Pediatric hypertension Supervisor : vs. 邱元佑

Pediatric hypertension

• Supervisor : VS. 邱元佑

• Speaker : Int. 謝宜勳

Case information

Review: Pediatric hypertension

• - Definition

• - Etiology

• - Clinical manifestation

• - Treatment

Definition

• Task Force on Blood Pressure Control in Children

• ( National Heart, Lung, and Blood Institute & National Institutes of Health)

• Age, sex and height

• Obesity important independent risk

Measurement of BP in Children

Measurement

• standard mercury sphygmo-manometer

•  right arm

•  bladder width: 40% of the circumference of

• the arm

•  cuff size covered 80% to 100% of the

• circumference of the arm

Etiology

• Primary hypertension

• Secondary hypertension

Primary hypertension

• Essential hypertension

• Often in adolescent

• family history

• Multi-factorial cause:

• - heredity, obesity, diet and stress

• - genetic alterations in Ca & Na transport

• - insulin resistance

• - vascular smooth muscle reactivity

• - renin- angiotensin system dysfunction

Prenatal cause

• (1) children with intrauterine growth retardation (IUGR)

•  had significantly higher mean values of systolic, diastolic, and mean blood pressure

• Fattal-Valevski A, Bernheim J, Leitner Y, et al.: Blood pressure values in children with intrauterine growth retardation. Isr Med Assoc J 2001;3:805–808.

• (2) intrauterine environment

• In women: resting SBP↓4.27 mm Hg and DBP↓ 2.18 mm Hg per kilogram increase in birth weight

• in men: no associations!

• Loos RJ, Fagard R, Beunen G, et al.: Birth weight and blood pressure in young adults: a prospective twin study. Circulation 2001;104:1633–1638

Secondary hypertension

• Most common in the period of infant and younger children

• Underlying disease:

• - Renal and renovascular disease

• - coarctation of the aorta

• - endocrine disorder

• - medication

• Conditions Associated with

• Transient or Intermittent Hypertension

• in Children

• RENAL

• Acute postinfectious glomerulonephritis
• Anaphylactoid (Henoch-Schönlein) purpura with nephritis
• Hemolytic-uremic syndrome
• Acute tubular necrosis
• After renal transplantation After blood transfusion in patients with azotemia
• Hypervolemia
• After surgical procedures on the genitourinary tract
• Pyelonephritis
• Renal trauma
• Leukemic infiltration of the kidney
• Obstructive uropathy associated with Crohn disease

• DRUGS AND POISONS

• Cocaine
• Oral contraceptives
• Sympathomimetic agents
• Amphetamines
• Phencyclidine
• Corticosteroids and adrenocorticotropic hormone
• Cyclosporine or sirolimus treatment post-transplantation
• Licorice (glycyrrhizic acid)
• Lead, mercury, cadmium, thallium
• Antihypertensive withdrawal (clonidine, methyldopa, propranolol)
• Vitamin D intoxication

• CENTRAL AND AUTONOMIC NERVOUS SYSTEM

• Increased intracranial pressure
• Guillain-Barré syndrome
• Burns
• Familial dysautonomia
• Stevens-Johnson syndrome
• Posterior fossa lesions
• Porphyria
• Poliomyelitis
• Encephalitis

• Conditions Associated with

• Chronic Hypertension in Children

• RENAL

• Chronic pyelonephritis
• Chronic glomerulonephritis
• Hydronephrosis
• Congenital dysplastic kidney
• Multicystic kidney
• Solitary renal cyst
• Vesicoureteral reflux nephropathy
• Segmental hypoplasia (Ask-Upmark kidney)
• Ureteral obstruction
• Renal tumors
• Renal trauma
• Rejection damage following transplantation
• Postirradiation damage
• Systemic lupus erythematosus (other connective tissue diseases)

• VASCULAR

• Coarctation of thoracic or abdominal aorta
• Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis, aneurysm)
• Umbilical artery catheterization with thrombus formation
• Neurofibromatosis (intrinsic or extrinsic narrowing of vascular lumen)
• Renal vein thrombosis
• Vasculitis
• Arteriovenous shunt
• Williams-Beuren syndrome
• Moyamoya disease

• ENDOCRINE

• Hyperthyroidism
• Hyperparathyroidism
• Congenital adrenal hyperplasia (11 β-hydroxylase and 17-hydroxylase defect)
• Cushing syndrome
• Primary aldosteronism
• Dexamethasone-suppressible hyperaldosteronism
• Pheochromocytoma
• Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma)
• Diabetic nephropathy
• Liddle syndrome

• CENTRAL NERVOUS SYSTEM

• Intracranial mass
• Hemorrhage
• Residual following brain injury
• Quadriplegia

Clinical manifestation

• Essential HTN:

• - asymptomatic

• - mild BP elevation

• - mild to moderate obesity

• Secondary HTN:

• - mild to severe BP elevation

• - not usually produce symptoms (headache, dizziness,

• epistaxis, anorexia, visual change)

• - underlying disease

• - hypertensive encephalopathy:

• vomiting, temperature↑, ataxia, stupor and seizure

• - End-organ (cardiac and renal ) dysfunction

Treatment

• Goal:

• Blood pressure below 95 th percentile

• according to age, sex and height

Treatment of essential HTN

• Non-pharmacologic therapy:

• - weight reduction

• - sodium intake reduction

• - aerobic exercise

• - No tobacco and alcohol

Treatment of essential HTN

• Pharmacologic therapy

• diuretics

•  volume-dependent HTN

• β-blocking agent

•  high-renin high cardiac output HTN

• CCB

• ACE-I

Treatment of secondary HTN

Treatment of hypertensive crisis

• Stepwise reduction:

• first 6 hr  1/3 total planned reduction BP

• following 48-72 hr  2/3

• Intravenous administration

• Labetalol

• Nitroprusside

• Sublingual nifedipine

Reference

• Nilson 17th ed. Novaritis; 1997 : p1592-1598

• Joseph D. Kay, Alan R. Sinaiko. Pediatric hypertension. Am Heart J 2001;142:422-3

• National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 task force report on high blood pressure in children and adolescents: a working group report from the National High Blood Pressure Education Program. Pediatrics 1996;98:649-58.

• Albert P. Rocchini. Pediatric hypertension 2001. Current Opinion in Cardiology 2002, 17:385–389

• Loos RJ, Fagard R, Beunen G, et al.: Birth weight and blood pressure in young adults: a prospective twin study. Circulation 2001;104:1633–1638.

• Umbereen S. Nehal and Julie R. Ingelfinger. Pediatric hypertension: recent literature. Current Opinion in Pediatrics 2002, 14:189–196