Treatment of Hypertension in Children

What does this percentile mean?2
Normal Prehypertension Stage 1 hypertension Stage 2 hypertension <90th 90-<95th or if >120-80 90>12095th-99th plus 5 mm Hg >99th plus 5 mm Hg
Let’s Practice
AMF is a 5 yo female weighing 25 kg in the 75th percentile of height. Her BP is taken when she goes to the Dr. for a routine visit. Her BP is 114/73. What is her BP percentile? What do we do with this information?
Definitions2
Hypertension: Hypertension: average SBP and/or DBP >95th percentile for gender, age, and height on > 3 occasions Prehypertension: Prehypertension: average SBP or DBP >90th percentile but <the 95th percentile
– Adolescents with BP levels >120/80 mm Hg should be considered prehypertensive
Measurement of Blood Pressure2
Children >3 years old should have their BP measured when seen in a medical setting Preferred method: Auscultation
– Requires a cuff that is appropriate for the child’s arm – Right arm preferred
Blood Pressure Cuff2
Equipment needed to measure BP in children (3-adolescents): (3– Child cuffs of different sizes – Standard adult cuff – Large adult cuff – Thigh cuff
Using the Blood Pressure Tables2
Use the standard height charts to determine the height percentile. Measure and record the child’s SBP and DBP. Use the correct gender table for SBP and DBP. Find the child’s age on the left side of the table. Follow the age row across the table to the intersection of the line for the height percentile. Find the 50th, 90th, 95th, and 99th percentiles for SBP in the left columns and for DBP in the right columns.
StepStep-wise Approach to Therapy2
1. 2.
3. 4.
Start with a small dose of a single antianti-hypertensive drug Increase dose of single antiantihypertensive drug (to max dose if tolerated) Add a small dose of a second drug Increase dose of second antiantihypertensive medication
Possible Etiologies Causing Hypertension2
Chronic Renal Failure Cushing Syndrome Turner Syndrome Hyperthyroidism Systemic Lupus Coarctation of the aorta Wilms tumor
Measurement of BP in children < 3 years old2
History of prematurity, VLBW, or other neonatal complications Congenital heart disease Recurrent UTI, hematuria, or proteinuria Known renal disease or urologic malformations Family history of congenital renal disease SolidSolid-organ transplant Malignancy or bone marrow transplant Treatment with drugs known to raise BP Systemic illnesses associated with hypertension Evidence of elevated ICP (intracranial pressure)
Drug Options for Initial Therapy1
Class of Patients’ Characteristics Drugs ACEACE-Is/ARBs First-line therapy FirstCCBs Diuretics β–Blocker First-line therapy FirstAdjunct second-line drug secondAvoid in athletes (controversial) and people with diabetes
Antihypertensionverting EnzymeEnzymeInhibitors Angiotensin Receptor Blockers Calcium Channel Blockers Diuretics BetaBeta-Blockers Central alpha-agonists alphaPeripheral alpha-antagonist alphaVasodilators
ACEACE-I1-3, 5
Angiotensin Converting Enzyme Inhibitors Benazepril*, Captopril, Enalapril*, Fosinopril*, Lisinopril*, Quinapril
Mechanism of Action: prevents conversion of
angiotensin I to angiotensin II, a potent vasoconstrictor; results in lower levels of angiotensin II which causes an increase in plasma renin activity and a reduction in aldosterone secretion
Treatment Strategies
Therapeutic lifestyle changes Drug therapy
Lifestyle changes
Weight reduction Regular physical activity Restriction of sedentary activity Dietary modification FamilyFamily-based intervention
Treatment of Hypertension in Pediatrics
Kelsey R. Green, Pharm.D. Pediatric Clinical Pharmacist LSULSU-HSC in Shreveport, LA
Objectives
Define hypertension in children Identify when blood pressure should be taken Practice determining BP percentile and interpreting how to use this information to best treat the patient Discuss treatment options used in pediatrics to treat hypertension
Prehypertension
Stage 1 Hypertension
Stage 2 Hypertension
Management Algorithm2
Diagnostic Work-Up6 WorkUrinalysis Protein/Cr Ratio Renal Ultrasound EKG CBC with differential Electrolyetes, BUN, Cr Rule out infection, hematuria, proteinuria Kidney function Rule out renal scarring, congenital renal anomalies Cardiomegaly Rule out anemia, consistent with chronic renal disease Rule out renal disease, pyelonephritis