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===Physical Examination===
===Physical Examination===


Common [[physical examination]] findings of hypertension include [[retinal]] [[vascular]] changes on [[fundoscopy]], [[cardiac]] [[heave]], and laterally displaced point of maximal intense ([[PMI]]) due to [[Left ventricular hypertrophy]] (LVH). <ref>Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.</ref>
*Common [[physical examination]] findings of hypertension include [[retinal]] [[vascular]] changes on [[fundoscopy]], [[cardiac]] [[heave]], and laterally displaced point of maximal impulse ([[PMI]]) due to [[Left ventricular hypertrophy]] (LVH). <ref>Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.</ref>


===Laboratory Findings===
===Laboratory Findings===


There are no [[diagnostic]] laboratory findings associated with hypertension. To evaluate for end-organ damage (renal), measurement of serum [[blood urea nitrogen]] (BUN), [[Plasma]] [[renin]] and [[aldosterone]] activity, [[creatinine]], and [[electrolytes]] and [[urinalysis]] can be done.
*There are no [[diagnostic]] laboratory findings associated with hypertension.  
*To evaluate for end-organ damage, hypertension causes or hypertension-associated conditions that may increase the cardiovascular risk the following exams may be useful:
*[[Lipid profile]]
*[[Complete blood count]]
*[[Fasting glucose]] or [[A1C level]]
*[[ALT]] and [[AST]]
*[[Drug screening]]
*Measurement of serum [[blood urea nitrogen]] (BUN)
*[[Plasma]] [[renin]]
*[[Aldosterone]] activity
*[[Creatinine]]
*[[Electrolytes]]
*[[Urinalysis]]


===[[Electrocardiogram]]===
===[[Electrocardiogram]]===
An ECG may be helpful in the diagnosis of [[hypertension]]. Findings on an ECG suggestive of hypertension include LVH, [[ST depression]] and T-inversion.
*ECG is not helpful in the diagnosis of [[hypertension]].  
*Findings on an ECG suggestive of hypertension include [[left ventricular hypertrophy]], [[ST depression]] and [[T wave inversion]].


===X-ray===
===X-ray===
 
*Chest [[X-ray]] is not helpful in the [[diagnosis]] of hypertension.  
 
*There are findings on x-ray suggestive of hypertension-associated complications, which include increased [[cardiothoracic ratio]], secondary to [[left ventricular hypertrohpy]].
An [[x-ray]] may be helpful in the [[diagnosis]] of hypertension. Findings on an x-ray suggestive of hypertension include increased [[cardiothoracic ratio]], secondary to LVH.


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===


There are no [[echocardiography]]/[[ultrasound]] findings diagnostic of hypertension. However, an echocardiography/ultrasound may be helpful in the diagnosis of [[complications]] of hypertension, which include Left ventricular hypertrophy and [[renovascular disease]].<ref>Chhadia S, Cohn RA, Vural G, Donaldson JS. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol 2013; 43:1549..</ref>
*There are no [[echocardiography]]/[[ultrasound]] findings diagnostic of hypertension.  
*However, an echocardiography/ultrasound may be helpful in the diagnosis of [[complications]] of hypertension, which include [[left ventricular hypertrophy]] and [[renovascular disease]].<ref>Chhadia S, Cohn RA, Vural G, Donaldson JS. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol 2013; 43:1549..</ref>


===CT scan===
===CT scan===
There are no CT scan findings associated with hypertension.
*There are no CT scan findings diagnostic of hypertension.
*It can diagnose some causes of hypertension such as [[coarctation of aorta]] or adrenal disease.


===MRI===
===MRI===
There are no MRI findings associated with hypertension.
*There are no CT scan findings diagnostic of hypertension.
*It can diagnose some causes of hypertension such as [[coarctation of aorta]] or adrenal disease.


===Other Imaging Findings===
===Other Imaging Findings===
There are no other imaging findings associated with hypertension.
*There are no other imaging findings associated with hypertension.


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with hypertension.
*There are no other diagnostic studies associated with hypertension.


==Treatment==
==Treatment==

Revision as of 19:29, 14 June 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dinesh Shah, M.B.B.S, José Eduardo Riceto Loyola Junior, M.D.[2]

Synonyms and keywords:

Overview

Hypertension is one of the major risk factor for cardiovascular diseases. It is often associated with adverse cardiac and vascular outcomes. Hypertension in pediatric age group often leads to development of cardiovascular compromises for the patient, such as atherosclerotic plaques development and renal function loss in the adulthood. To make matters worse, pediatric hypertension is greatly underdiagnosed due to difficulty in measurement of blood pressure in children and the need to refer to detailed tables of normative values. Thus, cautious monitoring, early diagnosis and treatment of hypertension in children is critical to prevent disease progression.

Classification

Pediatric hypertension may be classified according to AAP (American Academic of Pediatrics):[1]

Age<13 years Age>=13 years

Normal Blood pressure

<90th percentile

<180/<90 mmhg

Elevated or High Normal Blood Pressure

90th to <95th percentile

120-129/<80 mmHg

Stage 1 Hypertension

>95th percentile to <95th percentile +12 mmHg

130-139/80-89 mmHg

Stage 2 Hypertension

>95th percentile + 12 mmHg

>140/90 mmHg

Pathophysiology

It is thought that hypertension is caused by either increased resistance to blood flow, disturbance in Kidney's salt and water handling , or abnormalities of sympathetic nervous system.[2]

Causes

Based on etiology, hypertension in children can be classified into 2 groups:[3]

  • 1. Primary hypertension - No specific cause known
  • 2. Secondary hypertension - Common causes includes:[4]

Common causes of pediatric hypertension by pediatric age group

These conditions are displayed in order of prevalence[6][7][8]

One to six years:

Six to twelve years:

Twelve to eighteen years

Differentiating Hypertension in Adolescents from other Diseases

Hypertension in adolescent may be a symptom of other underlying and undiagnosed conditions. Thus, these patients require a detailed medical assessment. Secondary causes were discussed above and include: renal diseases, drugs, adrenal diseases and hyperthyroidism.

Epidemiology and Demographics

Risk Factors

Screening

  • According to the U.S. Preventive Services Task Force (USPSTF), screening for hypertension in asymptomatic children and adolescents is not recommended.[12]
  • According to the 2017 American Academy of Pediatrics guidelines, screening for hypertension in asymptomatic children and adolescents is recommended annually beginning at three years of age.[12]
  • According to the 2016 European Society of Hypertension guidelines, screening for hypertension in asymptomatic children and adolescents is recommended every two years beginning at three years of age.[12]

Natural History, Complications, and Prognosis

If left untreated, children with hypertension may progress to develop atherosclerotic heart disease in adulthood, increased risk of cardiovascular disease and mortality as well as left ventricular hypertrophy.

Diagnosis

Diagnostic Study of Choice

  • The diagnostic study of choice for diagnosing hypertension in adolescents is the attainment of accurate blood pressure measurement in children and adolescents.
  • It can be challenging due to the variance of the measurements with different cuff sizes, anxiety, patient positioning, caffeine intake, and activity levels.
  • To choose an adequate cuff size, one must pick an inflatable bladder that is at least 40% of the arm circumference and bladder length that is 80% to 100% of the arm circumference.[12]

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

  • There are no CT scan findings diagnostic of hypertension.
  • It can diagnose some causes of hypertension such as coarctation of aorta or adrenal disease.

MRI

  • There are no CT scan findings diagnostic of hypertension.
  • It can diagnose some causes of hypertension such as coarctation of aorta or adrenal disease.

Other Imaging Findings

  • There are no other imaging findings associated with hypertension.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with hypertension.

Treatment

The AAP guideline recommends keeping systolic and diastolic pressure under 90th percentile i.e <130/80 mmHg in adolescents to prevent any cardiovascular events.

Medical Therapy

The mainstay of treatment for hypertension in adolescents is pharmacotherapy. Pharmacological therapy is reserved for those patient who has persistent hypertension despite lifestyle modification, or has stage 2 hypertension or have hypertension secondary to chronic kidney disease or diabetes. First line medication generally include angiotensin converting enzymes inhibitors (ACEIs), Angiotensinogen receptor blockers (ARBs), long acting calcium channel blockers (CCBs) and thiazide diuretics.[16]

Surgery

Surgery is not the first-line treatment option for children with hypertension. Surgery is usually reserved for children with adrenal malignancy.

Primary prevention

Effective measures for the primary prevention of primary hypertension in children include low sodium intake, maintaining appropriate body weight, and regular physical activities.

Secondary prevention

There are no established measures for the secondary prevention of hypertension in children.

References

  1. Weaver DJ (2019). "Pediatric Hypertension: Review of Updated Guidelines". Pediatr Rev. 40 (7): 354–358. doi:10.1542/pir.2018-0014. PMID 31263043.
  2. Hypertension. In: Wikipedia [Internet]. 2021 [cited 2021 Jun 10]. Available from: https://en.wikipedia.org/w/index.php?title=Hypertension&oldid=1027062289.
  3. Khoury, M. and Urbina, E. M. (2021) ‘Hypertension in adolescents: diagnosis, treatment, and implications’, The Lancet Child & Adolescent Health, 5(5), pp. 357–366. doi: 10.1016/S2352-4642(20)30344-8
  4. Friedman K, Wallis T, Maloney KW, et al. An unusual cause of pediatric hypertension. J Pediatr 2007; 151:206.
  5. Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med 1998; 157:1098
  6. Flynn JT (2001). "Evaluation and management of hypertension in childhood". Prog Pediatr Cardiol. 12 (2): 177–188. doi:10.1016/s1058-9813(00)00071-0. PMID 11223345.
  7. Bartosh SM, Aronson AJ (1999). "Childhood hypertension. An update on etiology, diagnosis, and treatment". Pediatr Clin North Am. 46 (2): 235–52. doi:10.1016/s0031-3955(05)70115-2. PMID 10218072.
  8. Flynn JT (2005). "Hypertension in adolescents". Adolesc Med Clin. 16 (1): 11–29. doi:10.1016/j.admecli.2004.10.002. PMID 15844381.
  9. 9.0 9.1 Bell CS, Samuel JP, Samuels JA (2019). "Prevalence of Hypertension in Children". Hypertension. 73 (1): 148–152. doi:10.1161/HYPERTENSIONAHA.118.11673. PMC 6291260. PMID 30571555.
  10. 10.0 10.1 Song P, Zhang Y, Yu J, Zha M, Zhu Y, Rahimi K; et al. (2019). "Global Prevalence of Hypertension in Children: A Systematic Review and Meta-analysis". JAMA Pediatr. 173 (12): 1154–1163. doi:10.1001/jamapediatrics.2019.3310. PMC 6784751 Check |pmc= value (help). PMID 31589252.
  11. 11.0 11.1 Ewald DR, Haldeman PhD LA (2016). "Risk Factors in Adolescent Hypertension". Glob Pediatr Health. 3: 2333794X15625159. doi:10.1177/2333794X15625159. PMC 4784559. PMID 27335997.
  12. 12.0 12.1 12.2 12.3 Riley M, Hernandez AK, Kuznia AL (2018). "High Blood Pressure in Children and Adolescents". Am Fam Physician. 98 (8): 486–494. PMID 30277729.
  13. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  14. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  15. Chhadia S, Cohn RA, Vural G, Donaldson JS. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol 2013; 43:1549..
  16. Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2016; 34: 1887–920.


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