Download Hypertension

Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Short Title:
Hypertension
Full Title:
Guideline for the management of hypertension in children and young
people
Date of production/Last revision:
May 2008
Explicit definition of patient group
to which it applies:
This guideline applies to all children and young people under the age of 19
years.
Name of contact author
Dr Simon Rhodes, Paediatric SpR
Dr Damian Wood, Consultant Paediatrician
Ext: 64041
Revision Date
May 2011
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
Hypertension
Definition(s)
(See Appendix 1 for reference tables/data)
Normal BP
 systolic and/or diastolic < 91st centile for age and sex
Borderline
 91st – 98th centile
Hypertension
 ≥ 98th centile on at least 3 separate readings
Severe Hypertension
 Symptomatic or >10mmHg above 98th centile 1
Simon Rhodes
Page 1
March 2008
Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Causes

Newborn to 1 year
o Renal artery thrombosis
o Renal artery stenosis (RAS)
o Renal vein thrombosis
o Congenital abnormalities – dysplasia / hypoplasia / ARPKD
o Aortic coarctation
o Neuroblastoma
o Raised Intracranial Pressure
o Wilm’s tumour
o Bronchopulmonary dysplasia
o Patent ductus arteriosus
o Intraventricular haemorrhage
o Drugs - corticosteroids

1 to 5 years
o RAS
o Middle aortic syndrome
o Glomerulonephritis
o Renal vein thrombosis
o Phaeochromocytoma
o Neuroblastoma
o Cystic kidney disease
o Corticosteroids
o Monogenic hypertension (Liddle’s syndrome)
o Wilm’s tumour

5 to 10 years
o Reflux nephropathy
o Glomerulonephritis
o Cystic renal disease
o RAS
o Middle aortic syndrome
o Endocrine tumours
o Wilm’s tumour
o Other parenchymal renal disease – nephronopthisis
o Essential hypertension
o Obesity

10 to 20 years
o Essential HT
o Reflux nephropathy
o Glomerulonephritis
o RAS
o Endocrine tumours
o Monogenic HT
o Pregnancy
o Drugs: oral contraceptive, corticosteroids, alcohol, ecstasy, amphetamines
o Obesity
NB. Aetiologies may overlap at different ages. Renal failure should always be considered at
any age. Raised intracranial pressure and pain should always be thought of and excluded.
Presentation
Simon Rhodes
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Paediatric Clinical Guideline
Renal: 2.2
Hypertension
The vast majority of children with Hypertension are asymptomatic.
Infants
 vomiting / failure to thrive (rarely)
 irritability
 congestive cardiac failure / respiratory distress
Older children
 headache / nausea / vomiting
 visual symptoms
 tiredness / irritability
 Bell’s palsy / hemiplegia
 epistaxis
 growth failure
 altered conscious level / fitting
Hypertensive crisis is a medical emergency and can present at any age with:
 Encephalopathy
 Seizures
 Congestive cardiac failure
NB For the unconscious or fitting child refer to guideline “Management of a child with
decreased conscious level” (see page 7, table 13 for hypertension). See Appendix 2
Around two thirds of severe or symptomatic hypertension in childhood is likely to be renal in
origin.
Hypertension is linked to obesity with ~30% higher blood pressure with BMI centile >95%.
Evaluation
Full History to include specifically;
o
o
o
o
o
o

Polyuria / dysuria / enuresis - renal disease
Palpitations / flushing – phaeochromocytoma
failure to thrive / lethargy / visual disturbances / headache / nausea or
vomiting
prescribed drugs: oral contraceptives, ADHD medications, steroids
illicit drug use: ecstasy, amphetamines, cocaine
pregnancy
Family history
o essential hypertension
o familial hypertension.
o sudden death
o renal failure
o MI or stroke
Simon Rhodes
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March 2008
Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Examination
o Height / weight / OFC / body mass index
o radio-femoral delay or arm-leg BP discrepancy (i.e. leg < arm) – aortic coarctation
or Takayasu’s disease
o café-au-lait spots, axillary freckling – NF type1
o abdominal bruit - renovascular disease
o short stature, anaemia, deafness, renal osteodystrophy – chronic renal failure
o ambiguous genitalia - adrenogenital syndromes
o urinalysis: proteinuria +/- haematuria
o examine fundi and CVS for end-organ damage
Investigation
The 2 main purposes of investigation of hypertension are to define cause and assess
presence and severity of end-organ damage.
All children
o Urinalysis for protein / blood / infection
o Urine culture and microscopy (if indicated)
o FBC anaemia consistent with chronic disease
o Paediatric Renal Profile – i.e. U&E, Creatinine, Calcium, Phosphate, Albumin, PTH,
Alkaline Phosphatase
o Renal Ultrasound
o Fasting Lipids and Glucose (to review co-morbidity i.e. teenagers, chronic kidney
disease, diabetes mellitus, family history or signs of abnormal lipid metabolism
o Thyroid function tests
o Urinary catecholamine’s
Consider: pregnancy test, urinary steroid profile, toxicology screen, renin and
aldosterone.
End-organ damage
o Echocardiogram +/- ECG
o Retinal examination -ophthalmology review should be considered in children with
longstanding / severe hypertension
Children with evidence of renal disease and hypertension should be referred to
Paediatric Nephrology for further investigations and management
Further tests to consider at this point include: renin / aldosterone and renovascular imaging
NB. Try to obtain blood and urine samples before starting antihypertensive therapy BUT do
not delay necessary treatment.
Simon Rhodes
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March 2008
Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Management

The goal of treatment is to reduce BP to below the 98th percentile
o <91st if co-morbidity present e.g. Diabetes, LVH, chronic kidney disease
o In some groups of children it may be beneficial to aim for blood pressure to
be lower i.e. <50% because of their long-term cardiovascular disease risk

For some children where hypertension is ‘borderline’ and there is no obvious
abnormality or cause (following baseline investigations and examination) simple
lifestyle measures are appropriate along with regular (at least 6 monthly) blood
pressure monitoring.
o Such measures include: regular exercise, management of obesity, reducing
dietary salt intake, attention to use of alcohol/illicit drugs and prescribed
drugs.

The choice of drug should be discussed with the child’s Consultant, and varies
depending on the cause of hypertension in the individual patient.

Aim to keep the regime as simple as possible
o E.g. use of long-acting once-daily preparations, when the blood pressure is
stabilised
o It may be best to start off with short-acting preparations (e.g. Nifedipine) until
stability achieved and total daily dose calculated
NB. Children with Renal Failure may have hypertension secondary to retention of sodium and
water and generally need restriction of fluids and sodium intake together with diuretics as a
first line
Management of these children should be discussed with the relevant
Paediatric Nephrology Consultant
Management of hypertensive encephalopathy
This is a specialised area and is to be covered in a separate guideline (Acute severe
hypertension / Hypertensive encephalopathy). These children should be managed in an
appropriate ICU / HDU setting, with care led by PICU Consultant.
The important basic steps of management of hypertensive encephalopathy are:
 A,B,C,D approach
 Seizure control
 A controlled slow reduction in blood pressure to avoid CNS ischemia
Simon Rhodes
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March 2008
Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Appendix One
Measurement of Blood Pressure in children
Standards
 All Children should have their BP measured as part of their clinical assessment.

Palpation of the brachial pulse to identify systolic blood pressure followed by
auscultation (using stethoscope and aneroid sphygmomanometer) is the ‘gold
standard’ and should be used to verify / exclude abnormal blood pressure readings
measured on oscillometry (Dinamap). Oscillometry can be unreliable in severe
hypertension.

Use of an appropriately sized cuff is very important - bladder length should cover 80100% of the circumference of the arm. A cuff that is too small will overestimate the
blood pressure.

Ideally the measurement should be taken after the child has been at rest for 3 to 5
minutes, using the right arm, which should be supported at heart level (false low
readings in coarctation of the aorta when left arm used).

At least two measurements should be taken and the average used.

Systolic BP is determined by the onset of the ‘tapping’ Korotkoff sounds (K1), and
diastolic by the disappearance of all sounds (K5). (If sounds are heard to 0 mmHg,
diastolic pressure should be recorded as K4 – “muffled” sounds).

Hypertension should be confirmed on repeated visits (except in the presence of
severe or symptomatic hypertension) over a period of weeks. Severe / symptomatic
hypertension requires urgent action (i.e. discussion with Consultant on-call).

Doppler can be used to detect systolic blood pressure in young infants.

Ambulatory blood pressure monitoring may be available via the Paediatric Renal Unit
as some children may demonstrate “white-coat” hypertension. ABP is only suitable
for children of 6 years and over.
Simon Rhodes
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March 2008
Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Appendix Two
Reference data / tables for hypertension
1) Reference (90th Centiles for age and sex) for children 0-4 years
BOYS
GIRLS
Age
Systolic
Diastolic
Systolic
Diastolic
0
87
68
76
68
3 mth
106
63
104
64
6 mth
105
66
106
66
9 mth
105
68
106
67
1 yr
105
69
105
67
2 yrs
106
68
105
69
3 yrs
107
68
106
69
4 yrs
108
69
107
69
Simon Rhodes
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Paediatric Clinical Guideline
Renal: 2.2
Hypertension
2) Systolic BP for children aged 4-17 years (GB data)
Simon Rhodes
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March 2008
Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Simon Rhodes
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March 2008
Paediatric Clinical Guideline
Renal: 2.2
Hypertension
3) Diastolic BP for children aged 4-17 years (GB data)
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Paediatric Clinical Guideline
Renal: 2.2
Hypertension
Appendix Three
Algorithm summarizing management of Hypertensive children
Simon Rhodes
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Paediatric Clinical Guideline
Renal: 2.2
Hypertension
References
1. Blood pressure centiles for Great Britain. Children aged 4-17 years – oscillometric
data; ADC 2007;92:298-303.
2. Paediatrics 1996;98:649-658
3. Paediatric Clinics of North America 1999;46:235
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Paediatric Clinical Guideline
Renal: 2.2
Hypertension
4. Forfar and Arneil Fifth edition p 972-973
5. Blood pressure centiles for Great Britain; Jackson LV, Thalange NKS, Cole TJ.ADC
2007;92:298-303.
6. NICE guidelines – No. 34, Hypertension (adult guideline).
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March 2008