Pediatric

Hypertension
Elizabeth Burrows

Introduction

Hypertension in American children is

a growing epidemic
High blood pressure is estimated to
be prevalent in 4.5% of children
A recent study by Hansen found that
in the United States health care
providers fail to diagnose high blood
pressure in more than 75% of children

Why the rise in childhood

hypertension?

Increasing epidemic of childhood obesity

Sedentary lifestyles
Epidemiologic studies indicate that about 30%
of obese children have hypertension
Hypertension and obesity are two common
preventable disorders facing pediatric clinicians
Study by Couch in which obese patients
achieved a reduction in BMI of 8-10% showed a
decline in blood pressures that were in the
range of 8 to 16 mm Hg

Why are health care

providers failing to make
the diagnosis?

Blood pressure in children is a function

of age, sex, and height percentile
What is normal for one child may be
considered hypertensive in another
child of the same age
Clinicians usually cannot remember
normal blood pressures for the wide
range of children observed in their
typical primary care setting

Factors making diagnosis

more likely in children

Older age
Taller height
Obesity
Younger children and
adolescents who are
not overweight and
generally appear
healthy are typically
the patients where
hypertension is not
suspected and often
missed

Hansens 2007 Study

Analyzed the medical records of 507 hypertensive

and pre-hypertensive children and adolescents over
a span of seven years
All the children visited an outpatient clinic at least
three times
376 patients (74%) had undiagnosed hypertension
80 patients (15.8%) had a true hypertension
diagnosis
7 participants had undiagnosed stage 2
hypertension
Data to make the diagnosis of hypertension or
prehypertension was present in the patients' records

Hansens 2007 Study

There is a much needed modification for

identifying pediatric hypertension
Current discussion is centered on the
development of a computer program

Through electronic record keeping - send a

red flag alerting the provider when a
patients blood pressure is in the prehypertensive to hypertensive state

Why is it important to
diagnose and treat
hypertension
in
childhood?

Prevent progression and target organ damage of

the brain, eyes, heart, and kidneys
A study by Hanevoid demonstrated that severe
target organ damage occurs in hypertensive
children

41% of the 129 hypertensive children and adolescents

studied had left ventricular hypertrophy (LVH) by
pediatric criteria, and 16% had LVH even when using
adult criteria

If caught early, preventative measures can be

taken to reduce risks for other comorbidities in
childhood and adulthood

Pediatric Classifications

The Fourth Report 2004 includes

new classifications for hypertension
Prehypertension
Stage 1
Stage 2

Pediatric Classifications

Pre-hypertension- average systolic and/or

diastolic blood pressure between the 90th and
95th percentile for gender, age, and height
Lifestyle modifications and reevaluation every
six months are recommended to help prevent
progression to hypertension
Hypertension- average systolic and/or
diastolic blood pressure that is 95th
percentile for gender, age, and height
Elevated blood pressure must be confirmed
on three repeated visits before diagnosing a
child as having hypertension

Pediatric Classifications

Stage 1- average systolic and/or diastolic blood

pressure levels that range from the 95th percentile
to 5 mm Hg above the 99th percentile for gender,
age, and height
Initially patients in stage 1 should be reevaluated
within one to two weeks
Stage 2- average systolic and/or diastolic blood
pressure levels that are >5 mm Hg above the 99th
percentile for gender, age, and height
If symptomatic give immediate treatment and refer
to hypertension specialist
If asymptomatic refer to specialist within one week

Measurement of BP in
Pediatrics

The Fourth Report recommends that

children 3 years and older have their
blood pressure measured regularly
The preferred method of blood
pressure measurement is auscultation
In order to correctly diagnose
hypertension blood pressure must be
measured accurately

Measurement of BP in
Pediatrics

Main source of error Using wrong

cuff size
Small cuff- overestimates BP
Large cuff- underestimates BP

Appropriate Cuff Size

Inflatable bladder width that covers at

least 40% of the arm circumference
midway between the olecranon process
and the acromion process
The bladder length should cover 80100% of the circumference of the arm
The bladder width-to-length ratio
should be at least 1:2

Measurement of BP in
Pediatrics

Preparing the child for blood pressure

measurements
Sit quietly for five minutes with their back
and right arm supported at heart level and
feet flat on the floor
If a patient has a reading that is >90th
percentile
BP should be repeated twice at the same
office visit
Document average systolic and diastolic BP

ABPM

Ambulatory Blood Pressure Monitoring allows clinicians

to observe the patients BP 2-4 times per hour over at
least 24 hours
Patients are encouraged to continue normal everyday
activities while being monitored
Successful in children even as young as 2 months
Make diagnosis that would otherwise be missed

Nocturnal Blood
Pressure

Nocturnal BP Dip- Typically

individuals have 10-15% drop in their
mean day and night blood pressure
readings
ABPM can detect
An abnormality nocturnal BP dip
Elevations of nocturnal blood pressure
Both usually indicative of secondary
hypertension

Masked Hypertension

A condition where a patients office

blood pressure is normal but ABPM
classify the patient as hypertensive
Study of masked hypertension reviewed
by McNiece showed a prevalence of
7.6% among 592 children aged 618
years
Showed these children with have an
elevated left ventricular mass index
equivalent to truly hypertensive patients

White Coat Hypertension

A patient with blood pressure levels >95th

percentile in a physicians office or clinic
and who is normotensive outside a clinical
setting
Several studies suggest that in some
children this may be a prehypertensive
state that eventually may progress to
hypertension
Counsel patient about therapeutic lifestyle
changes and monitor for development of
true hypertension

Pediatric Symptoms

Hypertension is often thought of as a silent

disease because typically there have not
been any classic symptoms
A recent study by Croix found that 51% of
untreated hypertensive children when
surveyed reported 1-4 Symptoms, and 14%
reported more than four symptoms
3 most common symptoms
headache
difficulty initiating sleep
daytime tiredness
These were all reduced with treatment

After Hypertension is
Diagnosed

Want to rule out secondary causes

BP should be measured in both arms and a leg to
rule out coarctation of the aorta
Fasting lipid, Fasting glucose, standard chemistry
panel, serum urea nitrogen (BUN), CBC, creatine,
urinalysis and urine culture
Echocardiogram, renal ultrasound
Screen for major sleep disorders using BEARS:

Bedtime problems
Excessive daytime sleepiness
Awakenings during the night
Regularity and duration of sleep
Snoring

Treatment

Lifestyle modifications are typically

the initial treatment of choice
Indications for antihypertensive
drug therapy in children
Secondary hypertension
Insufficient response to lifestyle
modifications
Stage 2 hypertension

Pharmacologic Therapy of
Childhood Hypertension

2002 Best Pharmaceuticals for Children Act

has led to recent study and FDA approval of
several antihypertensive medications for use in
pediatrics
Unknown long-term effects of antihypertensive
therapy in children- especially with regard to
growth and development
ACE-I and calcium channel blockers are the
most commonly used antihypertensive
medications in children

Conclusion

Hypertension and obesity in

children are increasing in an
upward trend
It is imperative that pediatric
hypertension is recognized and
treated
It is advisable to measure blood
pressure at every visit with the
appropriate technique, use the
gender, age, and height specific
blood pressure table, and to
follow the recommendations of
the Fourth Report
It is important to encourage
healthy lifestyles in all children
and adolescents and help
institute lifestyle changes for
weight reduction in overweight
children

References

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