Hypertension


Table 2: Diagnostic Challenges in Paediatric 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 Use appropriately sized cuffs; of 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


repeated by auscultation three times in quiet setting11,21


>90th percentile obtained with


Management of Paediatric Hypertension Education of patients and their families is fundamental to the management of paediatric 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 summarise the various treatment strategies for hypertension: lifestyle modifications and pharmacological interventions. Patient and family engagement as well as education will also be discussed.


Lifestyle Modifications


The current literature emphasises 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, dyslipidaemia,


hepatic disease, orthopaedic 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 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 mmHg 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 kg29–32


Furthermore, it has


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


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 paediatric 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


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 apnoea (OSA).22–24 A review in adults found that β-1 adrenergic blockers were the most successful antihypertensive agents, while thiazide diuretics were the least successful.24


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.


Dietary counselling should also be made available to the patient and family. Interprofessional teams, including a dietician or nutritionist, may be optimally inclined to handle this avenue where educational programmes directed at parents, caregivers and schools are paramount. Decreasing salt and sugar intake and increasing fruit, vegetable, fibre and low-fat dairy products intake, as advocated by the Dietary Approaches to Stop Hypertension (DASH) diet, should be encouraged in all children, especially those with hypertension.10,33


The


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 co-morbidity. Screening for dyslipidaemia is also important. A study conducted in 2010 using a population-based medical


128


DASH study demonstrated that, with an increase in fruit and vegetable of 8–10 servings per day, systolic and diastolic blood pressure was lowered by 2.8 mmHg and 1.1 mmHg, respectively, in all participants, and by 7.2 mmHg and 2.8 mmHg, respectively, in hypertensive participants.34


insurance claims database found that 22.9 % of surveyed children had laboratory-defined dyslipidaemia,9


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.


This blood pressure lowering effect is similar to that obtained from taking medication. All care-givers should be educated in calorie restriction, portion control and interpreting food package


EUROPEAN NEPHROLOGY


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