The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents Flashcards
What is the definition of hypertension?
Average sBP and/or dBP >/= 95th percentile for age, sex, and height on three or more occasions
What is the definition of prehypertension in children?
Average sBP or dBP 90-95th percentile
What is the definition of prehypertension in adolescents?
Average BP >/= 120/80mmHg
What is the definition of white coat hypertension?
Patient with BP >95th percentile in a physician’s office or clinic, who is normotensive outside a clinical setting. Requires ambulatory BP monitoring to diagnosis
When should children have BP screened with medical visits?
> 3yo
What is the preferred method of BP measurement?
Auscultation with appropriate sized cuff
What conditions should children <3yo have BP measured?
- History of prematurity, very low birthweight, or other neonatal complication
requiring intensive care - Congenital heart disease (repaired or nonrepaired)
- Recurrent urinary tract infections, hematuria, or proteinuria
- Known renal disease or urologic malformations
- Family history of congenital renal disease
- Solid organ transplant
- Malignancy or bone marrow transplant
- Treatment with drugs known to raise BP
- Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc.)
- Evidence of elevated intracranial pressure
What is the definition of stage 1 hypertension?
95th to 99th percentile plus 5mmHg
What is the definition of stage 2 hypertension?
> 99th percentile plus 5mmHg
What is the definition of prehypertension?
90th to 95th percentile or if BP exceeds 120/80mmHg even if below 90th percentile
What is the recommended frequency of BP measurement for children with prehypertension?
q6m
What is the recommended frequency of BP measurement for children with stage 1 hypertension?
Recheck in 1-2w if symptomatic, if persistently elevated on 2 additional occasions, evaluate or refer within 1m
What is the recommended frequency of BP measurement for children with stage 2 hypertension?
Evaluate or refer within 1w or immediately if patient is symptomatic
What is the recommended management of prehypertension?
- Weight management counselling if overweight
- Introduce physical activity and diet management
- No pharmacologic therapy unless compelling indications such as CKD, DM, heart failure or LVH
What is the recommended management of stage 1 hypertension?
- Weight management counselling if overweight
- Introduce physical activity and diet management
- Pharmacologic therapy if compelling indications such as CKD, DM, heart failure or LVH or other indications
What is the recommended management of stage 2 hypertension?
- Weight management counselling if overweight
- Introduce physical activity and diet management
- Pharmacologic therapy
What are indications for antihypertensive drug therapy in children?
- Symptomatic hypertension
- Secondary hypertension
- Hypertensive target-organ damage
- Diabetes type 1 and 2
- Persistent hypertension despite non-pharmacologic measures
What evaluations for identifiable causes should be done in all children with persistent BP >95th percentile?
- History including sleep history, family history, risk factors, diet, habits such as smoking and drinking alcohol
- Physical examination
- BUN, Cr, lytes, urinalysis and urine culture
- CBC
- Renal US
What patients should have evaluation for comorbidity with fasting lipid panel and fasting glucose?
- Overweight patients with BP 90-94th %ile
- All patients with BP >95th %ile
- Family history of hypertension or cardiovascular disease
- Child with chronic renal disease
What patients should have a drug screen performed?
History suggestive of possible contribution of substances or drugs
What patients should have polysomnography performed?
History of loud, frequent snoring
What patients should receive evaluation for target-organ damage?
Patients with comorbid risk factors and BP 90-94th %ile
All patients with BP >95th %ile
How should patients be evaluated for target end-organ damage?
- Echocardiogram to r/o LVH
- Retinal exam to r/o retinopathy
- Urine for microalbuminuria is not routinely indicated
What additional evaluation should be done as indicated in young children with stage 1 hypertension or adolescent with stage 2 hypertension?
- Plasma renin determination
- Renovascular imaging (renal scan, MR angiography, duplex doppler flow studies, 3D CT, arteriography (DSA or classic)
- Plasma and urine steroid levels
- Plasma and urine catecholamines
When should ambulatory BP monitoring be done?
Patients in whom white-coat hypertension is suspected, and when other information on BP pattern is needed
What are some secondary causes of hypertension?
- Hyperthyroidism
- Pheochromocytoma
- Neuroblastoma
- Coarctation of the aorta
- Sleep disordered breathing
- Chronic renal failure
- Cushing syndrome
- Insulin resistance syndrome
- Williams syndrome
- Turner syndrome
- Anabolic steroid abuse
- Neurofibromatosis
- Tuberous sclerosis
- SLE
- Type 2 DM
- Collagen-vascular disease
- End stage renal disease
- Wilms tumor
- Renal artery stenosis
- PCKD
- Hydronephrosis
- Multicystic dysplastic kidney
- Adrenal hyperplasia
- Hyperaldosteronism
25 Liddle syndrome
What therapeutic lifestyle changes are recommended?
- Weight reduction is primary therapy for obesity related hypertension
- Prevention of excess or abdominal weight gain will limit future increases in BP
- Regular physical activity and restriction of sedentary activity will assist in weight management and may prevent an excess increase in BP over time
- Dietary modification should be encouraged in children with pre-hypertension and hypertension
- Family based intervention improves success
What are the recommendations regarding pharmacologic therapy of childhood hypertension?
- Indications for antihypertensive drug therapy in children include secondary
hypertension and insufficient response to lifestyle modifications. - Recent clinical trials have expanded the number of drugs that have pediatric dosing information. Dosing recommendations for many of the newer drugs are provided.
- Pharmacologic therapy, when indicated, should be initiated with a single drug.
Acceptable drug classes for use in children include ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium channel blockers, and diuretics. - The goal for antihypertensive treatment in children should be reduction of BP
to <95th percentile, unless concurrent conditions are present. In that case,
BP should be lowered to <90th percentile. - Severe, symptomatic hypertension should be treated with intravenous antihypertensive drugs
What are the most useful antihypertensive drugs for management of severe hypertension?
Esmolol (beta-blocker): SE profound bradycardia
Hydralazine (vasodilator)
Labetalol (alpha and beta blocker): contraindicated in asthma and overt heart failure
Nicardipine (CCB) SE reflex tachycardia
Sodium nitroprusside (vasodilator) SE: monitor cyanide levels if >72h use or in renal failure or co-administer sodium thiosulfate
What is a hypertensive emergency?
Hypertension accompanied by signs of encephalopathy and seizure
What is the treatment for hypertensive emergency?
IV antihypertensive, decrease 25% in first 8h and then normalize over 26-48h
What is a hypertensive urgency?
Less serious symptoms such as severe headache or emesis
