Pediatrics: HTN Flashcards
When do you begin BP screening?
At 3 (when you stop measuring head size, start doing BP)
What is normal BP determined by?
Age and gender as compared to the nomogram determined by the national heart, lung, and blood institute (last updated in 1996)
What is blood pressure?
CO * PVR
What normal BP for peds?
Systolic and diastolic uner 90% for age, height, and gender
What is pre-HTN for peds?
Average systolic and/or average diastolic BP between 90-95 percentiles for age, height, and gender
What is HTN in peds?
Average systolic and/or diastolic BP greater than or equal to the 95th % for age, height, and gender with measurements on at least 3 separate occasions
What 4 things are required for HTN Dx?
- Exclude errors of measurement
- Ensure proper interpretation
- In the same location
- Consistent method
What is stage 1 HTN?
95-99% for age, hieght, and gender
What is stage 2 HTN?
Greater than 99% + 5mmHg for age, height, and gender
What are 4 errors of measurement?
- Use of inappropriate cuff sizes
- Poor auscultation technique
- Use of unvalidated/uncalibrated monitorying device
- Improper use of nomogram (harriet-Lane Handbook)
What are 4 errors in ensuring proper BP interpretation
- Improper use of nomogram
- Use of improper nomogram
- Lack of use of nomogram
(Nomograms available in the Harriet Lane Handbook
What is the prevalence of pediatric HTN in the US?
Under 1%
What % of HTN children require medication?
Under 0.1%
What % of HTN children are symptomatic?
Less than 0.1%
In the US, what ethnic groups does pediatric HTN affect most?
- Mexican American
2. Non-hispanic black children
What are 4 RF for pediatric HTN?
- Ethnicity
- Gender
- Family history
- BMI
What is the classification based on for peds HTN?
ETIOLOGY
- Primary/essential
- Seconday
What % of peds HTN is primary?
10%
Primary is no identifiable cause…Dx of exclusion
Is primary peds HTN familial?
YES
What is the most common cause of HTN in adolescence?
Primary
What % of peds HTN is secondary?
90%
What are the 2 most common reasons for secondary HTN (remember, secondary HTN has an identifiable cause)?
- 70-80% renal
- 10% cardiac and endocrine
- Meds
What are the possible etiologies for neonate HTN?
- Coarctation of the Aorta
- Renal Artery Thromboembolism
- Renal Artery Stenosis
- Congenital Renal Abnormalities
- Hyperthyroidism
- Neoplasia
- Iatrogenic
- CNS causes
- Bronchopulmonary Dysplasia
What are the possible etiologies for HTN in infants to 6 years?
- Renal Parenchymal Disease
- Coarctation of the Aorta
- Renal Artery Stenosis
- Neoplasia
- Iatrogenic
What are the possible etiologies for HTN in 6-10 years?
- Renal Parenchymal Disease
- Renal Artery Stenosis
- Endocrinopathy
- Obesity
- Neoplasia
What are the possible etiologies for HTN in adolescence?
- Renal parenchymal disease
- Endocrinopathy
- Obesity
- Meds/drugs
What is the number 1 cause of secondary HTN in children?
Renal- Generally reflux nephropathy secondary to undiagnosed vesicoureteral reflux
What history is important to get for pediatric HTN?
- Family history of HTN
- Family history of endocrinologic disorders
- Trauma
- Medication use
What medications might contribute to pediatric HTN?
- Corticosteroids
- OCPs
- Alcohol
- Nicotine
- NSAIDS
- Lead/toxins
- Illicit drug use
What are special consideration in ROS for ped HTN?
- Epistaxis
- Headache
- Blurry vision
- Weight gain or loss
- Flushing
- Chest pain
- History of urinary tract infections
- Neonatal history
What should be part of the PE for pediatric HTN?
- Body habitus, growth curves, BMI: Adrenal dysfunction or growth failure secondary to renal dysfunction
- Dysmorphisms
- Integumentary exam for neurocutaneous stigmata: Neurofibromatosis
- Moon facies, Buffalo hump: Cushing
- Fundoscopic exam
- Proptosis
- Cardiovascular exam for murmurs, rubs, gallops, femoral/peripheral pulses (F/U with echo)
- Abdominal exam for masses, bruits, hepatosplenomegaly
- Genitalia for virilization or ambiguity (adrenal dysfunction)
- Neurologic exam for any deficits
For workup of ped HTN, what should all patients have?
- Urinalysis
- Urine culture
- Serum electrolytes, BUN, creatinine, calcium, uric acid, cholesterol/lipid panel
- CBC
- Echocardiogram
- Renal ultrasound
What are some other evaluations that may need to be done for pediatric HTN based on history and physical examination?
- VCUG
- DMSA Renal Scan
- Urine for Catecholamines and Metanephrines
- Plasma Renin Activity
- Aldosterone levels
- Renal Angiogram
- Renal Vein Renin Sampling
- MIBG Scan
- Renal Biopsy
What are 3 treatment goals for pediatric HTN?
- Identify those with secondary HTN and refer appropriately
- Identify comorbidities and address them (like increased weight)
- Identify patients requiring medication
What should be done for asymptomatic significant HTN (>95%)?
- Nonpharmacologic intervention: Lifestyle changes
2. Consider medication if no improvement over several weeks
What should be done for significant HTN with end organ damage (abnormal kidney function, ocular exam, ect.)?
Pharmacologic and nonpharmacologic interventions
What should be done for symptomatic HTN (malignant)?
Emergency intervention
What is the main goal in treatment of pediatric HTN?
Gradual reduction of BP to avoid symptoms of decreased perfusion (don’t go too fast)
What are long term goals of ped HTN treatment?
- Achieve BP below the 90% for age, height, and gender
- Prevent further end organ damage
- Reduce the CV risk
What are some nonpharmacologic interventions for ped HTN?
- Weight reduction
- Sodium restriction (under 2g a day) –> NATURAL FOODS)
- Exercise
- Avoidance of alcohol
- Avoidance of attributable medications
- Avoidance of tobacco use / passive smoke exposure
If your patients bp was 90-95% or 120/80 on 3 occasions what do you do and when do you re-evaluate?
- Lifestyle modifications
- 6 month re-check
If your patients BP was greater than 95% on 3 occasions what do you do?
Begin evaluation for secondary causes
*You need 3 high BP values unless in malignant HTN range
What does the choice of medication and route depend on?
- Age of patient: School age versus teen
- Etiology of HTN
- Severity of HTN
- Volume status of patient: Physically active, perhaps dehydrated and a diuretic would be bad
- Presence of associated heart failure
- Presence of renal impairment
- Presence of compromised cerebrovascular blood flow
What is the most common drug given for pediatric HTN?
Hydrochlorothiazide
What is the one major concern when prescribing hydrochlorothiazide?
VOLUME STATUS
-If your patient is athletic or outside a lot you worry about volume depletion and dehydration wtih a diuretic…besides this, this works well
What is the second most common drug given for pediatric HTN?
ACEi
What are the 6 categories of drugs that can be given for pediatric HTN?
- Hydrochlorothiazide
- ACEi
- CCB
- BB
- Diuretic
- Nitroprusside
What should be done at regular-follow for patients with pediatric HTN?
- Measure and assess adequacy of control
- Evaluate for end organ damage
- Examine for previously undetected etiologies/syndromes
- Counsel of importance of BP control
- Educate about lifestyle, diet, exercise, etc.
What are the NHBPEP guidlines for pre-HTN in kids?
Lifestyle changes
What are the NHBPEP guidelines for pre-HTN and comorbidity in kids?
Lifestyle and pharmacologic
What are the NHBPEP guidelines for stage 1 asymptomatic HTN in kids?
Lifestyle initially, then add pharmacologic if unsuccessful with lifestyle
What are the NHBPEP guidelines for stage 1 with CVD, symptoms or end organ damage and stage 2 HTN in kids?
Lifestyle and pharmacologic
What is the choice of medication for primary HTN without end-organ damage?
Hydrochlorothiazide
What is the choice of medication for HTN and chronic kidney disease or HTN and diabetes mellitus?
ACEi/ARB
When do you just observe HTN in infants
When systolic BP is 95th to 99th %
When do you initiate pharmacologic therapy in infants?
When BP is greater than 99%, in those with symptoms, or end-organ involvement
What are general thoughts on drugs for HTN in infants?
- Avoid ACEi in less than 44 weeks to prevent damage to developing renal structures
- Avoid BB in lung disease
What is the duration of therapy for infant HTN dependent on?
THE CAUSE
