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Pediatric Hypertension Treatment & Management

  • Author: Edwin Rodriguez-Cruz, MD; Chief Editor: P Syamasundar Rao, MD  more...
 
Updated: Jul 17, 2015
 

Approach Considerations

To the extent possible, treatment of hypertension (see the image below) should address the cause and correct it. It is essential to recognize remediable causes of hypertension, especially coarctation of the aorta in a symptomatic infant. Reserve the therapeutic modalities described below for those children who have irremediable causes of hypertension or essential hypertension.[13]

Management algorithm. AMC = Apparent mineralocorti Management algorithm. AMC = Apparent mineralocorticoid excess; GRA = Glucocorticoid remedial aldosteronism; VMA = Vanillylmandelic acid.

Nonpharmacologic measures are important in the treatment of all patients with hypertension, regardless of its etiology or severity. Pharmacologic treatment is indicated in some cases. Interventional cardiac catheterization procedures have been employed as well. Surgery may be required for children with severe renal vascular hypertension, renal segmental hypoplasia, coarctation of the aorta, Wilms tumor, or pheochromocytoma.

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Nonpharmacologic Therapy

In children with mild or moderate hypertension, nonpharmacologic therapy may suffice to lower blood pressure (BP) to within normal limits. This approach avoids the need for drugs that have adverse effects and that require a degree of compliance difficult to achieve in children.

Weight reduction should be a goal in all overweight children with hypertension, regardless of etiology. Obesity and hypertension are closely correlated, particularly in adolescents.[9]

Aerobic and isotonic exercises have a direct beneficial effect on BP. They help in reducing excess weight or maintaining appropriate body weight. Encourage participation in sports. Only patients with severe uncontrolled hypertension or cardiac abnormalities that require exercise restriction are exempt from aerobic and isotonic exercises.

Potassium supplementation can decrease BP and reduce ventricular hypertrophy in adults. How potassium supplementation affects children with hypertension remains to be determined. However, avoiding potassium depletion (eg, from diuretic therapy) and prescribing a potassium-rich diet in patients without renal insufficiency appear reasonable.

A low-fat diet is recommended for all patients with a high BP; a low-salt diet is also recommended for all such patients, though it may yield only a 4% reduction of the elevated pressure (see Dietary Measures). Stress-reducing activities (eg, meditation, yoga, biofeedback) can reduce BP when performed on a regular basis. However, this effect is lost when the activity is discontinued.

When sleep-disordered breathing is discovered, weight loss, tonsillectomy and adenoidectomy, or use of continuous positive airway pressure may improve the patient’s sleep and secondarily improve BP.

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Pharmacologic Therapy

Many of the antihypertensive agents available for adult use may also be used to manage hypertensive children and adolescents, even though only limited data are available to support this practice. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and calcium-channel blockers have the strongest data to support their use in pediatric patients. Nevertheless, there is a need for more trials in pediatric populations, especially comparative trials of different agents.[14, 15]

Indications for pharmacologic treatment include symptomatic hypertension, secondary hypertension, hypertensive target-organ damage, diabetes, and hypertension that persists despite nonpharmacologic measures.

The Fourth Report recommends starting with a class of antihypertensive medication appropriate for each specific patient. Pediatric clinical trials have focused on the ability of each drug to lower BP, but the effects of these drugs on clinical endpoints have not been compared. Therefore, the choice of drug is the clinician’s.

The Task Force recommends the use of ACE inhibitors or ARBs only for children with diabetes and microalbuminuria or proteinuric renal disease and recommends beta-blockers or calcium-channel blockers for children with hypertension and migraine headaches. A low dose of 1 drug should be started first. If this dose is unsuccessful, it should be titrated upward.

In children with uncomplicated primary hypertension, BP is considered controlled when it is below the 95th percentile. In children with chronic renal disease, diabetes, or hypertensive target-organ damage, the goal should be a BP below the 90th percentile. If BP is not controlled, a drug from another class should be added. If control is not achieved with 2 drugs, reconsider the possibility of secondary hypertension before adding a third drug.

In general, treatment of chronic hypertension requires expertise that is seldom available in the general pediatrician. Therefore, it is advisable to refer patients to physicians who specialize in treatment of children with high BP. The American Society of Hypertension, Inc. (ASH) identifies physicians with expert skills and knowledge in the management of clinical hypertension and related disorders. It also grants such physicians the title Specialist in Clinical Hypertension. ASH provides a list of available specialists ordered by city, state, and country.

After BP is stabilized, the patient can return to the general pediatrician for follow-up care. The pediatrician should work in close collaboration with the specialist.

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Management of Hypertensive Crisis

Hypertensive crises occur as a result of an acute illness (eg, postinfectious glomerulonephritis or acute renal failure), excessive ingestion of drugs or psychogenic substances, or exacerbated moderate hypertension.

The clinical manifestations may be those of cerebral edema, seizures, heart failure, pulmonary edema, or renal failure. Accurate assessment of BP in every patient presenting with a seizure is essential, particularly when no seizure disorder has been established in that patient.

Anticonvulsant drugs are usually ineffective in treatment of a seizure due to a hypertensive crisis. Seizures due to severe hypertension must be treated with a fast-acting antihypertensive drug.

The following drugs are currently used in the treatment of hypertensive emergencies:

  • Labetalol, 0.2-1 mg/kg/dose up to 40 mg/dose as an intravenous (IV) bolus or 0.25-3 mg/kg/h IV infusion
  • Nicardipine, 1-3 µg/kg/min IV infusion
  • Sodium nitroprusside, 0.53-10 µg/kg/min IV infusion to start

Sublingual nifedipine is no longer recommended for the treatment of acute hypertension, because of reports of death from hypotension in the adult population.

Additional drug recommendations for patients aged 1-17 years may be found in The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.[3] For neonatal doses, see Neonatal Hypertension.

The goal of therapy is to lower BP to normal. Clinicians should be familiar with the therapeutic effects and adverse effects of these drugs. Patients must be supervised closely to avoid an excessively rapid decrease in BP, which may result in underperfusion of vital organs.

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Transcatheter Therapy

Interventional cardiac catheterization procedures can be used to treat coarctation of the aorta. Balloon dilation of a previously untreated (native) coarctation remains controversial. Some pediatric cardiologists recommend this approach and may also place a stent across the coarctation site. The appropriateness of this approach remains to be determined in studies of long-term outcome. For detailed discussion of the role of transcatheter therapy (balloon angioplasty and stents), the reader is referred to the Medscape Drugs and Diseases topic Coarctation of the Aorta.[12] Most physicians seem to prefer surgical treatment for neonates and infants (<1 y). Children older than 1 year with discrete native coarctation may be adequately managed with balloon angioplasty. If the segment of aortic coarctation is long, surgical treatment in younger children and stents in adolescents and adults are appropriate treatment approaches.

A study by Sezer et al indicated that stent placement in pediatric patients with coarctation of the aorta can lower blood pressure but may not reduce it to normal levels. In the study, which involved 15 children with native or recurrent coarctation of the aorta who underwent stenting, as well as 30 healthy sex-and-age-matched control subjects, the investigators found that the patients’ mean arterial pressure prior to stenting, 134.4 mm Hg, had been reduced to 115.5 mm Hg by the sixth month postprocedure but was still not as low as that in the control group (107.3 mm Hg).[16]  

In a multi-institutional study of 350 patients in which surgery, balloon angioplasty, and stent implantation were used in the treatment of native aortic coarctation, investigators showed improvement in all three groups both immediately after the procedure and at follow-up.[17] However, the stent group (1) had less complications when compared with the surgical and balloon angioplasty groups, (2) had shorter hospitalization duration when compared with surgical patients, and (3) had lower coarctation gradients at follow-up when compared with balloon angioplasty patients. Despite those findings, the stent group also had higher reintervention rates when compared with the surgical and balloon groups, although these were noted as “planned” reinterventions.[17]

Balloon dilation, with or without stent placement, has gained widening acceptance for treatment of recurrent coarctation. Recurrence is most likely to arise when young infants must undergo surgical repair because of the severity of the lesion.

Interventional catheterization with balloon dilation can also successfully relieve many instances of discrete renal artery stenosis.

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Consultations

A pediatric endocrinologist should be consulted when pheochromocytoma is suspected. If the diagnosis is confirmed, surgical removal of the tumor is indicated. A pediatric endocrinologist should also be consulted when metabolic syndrome is diagnosed. A nutritionist can review the DASH eating plan with the patient’s family and make further suggestions for weight loss and sodium reduction.

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Dietary Measures

A low-fat diet should be followed by all patients with elevated BP. Low levels of adipocytokine has been noted in patients with elevated percent fat content.[18, 19] An absence of this substance may cause an elevation of BP.[20, 21]

Salt restriction probably benefits only a subgroup of patients with hypertension, particularly African American patients, who may have a defect in the cellular handling of sodium. However, given the excessive amount of salt in the typical American diet, reduced salt intake should be recommended to all patients with hypertension. The Task Force recommends the Dietary Approaches to Stop Hypertension (DASH) eating plan (see Your Guide To Lowering Your Blood Pressure With DASH from the NHLBI).

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Long-Term Monitoring

Closely monitor patients with hypertension, particularly during the initial phase of therapy. A chemistry panel should be checked after therapy with an ACE inhibitor or an ARB is started or increased.

The frequency of visits is dictated by various factors, including the following:

  • Degree of BP control
  • Extent of understanding of the disease and its treatment on the part of both the parents or caregivers and the patient
  • Adherence to nonpharmacologic and pharmacologic treatments
  • Ability to monitor BP properly at home
  • Likelihood of drug adverse effects
  • Need to monitor for complications of hypertension
  • Need to monitor for weight loss

After surgical or catheter treatment of coarctation of the aorta, patients must be monitored yearly with accurate measurement of systolic and diastolic pressures in the right arm. For these measurements, the patient should be properly positioned. Systolic pressures in both the right arm and leg should be obtained with the patient supine. Remember that systolic pressure in the lower leg should exceed that in the arm.

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Contributor Information and Disclosures
Author

Edwin Rodriguez-Cruz, MD Director, Section of Cardiology, Department of Pediatrics, San Jorge Children’s Hospital, Puerto Rico; Private Practice in Interventional Pediatric Cardiology and Internal Medicine, Centro Pedíatrico y Cardiovascular

Edwin Rodriguez-Cruz, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Pediatric Echocardiography, American College of Physicians-American Society of Internal Medicine, American Medical Association, Puerto Rico Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: St Jude's Medical Co.<br/>Received grant/research funds from NOVARTIS for investigator; Received consulting fee from St. Jude Medical Corp. for speaking and teaching.

Chief Editor

P Syamasundar Rao, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

Leigh M Ettinger, MD, MS Clinical Assistant Professor, Division of Pediatric Nephrology, The Joseph M Sanzari Children's Hospital, Hackensack University Medical Center

Disclosure: Nothing to disclose.

Ira H Gessner, MD Professor Emeritus, Pediatric Cardiology, University of Florida College of Medicine

Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

John W Moore, MD, MPH Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital

John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Adrian Spitzer, MD Clinical Professor Emeritus, Department of Pediatrics, Albert Einstein College of Medicine

Adrian Spitzer, MD is a member of the following medical societies: American Academy of Pediatrics, American Federation for Medical Research, American Pediatric Society, American Society of Nephrology, American Society of Pediatric Nephrology, International Society of Nephrology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. [Guideline] Task Force. Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics. 1987 Jan. 79(1):1-25. [Medline].

  2. [Guideline] Task Force. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control. Pediatrics. 1996 Oct. 98(4 Pt 1):649-58. [Medline].

  3. [Guideline] NHLBI. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004 Aug. 114(2 Suppl 4th Report):555-76. [Medline]. [Full Text].

  4. Gruskin AB. Factors affecting blood pressure. Drukker A, Gruskin AB, eds. Pediatric Nephrology: Pediatric and Adolescent Medicine. 3rd ed. Basel, Switzerland: Karger; 1995. 1097.

  5. Gavrilovici C, Boiculese LV, Brumariu O, Dimitriu AG. [Etiology and blood pressure patterns in secondary hypertension in children]. Rev Med Chir Soc Med Nat Iasi. 2007 Jan-Mar. 111(1):70-81. [Medline].

  6. Kapur G, Ahmed M, Pan C, Mitsnefes M, Chiang M, Mattoo TK. Secondary hypertension in overweight and stage 1 hypertensive children: a Midwest Pediatric Nephrology Consortium report. J Clin Hypertens (Greenwich). 2010 Jan. 12(1):34-9. [Medline].

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  8. Banker A, Gupta-Malhotra M, Syamasundar Rao P. Childhood hypertension: a review. J Hypertens. Dec 2013. 2(4):128. [Full Text].

  9. Dhuper S, Buddhe S, Patel S. Managing Cardiovascular Risk in Overweight Children and Adolescents. Paediatr Drugs. 2013 Apr 12. [Medline].

  10. Hanevold C, Waller J, Daniels S, Portman R, Sorof J. The effects of obesity, gender, and ethnic group on left ventricular hypertrophy and geometry in hypertensive children: a collaborative study of the International Pediatric Hypertension Association. Pediatrics. 2004 Feb. 113(2):328-33. [Medline].

  11. Leung LC, Sung RY, So HK, et al. Prevalence and risk factors for hypertension in Hong Kong Chinese adolescents: waist circumference predicts hypertension, exercise decreases risk. Arch Dis Child. 2011 Sep. 96(9):804-9. [Medline].

  12. Rao PS, Seib PM. Coarctation of the Aorta. Medscape Drugs & Diseases from WebMD. Available at http://emedicine.medscape.com/article/895502-overview. Updated Sep 25, 2014; Accessed: July 17, 2015.

  13. [Guideline] University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2009 Feb. [Full Text].

  14. Meyers RS, Siu A. Pharmacotherapy Review of Chronic Pediatric Hypertension. Clin Ther. 2011 Oct 7. [Medline].

  15. Schaefer F, Litwin M, Zachwieja J, Zurowska A, Turi S, Grosso A, et al. Efficacy and safety of valsartan compared to enalapril in hypertensive children: a 12-week, randomized, double-blind, parallel-group study. J Hypertens. 2011 Oct 21. [Medline].

  16. Sezer SS, Narin N, Ozyurt A, et al. Cardiovascular changes in children with coarctation of the aorta treated by endovascular stenting. J Hum Hypertens. 2014 Jun. 28(6):372-7. [Medline].

  17. Forbes TJ, Kim DW, Du W, et al, for the CCISC Investigators. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: an observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol. 2011 Dec 13. 58 (25):2664-74. [Medline].

  18. Aeberli I, Spinas GA, Lehmann R, l'Allemand D, Molinari L, Zimmermann MB. Diet determines features of the metabolic syndrome in 6- to 14-year-old children. Int J Vitam Nutr Res. 2009 Jan. 79(1):14-23. [Medline].

  19. Gonzalez-Juanatey JR, Paz FL, Eiras S, Teijeira-Fernandez E. [Adipokines as novel cardiovascular disease markers. Pathological and clinical considerations]. Rev Esp Cardiol. 2009 Jun. 62 Suppl 2:9-16. [Medline].

  20. Kshatriya S, Reams GP, Spear RM, Freeman RH, Dietz JR, Villarreal D. Obesity hypertension: the emerging role of leptin in renal and cardiovascular dyshomeostasis. Curr Opin Nephrol Hypertens. 2009 Oct 21. [Medline].

  21. Nakamura Y, Ueshima H, Okuda N, et al. Relation of serum leptin to blood pressure of Japanese in Japan and Japanese-Americans in Hawaii. Hypertension. 2009 Dec. 54(6):1416-22. [Medline].

  22. Moledina S, Pandya B, Bartsota M, Mortensen KH, McMillan M, Quyam S, et al. Prognostic Significance of Cardiac Magnetic Resonance Imaging in Children with Pulmonary Hypertension. Circ Cardiovasc Imaging. 2013 Apr 9. [Medline].

  23. Maxey DM, Ivy DD, Ogawa MT, Feinstein JA. Food and Drug Administration (FDA) Postmarket Reported Side Effects and Adverse Events Associated with Pulmonary Hypertension Therapy in Pediatric Patients. Pediatr Cardiol. 2013 Mar 27. [Medline].

 
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Management algorithm. AMC = Apparent mineralocorticoid excess; GRA = Glucocorticoid remedial aldosteronism; VMA = Vanillylmandelic acid.
Table 1. Ninety-Fifth Blood Pressure Percentiles for 50th and 75th Height Percentiles in Children and Adolescents [3]
Age, y 95th BP Percentile for Girls, mm Hg 95th BP Percentile for Boys, mm Hg
50th Height Percentile 75th Height Percentile 50th Height Percentile 75th Height Percentile
1 104/58 105/59 103/56 104/58
6 111/74 113/74 114/74 115/75
12 123/80 124/81 123/81 125/82
17 129/84 130/85 136/87 138/87
Table 2. Common Causes of Hypertension by Age
Infants Children Adolescents
1-6 y 7-12 y
Thrombosis of renal artery or vein



Congenital renal anomalies



Coarctation of aorta



Bronchopulmonary dysplasia



Renal artery stenosis



Renal parenchymal disease



Wilms tumor



Neuroblastoma



Coarctation of aorta



Renal parenchymal disease



Renovascular abnormalities



Endocrine causes



Essential hypertension



Essential hypertension



Renal parenchymal disease



Endocrine causes



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