • Abdominal Mass • Bruits

  28. Work-up: Hypertension • Lab • Chem 10: electrolyte pattern and renal function • Hypernatremia, hypokalemic and metabolic alkalosis: Mineralocorticoid excess • Urinanalysis: renal parenchymal disease • Thyroid Studies • 24 hour Norepinephrine urine and metaphrines: Pheochromocytoma • VMA, HMA and catholamines: Neuroblastoma

  29. Work-up Hypertension • Radiology • Renal US with Doppler flow: RAS and renal anomalies • CT angiogram or MRI/MRA: RAS and Neuroblastoma • CT Head: Increased IC pressure

  30. Hypertensive Emergencies • Severe Hypertension • Above 99th percentile • End organ damage • Headache, blurred vision, seizures, papilledema, congestive heart failure or renal failure • Treat Immediately!

  31. Left Ventricular Hypertrophy • Most common manifestation of end-organ damage in pediatric hypertension

  32. Target-organ abnormalities are detectable in hypertensive children and adolescents. • LVH reported (51 g/m2.7) in 34-38% of children with mild, untreated HTN with high correlation to BP and in particular ABPM • Working Group Recommendations: • Echocardiographic assessment of LV mass should be performed at diagnosis of HTN and periodically thereafter. • The presence of LVH is an indication to initiate or intensify antihypertensive therapy. • NO STUDIES HAVE BEEN DONE TO DEMONSTRATE REGRESSION WITH THERAPY AS YET (one completed and results pending)

  33. Hypertension and CKD Progression NAPRTCS CRI Database: • CrCl < 75ml/min/1.73m2 • HTN: >95th % (Task Force) • Normotensive: n=1987 (52%) • Hypertensive: n=1874 (48%) • Endpoint: • ↓ CrCl by 10 ml/min/1.73m2 • Renal replacement therapy P<0.001 58% 49% Mitsnefes et al, J Am Soc Nephrol 2003

  34. NewHTN patients (n=53) and NTN controls (n=33)HTN defined as BP > 95th percentile, and overweight BMI >25 kg/m2

  35. Recognizing or ruling out a hypertensive emergency is the 1st order of business in any hypertension evaluation.

  36. Vasodilators Sodium Nitroprusside IV gtt Hydralazine IV Minoxidil po Nifedipine po Nicardipine IV Enalapril IV Cardiac Labelatol IV Esmolol IV Emergency Medication

  37. Stepwise Approach • Weight Loss • Low Sodium Diet • Increase Cardiovascular Activity • Medications

  38. The DASH Diet • Daily Nutrient Goals Used in • the DASH Studies • (for a 2,100 Calorie Eating Plan) • Total fat 27% of calories • Sodium 2,300 mg* • Saturated fat 6% of calories • Potassium 4,700 mg • Protein 18% of calories • Calcium 1,250 mg • Carbohydrate 55% of calories • Magnesium 500 mg • Cholesterol 150 mg • Fiber 30 g • * 1,500 mg sodium was a lower goal tested and found to be even better for • lowering blood pressure. It was particularly effective for middle-aged and older • individuals, African Americans, and those who already had high blood pressure. • g = grams; mg = milligrams

  39. DASH Studies • Quick effect (within 2 weeks) • Low sodium, high potassium

  40. Treatment of Pre-Hypertension • The TROPHY Trial • RCT of adults with BPs <140/90 • Placebo vs. candesartan (ARB) • At 2 years, 13% vs 40% had HTN (p<0.001) • At 4 years, 53 vs 63% had HTN (p=0.007) • TROPHY Jr.

  41. Hypertension Medication • Arteriolar smooth muscle: relaxation • Direct smooth muscle relaxation • Minoxidil and hydralazine • Angiotension-renin (blockage) enzyme • ACE-Inhibitor: Captopril and enalapril • Angiotension receptor blockage • ARB: Cozaar(Losartan) • Calcium channel Blockage • Nifepidine and isradipine

  42. Hypertension Medication • Medulla or central mediated (CNS) • Clonidine • Alpha Adrenergic receptor blockade • Phenolamine, prasozin, and labelatol • Beta Adrenergic receptor blockade • Propranolol and labelatol • Sodium Retention and Fluid Overload • Thiazide, furosemide, spirolactone

  43. Pharmacologic Therapy Normal None Prehypertension Do not initiate therapy unless there are compelling indications such as chronic kidney disease (CKD), diabetes mellitus, heart failure, left ventricular hypertrophy (LVH). Stage 1 hypertension Initiate therapy based on indications Stage 2 hypertension Initiate therapy Classification of Hypertension in Childrenand Adolescents: Therapy Recommendations All patients to receive Therapeutic Life-style Changes (TLC)

  44. Recent Pediatric Phase III or IV Antihypertensive Programs • AstraZenecaFelodipine (Plendil)*Metoprolol (Toprol-XL)# Candesartan (Atacand) • Bristol-Myers Squibb Fosinopril (Monopril)**Irbesartan (Avapro)# • Boehringer Ingelheim Telmisartan (Micardis) • CibaGenevaBenazepril (Lotensin)# • MerckEnalapril (Vasotec)*Lisinopril* (Prinivil/Zestril)Losartan (Cozaar)* • NovartisValsartan (Diovan) • Parke-DavisQuinapril (Accupril)# • PfizerAmlodipine (Norvasc)*Eplerenone (Inspra) • SankyoOlmesartan (Benicar) • Wyeth-Ayerst/KingBisoprolol-HCTZ (Ziac)*Altace (Ramipril) • ESCAPE Trial* Germany Ramipril in CKD, proteinuria and BP Meta-analysis in progress *published # completed; not yet published

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