Summary of principles and important points
1. Measure blood pressure correctly
2. Interprete blood pressure measurements using centile charts for age and height
3. Repeated blood pressure measurements are required to diagnose hypertension – the method, timing, frequency and length of period of observation depends on circumstances. This will include manual measurement of BP where needed
4. In possible or diagnosed chronic hypertension, clinic measurements of blood pressure are ideally accompanied by home monitoring of blood pressure or ambulatory measurement
5. Investigation of hypertension is required when the cause is not known. Primary hypertension is a diagnosis of exclusion.Secondary hypertension will need to to be excluded with relevant history, physical examination and focussed investigations.
6. Hypertensive crisis and symptomatic hypertension require urgent treatment
7. Hypertension should never be corrected rapidly
8. Do NOT lower blood pressure if intracranial hypertension is raised or is a possibility – the intracranial hypertension needs to be managed as an emergency.
9. Acute severe asymptomatic hypertension, where systolic blood pressure is > 99th centile plus 5 mmHg (Stage II hypertension), will usually require treatment which depends on the cause. Treatment for acute asymptomatic hypertension where systolic blood pressure is between 95th centile and 99th centile plus 5 mmHg (Stage I hypertension) should be considered depending on circumstances. Fluid overload should be managed with appropriate fluid restriction and diuretics. If required, nifedipine (or amlodipine) is often a good first line antihypertensive agent if no contraindication. An ACE inhibitor or Angiotensin II receptor blocker should NOT be used to treat acute hypertension or where renal artery stenosis may be possible
10.Chronic hypertension should be assessed and investigated where the cause is not known but subsequent management and treatment depends on the severity and cause.
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DEFINITION
Normal blood pressure (BP) = average systolic and/or diastolic blood pressure (SBP/DBP) <90th percentile or < 120/<80 mmHg in adolescents
Elevated BP = SBP and/or DBP ≥90th percentile and <95th percentile;
or for adolescents, BP ≥120/80 mm Hg to <95th percentile, or ≥90th and <95th percentile, whichever is lower.
Hypertension = average clinic measured SBP and/or DBP ≥95th percentile on three or more occasions
In children with known renal problems the blood pressure should be maintained around the 50th percentile.
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2016 European Society for Hypertension Guideline Classification of hypertension in children and adolescents2.
Category | 0-15 years | 16 years and older |
Normal | <90th | <130/85 |
High-normal | >90th to <95th | 130-139/85-89 |
Hypertension | >95th | >140/90 |
Stage 1 hypertension | 95th to 99th and 5mmHg | 140-159/90-99 |
Stage 2 hypertension | >99th plus 5mmHg | 160-179/100-109 |
ASSESSMENT
Measurement of Blood Pressure in Children -
Use the right side upper arm -where possible, supported with the brachial artery at heart level
Use a cuff that is appropriate to the size of the child’s arm.
If a cuff is too small, the next largest cuff should be used, even if it appears large.
The pragmatic approach is to use the cuff that is the largest one that can be used which would leave room to auscultate at the antecubital fossa.
If necessary, the preference is to use a slightly larger cuff than one which is too small.
Manual measurements will always be more accurate than machine measurements.
If the initial BP is elevated (≥90th percentile), it is most likely to be artificially elevated due to e.g. anxiety.
It is therefore important to get serial measurements for a more accurate picture.
Perform 2 additional BP measurements at the same visit and average them.
Ensure a manual measurement has been obtained
Child needs to be calm – if upset will get a high reading which cannot be interpreted.
Ideally, the child should have been sitting/resting quietly for 5 minutes.
For manual BP measurement the sphygmomanometer should also be at heart level
To confirm a diagnosis of hypertension in children > 6 years old consider performing 24 hour ABPM.-ambulatory BP measurement
Indications for the use of ABPM in the diagnosis of hypertension include2:
- Confirming hypertension before drug treatment
- Chronic kidney disease
- Types 1 & 2 diabetes mellitus
- Renal, liver or heart transplant
- Severe obesity +/- Obstructive Sleep Apnoea (OSA).
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Presentation of hypertension
Hypertension may present as an asymptomatic incidental finding, during screening in at risk groups or with clinical signs and symptoms including:
Congestive cardiac failure
Headache
Cerebrovascular incident
Hypertensive encephalopathy
Facial nerve palsy
Failure to thrive
The history and examination needs to seek out these features and also look for features of any secondary causes.
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Blood Pressure Tables
See Appendices 1 (boys) and 2 (girls) NB. ..............insert link
Use a height chart to determine the height percentile.
Also, ensure you use the correct gender table for blood pressure
Click here for an online version.
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PHYYSICAL EXAMINATION CUES
- Signs of heart failure
- Tachycardia
- Gallop rhythm
- Hepatomegaly
- Raised jugular venous pressure
- Absent of weak femoral pulses potentially indicative of coartaction of the aorta - if this is detected then measure four limb blood pressure
- Neurological deficit
- Weakness
- Hypotonia or hypertonia
- Hyper-reflexia and clonus
- Upgoing plantars
- Cranial nerve deficits
- Papilloedema and/or retinal haemorrhages
- Organomegaly and/or abdominal masses
- Evidence of thyroid disease including goitre and eye signs
- Carotid, abdominal and/or femoral bruits
- Obesity and Cushingoid features
Obesity | |
Family history of hypertension or cardiovascular disease | |
Secondary hypertension in
| Renal causes
|
Cardiovascular causes
| |
Respiratory
| |
Neurological
| |
Iatrogenic
| |
Secondary hypertension in children and adolescents
| Renal causes
|
Cardiac causes
| |
Endocrine causes
| |
Neurological causes
| |
Drug-related causes including immunosuppressants, NSAID’s, sympathomimetics and antidepressants especially corticosteroids, calcineurin inhibitors, sympathomimetics, methylphenidate and related drugs, contraceptive pill, clonidine WITHDRAWAL |
Common causes of hypertension by age of presentation:
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All Children with Stage I or II hypertension
To identify a cause – the necessity for all these investigations depends on if the cause is known and if previous investigations have been undertaken:
Full blood count
U&Es, creatinine, bone profile
Thyroid function tests
Plasma renin and aldosterone
Urinalysis for protein / blood / infection
Urine HVA/VMA, catecholamines
Renal ultrasound (with renal vessel doppler if available)
Cardiac ultrasound scan Also consider depending on if cause known and clinical circumstances:
Urine pregnancy test
Urine toxicology screen
Plasma cortisol, ACTH
Urine steroid profile
To identify co-morbidities where appropriate, particularly where thought to be primary hypertension:
Fasting lipids
Fasting glucose, insulin
Consider HbA1c
Liver function tests
Consider ultrasound scan of liver
To assess for end-organ damage:
ECG
Echocardiogram (to look for presence of left ventricular hypertrophy but may also identify a cause eg. coarctation of aorta)
Retinal examination (in those with severe or long standing hypertension)
U&Es and urinalysis - also part of the end-organ assessment
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MANAGEMENT OF HYPERTENSION
Goals of Management
1. To reduce blood pressure to <95th percentile
2. To reduce blood pressure to <90th percentile in those with co-morbidities
3. To consider aggressive blood pressure control (<50th percentile) in some patient groups (e.g. those with chronic kidney disease)
European guideline targets for treatment2:
Hypertension without comorbidities
BP goal < 16 years: < 95th percentile
BP goal ≥ 16 years: < 140/90
HTN + diabetes mellitus type 1 or 2
BP goal < 16 years: < 90th percentile
BP goal ≥ 16 years: < 130/80
HTN + CKD
-Without proteinuria
BP goal < 16 years: < 75th percentile
BP goal ≥ 16 years: < 130/80
-With proteinuria
BP goal < 16 years: < 50th percentile
BP goal ≥ 16 years: < 125/75
From the 2016 European Society for Hypertension guidelines for the management of high blood pressure in children and adolescents.
Dietary advice regarding healthy eating (including reducing salt intake).
Ideally all children with hypertension and pre-hypertension should be referred to a dietician or local community programme for lifestyle advice regarding eating and exercise depending on circumstances.
Regular physical activity (30-60 minutes/day)
Weight reduction if overweight or obese
Assessment and interventions to improve sleep if sleep apnoea identified.
Advice regarding alcohol, caffeine and drugs
SHORT TERM TREATMENT OF ACUTE HYPERTENSION
eg acute nephritis leading to salt and water retention causing volume overload.
A well-tolerated combination would be a loop diuretic (e.g. furosemide)
plus a vasodilating Ca2+ channel blocker (e.g. nifedipine).
KEY ACTION STATEMENTS (AAP)
| Evidence Quality, Strength of Recommendation | |
|---|---|
| 1 BP should be checked in all children and adolescents ≥3 y of age at every health care encounter if they have obesity, are taking medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes. | C, moderate |
| 2. Trained health care professionals in the office setting should make a diagnosis of HTN if a child or adolescent has auscultatory-confirmed BP readings ≥95th percentile at 3 different visits. | C, moderate |
| 3. Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a device that has been validated in the pediatric age group. If elevated BP is suspected on the basis of oscillometric readings, confirmatory measurements should be obtained by auscultation. | B, strong |
| 4. ABPM should be performed for confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits. | C, moderate |
| 5. Routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage. | B, moderate |
| 6. Children and adolescents with suspected WCH should undergo ABPM. Diagnosis is based on the presence of mean SBP and DBP <95th percentile and SBP and DBP load <25%. | B, strong |
| 7. Children and adolescents ≥6 y of age do not require an extensive evaluation for secondary causes of HTN if they have a positive family history of HTN, are overweight or obese, and/or do not have history or physical examination findings (Table 14) suggestive of a secondary cause of HTN. | C, moderate |
| 8. Children and adolescents who have undergone coarctation repair should undergo ABPM for the detection of HTN (including MH). | B, strong |
| 9. In children and adolescents being evaluated for high BP, the provider should obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination to identify findings suggestive of secondary causes of HTN. | B, strong |
| 10. Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for LVH. | B, strong |
| 10-1. It is recommended that echocardiography be performed to assess for cardiac target organ damage (LV mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN. | C, moderate |
| 10-2. LVH should be defined as LV mass >51 g/m2.7 (boys and girls) for children and adolescents older than age 8 y and defined by LV mass >115 g/BSA for boys and LV mass >95 g/BSA for girls. | |
| 10-3. Repeat echocardiography may be performed to monitor improvement or progression of target organ damage at 6- to 12-mo intervals. Indications to repeat echocardiography include persistent HTN despite treatment, concentric LV hypertrophy, or reduced LV ejection fraction. | |
| 10-4. In patients without LV target organ injury at initial echocardiographic assessment, repeat echocardiography at yearly intervals may be considered in those with stage 2 HTN, secondary HTN, or chronic stage 1 HTN incompletely treated (noncompliance or drug resistance) to assess for the development of worsening LV target organ injury. | |
| 11. Doppler renal ultrasonography may be used as a noninvasive screening study for the evaluation of possible RAS in normal-wt children and adolescents ≥8 y of age who are suspected of having renovascular HTN and who will cooperate with the procedure. | C, moderate |
| 12. In children and adolescents suspected of having RAS, either CTA or MRA may be performed as noninvasive imaging studies. Nuclear renography is less useful in pediatrics and should generally be avoided. | D, weak |
| 13. Routine testing for microalbuminuria is not recommended for children and adolescents with primary HTN. | C, moderate |
| 14. In children and adolescents diagnosed with HTN, the treatment goal with nonpharmacologic and pharmacologic therapy should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥ 13 years old. | C, moderate |
| 15. At the time of diagnosis of elevated BP or HTN in a child or adolescent, clinicians should provide advice on the DASH diet and recommend moderate to vigorous physical activity at least 3 to 5 d per week (30–60 min per session) to help reduce BP. | C, weak |
| 16. In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy on echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic. | B, moderate |
| 17. ABPM may be used to assess treatment effectiveness in children and adolescents with HTN, especially when clinic and/or home BP measurements indicate insufficient BP response to treatment. | B, moderate |
| 18-1. Children and adolescents with CKD should be evaluated for HTN at each medical encounter. | B, strong |
| 18-2. Children or adolescents with both CKD and HTN should be treated to lower 24-hr MAP <50th percentile by ABPM. | |
| 19. Children and adolescents with CKD and HTN should be evaluated for proteinuria. | B, strong |
| 20. Children and adolescents with CKD, HTN, and proteinuria should be treated with an ACE inhibitor or ARB. | B, strong |
| 21. Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP ≥95th percentile or >130/80 mm Hg in adolescents ≥13 y of age. | C, moderate |
| 22. In children and adolescents with acute severe HTN and life-threatening symptoms, immediate treatment with short-acting antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 h. | Expert opinion, D, weak |
| 23. Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and cardiovascular risk have been assessed. | C, moderate |
| 24. Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participation in competitive sports. | C, moderate |
| ############################## Pharmacological Intervention indicated in - • Symptomatic hypertension • Secondary hypertension • Hypertension with associated target-organ damage • Diabetes (types 1 and 2) • Persistent hypertension despite non pharmacologic measures Follow BNFc and Tertiary Unit advice General Principles - • Once daily dosing regimens are preferable when possible to aid compliance. • Younger children (<1 yr) may need multiple daily dosing to increase dose flexibility e.g. propranolol rather than atenolol or captopril rather than enalapril. • Doses should be commenced at the starting dose in the BNFc and then gradually titrated until the desired blood pressure is achieved (see goals of therapy). • In infants or those with impaired cardiac function it may be necessary to initiate antihypertensive medication in hospital with BP monitoring – these patients should be discussed with a paediatric nephrologist. Calcium Channel Blockers (e.g. nifedipine, amlodipine, nicardipine) Can be used as first or second line agents in most cases of hypertension if not contraindicated (e.g. diabetes mellitus (nifedipine)) Amlodipine tablets can be dispersed in a known volume of water and a proportion taken. This avoids the need to order expensive special medications which also have a short shelf life. Nifedipine has a short half-life and so can lead to relatively large fluctuations in BP. Amlodipine is therefore preferable for long term treatment, though modified release preparations of nifedipine are an acceptable alternative in patients able to swallow tablets. Patients under 6 years of age may have an increased ability to clear amlodipine. Beta Blockers (e.g. propranolol, atenolol) Beta blockers are no longer recommended as first line in the treatment of hypertension. They can still be used as a second line agent in most cases of hypertension if not contraindicated (e.g. asthma, portal hypertension) Cases of phaeochromocytoma need concurrent alpha-blockade ACE Inhibitors (e.g. captopril, enalapril, lisinopril) Good first line agent in cases of chronic kidney disease providing renal artery stenosis has been excluded. Electrolytes and creatinine must be checked 7 – 10 days after initiating or increasing an ACE inhibitor dose because of the risk of renal impairment and hyperkalaemia. For this reason, they are not routinely used in neonates. Counsel teenage girls regarding the contraindication in pregnancy Counsel regarding the importance of stopping medication whilst unwell with diarrhoeal or vomiting illnesses Enalapril and lisinopril tablets can be crushed and made into a suspension. This removes the need for expensive Special Preparations. Angiotensin 2 receptor blockers (e.g. Losartan) may provide an alternative in those who are unable to tolerate ACE. Can increase risk of AKI if dehydrated. Patients / parents should be given information from Think Kidneys website with advice on what to do if they become dehydrated Diuretics (e.g. furosemide) May be the most appropriate treatment for hypertension in the context of fluid overload –for example, glomerulonephritis. Counsel regarding the importance of stopping medication whilst unwell with diarrhoeal or vomiting illnesses Can increase risk of AKI if dehydrated. Patients / parents should be given information from Think Kidneys website with advice on what to do if they become dehydrated https://www.thinkkidneys.nhs. Patient information - Parents and young people should be informed about information available on the website http://www.infoKID. ######################### HYPERTENSIVE CRISIS -seizures, encephalopathy or cardiac failure Intravenous Options: Labetalol Nicardipine Sodium Nitroprusside See BNFc for cautions / contraindications Special considerations; If proven / suspected phaeochromocytoma consideration should be given to alphablockade and patients should be managed in conjunction with paediatric oncologist Symptomatic hypertension and/or acute severe hypertension: Average SBP of ≥ 95th centile + 12mmHg or ≥140/90 (whichever is lowest) Nifedipine contraindications: Shock Advanced aortic stenosis Encephalopathy / cranial hypertension Cautions Impaired cardiac function Diabetes (may affect blood sugars) Hepatic impairment ############################## Hypertension within the neonatal period - (up to 28 days past the expected due date) Persistent SBP and/or DBP above the 95th centile for infants of similar post conceptional age It should be considered if raised on 3 correctly measured blood pressures, in the resting state. Discuss with Tertiary Unit EXAMINATION AND INVESTIGATIONS IN NEONATE Antenatal history as some antenatally detected renal tract anomalies may be associated with HTN and maternal cocaine abuse may have undesirable effects on developing kidneys leading to HTN Hypoxic ischaemic encephalopathy, which may cause renal failure and HTN The clinical course during NICU (umbilical artery catheter, medications). Physical examination which should include BP measurements in the four extremities (coarctation of aorta), examination of the abdomen (renal masses) and analysis of the urine (haematuria suggesting renal vein thrombosis). |
References
5/ https://www.clinicalguidelines.scot.nhs.uk/nhsggc-paediatric-clinical-guidelines/nhsggc-guidelines/kidney-diseases/hypertension-in-paediatrics-renal-unit-rhc/
6/ https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Hypertension%20UHL%20Childrens%20Medical%20Guideline.pdf
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