Hypertension in Children

Definition & Diagnosis - Pressure Points ID'd

• Definition: BP ≥ 95th percentile for age, sex, & height on ≥ 3 separate occasions.
• Classification (<13 yrs):
  • Elevated: ≥ 90th to < 95th %ile
  • Stage 1: ≥ 95th %ile to < (95th %ile + 12 mmHg)
  • Stage 2: ≥ (95th %ile + 12 mmHg)
• Classification (≥13 yrs):
  • Elevated: 120/<80 to 129/<80 mmHg
  • Stage 1: 130/80 to 139/89 mmHg
  • Stage 2: ≥ 140/90 mmHg
• Diagnostic Steps:
  • Accurate auscultatory measurement (correct cuff).
  • Ambulatory BP Monitoring (ABPM) to confirm.

⭐ Renal parenchymal disease is the most common cause of secondary HTN in children.

Etiology - Root Cause Roundup

• Primary (Essential) HTN:
  • Increasingly common, especially in adolescents.
  • Key associations: Obesity, positive family history, metabolic syndrome.
• Secondary HTN: More common in younger children; suspect if severe or <6 yrs.
  • Renal (Most common, ~70-80%):
    • Parenchymal Disease: Glomerulonephritis, reflux nephropathy, CAKUT, HUS, PKD.
    • Renovascular Disease: Renal artery stenosis (e.g., FMD, NF1, Williams syndrome).
  • Endocrine: Pheochromocytoma, neuroblastoma, CAH, hyperthyroidism, Cushing's.
  • Cardiac: Coarctation of aorta (check femoral pulses!).
  • Drugs: Corticosteroids, sympathomimetics, NSAIDs, OCPs.
  • Genetic: Liddle, Gordon, AME.

⭐ Renal parenchymal disease is the most common cause of secondary hypertension in children.

Clinical Clues & Consequences - Signs & System Stress

• Often asymptomatic. Symptoms (if present): headache, fatigue, visual changes, epistaxis.
• Severe HTN: seizures, VII nerve palsy, signs of heart failure, FTT (infants).
• Clues to etiology:
  • Abdominal bruit (Renovascular HTN)
  • Radio-femoral delay, BP discrepancy (Coarctation of Aorta)
• Target Organ Damage (TOD):
  • CNS: Hypertensive encephalopathy, retinopathy (Keith-Wagener grades).
  • CVS: Left Ventricular Hypertrophy (LVH), CHF.
  • Renal: Proteinuria, progressive renal insufficiency.

⭐ Left Ventricular Hypertrophy (LVH) is the most common early sign of target organ damage in children with chronic hypertension.

Workup & Management - The Takedown Plan

• Initial Workup:
  • Confirm BP: Multiple office visits or Ambulatory BP Monitoring (ABPM).
  • Basic Labs: Urinalysis, RFT, electrolytes (K+), uric acid, fasting lipids.
  • Renal Ultrasound with Doppler.
  • Further tests (ECHO, endocrine studies) if secondary HTN suspected.
• Management Strategy:

-   Non-pharmacological (cornerstone): Weight management, DASH diet (↓Na+, ↑K+), regular physical activity.
-   Pharmacological: Indicated for symptomatic HTN, Stage **2** HTN, target organ damage (TOD), or failure of lifestyle changes.
    -   ACE inhibitors / ARBs (preferred in CKD, DM).
    -   Long-acting Calcium Channel Blockers (CCBs).
    -   Thiazide diuretics.

⭐ Ambulatory Blood Pressure Monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing treatment efficacy in children.

Hypertensive Crisis - Emergency Pressure Drop

• Hypertensive Emergency: Severe HTN + acute end-organ damage (brain, heart, kidneys). Requires immediate, controlled BP ↓.
• Goal: ↓ Mean Arterial Pressure (MAP) or SBP/DBP by max 25% in first 8 hours.
  • Then, gradual normalization over 24-48 hours.
• ⚠️ Avoid rapid/excessive BP fall → risk of hypoperfusion injury.
• IV Antihypertensives:
  • Labetalol, Nicardipine
  • Sodium Nitroprusside (SNP) (⚠️ toxicity)
  • Hydralazine
• Flowchart:

• ⭐ > In children, hypertensive encephalopathy is the most common manifestation of hypertensive emergency.

High‑Yield Points - ⚡ Biggest Takeaways

• Renal parenchymal disease is the most common cause of secondary hypertension.
• Consider coarctation of aorta in infants with hypertension.
• Use appropriate cuff size (width 40%, length 80-100% arm circumference) for accurate BP.
• Hypertension: BP ≥95th percentile for age, sex, height on ≥3 occasions.
• Ambulatory BP Monitoring (ABPM) helps rule out white coat hypertension.
• Initial workup: Urinalysis, renal ultrasound, electrolytes, creatinine.
• Lifestyle modification is key; ACE inhibitors/ARBs for persistent/severe cases or proteinuria.