Overview
Definition:
Pediatric hypertension is defined as a systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) that is greater than or equal to the 90th percentile for age, sex, and height on three separate occasions
Stage 1 hypertension typically refers to SBP or DBP between the 90th and 95th percentiles, or between 120-129 mmHg SBP for adolescents
Stage 2 hypertension refers to SBP or DBP greater than or equal to the 95th percentile plus 5 mmHg, or >130 mmHg SBP for adolescents.
Epidemiology:
The prevalence of hypertension in children is increasing, estimated to affect 3-5% of children and adolescents
This prevalence rises with age, becoming more common in adolescence
Secondary causes are more frequent in younger children, while essential (primary) hypertension becomes more prevalent in older children and adolescents, often linked to obesity.
Clinical Significance:
Untreated pediatric hypertension poses a significant risk for the development of cardiovascular disease (CVD) in adulthood, including left ventricular hypertrophy, kidney damage, and cerebrovascular events
Early detection and management are crucial to prevent long-term morbidity and mortality
Understanding the staging helps guide the intensity of investigation and management.
Clinical Presentation
Symptoms:
Asymptomatic is common
Headaches, often occipital and worse in the morning
Visual disturbances like blurred vision or transient visual loss
Dizziness or lightheadedness
Nausea or vomiting
Epistaxis (nosebleeds)
In severe cases, seizures, altered mental status, or chest pain.
Signs:
Elevated blood pressure readings on multiple occasions
Funduscopic examination may reveal papilledema, hemorrhages, or cotton wool spots in severe cases
Cardiac examination may reveal a loud aortic component of S2 or an apical impulse displaced laterally
Palpable pulses may be bounding
Abdominal bruits may suggest renal artery stenosis
Findings suggestive of underlying conditions like coarctation of the aorta (femoral pulses weaker than brachial) or endocrine disorders.
Diagnostic Criteria:
Blood pressure measurements should be taken using appropriate cuff size, with the child at rest, after a 3-5 minute quiet period, and with the child seated
Readings are classified based on age, sex, and height percentiles according to established guidelines (e.g., American Academy of Pediatrics (AAP) guidelines)
Three separate elevated readings are required for diagnosis.
Diagnostic Approach
History Taking:
Detailed birth history (prematurity, low birth weight)
Family history of hypertension, early cardiovascular disease, kidney disease, or diabetes
Dietary habits (high sodium, processed foods)
Physical activity levels
Sleep patterns (snoring suggesting sleep apnea)
Medications (steroids, decongestants, OCPs)
Symptoms suggestive of secondary causes: fever, rash, abdominal pain (renal disease)
sweating, palpitations, headaches (pheochromocytoma)
polyuria, polydipsia (endocrine).
Physical Examination:
Accurate BP measurement in both upper and lower extremities
Assess height and weight for BMI and plotting on growth charts
Careful cardiac exam for murmurs, rubs, and displaced PMI
Assess peripheral pulses for equality and character
Funduscopic examination
Abdominal palpation for masses or bruits
Neurological assessment for focal deficits.
Investigations:
Initial investigations for all hypertensive children include: Urinalysis (proteinuria, hematuria, glycosuria)
Basic metabolic panel (BMP) to assess electrolytes, creatinine, and BUN
Lipid profile
Complete blood count (CBC)
ECG to assess for left ventricular hypertrophy
Renal ultrasound to assess kidney size, symmetry, and rule out structural abnormalities
Depending on clinical suspicion, further investigations may include: Echocardiogram for cardiac structure and function, Doppler of renal arteries for stenosis, 24-hour urine for catecholamines and metanephrines (suspected pheochromocytoma), thyroid function tests, adrenal imaging (CT/MRI), karyotyping.
Differential Diagnosis:
Essential (primary) hypertension (most common in adolescents, often associated with obesity)
Secondary hypertension (renal parenchymal disease like glomerulonephritis or polycystic kidney disease
renovascular hypertension like renal artery stenosis
endocrine disorders like Cushing's syndrome, hyperthyroidism, pheochromocytoma
coarctation of the aorta
obstructive sleep apnea
medications
neurological disorders).
Management
Initial Management:
Lifestyle modification is the cornerstone for all hypertensive children, especially those with Stage 1 hypertension or with elevated BP
This includes dietary changes (reduced sodium intake, DASH diet), regular physical activity, weight management/loss, and limiting screen time
For Stage 2 hypertension or symptomatic patients, pharmacologic therapy is often initiated concurrently with lifestyle changes.
Medical Management:
Pharmacological agents are chosen based on the child's age, comorbidities, and the severity of hypertension
Initial choices often include: Thiazide diuretics (e.g., Hydrochlorothiazide 1-2 mg/kg/day divided BID or OD)
ACE inhibitors (e.g., Enalapril 0.08-0.1 mg/kg/day divided BID)
Angiotensin II receptor blockers (ARBs) (e.g., Losartan 0.7-1.4 mg/kg/day divided OD)
Calcium channel blockers (e.g., Amlodipine 0.1-0.3 mg/kg/day divided OD)
Beta-blockers may be used, particularly in specific conditions like post-Kawasaki vasculitis
Combination therapy may be required for resistant hypertension
Dosages must be adjusted by age and weight.
Surgical Management:
Surgical intervention is reserved for specific secondary causes of hypertension, such as renal artery stenosis (angioplasty or bypass surgery) or pheochromocytoma (adrenalectomy)
Coarctation of the aorta repair is also indicated if severe and contributing to hypertension.
Supportive Care:
Regular blood pressure monitoring at home and in clinic
Education for the child and family on the condition, treatment plan, and importance of adherence
Nutritional counseling
Management of associated comorbidities
Referral to specialists (cardiology, nephrology, endocrinology) as needed
Psychological support may be beneficial.
Complications
Early Complications:
Hypertensive encephalopathy (headache, altered mental status, seizures)
Acute kidney injury
Hypertensive retinopathy (papilledema, hemorrhages)
Myocardial infarction or stroke (rare in children but possible with severe uncontrolled hypertension)..
Late Complications:
Left ventricular hypertrophy and diastolic dysfunction
Chronic kidney disease and end-stage renal disease
Atherosclerosis and premature cardiovascular disease (coronary artery disease, peripheral artery disease)
Cerebrovascular disease
Retinopathy.
Prevention Strategies:
Focus on early identification through regular BP screening in pediatric visits
Aggressive lifestyle modification from a young age
Prompt and effective management of identified hypertension
Addressing underlying secondary causes
Patient and family education on long-term adherence to treatment.
Prognosis
Factors Affecting Prognosis:
Severity and duration of hypertension
Presence and severity of end-organ damage at diagnosis
Adherence to treatment (lifestyle and pharmacologic)
Control of underlying secondary cause
Genetic predisposition
Obesity.
Outcomes:
With timely diagnosis and effective management, the progression of end-organ damage can be slowed or halted, and the risk of future cardiovascular events significantly reduced
Uncontrolled hypertension leads to progressive end-organ damage and poorer long-term outcomes.
Follow Up:
Children with hypertension require lifelong follow-up
Frequency of visits depends on severity and control, ranging from every 3-6 months for stable patients to more frequent visits for those with uncontrolled BP or significant end-organ damage
Monitoring includes BP measurements, laboratory tests (renal function, electrolytes), ECG, and assessment for end-organ damage progression.
Key Points
Exam Focus:
Know BP percentiles for age, sex, and height
Differentiate essential vs
secondary hypertension causes in children
Recall common antihypertensive drug classes and initial choices for pediatric hypertension
Understand the significance of lifestyle modifications.
Clinical Pearls:
Always use correct cuff size for accurate BP measurement
Screen all children annually for hypertension starting at age 3
Consider secondary causes in young children or those with resistant hypertension
The DASH diet and weight loss are powerful tools.
Common Mistakes:
Attributing elevated BP solely to "white coat hypertension" without proper evaluation
Underestimating the cardiovascular risk of pediatric hypertension
Inadequate investigation for secondary causes
Inconsistent BP monitoring
Poor adherence to lifestyle or medication recommendations.