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Treatment of

Hypertension in
Pediatrics
Etty Widyastuti
FK UNILA/RSUD Abul Moeloek

Objectives

Define hypertension in children


Identify when blood pressure should
be taken
Practice determining BP percentile
and interpreting how to use this
information to best treat the patient
Discuss treatment options used in
pediatrics to treat hypertension

Definitions2

Hypertension: average SBP and/or


DBP >95th percentile for gender, age,
and height on > 3 occasions
Prehypertension: average SBP or
DBP >90th percentile but <the 95th
percentile
Adolescents with BP levels >120/80 mm
Hg should be considered
prehypertensive

What does this


2
percentile mean?
Normal

<90th

Prehypertension

90-<95th or if >12080

Stage 1
hypertension

95th-99th plus 5 mm
Hg

Stage 2
hypertension

>99th plus 5 mm Hg

Measurement of Blood
2
Pressure

Children >3 years old should


have their BP measured when
seen in a medical setting
Preferred method: Auscultation
Requires a cuff that is appropriate
for the childs arm
Right arm preferred

Blood Pressure Cuf2

Equipment needed
to measure BP in
children (3adolescents):
Child cuffs of
different sizes
Standard adult cuff
Large adult cuff
Thigh cuff

Measurement of BP in
2
children < 3 years old

History of prematurity, VLBW, or other neonatal


complications
Congenital heart disease
Recurrent UTI, hematuria, or proteinuria
Known renal disease or urologic malformations
Family history of congenital renal disease
Solid-organ transplant
Malignancy or bone marrow transplant
Treatment with drugs known to raise BP
Systemic illnesses associated with hypertension
Evidence of elevated ICP (intracranial pressure)

Using the Blood


2
Pressure Tables

Use the standard height charts to determine


the height percentile.
Measure and record the childs SBP and DBP.
Use the correct gender table for SBP and DBP.
Find the childs age on the left side of the
table. Follow the age row across the table to
the intersection of the line for the height
percentile.
Find the 50th, 90th, 95th, and 99th percentiles
for SBP in the left columns and for DBP in the
right columns.

Lets Practice

AMF is a 5 yo female height 112


cm weight 25 kg. Her BP is taken
when she goes to the Dr. for a
routine visit. Her BP is 114/73.
What is her BP percentile?
What do we do with this
information?

Our Patient

AMF BP was in 95th percentile


Repeated BP at 3 office visits (93rd
percentile)
Recommend Lifestyle Changes
Repeat BP in 6 months (95th percentile)

Classification of
Hypertension & Therapy
Recommendations2

Classification
of
Hypertension

Therapy
Recommendations

Normal

Encourage healthy diet, sleep, &


physical activity

Prehypertension

Physical activity & diet management;


No medication unless compelling
indications such as chronic kidney
disease, DM, HF or LVH exist

Stage 1 Hypertension

Physical activity & diet management;


Initiate therapy

Stage 2 Hypertension

Physical activity & diet management;


Initiate therapy (more than 1 drug
may be required)

Management
2
Algorithm

Diagnostic Work-Up6
Urinalysis
Protein/Cr Ratio
Renal Ultrasound

Rule out infection,


hematuria, proteinuria
Kidney function

EKG

Rule out renal scarring,


congenital renal anomalies
Cardiomegaly

CBC with
differential
Electrolyetes,
BUN, Cr

Rule out anemia, consistent


with chronic renal disease
Rule out renal disease,
pyelonephritis

Possible Etiologies
2
Causing Hypertension

Chronic Renal Failure


Cushing Syndrome
Turner Syndrome
Hyperthyroidism
Systemic Lupus
Coarctation of the aorta
Wilms tumor

Treatment Strategies

Therapeutic lifestyle changes


Drug therapy

Lifestyle changes

Weight reduction
Regular physical activity
Restriction of sedentary activity
Dietary modification
Family-based intervention

Indications for
Antihypertensive Drug
Therapy2

Symptomatic hypertension
Secondary hypertension
Hypertensive target-organ
damage
Diabetes (types 1 and 2)
Persistent hypertension despite
nonpharmacologic measures

Step-wise Approach to
2
Therapy
1.
2.

3.
4.

Start with a small dose of a single


anti-hypertensive drug
Increase dose of single antihypertensive drug (to max dose if
tolerated)
Add a small dose of a second drug
Increase dose of second antihypertensive medication

Antihypertensive
Medication

Angiotensin Converting EnzymeInhibitors


Angiotensin Receptor Blockers
Calcium Channel Blockers
Diuretics
Beta-Blockers
Central alpha-agonists
Peripheral alpha-antagonist
Vasodilators

Drug Options for Initial


1
Therapy
Class of
Drugs
ACEIs/ARBs
CCBs
Diuretics

Patients Characteristics

Blocker

Avoid in athletes
(controversial) and people
with diabetes

First-line therapy
First-line therapy
Adjunct second-line drug

ACE-I1-3, 5

Angiotensin Converting Enzyme Inhibitors


Benazepril*, Captopril, Enalapril*,
Fosinopril*, Lisinopril*, Quinapril

Mechanism of Action: prevents

conversion of angiotensin I to angiotensin II,


a potent vasoconstrictor; results in lower
levels of angiotensin II which causes an
increase in plasma renin activity and a
reduction in aldosterone secretion

ACE-I

www.medscape.com

ACE-I

Patients Characteristics:
High plasma renin activity
Renal insufficiency (unilateral
renovascular hypertension, renal
parenchymal disease, renal proteinuria)
Congestive heart failure
Diabetes
Hyperlipidemia

ACE-I

Comments:

Contraindicated in pregnancy
Monitor serum potassium and SCr
Cough and angioedema
May require a dosing adjustment in renal
impairment
Fosinopril in children >50 kg
Good data on compounding Captopril into
a suspension

ARB1-3, 5

Angiotensin Receptor Blockers


Irbesartan*, Losartan*
Mechanism of Action:
angiotensin II receptor antagonist;
blocks the vasoconstrictor and
aldosterone-secreting effects of
anigotensin II

ARB

www.medscape.com

ARB

Patients Characteristics: same


as ACE-I

Comments:

Less studied than ACE-I


Dosing not available in Neofax or Pediatric
Dosing Handbook
All are contraindicated in pregnancy
Check serum potassium and SCr
Not available currently on formulary

CCB1-3, 5

Calcium Channel Blocker


Amlodipine*, Felodipine, Isradipine,
Extended-release Nifedipine

Mechanism of Action: inhibits calcium

ions from entering the slow channels or


select voltage-sensitive areas of vascular
smooth muscle and myocardium during
depolarization; produces a relaxation of
coronary vascular smooth muscle and
coronary vasodilation

CCB

Patients Characteristics:

Emergency hypertension (nifedipine)


Black race
Diabetes
Chronic obstructive lung disease
Broncho-pulmonary dysplasia
Gout
Hyperlipidemia
Peripheral Vascular Disease
Renal Transplant (cyclosporine-induced)

CCB

Comments:
ADR: edema, arrhythmias, headache,
fatigue, dizziness, flushing
No adjustment in renal impairment
May need adjustment in hepatic
impairment
Good data for compounding
Amlodipine oral suspension

Diuretics1-3, 5

Amiloride, Chlorothiazide,
Chlorthalidone, Triamterene,
Furosemide, HCTZ*, Spironolactone,
Metolazone, Bumetanide

Mechanisms of Action:
Loop Diuretic: (Furosemide, Bumetanide) Inhibits
reabsorption of Na and Cl in the ascending loop of
Henle and distal tubule causing increased
excretion of water, K, Na, Cl, Mg, & Ca

Diuretics

Mechanism of Action: continued


Thiazide Diuretic: (HCTZ, Chlorothiazide) Inhibits Na
reabsorption in the distal tubules causing increased
excretion of Na and water as well as K, Mg, Ca,
hydrogen, phosphate, & bicarb ions
K Sparing Diuretic: (Spironolactone) Competes
with aldosterone for receptor sites in the distal
renal tubules, increasing NaCl and water excretion
while conserving K and hydrogen ions; may block the
effect of aldosterone on arteriolar smooth muscle as
well
Miscellaneous: (Metolazone) Inhibits sodium
reabsorption in the cortical diluting site and
proximal convoluted tubules

Diuretics

http://sprojects.mmi.mcgill.ca/nephrology/
presentation/images/86no2.gif

Diuretics

Patients Characteristics:
Volume dependent, low plasma renin
activity
Black race
Congestive heart failure
Avoid in athletes

Diuretics

Comments:
ADR: Dizziness, Photosensitivity, Rash,
Vomiting
Monitor Electrolytes
Adjust in renal impairment
Furosemide and Chlorothiazide available in
solutions
Good data to compound Spironolactone,
Metolazone and HCTZ into oral suspensions

BB

1-3, 5

eta-Blocker
Atenolol, Bisoprolol/HCTZ,
Metoprolol, Propranolol*
Mechanism of Action: Selective
inhibitor of beta1-adrenergic
receptors at lower doses; also
inhibits beta2-receptors at higher
doses

BB
Patients

Characteristics:

High plasma renin activity


Hyperdynamic circulation
Anxiety
Migraine
Hyperthyroidism
Neuroadrenergic tumors

BB

Comments:
Good data to compound Metoprolol and
Atenolol
Propranolol available as a solution
Worried about higher doses in asthma
patients
Contraindicated in sick sinus syndrome
Avoid in athletes and people with diabetes

Goals of Therapy2
Disease State

Desired Percentile
for Gender, Age, &
Height

Uncomplicated primary
HTN with no target-organ
damage

<95th Percentile

Chronic renal disease,


diabetes, hypertensive
target-organ damage

<90th Percentile

Long-Term
3
Management

Monitor therapy for efficacy and


for potential adverse effects
Measure blood pressure every 2-4
weeks until good control
Once controlled, monitor every 34 months

Step-Down Therapy2

After blood pressure is stable,


gradually reduce medication
Goal: Discontinue medication
Best Candidates: Children with
uncomplicated HTN due to obesity
Continue to follow BP and continue
lifestyle changes

Conclusions

Use patients BP Percentile to


determine if they have
hypertension.
First-line agents to treat
hypertension are ACE-I/ARB or
CCB.
Diuretics are usually used as
second line therapy.

References
1. Seikaly, Mouin G. Hypertension in children: an update on
treatment strategies. Curr Opin Pediatr 2007; 19:170-177.
2. National High Blood Pressure Education Program Working
Group on High Blood Pressure in Children and Adolescents.
The fourth report on the diagnosis, evaluation, and
treatment of high blood pressure in children and
adolescents. Pediatrics 2004; 114:555-576.
3. Flynn, JT. Pharmacologic Treatment of Hypertension in
Children and Adolescents. J Pediatr 2006; 149:746-54.
4. McNiece, Karen and Portman R. Ambulatory blood pressure
monitoring: what a pediatrician should know. Curr Opin
Rediatr 19:178-182.
5. Pediatric Dosage Handbook, 14th ed. Hudson, OH: Lexi-Com,
2005.
6. Luma, GB and Spiotta, RT. Hypertension in Children and
Adolescents. AAFP 2006; 73: 1158-68.

Questions

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