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 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 or Metabolic Syndrome
  2. Black ethnicity
  3. Snoring or other findings of Sleep Apnea
  4. 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
      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. Continue monitoring Blood Pressure at least every 6 months
  2. Evaluate for Obesity
    1. Weight loss if Overweight
    2. Consider secondary Hypertension Evaluation if weight is normal
  3. Evaluate cardiovascular risks
    1. Obtain Lipid profile
    2. Obtain Fasting Glucose
  4. 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
    4. Stage 2 Hypertension
    5. 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. Beta Blockers (age 6 years old and over)
      1. Propranolol 1-2 mg/kg/day (max: 4 mg/kg or 640 mg/day)
      2. Metoprolol XL 1 mg/kg up to 50 mg (max: 2 mg/kg or 200 mg/day)
    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 if age over 6 years and weight at least 50 kg or 111 lb (maximum: 40 mg daily)
    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 (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. Miscellaneous
      1. Hydrochlorothiazide 1 mg/kg/day (max: 3 mg/kg or 50 mg/day)
      2. Amlodipine 2.5 to 5 mg/day (max: 10 mg/day) if age 6 years or older
      3. 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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