Frank Tenney MD
Normal Blood Pressure
Systolic and/or diastolic arterial blood pressure <90th percentile
Pre-Hypertension
Systolic and/or diastolic arterial blood pressure >= 90th but <95th percentile or if BP exceeds 120/80 even if <90th percentile
Stage I Hypertension (Significant Hypertension)
Systolic and/or diastolic BP between the 95th percentile and 5 mmHg above the 99th percentile
Stage II Hypertension (Severe Hypertension)
Systolic and/or diastolic BP >=99th percentile plus 5 mmHg
Hypertensive Urgency**
Sustained* arterial blood pressure >5 mmHg above the 99th percentile for height / gender / and age
**WITHOUT evidence for end-organ damage
Hypertensive Emergency***
Sustained* arterial blood pressure >5 mmHg above the 99th percentile for height / gender / and age
***WITH evidence for end-organ damage
*Sustained - persistent on more than 3 separate occasions
or
as determined by ambulatory blood pressure monitoring
or
if Urgency, persistent for more than 1 hour
Clinical Scenarios
Hypertension: Infants, Children and Adolescents
Frank Tenney, M.D. Pediatric Nephrology
Case 1
Jane Doe is a 23 month old girl born at 29 weeks gestation. Her neonatal course was complicated by a grade III intra-ventricular hemorrhage (IVH). She had respiratory distress syndrome (RDS) and spent several weeks intubated on mechanical assisted ventilation. She had an indwelling umbilical arterial catheter (UAC) for much of her 3 month NICU stay. Before discharge, she was found to be hypertensive, with sustained arterial blood pressures well above the 95 percentile for age.
Peripheral pulses were synchronous and symmetrical. Cardiac ECHO did not reveal a coarctation of the aorta. Renal ultrasound was normal for age. Urinalysis was normal. Electrolytes and tests for renal function were normal.
Antihypertensive medication was started in the NICU and BP came down to values below the 90-95 percentile for age. She has been on medication daily since her discharge. She is now in for interval clinical exam and review. Renal function tests and UA are normal. She has recently had renal ultrasound that shows both kidneys to have length of 5.9 cm. (>2SD below the mean). Doppler ultrasound of the renal vessels reveals Resistive Indices of approximately 0.7 – 0.8 (expected, 0.5 range). The child’s linear growth is good, with length of 26.8 inches (25 percentile). BP is 94/32, and she continues to take medication. Mother is counseled regarding the ultrasound results and their implications. She is counseled regarding over-the-counter (OTC) medications for her toddler. An appointment for a return in 4 months is made.
Questions
Which antihypertensive medication is best for this patient? Why?
Which OTC medications should be avoided if a child has hypertension?
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Case 2
John Doe is a 6 year old boy, with a 4 year old brother and infant sister. Two weeks ago, the 4 year old was treated for streptococcal pharyngitis. John had a minimal sore throat for only a few hours so he was not evaluated or treated. He continues to attend first grade, which he loves. Today he wakens feeling “bad” and he vomited his breakfast. He stays home from school. He voids little during the day. After supper (which he did not eat), Mother thinks he looks a little swollen and brings him to the emergency room.
At the emergency room, John vomits again and seems fatigued. He complains of abdominal pain. His weight is 24 kg (85 percentile), Respiratory Rate 58, and BP 150/118. Physical examination reveals a mild periorbital edema (difficult for the examiner to identify, but the mother clearly points this out), and a slightly protuberant abdominal contour is noted while he is supine. A few fine crackles are heard at the posterior bases of the lungs. He has a soft 1/6 systolic murmur and a gallop with tachycardia is noted. Minimal peripheral edema is noted. The liver edge is palpable 2-3 fingerbreadths (3-5 cm) below the right costal margin. He appears lethargic but will respond to command. BP is repeated and is 160/124.
Laboratory investigation reveals the following:
UA + + + blood, + + + albumen, Sp Gr 1.020, numerous WBC and RBC’s are seen and RBC casts are seen.
Elecrolytes are normal except for BUN (55) and Creatinine (4.6).
He is admitted to the PICU, where antihypertensive medications are started. BP is gradually brought to a normal value for his height and age. Renal function steadily returns to normal. He is discharged on one medication, with instructions to discontinue it within 2 weeks. At subsequent follow up visits, his BP is well below the 95 percentile for height and age, off of all medications and dietary restrictions, and he is discharged from the Pediatric Nephrology Clinic.
Questions
Which antihypertensive medication(s) is/are best for this patient?
What dietary restrictions would you offer? Why?
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Case 3
Jimmy Doe is a 15 year old boy who comes to your office in August with a set of forms for you to fill out to authorize him to play football in high school. You obtain an brief history (he has been completely well in the parents' view, and has not “needed” to visit the doctor since he was 9 years old). You perform a Pre-Participation Sports Examination. You have your nurse schedule him for a complete “well-child” exam in 2 weeks, when you have an opening in your appointment book.
You find that Jimmy is 69” tall, has a weight of 210 lb, and has a BP of 150/96.
Questions
Do you authorize participation in competitive athletics? Why/Why not?
What plans to do you make for evaluation of his BP?
Future visits? Laboratory investigation?
Imaging studies? Family investigation?
Home BP readings?
Do you begin pharmacologic therapy? If so, when? With what agent?
Do you offer dietary advice? If so, what do you recommend?
Do you discuss concomitant OTC drug use? Recreational drug use?
What “associated risk factors” might you discuss as you counsel Jimmy and his family?
Is his HBP likely to be “secondary” to another medical condition?