Pediatric acute hypertension

Prof .Dr. Saad S Al Ani

Senior Pediatric Consultant

Head of Pediatric Department

Khorfakkan Hospital

Sharjah ,UAE

saadsalani@yahoo.com

PediatricAcute Hypertension

Background

Adolescents may acquire primary or essential hypertension

In infants and younger children, systemic hypertension is uncommon, but when present, it is usually indicative of an underlying disease process (secondary hypertension).

03/20/2012 2Pediatric Acute hypertension Prof. Dr. Saad S Al Ani

Khorfakkan Hospital ,Sharjah ,UAE

Correlate with BP tables for age, height, and weight

Accurate blood pressure measurements should be part of the routine annual physical examination of all children 3 yr or older.

A complete family history of hypertension should be elicited

Use appropriate cuff size for blood pressure (BP) measurement.

03/20/2012 3Pediatric Acute hypertension Prof. Dr. Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE

Etiology and Pathophysiology

Many childhood diseases may be responsible for

both acute and chronic elevation of blood pressure

Secondary hypertension is most common in infants and younger children

Cont.Hypertension in the newborn

is most often associated with:

1. umbilical artery catheterization

2. renal artery thrombosis

Hypertension during early childhood

may be due to :

1.renal disease

2.coarctation of the aorta

3. endocrine disorders

4.medications.

Cont. In adolescents

essential hypertension becomes increasingly common

03/20/2012 7Pediatric Acute hypertension Prof. Dr.

Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE

In general, children and adolescents with essential hypertension

have blood pressure values at or only slightly above the 95th

percentile for age

The severity of hypertension is also helpful in distinguishing secondary from primary hypertension

Renal and renovascular hypertension accounts for the majority of children with secondary hypertension

A history of urinary tract infection is present in 25-50% of these patients and is often related to an obstructive lesion of the urinary tract

Conditions Associated with Transient or Intermittent Hypertension in Children

• Acute postinfectious glomerulonephritis • Anaphylactoid (Henoch-Schönlein) purpura with nephritis • Hemolytic-uremic syndrome

• Acute tubular necrosis • After renal transplantation (immediately and during episodes of

rejection) • After blood transfusion in patients with azotemia

• Renal trauma • Leukemic infiltration of the kidney • Obstructive uropathy associated with Crohn

disease

• Hypervolemia • After surgical procedures on the genitourinary

tract • Pyelonephritis

Drugsand

Poisons

• Cocaine • Oral contraceptives • Sympathomimetic agents • Amphetamines • Phencyclidine • Corticosteroids and

adrenocorticotropic hormone

• Cyclosporine or sirolimus treatment post-transplantation • Licorice (glycyrrhizic acid) • Lead, mercury, cadmium, thallium • Antihypertensive withdrawal (clonidine, methyldopa, propranolol) • Vitamin D intoxication

Central and

Autonomic nervous system

• Increased intracranial pressure • Guillain-Barré syndrome • Burns • Familial dysautonomia

• Stevens-Johnson syndrome

• Posterior fossa lesions • Porphyria • Poliomyelitis • Encephalitis

Miscellaneous

• Preeclampsia • Fractures of long bones • Hypercalcemia

• After coarctation repair • White cell transfusion • Extracorporeal membrane

oxygenation • Chronic upper airway obstruction

Conditions Associated with Chronic Hypertension

in Children

• Chronic pyelonephritis • Chronic glomerulonephritis • Hydronephrosis • Congenital dysplastic kidney

• Multicystic kidney • Solitary renal cyst • Vesicoureteral reflux nephropathy • Segmental hypoplasia (Ask- Upmark

kidney)

• Ureteral obstruction • Renal tumors • Renal trauma • Rejection damage following transplantation • Postirradiation damage • Systemic lupus erythematosus (other connective tissue diseases

Vascular

• Coarctation of thoracic or abdominal aorta • Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis,

aneurysm) • Umbilical artery catheterization with thrombus formation • Neurofibromatosis (intrinsic or extrinsic narrowing of vascular lumen)

• Renal vein thrombosis • Vasculitis • Arteriovenous shunt • Williams- Beuren syndrome • Moyamoya disease

Endocrine

• Hyperthyroidism • Hyperparathyroidism • Congenital adrenal hyperplasia (11 β- hydroxylase

and 17-hydroxylase defect)

• Cushing syndrome • Primary aldosteronism • Dexamethasone-suppressible hyperaldosteronism

• Pheochromocytoma • Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma) • Diabetic nephropathy • Liddle syndrome

Central Nervous System

• Intracranial mass • Hemorrhage • Residual following brain

injury • Quadriplegia

Essential hypertension

• Low renin • Normal renin • High renin

Acute Hypertension

• Hypertensive urgency:

Significant elevation in BP without accompanying end-organ damage; more common in children.

Symptoms include headache, blurred vision, and nausea

• Hypertensive emergency: Elevation of both systolic and diastolic BP with acute end-organ damage (e.g., cerebral infarction or hemorrhage, pulmonary edema, renal failure, hypertensive encephalopathy, or seizures)

Physical examination

• Four-extremity BP• Funduscopy (papilledema, hemorrhage, exudate) • Visual acuity • Thyroid examination • Evidence for congestive heart failure (tachycardia, gallop rhythm,

hepatomegaly, edema) • Abdominal examination (mass, bruit) • Thorough neurologic examination • Evidence of virilization, cushingoid effect

Initial diagnostic evaluation

• Urinalysis• Blood urea nitrogen• Creatinine,• Electrolytes• Chest radiograph• Electrocardiogram

Consider

• Renin level• Toxicology screen• Thyroid and adrenal testing • Urine catecholamines• Abdominal ultrasound• Renal Doppler ultrasound • Head CT

Management

Hypertensive emergency:

Goal: Lower BP promptly but gradually to preserve cerebral autoregulation

(a) Mean arterial pressure (MAP) = 1/3 systolic + 2/3 diastolic BP(b) Lower by 1/3 of planned MAP reduction over first 6 hours, then(c) Lower by additional 1/3 over next 24–36 hours, then(d) Lower final 1/3 over next 48 hours

After elevated ICP is ruled out, do not delay treatment because of further diagnostic workup

Hypertensive urgency:

To lower MAP by 20% over 1 hour and return to baseline levels over 24 to 48 hours

An oral route may be adequate. (Use of sublingual nifedipine is not recommended, as a precipitous, uncontrolled fall in BP may result.)

Algorithm for identifying children with high blood pressure (BP)

References

• Flynn JT: What's new in pediatric hypertension? Curr Hypertens Rep 2001;3: 503-10.

• Kay JD, Sinaiko AR, Daniels SR: Pediatric hypertension. Am Heart J 2001;142:422-32.

• Blaszak RT, Savage JA, Ellis EN: The use of short-acting nifedipine in pediatric patients with hypertension. J Pediatr 2001;139:34-7.

• Katherine M. Steffen. Trauma, Burns, and Common Critical Care Emergencies(in) The Harriet Lane handbook. 19th ed. Philadelphia 2012 Ch.4 p:113-115

Thank you

Pediatric acute hypertension

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