eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology
Hypertension: Treatment & Medication
Updated: Nov 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
To the extent possible, treatment of hypertension should address the cause and correct it. Reserve the therapeutic modalities described below for those children who have irremediable causes of hypertension or essential hypertension.6
- Nonpharmacologic measures
- Nonpharmacologic measures are important in the treatment of all patients with hypertension, regardless of its etiology or severity. In children with mild or moderate hypertension, this approach may suffice to lower blood pressure (BP) to within normal limits. A nonpharmacologic 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 overweight children with hypertension regardless of its etiology. Obesity and hypertension are closely correlated, particularly in adolescents.
- 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.
- 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).
- Potassium supplementation can decrease BP and reduce ventricular hypertrophy in adults. How potassium supplementation affects children with hypertension remains to be tested. However, avoiding potassium depletion (eg, from diuretic therapy) and prescribing a potassium-rich diet in patients without renal insufficiency appear reasonable.
- 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, and/or use of continuous positive airway pressure may improve the patient's sleep and secondarily improve BP.
- Pharmacologic measures
- Some drugs currently used to treat hypertension in adults have been formally tested in children. 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 angiotensin II receptor blockers (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 one drug should be started first. If unsuccessful, the dose should be uptitrated. BP is considered controlled when it is less than the 95th percentile in children with uncomplicated primary hypertension. When patients have chronic renal disease, diabetes, or hypertensive target-organ damage, the goal should be less than 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, the treatment of chronic hypertension requires expertise that is seldom available in the general pediatrician. Therefore, referring patients to physicians who specialize in treatment of children with high BP is advisable. 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 by city, state, and country (see the ASH Specialist Directory).
- 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.
- Management of hypertensive crisis
- Hypertensive crises occur as a result of an acute illness, such as postinfectious glomerulonephritis or acute renal failure, the 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. Remember that accurately assessing 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. However, seizures due to severe hypertension must be treated with a fast-acting antihypertensive drug.
- Drugs currently used to treat hypertensive emergencies include nicardipine, labetalol, and sodium nitroprusside.
- The goal of therapy is to decrease BP to normal. Clinicians should be familiar with the effect 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.
- Transcatheter therapy
- Interventional cardiac catheterization procedures can be used to treat coarctation of the aorta. Balloon dilation of a previously untreated coarctation remains controversial. Some pediatric cardiologists recommend this approach and may also place a stent at the coarctation site. The appropriateness of this approach remains to be determined in studies of long-term outcome.
- 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.
Surgical Care
- Surgery may be required for children with severe renal vascular hypertension, renal segmental hypoplasia, coarctation of the aorta, Wilms tumor, or pheochromocytoma.
Consultations
- A pediatric endocrinologist should be consulted when pheochromocytoma is suspected. If the diagnosis is confirmed, a qualified surgeon must remove the tumor. 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.
- The Fourth Report provides a management algorithm (see Media file 1).
Management algorithm. AMC = Apparent mineralocorticoid excess; GRA = Glucocorticoid remedial aldosteronism; VMA = Vanillylmandelic acid.
Medication
The following drugs currently are 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 mcg/kg/min IV infusion, and sodium nitroprusside 0.53-10 mcg/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 the eMedicine article Neonatal Hypertension.
Many antihypertensive drugs are available for the treatment of chronic hypertension. The choice of drug is usually based on the mode of action and the potential for adverse effects. From a pharmacologic point of view, antihypertensive drugs are classified in the following categories: diuretics, which block sodium reabsorption at various levels of the renal tubules; adrenergic blockers, which act by competitively inhibiting the catecholamines; direct vasodilators, which act by means of a variety of mechanisms; ACE inhibitors, which block the conversion of angiotensin I to angiotensin II; angiotensin II receptor blockers (ARBs), which interfere with the binding of angiotensin II to angiotensin I receptors; and calcium-channel blockers, which block the entry of calcium into the cells, producing vasodilation.
Drug Category: ACE inhibitors –- These drugs prevent conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, and lower aldosterone secretion. ACE inhibitors are effective and well-tolerated drugs with no adverse effects on plasma lipid levels or glucose tolerance. They prevent the progression of diabetic nephropathy and other forms of glomerulopathies but appear to be less effective in African American patients than in Caucasian patients.
Patients with high plasma renin activity may have an excessive hypotensive response to ACE inhibitors. Patients with bilateral renal vascular disease or with single kidneys, whose renal perfusion is maintained by high levels of angiotensin II, may develop irreversible acute renal failure when treated with ACE inhibitors. ACE inhibitors may cause hyperkalemia; therefore, monitor serum potassium levels. ACE inhibitors are contraindicated in pregnancy. Cough and angioedema are less common with newer members of this class than with captopril. Serum potassium and serum creatinine concentrations should be monitored for the development of hyperkalemia and azotemia. Examples of agents from this class include captopril, lisinopril, and enalapril.
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Table
| ACE Inhibitors | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Captopril (Capoten) | 0.3-0.5 mg/kg/dose PO tid; may gradually increase to 6 mg/kg/d | 6.25-25 mg PO bid/tid initially; may uptitrate; not to exceed 450 mg/d divided bid/tid |
| Enalapril (Vasotec) | 0.08 mg/kg/d PO qd or divided bid; not to exceed 5 mg/d initially; may gradually increase to 0.6 mg/kg/d; not to exceed 40 mg/d | 2.5-5 mg PO qd or divided bid initially; may uptitrate by 2.5-5 mg/d q1-2wk; dosage range 10-40 mg/d |
| Lisinopril (Prinivil, Zestril) | 0.07 mg/kg/d PO qd; not to exceed 5 mg/d initially; may gradually increase to 0.6 mg/kg/d; not to exceed 40 mg/d | 10 mg PO qd; may gradually uptitrate by 5-10 mg/d q1-2 wk; not to exceed 40 mg/d |
| ACE Inhibitors | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Captopril (Capoten) | 0.3-0.5 mg/kg/dose PO tid; may gradually increase to 6 mg/kg/d | 6.25-25 mg PO bid/tid initially; may uptitrate; not to exceed 450 mg/d divided bid/tid |
| Enalapril (Vasotec) | 0.08 mg/kg/d PO qd or divided bid; not to exceed 5 mg/d initially; may gradually increase to 0.6 mg/kg/d; not to exceed 40 mg/d | 2.5-5 mg PO qd or divided bid initially; may uptitrate by 2.5-5 mg/d q1-2wk; dosage range 10-40 mg/d |
| Lisinopril (Prinivil, Zestril) | 0.07 mg/kg/d PO qd; not to exceed 5 mg/d initially; may gradually increase to 0.6 mg/kg/d; not to exceed 40 mg/d | 10 mg PO qd; may gradually uptitrate by 5-10 mg/d q1-2 wk; not to exceed 40 mg/d |
Drug Category: Beta-blockers -- Beta-blockers are especially useful in the concurrent treatment of hypertension and migraine disorder. Dosing is limited by the bradycardia adverse effect. Drugs of this class should not be prescribed to athletes because their athletic performance may be compromised. This class should not be used in patients with insulin-dependent diabetes because these drugs blunt the normal warning symptoms of hypoglycemia. Noncardioselective agents (ie, agents that elicit beta1 and beta2 blockade, eg, propranolol) are contraindicated in asthma and heart failure, due to their ability to cause bradycardia and bronchospastic actions. Selective beta1-adrenergic blockers include atenolol and metoprolol. Labetalol elicits a mixed alpha and beta blockade. Another agent from this class is propranolol.
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Table
| Beta-Blockers | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Atenolol (Tenormin) | 0.5-1 mg/kg/d PO qd or divided bid initially; may gradually increase to 2 mg/kg/d; not to exceed 100 mg/d | 50 mg PO qd; may increase to 100 mg/d |
Labetalol | 1-3 mg/kg/d PO divided bid initially; may gradually increase to 10-12 mg/kg/d; not to exceed 1200 mg/d | 100 mg/d PO bid; may increase q2-3d by 100 mg until adequate response; not to exceed 2.4 g/d |
| Metoprolol (Lopressor, Toprol XL) | 1-2 mg/kg/d PO divided bid initially; may gradually increase to 6 mg/kg/d; not to exceed 200 mg/d | 100 mg/d PO qd or divided bid/tid initially; may increase q1wk; not to exceed 450 mg/d |
| Propranolol (Inderal, Betachron E-R) – nonselective beta-blocker | 1-2 mg/kg/d PO divided bid/tid initially; may gradually increase to 4 mg/kg/d; not to exceed 640 mg/d | 10 mg PO bid/tid (prompt release) or 30-40 mg qd (sustained-release cap); increase dose q3-5d; not to exceed 640 mg/d |
| Beta-Blockers | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Atenolol (Tenormin) | 0.5-1 mg/kg/d PO qd or divided bid initially; may gradually increase to 2 mg/kg/d; not to exceed 100 mg/d | 50 mg PO qd; may increase to 100 mg/d |
Labetalol | 1-3 mg/kg/d PO divided bid initially; may gradually increase to 10-12 mg/kg/d; not to exceed 1200 mg/d | 100 mg/d PO bid; may increase q2-3d by 100 mg until adequate response; not to exceed 2.4 g/d |
| Metoprolol (Lopressor, Toprol XL) | 1-2 mg/kg/d PO divided bid initially; may gradually increase to 6 mg/kg/d; not to exceed 200 mg/d | 100 mg/d PO qd or divided bid/tid initially; may increase q1wk; not to exceed 450 mg/d |
| Propranolol (Inderal, Betachron E-R) – nonselective beta-blocker | 1-2 mg/kg/d PO divided bid/tid initially; may gradually increase to 4 mg/kg/d; not to exceed 640 mg/d | 10 mg PO bid/tid (prompt release) or 30-40 mg qd (sustained-release cap); increase dose q3-5d; not to exceed 640 mg/d |
Drug Category: Thiazide diuretics -- These drugs inhibit the reabsorption of sodium in the distal tubules, increasing the excretion of sodium, water, and potassium and hydrogen ions. Thiazide diuretics have been effective in treating hypertension of various etiologies. Their primary effect is to diminish sodium reabsorption. They also appear to diminish the sensitivity of blood vessels to circulating vasopressor substances. In all patients treated with diuretics, electrolyte levels should be monitored. Examples from this class include hydrochlorothiazide and chlorthalidone.
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| Thiazide Diuretics | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Hydrochlorothiazide (Esidrix) | 1 mg/kg PO qd initially; may gradually increase to 3 mg/kg/d; not to exceed 50 mg/d | 25-100 mg/d PO divided qd/bid, may increase gradually; not to exceed 200 mg/d |
| Chlorthalidone (Hygroton) | 0.3 mg/kg PO qd initially; may gradually increase to 2 mg/kg/d; not to exceed 50 mg/d | 25 mg PO qd initially; may gradually increase to 100 mg/d |
| Thiazide Diuretics | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Hydrochlorothiazide (Esidrix) | 1 mg/kg PO qd initially; may gradually increase to 3 mg/kg/d; not to exceed 50 mg/d | 25-100 mg/d PO divided qd/bid, may increase gradually; not to exceed 200 mg/d |
| Chlorthalidone (Hygroton) | 0.3 mg/kg PO qd initially; may gradually increase to 2 mg/kg/d; not to exceed 50 mg/d | 25 mg PO qd initially; may gradually increase to 100 mg/d |
Drug Category: Loop diuretics -- These agents inhibit the reabsorption of sodium chloride in the thick ascending limb of the loop of Henle. Loop diuretics can be used to treat hypertension in patients with renal insufficiency. They are less effective than thiazide diuretics in patients who are hypertensive with normal renal function. Examples from this class include furosemide and bumetanide.
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| Loop Diuretics | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Furosemide (Lasix) | 0.5-2 mg/kg PO qd/bid initially; may gradually increase to 6 mg/kg/d | 20-80 mg/d PO qd or in divided doses; may uptitrate to 600 mg/d for severe edematous conditions |
| Bumetanide (Bumex) | 0.015-0.1 mg/kg/dose PO q6-24h; not to exceed 10 mg/d | 0.5-2 mg PO qd/bid; may gradually increase; not to exceed 10 mg/d |
| Loop Diuretics | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Furosemide (Lasix) | 0.5-2 mg/kg PO qd/bid initially; may gradually increase to 6 mg/kg/d | 20-80 mg/d PO qd or in divided doses; may uptitrate to 600 mg/d for severe edematous conditions |
| Bumetanide (Bumex) | 0.015-0.1 mg/kg/dose PO q6-24h; not to exceed 10 mg/d | 0.5-2 mg PO qd/bid; may gradually increase; not to exceed 10 mg/d |
Drug Category: Potassium-sparing diuretics -- Potassium-sparing diuretics are used alone or in combination with other diuretics to prevent or correct hypokalemia. However, these drugs can cause hyperkalemia, particularly in patients with renal insufficiency or when they are administered in combination with ACE inhibitors and ARBs. Examples from this class include spironolactone and amiloride.
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| Potassium-Sparing Diuretics | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Spironolactone (Aldactone) | 1 mg/kg/d PO qd or divided bid initially; may gradually increase to 3.3 mg/kg/d; not to exceed 100 mg/d | 25-200 mg/d PO qd or divided bid |
| Amiloride (Midamor) | 0.4-0.625 mg/kg PO qd initially; may gradually increase to 20 mg/d | 5 mg PO qd initially; may gradually increase to 20 mg/d |
| Potassium-Sparing Diuretics | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Spironolactone (Aldactone) | 1 mg/kg/d PO qd or divided bid initially; may gradually increase to 3.3 mg/kg/d; not to exceed 100 mg/d | 25-200 mg/d PO qd or divided bid |
| Amiloride (Midamor) | 0.4-0.625 mg/kg PO qd initially; may gradually increase to 20 mg/d | 5 mg PO qd initially; may gradually increase to 20 mg/d |
Drug Category: Calcium-channel blockers -- These drugs affect BP by decreasing vascular peripheral resistance. With short-acting calcium-channel blockers the cardiac response to this action is variable, resulting in tachycardia. Long-acting preparations may cause decrease in heart rate. Calcium-channel blockers are classified by their structure, and they have different degrees of selectivity in their effects on vascular smooth muscle. The dihydropyridines do not exert electrophysiologic effects and are commonly used to manage hypertension. Facial flushing may occur. Examples from this class include amlodipine and isradipine.
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| Calcium-Channel Blockers | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Amlodipine (Norvasc) | <6 years: Not established 6-17 years: 2.5-5 mg PO qd | 5 mg PO qd; may increase to 10 mg/d |
| Isradipine (DynaCirc) | 0.15-0.2 mg/kg/d PO divided tid/qid initially; may gradually increase to 0.8 mg/kg/d; not to exceed 20 mg/d | 2.5 mg PO bid (prompt release) or 5 mg PO qd (sustained release); may gradually increase to 20 mg/d |
| Calcium-Channel Blockers | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Amlodipine (Norvasc) | <6 years: Not established 6-17 years: 2.5-5 mg PO qd | 5 mg PO qd; may increase to 10 mg/d |
| Isradipine (DynaCirc) | 0.15-0.2 mg/kg/d PO divided tid/qid initially; may gradually increase to 0.8 mg/kg/d; not to exceed 20 mg/d | 2.5 mg PO bid (prompt release) or 5 mg PO qd (sustained release); may gradually increase to 20 mg/d |
Drug Category: ARBs -- These drugs lower BP by blocking the final receptor (ie, angiotensin II) in the renin-angiotensin axis. Like the ACE inhibitors, this class is contraindicated in pregnancy. Serum electrolyte and creatinine levels should be monitored. Examples from this class include irbesartan and losartan.
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| ARBs | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Irbesartan (Avapro) | <6 years: Not established 6-12 years: 75-150 mg PO qd >13 years: Administer as in adults | 150 mg PO qd; may gradually increase, not to exceed 300 mg/d |
| Losartan (Cozaar) | 0.7 mg/kg/d PO qd; not to exceed 50 mg/d initially; may gradually increase to 1.4 mg/kg/d; not to exceed 100 mg/d | 25 mg PO qd or divided bid initially; may gradually increase, not to exceed 100 mg/d |
| Valsartan (Diovan) | <6 years: Not established >6 years: 1.3 mg/kg PO qd initially, not to exceed 40 mg/d; may adjust dose according to blood pressure response up to 2.7 mg/kg/d (not to exceed 160 mg/d) | 80-160 mg PO qd; may gradually increase, not to exceed 320 mg/d |
| ARBs | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Irbesartan (Avapro) | <6 years: Not established 6-12 years: 75-150 mg PO qd >13 years: Administer as in adults | 150 mg PO qd; may gradually increase, not to exceed 300 mg/d |
| Losartan (Cozaar) | 0.7 mg/kg/d PO qd; not to exceed 50 mg/d initially; may gradually increase to 1.4 mg/kg/d; not to exceed 100 mg/d | 25 mg PO qd or divided bid initially; may gradually increase, not to exceed 100 mg/d |
| Valsartan (Diovan) | <6 years: Not established >6 years: 1.3 mg/kg PO qd initially, not to exceed 40 mg/d; may adjust dose according to blood pressure response up to 2.7 mg/kg/d (not to exceed 160 mg/d) | 80-160 mg PO qd; may gradually increase, not to exceed 320 mg/d |
Drug Category: Central alpha-agonists -- This class of drug lowers BP by stimulating alpha2-adrenergic receptors in the brainstem and activates an inhibitory neuron resulting in decreased vasomotor tone and heart rate. This class of drugs may cause dry mouth and/or sedation. Caution is warranted in patients with cerebrovascular disease, coronary insufficiency, sinus-node dysfunction, or renal impairment. A transdermal patch is available. The sudden discontinuation of this drug may lead to severe rebound hypertension. This drug has been used in the past for the treatment of children with ADHD, and it still may be used successfully in patients with ADHD who also have hypertension. An example from this class is clonidine.
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| Central Alpha-Agonists | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Clonidine (Catapres) | 1-11 years: Not established >12 years: Administer as in adults | 0.1 mg PO bid initially; may increase to 0.2-1.2 mg/d divided bid/qid; not to exceed 2.4 mg/d |
| Central Alpha-Agonists | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Clonidine (Catapres) | 1-11 years: Not established >12 years: Administer as in adults | 0.1 mg PO bid initially; may increase to 0.2-1.2 mg/d divided bid/qid; not to exceed 2.4 mg/d |
Drug Category: Direct Vasodilator -- This class of drug directly vasodilates the smooth muscle in the peripheral vasculature, causing vasodilation. Tachycardia and fluid retention are common side effects. Prolonged use of minoxidil can cause hypertrichosis. Hydralazine can cause a lupus-like syndrome in certain populations of slow acetylators. Examples from this class include minoxidil and hydralazine.
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| Direct Vasodilators | Pediatric Dose (1-17 y) | Adult dose |
|---|---|---|
| Minoxidil (Loniten) | 1-11 years: 0.2 mg/kg/d PO qd or divided tid; not to exceed 50 mg/d 12-17 years: Administer as in adults | 5 mg PO qd initially; may gradually increase q3d to 10-40 mg/d qd or divided bid; not to exceed 100 mg/d |
| Hydralazine (Apresoline) | 0.75 mg/kg/d PO divided qid initially; may gradually increase to 7.5 mg/d; not to exceed 200 mg/d | 10 mg PO qid initially for 2-4 days; may gradually increase to 25 mg PO qid for rest of first wk; increase to 50 mg qid second wk; not to exceed 300 mg/d |
| Direct Vasodilators | Pediatric Dose (1-17 y) | Adult dose |
|---|---|---|
| Minoxidil (Loniten) | 1-11 years: 0.2 mg/kg/d PO qd or divided tid; not to exceed 50 mg/d 12-17 years: Administer as in adults | 5 mg PO qd initially; may gradually increase q3d to 10-40 mg/d qd or divided bid; not to exceed 100 mg/d |
| Hydralazine (Apresoline) | 0.75 mg/kg/d PO divided qid initially; may gradually increase to 7.5 mg/d; not to exceed 200 mg/d | 10 mg PO qid initially for 2-4 days; may gradually increase to 25 mg PO qid for rest of first wk; increase to 50 mg qid second wk; not to exceed 300 mg/d |
Drug Category: Peripheral alpha-antagonists -- These agents inhibit postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles and decreasing total peripheral resistance and BP. These drugs often cause marked hypotension after the first dose. High doses are likely to cause postural hypotension. Drugs of this class that are selective for alpha1-receptors include doxazosin and terazosin. Prazosin is nonselective and inhibits both alpha1- and alpha2-receptors.
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| Peripheral Alpha-Antagonists | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Doxazosin (Cardura) | 1 mg PO qd initially; may gradually increase to 4 mg/d | 1 mg PO qd; may gradually increase to 2-4 mg/d; further increases may be needed, not to exceed 16 mg/d |
| Prazosin (Minipress) | 0.05-0.1 mg/kg/d PO divided tid initially; may gradually increase to 0.5 mg/kg/d | 1 mg PO bid/tid initially; may gradually increase to 6-15 mg/d; further increases may be needed, not to exceed 20 mg/d |
| Terazosin (Hytrin) | 1 mg/d PO qd; may gradually increase to 20 mg/d | 1 mg PO hs initially; may gradually increase to 2-5 mg/d; further increases may be needed, not to exceed 20 mg/d |
| Peripheral Alpha-Antagonists | Pediatric Dose (1-17 y) | Adult Dose |
|---|---|---|
| Doxazosin (Cardura) | 1 mg PO qd initially; may gradually increase to 4 mg/d | 1 mg PO qd; may gradually increase to 2-4 mg/d; further increases may be needed, not to exceed 16 mg/d |
| Prazosin (Minipress) | 0.05-0.1 mg/kg/d PO divided tid initially; may gradually increase to 0.5 mg/kg/d | 1 mg PO bid/tid initially; may gradually increase to 6-15 mg/d; further increases may be needed, not to exceed 20 mg/d |
| Terazosin (Hytrin) | 1 mg/d PO qd; may gradually increase to 20 mg/d | 1 mg PO hs initially; may gradually increase to 2-5 mg/d; further increases may be needed, not to exceed 20 mg/d |
More on Hypertension |
| Overview: Hypertension |
| Differential Diagnoses & Workup: Hypertension |
 Treatment & Medication: Hypertension |
| Follow-up: Hypertension |
| Multimedia: Hypertension |
| References |
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References
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[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. Oct 1996;98(4 Pt 1):649-58. [Medline].
[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. Aug 2004;114(2 Suppl 4th Report):555-76. [Medline]. [Full Text].
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Gerber LM, Stern PM. Relationship of body size and body mass to blood pressure: sex-specific and developmental influences. Hum Biol. Aug 1999;71(4):505-28. [Medline].
Hindmarsh PC, Brook CG. Evidence for an association between birth weight and blood pressure. Acta Paediatr Suppl. Feb 1999;88(428):66-9. [Medline].
Lauer RM, Connor WE, Leaverton PE, Reiter MA, Clarke WR. Coronary heart disease risk factors in school children: the Muscatine study. J Pediatr. May 1975;86(5):697-706. [Medline].
Moore VM, Cockington RA, Ryan P, Robinson JS. The relationship between birth weight and blood pressure amplifies from childhood to adulthood. J Hypertens. Jul 1999;17(7):883-8. [Medline].
Simsolo RB, Romo MM, Rabinovich L, et al. Family history of essential hypertension versus obesity as risk factors for hypertension in adolescents. Am J Hypertens. Mar 1999;12(3):260-3. [Medline].
Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. Mar 2004;113(3 Pt 1):475-82. [Medline].
Further Reading
Keywords
hypertension, pediatric hypertension, infantile hypertension, adolescent hypertension, prehypertension, high blood pressure, high BP, elevated BP, hypertensive, prehypertensive, white-coat hypertension, treatment, diagnosis
