II. Epidemiology

  1. Prevalence under age 18 years old
    1. Prehypertension: 3.4%
    2. Hypertension: 3.6%
  2. Prevalence of Hypertension or prehypertension in Overweight or obese adolescents
    1. Boys: 30%
    2. Girls: 23-30%

III. Criteria

  1. See Hypertension Criteria
  2. Routine Blood Pressure screening over age 3 years

IV. Causes

  1. See Hypertension Causes in Children
  2. Renovascular disease is most common cause in children
  3. Features most suggestive of Secondary Hypertension
    1. Hypertension under age 10 years
    2. Stage 2 Hypertension in Children

V. Risk Factors

  1. Obesity
  2. Metabolic Syndrome or Diabetes Mellitus
  3. Black ethnicity
  4. Snoring or other findings of Sleep Apnea
  5. Family History
    1. Essential Hypertension
      1. Coronary Artery Disease
      2. Hyperlipidemia
      3. Hypertension
    2. Renovascular disease
      1. Kidney disease
      2. Deafness
    3. Endocrinopathy
      1. Diabetes Mellitus
      2. Thyroid disorder
      3. Adrenal disease

VI. History

  1. See Family History above
  2. See Medication Causes of Hypertension
  3. General
    1. Weight change
  4. Lung
    1. Dyspnea on exertion
  5. Cardiovascular
    1. Chest Pain
    2. Palpitations
  6. Renal
    1. Hematuria
    2. Recurrent Urinary Tract Infection
  7. Extremities
    1. Edema
    2. Joint Pain or swelling
    3. Myalgias
  8. Neurologic
    1. Headaches
  9. Endocrine
    1. Profuse sweating
    2. Hot or cold intollerance

VII. Examination: Secondary Hypertension clues

  1. General
    1. Growth delay (Chronic Kidney Disease)
  2. Eyes
    1. Fundoscopic exam
  3. Throat
    1. Tonsil or adenoid hypertrophy (Sleep Apnea)
  4. Neck
    1. Thyromegaly (Hyperthyroidism)
  5. Cardiovascular
    1. Tachycardia (Hyperthyroidism, Pheochromocytoma)
  6. Abdomen
    1. Abdominal mass (renal lesion)
    2. Abdominal bruit (Renal Artery Stenosis)
  7. Extremities
    1. Cold legs with diminished pulses (Aortic Coarctation)
    2. Joint Swelling (Systemic Lupus Erythematosus)
  8. Skin
    1. Acne Vulgaris, Hirsutism (Cushing's Disease)
    2. Malar Rash (Systemic Lupus Erythematosus)
    3. Profuse sweating (Pheochromocytoma)
  9. Neurologic
    1. Motor weakness (Hyperaldosteronism)
  10. Endocrine
    1. Truncal Obesity, moon facies (Cushing's Syndrome)

VIII. Diagnosis

  1. See Hypertension Criteria
  2. Obtain 3 elevated Blood Pressures on different days
  3. Consider Ambulatory Blood Pressure Monitoring

IX. Labs

  1. Complete Blood Count
    1. Includes Leukocyte differential and Platelet Count
  2. Chemistry panel
    1. Electrolytes
    2. Serum Glucose (consider obtaining with Insulin)
    3. Blood Urea Nitrogen
    4. Serum Creatinine
    5. Serum Calcium
    6. Serum Phosphorus
    7. Serum Uric Acid
  3. Urine testing
    1. Urinalysis
    2. Urine Drug Screen (if indicated)
    3. Urine Culture
    4. Consider Urine Microalbumin
  4. Endocrine tests
    1. Thyroid Stimulating Hormone (TSH)
    2. Consider 24 hour Urine Cortisol
    3. Consider plasma renin level
    4. Consider 24 hour Urine VMA and metanephrines

X. Diagnostics

  1. Electrocardiogram
  2. Echocardiogram
    1. Obtain in all children with confirmed Hypertension
  3. Other studies to consider
    1. Sleep Study (if Sleep Apnea suspected)
    2. MRA of renal arteries
    3. Renal Ultrasound

XI. Management: Non-pharmacologic

  1. Mnemonic: 5-2-1-0
    1. Five fruits and vegetables per day
    2. Maximum of 2 hours per day screen time daily
    3. One hour or more of Physical Activity daily
    4. No sugary drinks
  2. Continue monitoring Blood Pressure at least every 6 months
  3. Evaluate for Obesity
    1. Weight loss if Overweight (5-10% in a year, or maintain without gain)
    2. Consider secondary Hypertension Evaluation if weight is normal
  4. Evaluate cardiovascular risks
    1. Obtain Lipid profile
    2. Obtain Fasting Glucose
  5. Cardiovascular Risk Management
    1. Regular Exercise program of 30-60 minutes on most days
    2. Limit sedentary activities to <2 hours per day
    3. Low Fat Diet
    4. Low Sodium diet (e.g. DASH Diet)
    5. Fruits and vegetables at least 5 daily
    6. Tobacco Cessation
    7. Avoid Alcohol

XII. Management: Pharmacologic

  1. Indications
    1. Symptomatic Hypertension
    2. Secondary Hypertension
    3. Stage 1 Hypertension refractory to general measures (for at least 6 months)
    4. Stage 2 Hypertension
    5. Significant comorbidity
      1. Diabetes Mellitus
      2. Chronic Kidney Disease
    6. End-organ involvement
      1. Proteinuria
      2. Retinopathy
      3. Left Ventricular Hypertrophy
  2. Goal Blood Pressures
    1. Less than 95%: No end organ damage
    2. Less than 90%: End-organ involvement or comorbidity
  3. Agents FDA approved in children
    1. Precautions
      1. Use ACE Inhibitors or ARB agents in patients with Diabetes Mellitus or Kidney disease
      2. Consider Calcium Channel Blocker (e.g. Amlodipine) in teen girls due to Teratogenicity of other agents
    2. ACE Inhibitors (age 6 and over)
      1. Lisinopril 0.07 mg/kg/day up to 5 mg daily (max: 0.6/mg/kg up to 40 mg/day)
      2. Benazepril (Lotensin) 0.2 mg/kg up to 10 mg (max: 0.6 mg/kg up to 40 mg/day)
      3. Enalapril (Vasotec) 0.08 mg/kg up to 5 mg (max: 0.6 mg/kg up to 40 mg/day)
      4. Fosinopril (Monopril) 5 to 10 mg daily (max: 40 mg day)
        1. Avoid if age <6 years or weight <50 kg or 111 lb
    3. Angiotensin Receptor Blockers (age 6 and over)
      1. Losartan 0.7 mg/kg/day (max: 1.4 mg/kg or 100 mg daily)
      2. Irbesartan (Avapro) 75 to 150 mg daily for ages 6 to 12 years old
        1. Use adult dosing for age 13 and over
      3. Valsartan (Diovan) 1.3 mg/kg/day up to 40 mg/day (max: 2.7 mg/kg/day up to 160 mg/day)
    4. Calcium Channel Blockers
      1. Amlodipine 2.5 to 5 mg/day (max: 10 mg/day) if age 6 years or older
    5. Beta Blockers (age 6 years old and over)
      1. Use other agents first-line, unless other indications (e.g. Migraine Prophylaxis)
      2. Propranolol 1-2 mg/kg/day (max: 4 mg/kg or 640 mg/day)
      3. Metoprolol XL 1 mg/kg up to 50 mg (max: 2 mg/kg or 200 mg/day)
    6. Miscellaneous: Second-line agents
      1. Hydrochlorothiazide 1 mg/kg/day (max: 3 mg/kg or 50 mg/day)
      2. Clonidine (Catapres) 0.2 mg twice daily (if age 12 years or older)

XIII. Complications

  1. Left Ventricular Hypertrophy
    1. May present as early as childhood

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