definition,types,causes,clinical presentation ,investigations ,management

1. Pediatric Prof .Dr. Saad S Al Ani
Senior Pediatric Consultant
Acute Head of Pediatric Department
Khorfakkan Hospital
Hypertension Sharjah ,UAE
saadsalani@yahoo.com

2. Background
In infants and younger children, systemic hypertension is uncommon, but
when present, it is usually indicative of an underlying disease process
(secondary hypertension).
Adolescents may acquire primary or essential hypertension
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 Khorfakkan Hospital ,Sharjah ,UAE 2

3. Cont.
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.
Correlate with BP tables for age, height, and weight
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 3
Khorfakkan Hospital ,Sharjah ,UAE

4. Etiology and Pathophysiology
Secondary hypertension is most common in infants
and younger children
Many childhood diseases may be responsible for
both acute and chronic elevation of blood pressure
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 4
Khorfakkan Hospital ,Sharjah ,UAE

5. Hypertension in the newborn
Cont. is most often associated with:
1. umbilical artery catheterization
and
2. renal artery thrombosis
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 5
Khorfakkan Hospital ,Sharjah ,UAE

6. Hypertension during early childhood
may be due to :
Cont. 1.renal disease
2.coarctation of the aorta
3. endocrine disorders
4.medications.
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 6
Khorfakkan Hospital ,Sharjah ,UAE

7. In adolescents
Cont. essential hypertension becomes increasingly common
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 7
Khorfakkan Hospital ,Sharjah ,UAE

8. The severity of hypertension is also helpful in distinguishing
secondary from primary hypertension
Cont.
In general, children and adolescents with essential hypertension
have blood pressure values at or only slightly above the 95th
percentile for age
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 8
Khorfakkan Hospital ,Sharjah ,UAE

9. Cont.
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
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 9
Khorfakkan Hospital ,Sharjah ,UAE

10. Conditions Associated with Transient or Intermittent
Hypertension in Children
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 10
Khorfakkan Hospital ,Sharjah ,UAE

11. Renal
• 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
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 11
Khorfakkan Hospital ,Sharjah ,UAE

12. Cont.
• Hypervolemia
• After surgical procedures on the genitourinary tract
• Pyelonephritis
• Renal trauma
• Leukemic infiltration of the kidney
• Obstructive uropathy associated with Crohn disease
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 12
Khorfakkan Hospital ,Sharjah ,UAE

13. Drugs
and
Poisons
• Cocaine • Cyclosporine or sirolimus treatment
• Oral contraceptives post-transplantation
• Sympathomimetic agents • Licorice (glycyrrhizic acid)
• Amphetamines • Lead, mercury, cadmium, thallium
• Antihypertensive withdrawal
• Phencyclidine
(clonidine, methyldopa, propranolol)
• Corticosteroids and • Vitamin D intoxication
adrenocorticotropic hormone
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 13
Khorfakkan Hospital ,Sharjah ,UAE

14. Central
and
Autonomic
nervous
system
• Increased intracranial pressure • Stevens-Johnson syndrome
• Posterior fossa lesions
• Guillain-Barré syndrome
• Porphyria
• Burns • Poliomyelitis
• Familial dysautonomia • Encephalitis
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 14
Khorfakkan Hospital ,Sharjah ,UAE

15. Miscellaneous
• Preeclampsia
• Fractures of long bones
• Hypercalcemia
• After coarctation repair
• White cell transfusion
• Extracorporeal membrane oxygenation
• Chronic upper airway obstruction
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 15
Khorfakkan Hospital ,Sharjah ,UAE

16. Conditions Associated with
Chronic Hypertension
in Children
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 16
Khorfakkan Hospital ,Sharjah ,UAE

17. Renal
•Chronic pyelonephritis
•Chronic glomerulonephritis
•Hydronephrosis
•Congenital dysplastic kidney
•Multicystic kidney
•Solitary renal cyst
•Vesicoureteral reflux nephropathy
•Segmental hypoplasia (Ask- Upmark kidney)
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 17
Khorfakkan Hospital ,Sharjah ,UAE

18. Cont.
• Ureteral obstruction
• Renal tumors
• Renal trauma
• Rejection damage following transplantation
• Postirradiation damage
• Systemic lupus erythematosus (other connective tissue diseases
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 18
Khorfakkan Hospital ,Sharjah ,UAE

19. 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
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 19
Khorfakkan Hospital ,Sharjah ,UAE

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

21. Central
Nervous
System
• Intracranial mass
• Hemorrhage
• Residual following brain injury
• Quadriplegia
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 21
Khorfakkan Hospital ,Sharjah ,UAE

22. Essential
hypertension
• Low renin
• Normal renin
• High renin
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 22
Khorfakkan Hospital ,Sharjah ,UAE

23. 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)
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 23
Khorfakkan Hospital ,Sharjah ,UAE

24. 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
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 24
Khorfakkan Hospital ,Sharjah ,UAE

25. Initial
diagnostic
evaluation
• Urinalysis
• Blood urea nitrogen
• Creatinine,
• Electrolytes
• Chest radiograph
• Electrocardiogram
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 25
Khorfakkan Hospital ,Sharjah ,UAE

26. Consider
• Renin level
• Toxicology screen
• Thyroid and adrenal testing
• Urine catecholamines
• Abdominal ultrasound
• Renal Doppler ultrasound
• Head CT
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 26
Khorfakkan Hospital ,Sharjah ,UAE

27. 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
Pediatric Acute hypertension Prof. Dr.
03/20/2012 Saad S Al Ani 27
Khorfakkan Hospital ,Sharjah ,UAE

28. Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 28
Khorfakkan Hospital ,Sharjah ,UAE

29. Hypertensive urgency:
Goal:
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.)
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 29
Khorfakkan Hospital ,Sharjah ,UAE

30. Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 30
Khorfakkan Hospital ,Sharjah ,UAE

31. Algorithm for identifying children with high blood pressure (BP)
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 31
Khorfakkan Hospital ,Sharjah ,UAE

32. 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
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 32
Khorfakkan Hospital ,Sharjah ,UAE

33. Thank you
Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
03/20/2012 33
Khorfakkan Hospital ,Sharjah ,UAE