Hypertension


Table 2: Diagnostic Challenges in Pediatric Hypertension and Recommendations


Challenge Why Is it a Challenge?


Presentation Primary hypertension is often asymptomatic


Definition Recommendation Routinely measure and record


blood pressure as part of the general physical examination, starting at the age of 311,17


Complex definition varying Explore options for modifying according to gender, age, diagnostic method in order and height, which leads to to produce more simple many abnormal cut-offs


cut-offs; proposed cut-offs


that are difficult to use in for both girls and boys: fast-paced clinical practice • Age 3 90th percentile ± 100/60


• Age 6 90th percentile ± 105/70


• Age 14 90th percentile ± 120/75


Cuff size


Children and adolescents of Use appropriately sized cuffs; different sizes require different cuff sizes, as using an unsuitably sized


the cuff bladder should cover 80–100 % of the arm


circumference of the child;


cuff may give false readings clinicians should keep a range of cuff sizes in the clinic, including newborn, infant, child, small adult, adult and large adult sizes, as well as thigh cuffs11


Method


Ideal method is auscultation; Blood pressure measurements however, oscillometric


instruments are commonly oscillometric device or cut-off used in children for reasons measurements should be of convenience


>90th percentile obtained with


repeated by auscultation three times in quiet setting11,21


The frequency of testing for end-organ disease depends on the severity of the hypertension and overall blood pressure control.


It is also important to screen for disorders that may commonly occur with hypertension, such as obstructive sleep apnea (OSA).22–24


A review


Studies have never been conducted in children with OSA hypertension, so we are limited in our ability to make the appropriate recommendations on drug classes to choose for patients with this comorbidity. Screening for dyslipidemia is also important. A study conducted in 2010 using a population-based medical insurance claims database found that 22.9 % of surveyed children had laboratory-defined dyslipidemia,9


in adults found that β-1 adrenergic blockers were the most successful antihypertensive agents, while thiazide diuretics were the least successful.24


a figure that is similar to the prevalence estimate of


23.9 % derived from the National Health and Nutrition Examination Survey data for 1999–2004.


Management of Pediatric Hypertension Education of patients and their families is fundamental to the management of pediatric hypertension. Patients should understand the possible causes of hypertension, the medical complications of inadequately controlled hypertension, and the importance of maintaining a healthy lifestyle. The following sections summarize the various treatment strategies for hypertension: lifestyle modifications and pharmacologic interventions. Patient and family engagement as well as education will also be discussed.


Lifestyle Modifications


The current literature emphasizes that the increasing prevalence of childhood hypertension and the increase in [high] childhood blood pressure levels have in large part been a product of the childhood obesity epidemic.18,23,25,26


Impaired glucose tolerance, dyslipidemia,


Screening for Other Causes of Hypertension It is important to screen for secondary causes of hypertension, which are more often seen in children than in adults and tend to occur more commonly in younger children and in those with more severe hypertension; this requires a thorough work-up.20


hepatic disease, orthopedic issues, psychosocial stressors, and elevated blood pressure may all result from childhood obesity.19 Studies conducted in children with hypertension have shown that blood pressure values decrease with weight loss.27,28


To achieve weight Secondary causes of


hypertension can sometimes be treated, leading to a normalisation of blood pressure without the need for additional antihypertensive medication.8


Renal parenchymal disease accounts for approximately


75 % of all secondary causes of hypertension, while renovascular disease accounts for 10 %.20


Other less common secondary causes of


hypertension include endocrine disorders, cardiovascular disease and rare monogenic forms of hypertension. Screening for secondary causes should be considered in all children with hypertension and should start with simple measures such as history taking, physical examination, four-limb blood pressure measurement, blood chemistry, and urinalyses. Further screening will vary depending on preliminary history and findings. If secondary hypertension is suspected, further evaluation is necessary to determine the underlying cause. It can be conducted by pediatric nephrologists or cardiologists. In addition, screening for a family history of all three conditions should be conducted. The work-up to evaluate end-organ damage as a result of hypertension includes an echocardiogram for left ventricular hypertrophy, a urine albumin:creatinine ratio for endothelial damage, and a retinal examination for retinopathy.8


112


reduction, the emphasis should be on physical activity and dietary counselling. Exercise has been shown to lower systolic and diastolic blood pressure by approximately 3 and 2.4 mmHg, respectively. Weight loss has been shown to reduce systolic and diastolic blood pressure by approximately 1 mmHg per kilogram lost and a more pronounced blood pressure reduction in those with a weight loss of more than 5 kg.29–32


Furthermore, it has been demonstrated that


exercise and weight loss combined have a greater antihypertensive effect than either alone.33


When advising a patient to take part in physical activities, physicians should clearly define the type, frequency, intensity and duration of the exercise. The US National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents recommends regular moderate aerobic physical activity, where the child generates energy expenditure above the resting level, for 30–60 minutes four or five times per week.8


Furthermore, sedentary activities, such as


watching television and playing video games, should be restricted to less than two hours per day.8


Common physical activities may include walking, running, swimming, and cycling. US NEPHROLOGY


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