Hypertension in
Pediatrics
Etty Widyastuti
FK UNILA/RSUD Abul Moeloek
Objectives
Definitions2
<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
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
Lets Practice
Our Patient
Classification of
Hypertension & Therapy
Recommendations2
Classification
of
Hypertension
Therapy
Recommendations
Normal
Prehypertension
Stage 1 Hypertension
Stage 2 Hypertension
Management
2
Algorithm
Diagnostic Work-Up6
Urinalysis
Protein/Cr Ratio
Renal Ultrasound
EKG
CBC with
differential
Electrolyetes,
BUN, Cr
Possible Etiologies
2
Causing Hypertension
Treatment Strategies
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.
Antihypertensive
Medication
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
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
ARB
www.medscape.com
ARB
Comments:
CCB1-3, 5
CCB
Patients Characteristics:
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
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:
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
<90th Percentile
Long-Term
3
Management
Step-Down Therapy2
Conclusions
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