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Hypertension in Pediatrics

Hypertension in children depends on age, gender and height specific blood pressure percentiles that can be calculated using the calculators below:
*Calculators for boys ( calculator 1 ) or for girls ( calculator 2 ).
o   Normal blood pressure is defined as both systolic and diastolic blood pressure <90 th percentile.
  • Prehypertension – Systolic and/or diastolic BP ≥90 th percentile but <95 th percentile or if BP exceeds 120/80 mmHg
 
  • Hypertension (HYPERTENSION) – HYPERTENSION is defined as either systolic and/or diastolic BP ≥95 th percentile measured upon three or more separate occasions.
  • Stage 1 hypertension – Systolic and/or diastolic BP between the 95 th percentile and 5 mmHg above the 99 th percentile.
  • Stage 2 hypertension – Systolic and/or diastolic BP ≥99 th percentile plus 5 mmHg.
 

Hypertension in children, can also be divided into:

  • Primary: no identified cause of hypertension.
  • Secondary: hypertension is due to a certain cause.
Treatment of hypertension in pediatrics should be initiated with pharmacological/ non pharmacological and in cases of secondary hypertension the cause should be identified and treated to prevent the development of early cardiovascular disease.
 

Non-pharmacological measures:

These measures should be done for children with hypertension and pre-hypertension: 
o   1. Weight reduction in obese patients (especially in children with type 2 diabetes)
o   2. Regular exercise (20 to 60 minutes of aerobic exercise three to four times a week) and limitation of sedentary activities to less than two hours per day.
o   3. DASH diet (low salt diet and increase fresh fruits and vegetables and low fat diary products)
·       It is advised that Sodium intake is restricted to 2 g/day, which corresponds to a salt intake of 3.1 g/day
·       Avoid food high in salt like potato chips and canned, processed food
o   4. Avoid smoking
o   5. Frequent blood pressure monitoring 
 
 

Pharmacological therapy

When to treat?
  • Symptomatic patients (headache, seizures, changes in mental status, focal neurologic complaints, visual disturbances, and cardiovascular complaints indicative of heart failure, such as chest pain, palpitations, cough, or shortness of breath).
  • Stage 2 HYPERTENSION defined above.
  • Stage 1 hypertension that persists despite a trial of four to six months of non-pharmacologic therapy.
  • Hypertensive target-organ damage, most often left ventricular hypertrophy (LVH).
  • Stage 1 hypertension in patients with diabetes mellitus or dyslipidemia
  • Prehypertension in presence of comorbid conditions, such as chronic kidney disease or diabetes mellitus.
 
Pharmacotherapy should be initiated with the goal to prevent premature cardiovascular disease and lower blood pressure to target goals.
 

Blood pressure goals:

  • In children and adolescents with hypertension and no evidence of target-organ damage, comorbid risk factors, or cardiovascular disease; the targeted goal is less than the 95 th percentile based upon age, height, and gender.
  • If there are comorbid risk factors (eg, obesity or dyslipidemia), cardiovascular diseases (eg, diabetes mellitus), or chronic kidney disease, the BP targeted goal is lowered to below the 90 th percentile for age, height, and gender.
 
Antihypertensive drugs:
Thiazide diuretics  
thiazide diuretics can be considered an effective and safe option in children, can be given alone or in combination.
Agent
Dose
Notes
Hydrochlorothiazide
Start with 1mg/ kg/ day to a maximum of 3 mg/kg/ day or 50 mg
Close monitoring of blood chemistry is required
chlorthalidone
Start with 0.5 mg/kg/day to a maximum of 2mg/kg/ day or 50 mg
Avoid in patients with renal impairment as it may cause azotemia
 
ACE inhibitors/ARBs  
Ace inhibitors & ARBs are approved for children older than 6 years, and are the preferred choice for children with diabetes mellitus  and chronic kidney disease due to renal protective effects.
Black children appear to require higher doses of Ace inhibitors than non-black children.
All Ace inhibitors/ ARBs should be avoided in females of childbearing age, unless a reliable contraception method is used.
 
Agent
Dose
Notes
enalapril
Start with 0.08 mg/kg per day up to 5 mg/day and titrate to 0.6 mg/kg per day up to 40 mg/day
Monitor potassium levels and renal function
lisinopril
0.07 mg/kg per d up to 5 mg/day and titrate to 0.6 mg/kg per day up to 40 mg/day
Monitor potassium levels and renal function
benzapril
0 .2 mg/kg per day up to 10 mg/day
and titrate to 0.6 mg/kg per day up to 40 mg/day
Monitor potassium levels and renal function
fosinopril
5-10 mg/ day and up to 40 mg daily
 
 
 
Used in children > 50 kg only.
Monitor potassium levels and renal function
losartan
0.7 mg/kg per day up to 50 mg/day
and up to 1.4 mg/kg per day
Monitor potassium levels and renal function
 
Beta blockers  
 Beta blockers are one of the first options for children with hypertension.
Agent
Dose
Notes
propranolol
1-2 mg/kg/ day and to a maximum of 4 mg/kg/day
Contraindicated in children with asthma, heart block.
Avoid in insulin dependent diabetics
metoprolol
1-2 mg/kg/ day and to a maximum of 6mg/kg/day
Avoid in insulin dependent diabetics
Atenolol
0.5-2 mg/kg/day
Avoid in insulin dependent diabetics
labetalol
Start with 1-2mg/ kg/day and up to 10-12 mg/kg/day
Contraindicated in children with asthma, heart block.
Avoid in insulin dependent diabetics
 
Calcium channel blockers  
Considered the drug of choice in cases of asthma and hypertension, also preferred in cases of secondary because it will not affect renal function.
Agent
Dose
Notes
Amlodipine
2.5-5 mg daily
 
For children 6 years and older.
Check heart rate
Felodipine
2.5 mg-10 mg daily
Check heart rate
Nifedpine (extended release)
Start with 0.25 -0.5 mg/kg/day and up to 3 mg/kg/day
Check heart rate
Tablets must be swallowed whole
 
Continued follow-up is required to monitor the response to therapy and to detect any drug-related adverse effect.
 
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