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Guidelines > The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents > Flashcards

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents Flashcards

1
Q

What is the definition of hypertension?

A

Average sBP and/or dBP >/= 95th percentile for age, sex, and height on three or more occasions

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2
Q

What is the definition of prehypertension in children?

A

Average sBP or dBP 90-95th percentile

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3
Q

What is the definition of prehypertension in adolescents?

A

Average BP >/= 120/80mmHg

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4
Q

What is the definition of white coat hypertension?

A

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

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5
Q

When should children have BP screened with medical visits?

A

> 3yo

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6
Q

What is the preferred method of BP measurement?

A

Auscultation with appropriate sized cuff

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7
Q

What conditions should children <3yo have BP measured?

A
  1. History of prematurity, very low birthweight, or other neonatal complication
    requiring intensive care
  2. Congenital heart disease (repaired or nonrepaired)
  3. Recurrent urinary tract infections, hematuria, or proteinuria
  4. Known renal disease or urologic malformations
  5. Family history of congenital renal disease
  6. Solid organ transplant
  7. Malignancy or bone marrow transplant
  8. Treatment with drugs known to raise BP
  9. Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc.)
  10. Evidence of elevated intracranial pressure
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8
Q

What is the definition of stage 1 hypertension?

A

95th to 99th percentile plus 5mmHg

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9
Q

What is the definition of stage 2 hypertension?

A

> 99th percentile plus 5mmHg

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10
Q

What is the definition of prehypertension?

A

90th to 95th percentile or if BP exceeds 120/80mmHg even if below 90th percentile

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11
Q

What is the recommended frequency of BP measurement for children with prehypertension?

A

q6m

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12
Q

What is the recommended frequency of BP measurement for children with stage 1 hypertension?

A

Recheck in 1-2w if symptomatic, if persistently elevated on 2 additional occasions, evaluate or refer within 1m

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13
Q

What is the recommended frequency of BP measurement for children with stage 2 hypertension?

A

Evaluate or refer within 1w or immediately if patient is symptomatic

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14
Q

What is the recommended management of prehypertension?

A
  1. Weight management counselling if overweight
  2. Introduce physical activity and diet management
  3. No pharmacologic therapy unless compelling indications such as CKD, DM, heart failure or LVH
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15
Q

What is the recommended management of stage 1 hypertension?

A
  1. Weight management counselling if overweight
  2. Introduce physical activity and diet management
  3. Pharmacologic therapy if compelling indications such as CKD, DM, heart failure or LVH or other indications
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16
Q

What is the recommended management of stage 2 hypertension?

A
  1. Weight management counselling if overweight
  2. Introduce physical activity and diet management
  3. Pharmacologic therapy
17
Q

What are indications for antihypertensive drug therapy in children?

A
  1. Symptomatic hypertension
  2. Secondary hypertension
  3. Hypertensive target-organ damage
  4. Diabetes type 1 and 2
  5. Persistent hypertension despite non-pharmacologic measures
18
Q

What evaluations for identifiable causes should be done in all children with persistent BP >95th percentile?

A
  1. History including sleep history, family history, risk factors, diet, habits such as smoking and drinking alcohol
  2. Physical examination
  3. BUN, Cr, lytes, urinalysis and urine culture
  4. CBC
  5. Renal US
19
Q

What patients should have evaluation for comorbidity with fasting lipid panel and fasting glucose?

A
  1. Overweight patients with BP 90-94th %ile
  2. All patients with BP >95th %ile
  3. Family history of hypertension or cardiovascular disease
  4. Child with chronic renal disease
20
Q

What patients should have a drug screen performed?

A

History suggestive of possible contribution of substances or drugs

21
Q

What patients should have polysomnography performed?

A

History of loud, frequent snoring

22
Q

What patients should receive evaluation for target-organ damage?

A

Patients with comorbid risk factors and BP 90-94th %ile

All patients with BP >95th %ile

23
Q

How should patients be evaluated for target end-organ damage?

A
  1. Echocardiogram to r/o LVH
  2. Retinal exam to r/o retinopathy
  3. Urine for microalbuminuria is not routinely indicated
24
Q

What additional evaluation should be done as indicated in young children with stage 1 hypertension or adolescent with stage 2 hypertension?

A
  1. Plasma renin determination
  2. Renovascular imaging (renal scan, MR angiography, duplex doppler flow studies, 3D CT, arteriography (DSA or classic)
  3. Plasma and urine steroid levels
  4. Plasma and urine catecholamines
25
Q

When should ambulatory BP monitoring be done?

A

Patients in whom white-coat hypertension is suspected, and when other information on BP pattern is needed

26
Q

What are some secondary causes of hypertension?

A
  1. Hyperthyroidism
  2. Pheochromocytoma
  3. Neuroblastoma
  4. Coarctation of the aorta
  5. Sleep disordered breathing
  6. Chronic renal failure
  7. Cushing syndrome
  8. Insulin resistance syndrome
  9. Williams syndrome
  10. Turner syndrome
  11. Anabolic steroid abuse
  12. Neurofibromatosis
  13. Tuberous sclerosis
  14. SLE
  15. Type 2 DM
  16. Collagen-vascular disease
  17. End stage renal disease
  18. Wilms tumor
  19. Renal artery stenosis
  20. PCKD
  21. Hydronephrosis
  22. Multicystic dysplastic kidney
  23. Adrenal hyperplasia
  24. Hyperaldosteronism
    25 Liddle syndrome
27
Q

What therapeutic lifestyle changes are recommended?

A
  1. Weight reduction is primary therapy for obesity related hypertension
  2. Prevention of excess or abdominal weight gain will limit future increases in BP
  3. Regular physical activity and restriction of sedentary activity will assist in weight management and may prevent an excess increase in BP over time
  4. Dietary modification should be encouraged in children with pre-hypertension and hypertension
  5. Family based intervention improves success
28
Q

What are the recommendations regarding pharmacologic therapy of childhood hypertension?

A
  1. Indications for antihypertensive drug therapy in children include secondary
    hypertension and insufficient response to lifestyle modifications.
  2. Recent clinical trials have expanded the number of drugs that have pediatric dosing information. Dosing recommendations for many of the newer drugs are provided.
  3. 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.
  4. 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.
  5. Severe, symptomatic hypertension should be treated with intravenous antihypertensive drugs
29
Q

What are the most useful antihypertensive drugs for management of severe hypertension?

A

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

30
Q

What is a hypertensive emergency?

A

Hypertension accompanied by signs of encephalopathy and seizure

31
Q

What is the treatment for hypertensive emergency?

A

IV antihypertensive, decrease 25% in first 8h and then normalize over 26-48h

32
Q

What is a hypertensive urgency?

A

Less serious symptoms such as severe headache or emesis

Guidelines (13 decks)

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