pediatric hypertension

1. Pediatric Hypertension
BHADRA TRIVEDI, MD Pediatrics
Pediatric cardiologist
Room – 5 , B & M Patel cardiology centre
Bhadrayt@charutarhealth.org

2. Objectives
• Get acquainted with online teaching / learning
• Learn differences between pediatrics and adult hypertension
• Basic principals of management strategy

3. House Rules
1. I will speak
2. You may speak as well
3. For queries – Raise Hand and ask Question – during presentations
4. Q and A – keep typing in chat box – discussed at the end of the
session

4. Why problem of Hypertension is
different in Pediatric than in adult?
Question –
Mr XYZ – 29 years old, 60 kg, 158 cm.
What will his Blood Pressure?

5. Adult VsPediatrics –What is problem with Growth
Mr XYZ – 29 years old, 60 kg, 158 cm 120 / 80 mmHg
Master ABC – 5 years
18 kg, 42 cm
Normal Blood Pressure ?
? 120 / 80 mmHg
Too High
90 / 50 mmHg
Pediatric Range - 1 day till 18 years , 800 gm to 50 kg, 37 cm to 145 cm

6. Prima Facie – Pediatric Hypertension
• Hypertension definition has to compound for age, weight and height
as well as growth
• Gender differences should be factored
SOLUTION
Z Score – Population Based Charts

7. Normal Distribution Curve
Normal Distribution Curve- Gaussian Curve - Curve of Nature itself
Karl Friedrich Gauss - German Math Genius – 1777 - 1855
Frequency
Observations

8. Cricket and Bell Curve

9. Bell Curve
Distribution

10. Bell Curve
&
Outliers
Height
164.7 cm 178.5 cm

11. Bell Curve
&
Outliers
Height
157 –178
68%

12. Bell Curve
&
Outliers
Height
163 –193
95%

13. Who is the superhero now?
Carl Friedrich Gauss
1777-1855
• Born in Brunswick, Germany, on April 30, 1777
• Died on February 23, 1855

14. Pediatric Hypertension :
What is Normal ?
Rules of the Game
Measure Blood pressure of as many children as
possible, across gender, age, weight and height
•25228 children, Ernakulam Kerala, 3 readings of each
child, 2 minutes away
Compile the data, create charts
Define normal range
If higher than normal – hypertension

15. Stethoscope Sphygmomanometer
• Bell
• For low-pitched sounds
• Mid-diastolic murmur of mitral stenosis
or S3 in heart failure
• Diaphragm
• Filters out low-pitched sounds
• For high-pitched sounds
• Second heart sound,
ejection and
midsystolic clicks
• Diastolic murmur of
aortic regurgitation

16. Stethoscope Sphygmomanometer
• Done best when child is un-
aware of examination
• Preferably smaller chest piece
for better localisation
• Areas of interest – four valve
area and Lt Sternal Border
• Site of measurement – both
upper limb and one lower limb –
Brachial and popliteal
• Ideal – both – systolic and
diastolic
• Systolic blood pressure –
Palpation and Flush technique

17. Pediatric HTN in Brief
BP Classification
• BP < 90th Percentile – Normal
• 90th < BP < 95th Centile – Pre-hypertension
• 95th < BP < 99th Centile – Stage 1 HTN
• < 99th Centile – Stage 2 HTN

18. Causes of HTN in Pediatrics
• Primary Hypertension ( Essential ) – Cause NOT FOUND
• Secondary – Systemic Causes
RENAL
Renal parenchymal disease
Glomerulonephritis, acute and chronic
Pyelonephritis, acute and chronic
Congenital anomalies (polycystic or dysplastic kidneys)
Obstructive uropathies (hydronephrosis)
Hemolytic-uremic syndrome
Collagen disease (periarteritis, lupus)
Renal damage from nephrotoxic medications, trauma, or radiation
Renovascular disease
Renal artery disorders (e.g., stenosis, polyarteritis, thrombosis)
Renal vein thrombosis

19. Causes of HTN in Pediatrics – Cont.
CARDIOVASCULAR
Coarctation of the aorta
Conditions with large stroke volume (patent
ductus arteriosus, aortic insufficiency, systemic
arteriovenous fistula, complete heart block) (these
conditions cause only systolic hypertension)
ENDOCRINE
Hyperthyroidism (systolic hypertension)
Excessive catecholamine levels
Pheochromocytoma
Neuroblastoma
Adrenal Dysfunction
Congenital adrenal hyperplasia
11-β-Hydroxylase deficiency
17-Hydroxylase deficiency
Cushing's syndrome
Hyperaldosteronism
Conn's syndrome
Idiopathic nodular hyperplasia
Dexamethasone-suppressible hyperaldosteronism
Renovascular hypertension
Renin-producing tumor
Hyperparathyroidism (and hypercalcemia)

20. Causes of HTN in Pediatrics – Cont.
NEUROGENIC
Increased intracranial pressure (any cause,
especially tumors, infections, trauma)
Poliomyelitis
Guillain-Barré syndrome
Dysautonomia (Riley-Day syndrome)
DRUGS AND CHEMICALS
Sympathomimetic drugs (nose drops, cough
medications, cold preparations, theophylline)
Amphetamines Steroids
Nonsteroidal anti-inflammatory drugs
Oral contraceptives
Heavy-metal poisoning (mercury, lead)
Cocaine, acute or chronic use
Cyclosporine
MISCELLANEOUS
Hypervolemia and hypernatremia
Stevens-Johnson syndrome
Bronchopulmonary dysplasia (newborns)

21. Most Common Causes
• Obesity
• Renal parenchymal disease
• Renal artery stenosis
• Coarctation of aorta

22. Imp Causes of Sustained HTN

23. Diagnosis and Workup
• Symptoms – Mostly accidental findings of HTN, significant HTN – headache,
irritability, excessive crying, nausea, vomiting
• Measurement – three readings
• White Coat Hypertension
• Risk Factors
• Obesity
• Family H/O Heart Disease
• Hypercholesterolemia
• Reduced HDL
• DM / Cig. Smoking Exposure
• Lifestyle

24. Clinical Evaluation
• Details of systemic involvement
1. CVS – Coarctation of Aorta, HTN related echocardiogram and ECG
changes
2. Renal – Either as a cause of HTN or effects of HTN – parenchymal
disease, obstructive uropathies, UTI
3. Endocrine – Cushing, hyperthyroid
4. Medications – Steroids, anti-asthmatics, anti-metabolites,
5. CNS – irritability, vomiting, headache

25. Lab Work-up
Intention – To find Cause and To find
Involvement of other systems

26. Management
Essential HTN
• Non-Pharmacological
• Weight Reduction
• Low Salt Diet
• Healthy Practices
When to Start Pharmacological Rx
1. Severe symptomatic hypertension, which should
be treated with intravenous (IV) antihypertensive
medications
2. Significant secondary hypertension, such as that
due to renovascular and Reno parenchymal diseases
3. Hypertensive target organ damage
4. Family history of early complications of
hypertension
5. Diabetes (types 1 and 2)
6. Child who has dyslipidemia and other coronary
artery risk factors
7. Persistent hypertension despite nonpharmacologic
measures

27. Pre-Load
&
After-Load

29. • Arteriolar vasodilators – hydralazine
• Venodilators -nitroglycerin, isosorbide
dinitrate
• Mixed vasodilators include ACE
inhibitors captopril, enalapril,
nitroprusside, and prazosin
• Calcium channel blockers

30. Secondary Hypertension
Treatment of Cause
Coarctation of Aorta – Surgical and / or Percutaneous intervention
Renal Parenchymal Disease
Medical Management
Surgical Management

31. Aim of Treatment
The goal of the treatment is reduction of BP to less than the 95th percentile for
children with uncomplicated primary hypertension without hypertensive end-organ
damage. For children with chronic renal disease, diabetes, or hypertensive target
organ damage, the goal is reduction of BP to less than the 90th percentile.
A “step-down” therapy or cessation of therapy may be considered in selected
patients who have uncomplicated primary hypertension that is well under control,
especially overweight children who successfully lose weight. Such patients require
ongoing follow-up of their BP levels and nonpharmacologic treatment.

32. Hypertensive Crisis Hypertensive Crisis Treatment

33. Sources
1. Textbook – Pediatric Cardiology for Practitioners – Myung K Park
2. Articles
Raj, M., Sundaram, K. R., Paul, M., & Kumar, R. K. (2010). Blood pressure distribution in Indian children. Indian
pediatrics, 47(6), 477-485.
Narang, R., Saxena, A., Ramakrishnan, S., Dwivedi, S. N., & Bagga, A. (2015). Oscillometric blood pressure in
Indian school children: Simplified percentile tables and charts. Indian pediatrics, 52(11), 939-945

34. May 9th 1945 – 75 years back