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Hypertension In Children

Hypertension In Children. October, 2003. What are we doing here? 1. The Whys and Whats of hypertension. Importance, epidemiology, definition. 2. The Hows of testing. Technique, cuff size. 3. The Evaluation. Coexisting disease, sustained, organ damage,

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Hypertension In Children

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  1. HypertensionIn Children October, 2003

  2. What are we doing here? 1. The Whys and Whats of hypertension. Importance, epidemiology, definition. 2. The Hows of testing. Technique, cuff size. 3. The Evaluation. Coexisting disease, sustained, organ damage, curable, benefit from tx, acute vs chronic? 4. The Treatment. Meds, lifestyle

  3. The Whys and Whats

  4. Effects of Hypertension Sustained elevated blood pressures associated with LVH, and chronic macro and micro-vascular injury – kidneys, brain, heart, peripheral vasculature. Acute elevations associated with encephalopathy, renal dysfunction/failure, CHF, stroke in otherwise healthy organs.

  5. Prevalence • 1 - 3% of children have hypertension • increases in adolescents • 9 - 30 % of adults (and maybe 90% eventually?)

  6. Blood Pressure Standards 1996 Update on the 1987 task force report on high blood pressure in children and adolescents Standard tables based onage, sex, and height Pediatrics 88(4):649-658, 1996

  7. Interpretation of Blood Pressure Normal < 90 %tile High Normal 90 - 95 %tile Hypertension > 95 %tile

  8. Classification of Hypertension • Significant 95 - 99 %tile • no acute target organ injury • Severe > 99 %tile

  9. Blood Pressure Guestimates – 95th percentile Blood Pressures for a 50th percentile Child Systolic BP at 1 to 17 years = 100 + (age in years x 2) Diastolic BP at 1 to 10 years = 60 + (age in years x 2) Diastolic BP at 11 to 17 years = 70 + (age in years) Somu et al Arch Dis Child 2003; 88:302

  10. Severe Hypertension (99th percentile) – add 8 With two caveats: Is it chronic or acute? Is there acute or chronic end organ damage? As always, you treat the patient and not the number.

  11. The Hows of Testing

  12. The Right Cuff • Bladder width 40% of arm circumference measured midway between olecranon and acromion • Cuff should cover 80-100% of upper arm circumference

  13. Standard Position • Patient seated • 3-5 minutes rest • Right arm supported • Brachial artery at heart level

  14. Thigh BP • Supine • Cuff guidelines as for arm

  15. Korotkoff Sounds • K4 muffling • K5 disappearance • Age limitations

  16. Evaluation Sustained, coexisting disease, organ damage, curable, benefit from tx, acute or chronic?

  17. Sustained? • take your time to evaluate if hx and physical do not suggest an acute, escalating problem • repeated bp checks with appropriate cuff in office or at home • consider abpm

  18. Patient ROS • abdominal pain, dysuria, frequency, nocturia, enuresis, cola colored urine, polyuria (intrinsic renal) • joint pain or swelling, fatigue, rash, Raynaud’s (autoimmune) • headaches, dizziness, epistaxis, visual problems • weight loss, sweating, pallor, fever, palpitations (catecholamine secreting tumor, thyroid) • muscle cramps, weakness, constipation (hyperaldosteronism with hypokalemia)

  19. PMH/Social Hx • Umbilical artery catheter • Substance abuse - steroids, cocaine • Medications - steroids, amphetamines, sympathomimetics, oral contraceptives, calcineurin inhibitors, NSAIDS • Herbals – ma huang/ephedra

  20. FamilyHistory • hypertension • myocardial infarction • cerebrovascular disease • diabetes mellitus • hyperlipidemia • pheochromocytoma • polycystic kidney disease

  21. Physical Examination • general pallor and edema (renal disease) • low leg pressures & high arm pressures (coarctation of the aorta) • bruits (renovascular disease or arteritis) • café-au-lait spots or neurofibromas (neurofibromatosis) • moon facies, buffalo hump (Cushing syndrome)

  22. Physical Examination - 2 • Bell palsy, neurologic deficits • fundi with a-v nicking, arteriolar narrowing, flame lesions • features of Turner syndrome • features of Williams syndrome

  23. Etiology: Newborn • Renal artery thrombosis • Renal artery stenosis • Renal vein thrombosis • Congenital renal abnormalities • Coarctation of the aorta • Bronchopulmonary dysplasia

  24. Etiology: 1 to 6 years • Renal parenchymal diseases • Coarctation of the aorta • Renal artery stenosis

  25. Etiology: 6 to 10 years • Renal artery stenosis • Renal parenchymal disease • Essential hypertension

  26. Etiology: Adolescence • Essential hypertension • Obesity • Renal parenchymal disease • Renal artery stenosis

  27. Nephropathy Renal Malformation Obstructive Nephropathy Pyelonephritis Segmental hypoplasia Renovascular Wilms’ Tumor Trauma Metabolic (cystinosis, oxalosis) Renal Causes of Secondary HTN in Children

  28. CVCauses of Secondary HTN in Children • Aortic Coarctation • Patent Ductus Arteriosus • Renal Artery Stenosis • Arteriovenous Fistula • Aortic Insufficiency • Polycythemia • Takayasu’s Arteritis

  29. Obesity Pheochromocytoma Hyperthyroidism Congenital Adrenal Hyperplasia 17-hydroxylase Deficiency Primary Hyperaldosteronism Cushing’s Syndrome EndocrineCauses of Secondary HTN in Children

  30. Causes of Secondary HTN in Children Neurogenic Tumors • Neurofibromatosis • Neuroblastoma Central Nervous System • Increased Intracranial Pressure • Dysautonomia

  31. Causes of Secondary HTN in Children • Drug Exposure • Sympathomimetic agents • Glucocorticoids • Fracture immobilization • Scoliosis repair • Burns • Heavy metal exposure (lead, cadmium) • Scorpion bites

  32. Tailor Evaluation History and Physical Examination Age of patient Severity of disease

  33. Evaluation: High Normal • Family History • Social History • tobacco use • drugs • Examination • weight • target organ injury

  34. Evaluation: Phase I • Serum electrolytes • BUN and creatinine • Urinalysis and culture • Echocardiography • + Hematocrit, plasma lipids • + Renal ultrasound with doppler

  35. Evaluation: Phase II • plasma renin/aldo • catecholamines • 24 hour urine • plasma

  36. Evaluation: Phase III Directed by history, physical and prior studies • VCUG, DMSA • Renal biopsy for nephropathy • CT or MRI for tumor

  37. Evaluation: Phase III continued • steroid suppression/stimulation • adrenal scintigraphy/MIBG • renal angiography for renal artery stenosis

  38. Reasons to consider arteriogram Severe resistant hypertension without other etiology Increased PRA with normal noninvasive tests Bruit Solitary kidney with severe hypertension

  39. Renal ArteriographyTrachtman et al, P. Neph 14:816-819 Abnormal Normal (N=12) (N=16) Age 11.8 11.5 Sex (M:F) 6:6 6:10 Race (W:B:O) 5:5:2 9:6:1 Duration (mo) 12.1 9.8 Peak BP 182/113 175/102 Creatinine 1.1 1.0 Prior Rx 4 5 Abnormal imaging studies Renal US 5/9 1/9 Renal scan 2/3 2/3

  40. Chronic TherapyNon-pharmacologic Primary hypertension • weight control • exercise • stress reduction • dietary (salt and calories) • elimination of contributory medications • smoking cessation

  41. Chronic TherapyPharmacologic • Diuretics • Beta-adrenergic blockers • Angiotensin converting enzyme inhibitors • ARB’s • Calcium channel blockers • Vasodilators • Alpha-1-adrenergic blockers • Alpha-2-agonists • Selective aldosterone antagonists (Eplerenone) • Dopamine-1 agonist (Fenoldopam)

  42. Diuretics • Concerns • Lipid disorders • Contraindications • salt wasting nephropathy • athletes in hot weather • Reserve for those with Renal Disease • Thiazide - GFR 50 - 100 % • Furosemide - GFR < 50% • Aldactone - Hyperaldosterone states • Nephrotic syndrome, CHF, Liver failure

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