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Hypertension In Children Lecture on Causes Investigations Treatment for HTN

Hypertension In Children

This is the Lecture of Hypertension In Children taken by our teacher Dr. Shahabuddin Mahmud Assistant Professor, Paediatric Nephrology in Rajshahi Medical College. It contains Definitions, Causes, When to take BP in a child, Stages of HTN, Investigations for HTN both essential and Optional, Treatment options etc. This is mostly suitable for the Medical students to prepare their lessons. I have also included the PDF download link of the Power point presentation. I also believe that this document will help the teachers to arrange the Lectures. If you want to include any information’s here, feel free to write me.

Objectives of the Lecture:

The Students will know:

  1. When to take BP in a child.
  2. The definition of HTN & other related terms.
  3. Stages of HTN
  4. Causes of HTN
  5. Investigations for HTN
  6. Treatment motalities of HTN

WHEN TO TAKE BP IN A CHILD:

Blood pressure should be determined at every pediatric visit beginning at 3 years. Blood pressures in children must be obtained when the child is relaxed and an appropriate-size cuff must always be used. Hypertension In Children should be checked regularly.

  • All children >3 years old, seen in a medical care setting.
  • Children <3 years old in high risk group:
  1. H/O prematurity. Very LBW baby.
  2. Recurrent UTI. Hematuria & Proteinuria.
  3. Known renal disease or urological malformation.
  4. Family H/O congenital renal disease.
  5. On certain medication, known to raise BP.
  6. Syndromes associated with HTN- Neurofibromatosis.
  7. Malignancy: Post-organ transplantation.
  • Non-specific signs: Failure to thrive, Irritability, vomiting seizures.

Definition of Hypertension:

NORMAL BP: It may be defined as systolic or diastolic BP <90th percentile for age, gender & height.

PRE-HYPERTENSION: Systolic or diastolic BP between 90th & 95th percentile is defined as pre-hypertension.

HYPERTENSION: Hypertension is defined as an average systolic or diastolic BP >95th percentile for age, gender & height on at least 3 separate occasions.

Stages of HTN:

Stage-I HTN: BP level between 95th & 99th percentile plus 5 mmHg. Needs thorough evaluation & management.

Stage-II HTN: BP level ≥99th percentile plus 5 mmHg. Needs to look for hypertensive emergencies & immediate referral to center with expertise in pediatric.

Hypertension In Children Chart

Hypertensive Emmergency:

It is a situation of HTN which needs an immediate (within 1 hour) reduction of BP by approximately 25-30% to prevent life threatening injury.

Examples:

  • Hypertensive encephalopathy
  • HTN associated with heart failure, pulmonary edema, acute renal failure, stroke, MI, malignant HTN etc.

END ORGAN DAMAGE BY HTN:

  1. Atherosclerosis
  2. Left ventricular hypertrophy
  3. Retinal artery narrowing
  4. Micro-albuminuria
  5. Renal failure

Common Cause of Hypertension By Age Presentation:

Newborn:

  1. Renal artery thrombosis or embolus
  2. Renal vein thrombosis
  3. Congenital renal malformation
  4. Renal artery stenosis

Infancy-6 YEARS:

  1. Renal artery stenosis
  2. Coarctation of aorta
  3. Medications (i.e corticosteroid)
  4. Endocrine cause

6 YEARS-10 YEARS:

  1. Renal parenchymal disease
  2. Renal artery stenosis
  3. Primary (essential) HTN
  4. Endocrine cause

Adolescence:

  1. Primary (essential) HTN
  2. White coat HTN
  3. Renal parenchymal disease
  4. Substance abuse- cocaine, caffeine, amphetamines.
  5. Endocrine cause

Renal Parenchymal Diseases Associated with HTN:

  1. Glomerulonephritis: APSGN, IgA nephropathy, MPGN, RPGN, FSGS.
  2. Systemic vasculitis with renal involvement: HSP, SLE, PAN.
  3. Hemolytic uremic syndrome
  4. Chronic pyelonephritis
  5. Hereditary disease: PKD (AR/AD), Medullary cystic disease.
  6. Congenital renal abnormalities: VUR, Obstructive uropathy.

Endocrine Abnormalities Associated with HTN:

  1. Tumors secreting vaso-active substances (catecholamines, rennin etc):  Pheochromocytoma, Neuroblastoma, Wilm’s tumor.
  2. Thyroid disorders: Hyperthyroidism
  3. Cushing syndrome
  4. Hyperaldosteronism: Adrenal tumor
  5. Congenital adrenal hyperplasia

Mandatory Investigations in HTN:

*  Urinalysis: cell, protein, 24 hour protein excretion

*  Urine culture

*  Blood urea, creatinine, electrolytes, uric acid, calcium

*  Fasting cholesterol, Triglyceride

*  Chest X-ray

*  ECG, echocardiogram, fundus of eye examination

*  Abdominal USG

*  99mTc- DMSA scan

Additional Investigations in HTN:

Glomerulonephritis: Serum C3, C4, ASO titre, Auto antibodies (ANA, Anti-ds DNA, ANCA), renal biopsy

Reflux Nephropathy: Micturating cystourethrogram (MCU), DMSA scan, Intravenous urogram

Pheochromocytoma: Urine & plasma catecholamines, Plasma calcitonin, Parathormone, MIBG scan

Renovaculas disease: Doplar USG, Captopril primed isotope scan (DPTA/MAG-3), Renin sampling from renal veins & IVC

Hypertension In Children Treatment Options

Non-pharmacological Treatment of HTN:

Life style modification:

1)    Weight reduction for obesity related HTN.

2)   Regular physical activity & restriction of sedentary activity.

3)   Diet modification- salt restriction, increased intake of fresh vegetables, fruits, fibres & non-fatty dairy.

5)   Family support.

Pharmacological Treatment of HTN:

Indications for drug therapy:

I. Symptomatic HTN II. Secondary HTN.

III. HTN with Target Organ Disease (TOD) IV. Stage-II HTN V. Stage-I HTN with DM VI. Stage-I HTN who failed life style modification VII. Hypertensive patients with additional CVS risk factors- dyslipidemia, smoking

Anti-hypertensive Drug Therapy:

In most hypertensive emergencies, the drugs of choice are intravenous labetalol or sodium nitroprusside or sublingual nifedipine. ACE inhibitors and calcium channel blockers may be considered for initial therapy in an adolescent with significant hypertension. Although captopril has been used more often in young patients, enalapril has a longer duration of action and thus requires less frequent administration. Hypertension In Children must be treated with caution.

Diuretics: Hydrochlorothiazide, Furosemide, Bumetanide

Calcium channel blocker: Nifedipin, Amlodipin, Nicardipine

Beta Adrenoceptor blocker: Propanolol, Atenolol, Labetalol

Alpha Adrenoceptor blocker: Prazosin, Phentolamin

Angiotensin Converting Enzyme Inhibitor: Captopril, Enalapril, Enalaprilat

Angiotensin receptor Blocker: Losartan, irbesartan

Vasodilators: Hydralazine, Minoxidil, Sodium Nitroprusside

Important Links:

http://www.karger.com/Article/Pdf/185882

http://en.wikipedia.org/wiki/Hypertension#In_children

http://pediatrics.aappublications.org/content/114/Supplement_2/555.long

http://emedicine.medscape.com/article/889877-overview

http://www.mayoclinic.com/health/high-blood-pressure-in-children/DS01102

http://www.webmd.com/hypertension-high-blood-pressure/guide/hypertension-in-children

Thank you.

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