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ARTICLE

PEDIATRIC HYPERTENSION
PEDIATRIC HYPERTENSION
RANGE OF
RANGE OF
HYPERTENSION
HYPERTENSION
The Fourth Report on the Diagnosis, Evaluation, and
The Fourth Report on the Diagnosis, Evaluation, and
Treatment of High Blood Pressure in Children and Adolescent
Treatment of High Blood Pressure in Children and Adolescent

Hypertension
Hypertensionisisdefined
definedasasaverage
averageSystolic
Systolic
Blood Pressure and Diastolic Blood Pressure
Blood Pressure and Diastolic Blood Pressure
that is greater than or equal
that is greater than or equal to 95th to 95 th

percentile
percentilefor
forsex,
sex,age,
age,and
andheight
heighton
onthree
three
or
ormore
moreoccasions.
occasions.
THE CLASSIIFICATION OF
THEHYPERTENSION
CLASSIIFICATION OF
HYPERTENSION

CLASSIFICATION RANGE
Normal Blood Pressure Systolic and Diastolic less
than 90th Percentile
Pre-Hypertension Systolic or Diastolic 90th
percentile but < 95th
Percentile
Hypertension Systolic or Diastolic 95th
percentile
Hypertension grade 1 Systolic or Diastolic between
95th and 99th percentile plus
5 mmHg
Hypertension grade 2 Systolic or diastolic < 99th
plus 5 mmHg
EVALUATION
EVALUATION

Additional Evaluation Initial Evaluation


DMSA 1. Anamnesis
DTPA 2.Physical
examination
3.Abdominal
Ultrasonography
Non-
Non-
Pharmacological
Pharmacological
THERAPY
THERAPY pharmacologic
pharmacologic

Aim : Reduce short term or long term


Aim
risk: of
Reduce short term
cardiovaskular or longan
disease term
risk of cardiovaskular
target disease an
organ damage
target organ damage

1. The effort to lowering blood


1. The effort to lowering blood
pressure
pressure
2. Relieve clinical manifestation
2. Relieve
3. Target organmanifestation
clinical damage
3.4.Target organ
Comorbid damage
factors
4. Comorbid
5. Obesity factors
5. Obesity
6. Hyperlipidemia
6. Hyperlipidemia
7. Glucose intolerance
7. Glucose intolerance
Non-
Non-
Pharmacological
Pharmacological

Lifestyle changes is suggested for children and


Lifestyle changes is suggested for children and
adolescent who have prehypertension and stadium
adolescent who have prehypertension and stadium
1 hypertension
1 hypertension
Initial Therapy of hypertension in children include reduce body
Initial Therapy of hypertension in children include reduce body
weight , low fat and salt diet, regular exercise, stop smoking
weight , low fat and salt diet, regular exercise, stop smoking
and drinking habit..
and drinking habit..

Prescribing anti hypertension is considered for the children


Prescribing anti hypertension is considered for the children
who cannot cooperate and do lifestyle changes
who cannot cooperate and do lifestyle changes
Pharmacologic
Pharmacologic
We have to understand the underlying mechanism of
We have to understand the underlying mechanism of
hypertension during treatment
hypertension during treatment

Based on the National High Blood Pressure Education Program


Based on
(NHBEP) the National
Working High
Group on HighBlood
BloodPressure
PressureEducation Program
in Children and
(NHBEP) Working Group on High Blood Pressure in Children and
Adolescents : The Administering drug should follow the step up rule
Adolescents : The Administering drug should follow the step up rule
Hypertension grade I
Hypertension grade Hypertension Grade
which respond to life I Hypertension Grade
which respond to life II
style modification II
style modification

Symptomatic
Diabetes Mellitus Indication Symptomatic
Diabetes Mellitus Indication hypertension
hypertension

Secondary Target Organ


Secondary
Hypertenesion Target
DamageOrgan
Hypertenesion Damage
Drugs Type Dose and Interval Side effect
Classification
Angiotensin Captopril Dose: 0,3 up to 0,5 Contraindicated
Converting mg/kg/dose in pregnancy
Enzyme Maximum 6
inhibitor mg/kg/day Check serum
(ACEi) Enalapril Dose: 0,08 creatinine and
mg/kg/hari Up to 5 potassium
mg/hari
Caution for renal
Benazepril Dose: 0,2 mg/kg/day disease with
Up to 10 mg/hari proteinuria and
Maximum: 0,6 diabetic mellitus
mg/kg/day up to 40
mg/day
Lisinopril Dose: 0,07
mg/kg/day up to 40
mg/day
children > 50 kg:
dose 5 up to 10
mg/hari
Maximum dose : 40
mg/day
fosinopril Dose: 5 up to 10
Drug Type Dose and Interval Side Effect
Classification
Angiotensin Irbesartan 6 -12 yo: 75 up to All ARBs is
Receptor 150 mg/day (once contraindicated
Blocker daily) 13 yo : 150 in pregnancy
(ARB) s/d 300 mg/day
Losartan Dose: 0,7 mg/kg/day Check serum
Up to 50 mg/hari creatinine and
(once daily) potassium
Maximum dose: 1,4
mg/ kg/hari up to Losartan have
100 mg/ the preparation
of sispension

FDA approvak
for ARBs is
limited to
children 6
years old with
creatinine
clearance 30
mL/min per 1,73
m2
Drug Type Dose and Side Effect
classification interval

Calcium Amlodipin Age 6 - 7 yo 2.5-5 May cause


channel blocker mg once daily tachycardia and
oedema

felodipin Dose 2.5 mg/day


Maximum dose 10
mg/day
Golongan Jenis obat Dosis dan Efek samping
obat interval

Beta blocker Propanolol Dose: 1-2 Noncardioselect


mg/kg/day ive agents
(divided two until
three dose) Should not be
maximum dose : 4 use in insuline-
mg/kg/day up to dependent
640 mg/day diabetic
Atenolol Dose: 0,5 s/d 1
mg/day (once to
twice a day)
Maximum dose :
2mg/kg/ day up to
100 mg/hari
Drug Type Dose and Interval Side Effect
Classificati
on
Diuretic Hydrochlorotiaz Dose: 1 mg Should have
ide /kg/day(once daily) electrolytesmoni
tored shortly
Furosemide Dose: 0,5 mg up to
after initiated
2 mg/kg/day
therapy and
Maximum dose: 6
periodically
mg/kg/day
thereafter.
Spironolactone Dose: 1 Potassium-
mg/kg/day(divided sparing diuretic
1-2 dose) may cause
severe
hyperkalemia ,
especially if
given with ACE
or ARB

Furosemide may
be useful as
Adrenergic blockers
Start minimal Adrenergic blockers
Step Start minimal (Alpha or beta) start
dose of Diuretic
1 Step dose of Diuretic Or
(Alpha or beta)
with minimal dosestart
1 Or with minimal dose

If necessary, increase the


If necessary,
dose increase
till maximum dosethe
dose till maximum dose
Adds on or
Adds on
change or
with Add or change with
change with Or Add or change with
diuretic
Step adrenergic Or diuretic
adrenergic
2Step blockers
2 blockers
Continue till achieved
Continue dose
maximum till achieved
If blood pressure
maximum persist
If blood dose
pressure persist

Adds on
Step Adds on Refer toPediatric of
vasodilator ckass Refer toPediatric of
3Step vasodilator ckass Or
Or nephrology
3 (hidralazin) nephrology
(hidralazin)
Management of Hypertensive
Management of Hypertensive
Emergency
Emergency
Hypertensive emergency is a condition which is blood
Hypertensive emergency is a condition which is blood
pressure should be reduced in one hour, because of the
pressure should be reduced in one hour, because of the
symptoms like seizures, headache, blur vision, or heart
symptoms like seizures, headache, blur vision, or heart
failure.
failure.

Initian therapy is by administering oral nifedipine /


Initian therapy is by administering oral nifedipine /
sublingual and intravenous
sublingual and intravenous
Druges Drug Initial Dose Initial Duratio Side Effect
administrati respond n of
on respons
e
Diazoxide Rapid 2-5 mg/kg 3-5 4-24 Nausea,
Intravenous In 30 minutes minutes hours hyperglikemi
(1-2 minutes) respond (-) a, natrium
readministere retension
d Drug of
choice
Sodium Infuse pump 50 mg/l in Immediat During Required
Nitropusid D5% Solution ely infuse contini ous
e (5 monitoring,
mikrogram/ ,Thyocyanate
ml) 0,5-8 toxicated risk
mikrogram/
kg/minutes or
0,01-0,16 ml/
kg/minutes
hidralazin IV or IM 0,1-0,2 10-30 2-6 Tachycardia.
e mg/kg minutes hours Flushing,
headache
Some conditions need longterm treatment,
Some conditions need longterm treatment,
while others improving in short time
while others improving in short time

If blood pressure under controlled and


If blood pressure under controlled and
there is no target organ damage, tappering
there is no target organ damage, tappering
off the drugs and close monitoring were
off the drugs and close monitoring were
given
given
Infant Elevated blood pressure under control for 1
month
The dose is not increase, and the infant keep
growing
The constant and controlled blood pressure
Reduced dose once a week and tappering it off
Anak dan Remaja Blood pressure is under control in normal range
for 6 months until 1 year
Controlled blood pressure with time interval 6-8
weeks
Change to monotherapy
After blood pressure is under controlled for about
six weeks, lowering the monotherapy dose
every week and tappering it off
Prevention
Prevention

Primary
Primary Secondary
Secondary

Tertiary
Tertiary
THANKS
THANKS