Pediatric hypertension Supervisor : vs. 邱元佑



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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




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