HYPERTENSION IN

CHILDREN

Definition
Blood pressure greater than 95th
percentile for age, gender and height
on at least three different occasions.

Classification
Blood pressure category

Blood pressure percentile

Normal

<90th

Prehypertension

90th to 95th

Stage 1 hypertension

95th to (99th + 5 mm Hg)

Stage 2 hypertension

>99th + 5 mm Hg

Causes of Hypertension
Primary (essential) Hypertension
Diagnosis by exclusion
Predisposing factors

High BMI
Excessive salt intake
Lack of exercise
Family history

Causes of Hypertension
Secondary hypertension
RENAL (commonest cause)
Congenital anomalies ( renal dysplasia, obstructive
uropathy)
Structural disorders ( Wilms tumor, polycystic
kidney disease)
Acquired injury ( renal scarring, acute tubular
ENDOCRINE
necrosis)
Catecholamine-secreting tumors
(pheochromocytoma)
Hypercortisolism (Cushing syndrome)
Hyperaldosteronism
Hyperthyroidism

Causes of hypertension
Neurological
Increased sympathetic activity (stress, anxiety,
pain)
Dysautonomia
Increased intracranial pressure
Vascular
Coarctation of aorta
Renal artery embolism
Renal vein thrombosis
Renal artery stenosis
Vasculitis
Others
white-coat hypertension
Obstructive sleep apnea

Clinical Features
Mostly asymptomatic
Signs and symptoms associated with severe
HTN
Encephalopathy (headache, vomiting, seizures)
Retinopathy ( blurred vision, flame haemorrhage
and cotton wool spots on retinal exam)
Heart failure
Facial nerve palsy
Cerebrovascular incidents

Clinical Features
Additional findings that may suggest
specific causes
Abdominal bruit (renal artery stenosis)
Diminised leg pressure and weak femoral pulse
(coarctation of aorta)
Caf-au-lait spots (neurofibromatosis a/w renal
artery stenosis)
Tachycardia with flushing and diaphoresis
(pheochromocytoma)
Truncal obesity, acne, striae and buffalo hump
(Cushing syndrome)

Investigations
To identify a cause
o Urinalysis for protein / blood / infection
o Full blood count
o U&Es, creatinine
o Renal ultrasound (with renal vessel doppler
if available)
o Thyroid function tests
o Urine catecholamines
o Plasma renin and aldosterone
o Vanillymandelic acid (VMA)

Investigations
To identify co-morbidities
o Fasting lipids
o Glucose

To assess for end-organ damage

ECG
Echocardiogram (presence of left ventricular
hypertrophy, may also identify a cause eg.
Coarctation of aorta)
Retinal examination (in those with severe or long
standing hypertension)
U&Es and urinalysis

Management
Goals of Therapy
1. To reduce blood pressure to <95th
percentile
2. To reduce blood pressure to <90th
percentile in those with co-morbidities
3. To consider aggressive blood pressure
control (<50th percentile) in some patient
groups (e.g. those with chronic kidney
disease)

Management
Lifestyle advice
This may be all that is required in prehypertensive
children and should be given to all children with
hypertension:
Dietary advice regarding healthy eating (including
reducing salt intake). All children with hypertension
and pre-hypertension should be referred to a dietician.
Regular physical activity (30-60 minutes/day)
Weight reduction if overweight or obese
Interventions to improve sleep if sleep apnoea
identified.
Advice regarding alcohol, caffeine and drugs

Management
Pharmacological Intervention
indicated in: Symptomatic hypertension
Secondary hypertension
Hypertension with associated targetorgan damage
Diabetes (types 1 and 2)
Persistent hypertension despite non
pharmacologic measures

Management
First line antihypertensive agent
Calcium channel blockers
Nifedipine : 0.25-2 mg/kg/24hr in 2 divided dose

ACE inhibitiors
Captopril : 0.3-6mg/kg/24hr in 2-3 divided dose
Enalapril : 0.1-1mg/kg/24hr in single dose

Angiotensin receptor blockers

Beta blockers
Propranolol : 1-6mg/kg/24hr in 2-3 divided dose
Atenolol : 1-4mg/kg/24hr once a day if adequate renal
function

Diuretics
Furosemide : 1-5mg/kg/24hr in 1-2 divided dose
Spironolactone : 1-3 mg/kg/24hr in 1-2 divided dose

More than one agent may be needed

Reference
Nelson Essentials of Pediatrics, 7th
Edition
Oxford Handbook of Paeditrics, 2nd
Edition
Hypertension Guideline Nottingham
Children Hospital, Nottingham
University Hospital