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Back to: eMedicine Specialties > Pediatrics > Cardiology "#pertension ast $pdated% January 7, 2002 S#non#ms and related !e#&ords% high #lood pressure A$'"() I*+()MA'I(* Section 1 o, 11 Rate this rticle !"ail to a Colleague

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uthor $n%or"ation $ntroduction Clinical &i%%erentials 'orkup (reat"ent Medication )ollo*+up Miscellaneous Pictures Bi#liography uthor: Adrian Spit-er, M., Pro%essor, &epart"ent o% Pediatrics, l#ert !instein College o% Medicine, &irector o% -$. (raining Progra", Children/s .ospital at Monte%iore Medical Center drian Spit0er, M&, is a "e"#er o% the %ollo*ing "edical societies: "erican cade"y o% Pediatrics, "erican )ederation %or Medical Research, "erican Pediatric Society, "erican Society o% -ephrology, "erican Society o% Pediatric -ephrology, $nternational Society o% -ephrology, and Society %or Pediatric Research !ditor1s2: Ira " /essner, M., Pro%essor, &epart"ent o% Pediatrics, 3ni4ersity o% )lorida College o% Medicine, )obert 0onop, Pharm., Clinical ssistant Pro%essor, &epart"ent o% Phar"acy, Section o% Clinical Phar"acology, 3ni4ersity o% Minnesota, 1ohn 2 Moore, M., MP", &irector o% the .eart Center %or Children, St Christopher/s .ospital %or Children, Pro%essor, &epart"ent o% Pediatrics, MCP .ahne"ann School o% Medicine, /ilbert "er-berg, M., ssistant Pro%essor, &epart"ent o% Pediatrics, Section o% Pediatric Cardiology, -e* 5ork Medical College, and Steven *eish, M., &irector o% Pediatric Cardiac Catheteri0ation Ser4ices, .ead o% Pediatric Cardiology &i4ision, ssociate Pro%essor, &epart"ent o% Pediatrics, 3ni4ersity o% 'isconsin and Children/s .ospital I*')(.$C'I(* Section 2 o, 11

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uthor $n%or"ation $ntroduction Clinical &i%%erentials 'orkup (reat"ent Medication )ollo*+up Miscellaneous Pictures Bi#liography 3ac!ground% .ypertension is a "a6or cause o% "or#idity and "ortality in the 3S and "any other countries7 (he pre4alence o% hypertension in the adult population o% the 3nited States, de%ined #y a single "easure"ent o% 890:;0 "" .g or "ore o#tained under nonstandardi0ed conditions, is esti"ated to #e 8<+20=7 (his co"pares *ith a pre4alence o% 87<+270= a"ong children aged 9+8< years in *ho" hypertension *as de%ined as a #lood pressure persistently greater than the ;<th percentile %or age7 (his %igure, ho*e4er, %ails to con4ey the o#ser4ation that children *ith #lood pressures *ithin the upper percentiles o% nor"al range are at risk o% #eco"ing hypertensi4e later on in li%e7 3lood pressure standards

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)or children in the 3S, e?tensi4e nor"ati4e #lood pressure data are not a4aila#le7 Standards ha4e #een de4eloped #y a (ask )orce on Blood Pressure Control in Children co""issioned #y the .eart, Blood, and @ung $nstitute o% the -ational $nstitutes o% .ealth, using the results o% ; sur4eys o% 70,000 in%ants and children7 ppro?i"ately eAual nu"#ers o% #oys and girls *ere sur4eyed7 (he percentile cur4es descri#ing the age+speci%ic distri#utions o% systolic and diastolic #lood pressures in in%ants and children, *ith corrections %or height and *eight, *ere pu#lished in 8;B7 and ha4e #een reproduced e?tensi4ely in other pu#lications7 )urther details regarding the diagnosis and treat"ent o% hypertension in in%ants and children are pro4ided in the third report o% the task %orce, pu#lished in 8;;C7 $n accordance *ith the reco""endations o% the task %orce, a #lood pressure is considered nor"al *hen the systolic and diastolic 4alues are less than the ;0th percentile7 4erage systolic and:or diastolic 4alues, corrected %or #ody si0e, at or greater than this percentile le4el #ut not e?ceeding the ;<th percentile are considered high nor"al7 .ypertension is de%ined as a4erage systolic and:or diastolic #lood pressures greater than the ;<th percentile7 (hese de%initions allo* construction o% a ta#le that can ser4e as a guide to the practicing physician 1see (a#le 827 (a#le 87 (he ;<th Percentile o% Blood Pressures 1"" .g2 in Children and dolescentsD

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D dapted %ro" F3pdate on the 8;B7 (ask )orce Report on .igh Blood Pressure in Children and dolescents: a *orking group report %ro" the -ational .igh Blood Pressure !ducation Progra"F Pathoph#siolog#% (he le4el o% #lood pressure is deter"ined #y the #alance #et*een cardiac output and 4ascular resistance7 rise in either o% these 4aria#les, in the a#sence o% a co"pensatory decrease in the other, increases "ean #lood pressure, *hich is the actual dri4ing pressure7 Multiple %actors regulate cardiac output and 4ascular resistance 1see (a#le 227 $n addition, so"e o% these %actors are a%%ected #y changes in electrolyte ho"eostasis, particularly changes in sodiu", calciu", and potassiu"7 3nder nor"al conditions, the a"ount o% sodiu" e?creted in the urine "atches the a"ount ingested, resulting in near constancy o% e?tracellular 4olu"e7 Retention o% sodiu" results in increased e?tracellular 4olu"e, *hich is associated *ith an ele4ation o% #lood pressure7 (hrough a 4ariety o% physical and hor"onal "echanis"s, this triggers changes in #oth glo"erular %iltration rate and tu#ular rea#sorption o% sodiu", resulting in e?cretion o% e?cess sodiu" and restoration o% sodiu" #alance7

rise in intracellular concentration o% calciu", #rought a#out #y changes in plas"a calciu" concentration, increases 4essel contractility7 $n addition, calciu" sti"ulates the release o% renin, the synthesis o% epinephrine, and the acti4ity o% the sy"pathetic ner4ous syste"7 Gn the other hand, increased potassiu" intake suppresses production and release o% renin and induces natriuresis, thus decreasing #lood pressure7 (he co"ple?ity o% the syste" e?plains the di%%iculties encountered in identi%ying the "echanis" that accounts %or hypertension in a particular patient7 (his e?plains *hy, in a large nu"#er o% patients, treat"ent is designed to a%%ect regulatory %actors rather than the cause o% the disease7 (a#le 27 )actors %%ecting Blood PressureD

Cardiac (utput Baroreceptors !?tracellular 4olu"e !%%ecti4e circulating 4olu"e trial natriuretic hor"ones Mineralocorticoids ngiotensin Catechola"ines Sy"pathetic ner4ous syste"

5ascular )esistance Pressors ngiotensin $$ Calciu" 1intracellular2 Catechola"ines Sy"pathetic ner4ous syste" Hasopressin &epressors trial natriuretic hor"ones !ndothelial rela?ing %actors Iinins Prostaglandin !2 Prostaglandin $2

DModi%ied %ro" >ruskin B et al +re6uenc#%

In the $S% (rue incidence o% hypertension in the pediatric population is not kno*n7 (his ste"s, in part, %ro" the rather ar#itrary de%inition o% hypertension7 $n adults, hypertension *as de%ined on the #asis o% e?tensi4e studies that allo*ed correlation o% the le4el o% #lood pressure *ith detri"ental outco"es, such as heart %ailure or stroke7 Such studies ha4e not #een per%or"ed in children, although reports on s"all sa"ple populations o% children pro4ide co"pelling e4idence o% a relationship #et*een hypertension and #oth 4entricular hypertrophy and atherosclerosis7 (he %igure Auoted a#o4e 1ie, 87<+27<= o% children ha4ing hypertension2 is #ased on a co"pilation o% studies7 .o* "any o% these children Auali%y as hypertensi4e and de4elop co"plications during adulthood re"ains unkno*n7 Internationall#% Because o% di%%erences in genetic and en4iron"ental %actors, incidence 4aries %ro" country to country and e4en %ro" region to region *ithin the sa"e country7

)ace% (he task %orce noted no di%%erences in #lood pressure #et*een #lack and *hite children7 .o*e4er, #lack children o% any age appear to de"onstrate higher peripheral 4ascular resistance and a greater sensiti4ity o% their #lood pressure to salt intake than *hite children7 Se7% -o signi%icant di%%erences in #lood pressure e?ist #et*een girls and #oys younger than C years7 )ro" that age until pu#erty, #lood pressure is slightly higher in girls than in #oys7 t pu#erty and #eyond, "ales ha4e a slightly higher #lood pressure than %e"ales7

Age% Blood pressure is a%%ected #y height and *eight7 .o*e4er, these relationships do not #eco"e e4ident until children are school+aged7 (he nor"ati4e data pu#lished #y the task %orce in 8;B7 consider these %actors7 -u"erous in4estigators ha4e noted a correlation #et*een the #lood pressure o% parents and that o% their o%%spring7 (he %a"ilial aggregation o% #lood pressure is detecta#le early in li%e7 C I*ICA Section 8 o, 11

uthor $n%or"ation $ntroduction Clinical &i%%erentials 'orkup (reat"ent Medication )ollo*+up Miscellaneous Pictures Bi#liography "istor#%

*ell+taken history pro4ides clues a#out the cause o% hypertension and guides the nature and seAuence o% the ensuing in4estigations7 Rele4ant pieces o% in%or"ation include the %ollo*ing:
o o o o o o o o

Pre"aturity Bronchopul"onary dysplasia .istory o% u"#ilical artery catheteri0ation )ailure to thri4e .istory o% head or a#do"inal trau"a )a"ily history o% herita#le diseases 1eg, neuro%i#ro"atosis, hypertension2 Medications 1eg, a"pheta"ines, pressor su#stances, steroids, tricyclic antidepressants, e?cessi4e ingestion o% licorice, su#stance a#use2 !pisodes o% pyelonephritis 1suggested perhaps #y une?plained #outs o% %e4er2 possi#ly resulting in renal scarring

Presenting sy"pto"s and signs are not speci%ic in neonates and are a#sent in "ost older children unless the hypertension is se4ere7 (he signs and sy"pto"s that should alert the physician to the possi#ility o% hypertension are depicted in (a#le E7 (a#le E7 Presenting Signs in -eonates and Children *eonates Children 9Additional:

)ailure to thri4e

.eadaches

Sei0ure

)atigue

$rrita#ility or lethargy

Blurred 4ision

Respiratory distress

!pista?is

Congesti4e heart %ailure

Bell palsy

Ph#sical% Measure"ent and recording o% #lood pressure

Blood pressure "ust #e "easured once a year in e4ery child, pre%era#ly using a "ercury gra4ity "ano"eter7 &oppler and oscillo"etric techniAues can #e used in children in *ho" auscultatory #lood pressure "easure"ents are di%%icult to o#tain7 Repeated "easure"ents o4er ti"e are reAuired to o#tain "eaning%ul in%or"ation7 Proper cu%% si0e is essential %or accurate #lood pressure "easure"ent7 (he ru##er #lade inside the cloth co4er should #e long enough to encircle the ar" and *ide enough to co4er appro?i"ately three %ourths o% the distance %ro" shoulder to el#o*7 (he child should #e rela?ed and in a co"%orta#le sitting or supine 1in%ants2 position *ith the right ar" resting on a supporti4e sur%ace at the le4el o% the heart7 (he cu%% should #e in%lated at a pressure appro?i"ately 20 "" greater than that at *hich the radial pulse disappears and then allo*ed to de%late at a rate o% 2+E "" .g:s7 (he %irst Iorotko%% sound 1ie, appearance o% a clear tapping sound2 de%ines the systolic pressure, *hile the %i%th Iorotko%% sound 1ie, disappearance o% all sounds2 de%ines the diastolic pressure7 (he %ourth 1lo*+pitched, "u%%led2 sound and the %i%th sound %reAuently occur si"ultaneously, and the %i%th sound "ay not occur at all7 (he sound on *hich the diastolic #lood pressure is #ased "ust #e recorded7 Systolic #lood pressure in the lo*er e?tre"ities "ust #e "easured *hen the ele4ation o% the systolic #lood pressure in the upper e?tre"ities is %irst noted and *hen the e?a"iner %inds a"plitude o% the arterial pulse in the legs to #e lo*er than that in the ar"s7 discrepancy #et*een these 4alues is indicati4e o% coarctation o% the aorta7 'ith the patient in the supine position, place a cu%% on the cal%7 (he cu%% should #e *ide enough to co4er at least t*o thirds o% the distance %ro" knee to ankle7 &oppler ultrasound can #e used to detect onset o% #lood %lo*, re%lecting systolic #lood pressure, in either the posterior ti#ial or dorsalis pedis artery7 (he 4alue should #e co"pared *ith si"ilarly o#tained &oppler systolic #lood pressure in the ar"7 Re"e"#er that the arti%act o% distal pulse a"pli%ication causes the 4alue o% systolic #lood pressure at the #rachial artery to #e less than that at the posterior ti#ial or dorsalis pedis artery7 (his di%%erence "ay #e only a %e* "illi"eters in the in%ant #ut can rise to 80+20 "" .g in the older child or adult7 t no ti"e should the systolic pressure in the ar" e?ceed that in the %oot7 $% systolic pressure in the ar" e?ceeds that in the %oot, the pressures in #oth ar"s and legs should #e "easured7 Consistent recording o% a di%%erence indicates presence o% aortic coarctation7

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$nterpretation o% #lood pressure "easure"ents

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.ypertension is de%ined as a4erage systolic and:or diastolic #lood pressures greater than the ;<th percentile 1see (a#le 827 ny child *ith a #lood pressure e?ceeding the ;0th percentile reAuires scrutiny7 !?cept %or patients *ith se4ere hypertension and target organ da"age, *ho call %or i""ediate attention, se4eral "easure"ents o% #lood pressure should #e "ade at *eekly inter4als to deter"ine *hether the ele4ation is sustained7 (he a4erage o% these "ultiple "easure"ents should #e plotted on the appropriate percentile chart7 $% the a4erage "easure"ent, corrected %or #ody si0e, is #et*een the ;0th and ;<th percentiles, the child/s #lood pressure should #e "onitored at C+"onth inter4als7 $% the a4erage #lood pressure places the child at or greater than the ;<th percentile, the child should #e e4aluated %urther and considered %or therapy7

pri"ary o#6ecti4e o% the physical e?a"ination is identi%ication o% signs indicati4e o% secondary hypertension, including the %ollo*ing:
o o o o

Ca%J au lait spots 1pheochro"ocyto"a2 #do"inal "ass 1'il"s tu"or2 #do"inal #ruit 1coarctation o% the aorta, renal 4ascular a#nor"alities2 Blood pressure di%%erence #et*een upper and lo*er e?tre"ities 1coarctation o% the aorta2 (hyro"egaly 1hyperthyroidis"2 Hirili0ation 1adrenal hyperplasia2 Stig"ata o% Bardet+Biedl, 4on .ippel+@andau, 'illia"s, or (urner syndro"es

o o o

Causes% .ypertension can #e pri"ary 1ie, essential2 or secondary7 $n general, the younger the child and the higher the #lood pressure, the greater the chance that the hypertension is secondary to a potentially identi%ia#le cause7

re4ie* o% literature re4ealed that 7B= o% <CE young patients *ith secondary hypertension had a renal parenchy"al a#nor"ality7 $n the re"aining 22=, the cause o% hypertension, in order o% %reAuency, *as renal artery stenosis, coarctation o% the aorta, pheochro"ocyto"a, and a 4ariety o% other conditions7 (he "ost co""on causes o% hypertension in order o% their relati4e %reAuency at 4arious ages are listed in (a#le 97 (a#le 97 Co""on Causes o% .ypertension #y ge

In,ants

Aged 1;6 #ears

Aged <;12 #ears

Adolescents

Renal artery or 4ein thro"#osis

Renal artery stenosis

Renal parenchy"al disease

!ssential hypertension

Congenital renal ano"alies

Renal parenchy"al disease

Reno4ascular a#nor"alities

Renal parenchy"al disease

Coarctation o% the aorta

'il"s tu"or

!ndocrine causes

!ndocrine causes

Bronchopul"onary dysplasia

-euro#lasto"a

!ssential hypertension

Pre"aturity 1K2

Coarctation o% the aorta .I++E)E*'IA S

Pre"aturity 1K2

Section = o, 11

uthor $n%or"ation $ntroduction Clinical &i%%erentials 'orkup (reat"ent Medication )ollo*+up Miscellaneous Pictures Bi#liography (ther Problems to be Considered% step+*ise approach to the di%%erential diagnosis o% hypertension in a child is depicted in Picture 87

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Section > o, 11

uthor $n%or"ation $ntroduction Clinical &i%%erentials 'orkup (reat"ent Medication )ollo*+up Miscellaneous Pictures Bi#liography

ab Studies% Proceed %ro" si"ple tests that can #e per%or"ed in an a"#ulatory setting to co"ple? nonin4asi4e tests and %ina in4asi4e tests7 (he appro?i"ate order o% the tests is as %ollo*s:
o o

3rine dip+stick: (his test is indicati4e o% renal disease i% positi4e %or #lood and:or protein7

Blood che"istry: n increased seru" creatinine concentration is indicati4e o% renal disease7 .ypokale" suggests hyperaldosteronis"7

Blood hor"ones: .igh plas"a renin acti4ity indicates renal 4ascular hypertension, including coarctation aorta7 4ery lo* plas"a renin acti4ity is indicati4e o% glucocorticoid re"edia#le aldosteronis", @iddle sy or apparent "ineralocorticoid e?cess7 .igh plas"a aldosterone concentration is diagnostic o% hyperaldosteronis"7 .igh catechola"ines 1epinephrine, norepinephrine, dopa"ine2 are diagnostic o% pheochro"ocyto"a or neuro#lasto"a7

3rine hor"ones: .igh e?cretion o% catechola"ines and catechola"ine "eta#olites 1"etanephrine2 indic pheochro"ocyto"a or neuro#lasto"a7

Imaging Studies% !chocardiography

o o

@e%t 4entricular hypertrophy results %ro" chronic hypertension7 (he hypertrophy is sy""etric, consisting o% eAui4alent increases in thickness o% #oth the le%t 4entricular the 4entricular septu" and the le%t 4entricular posterior *all7 lso assess le%t 4entricular %unction7

#do"inal ultrasonography
o o o o

(his test "ay re4eal structural ano"alies o% the kidneys, renal 4asculature, or the presence o% tu"ors7 Renal scarring is suggesti4e o% e?cessi4e renin release7 Renal si0e asy""etry is suggesti4e o% renal dysplasia or renal artery stenosis7 Renal or e?trarenal "asses are suggesti4e o% 'il"s tu"or or neuro#lasto"a, respecti4ely7

Radionuclide i"aging 1*ithout or *ith captopril2: sy""etry is suggesti4e o% renal artery stenosis7 &oppler studies: sy""etry in renal artery #lood %lo* is suggesti4e o% renal artery stenosis7 &igital su#traction arteriography: sy""etry #et*een the 2 renal arteries is indicati4e o% renal artery stenosis7 ngiography
o o

(his test "ay re4eal di%%erences in the structure 1dia"eter2 o% the renal 4essels7

Sa"pling o% #lood %ro" renal arteries, renal 4eins, and aorta "ay re4eal di%%erences in renin secretion #e

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