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Hypertension management in children
You see a 3-year-old with hypertension (documented on three different visits) in your primary care clinic. Describe the workup, differential diagnoses, assessment, and management.
Hypertension is a well-recognized cardiovascular risk factor in adults and children, contributing to morbidity and mortality from myocardial infarction, stroke, congestive heart failure, peripheral vascular disease, retinopathy, and end-stage renal disease. The workup or assessment to determine hypertension in children is no different than that of an adult. During the visit the child’s blood pressure should be measure twice using different arm or method. (McCrindle, 2010) Evaluation, and treatment of High Blood Pressure in Children and adolescents provides systolic and diastolic blood pressure levels corresponding to the 50th, 90th, 95th, and 99th percentiles based on the child’s sex, age, and height percentile. The height percentile is plotted from normal growth charts.
Blood pressure status can be classified on the basis of systolic and diastolic blood pressure percentiles. measurements below the 90th percentile are considered normal. Prehypertension or hypertension are present when measurements of either systolic or diastolic pressure, or both, are at and above the 90th percentile. Hypertension is present when repeated measurements are at or above the 95th percentile. Hypertension is further classified as either stage 1, in which blood pressure ranges from the 95th to the 99th percentile plus 5 mmHg, or stage 2, where blood pressure is above the 99th percentile plus 5mmHg. If hypertension is confirmed, blood pressure should be measured in both arms and a leg. The classification of blood pressure influences decisions on evaluation and management. (Burns et al., 2017)
Secondary hypertension is more commonly seen in children younger than six years old and some of the primary reasons of secondary, severe hypertension is renovascular or parenchymal renal disease, therefore some of the differential diagnosis would include renal disease, cardiovascular disease, endocrine disorders genetic disorders such as Williams syndrome, drugs induced hypertension and/or obesity, sedentary lifestyle. Management of hypertension in children should include regular blood pressure measurement with each clinic visit for all patients three years and older. (Burns et al., 2017) If patient is found to have HTN a regular healthcare provider visit would be warranted. Hypertension secondary to overweight, can be as serious as hypertension caused by other organic diseases and should management with as much seriousness as other diseases.
Dietary intervention to control or reduce overweight should be a priority in our overweight or morbidly obese young patients. An increase in physical activities, exercises and sports participation should be balanced with rest periods and relaxation. (Burns et al., 2017)
How would your plan of care be different if the child were 10 years old?
The onset of primary hypertension is more likely to occur after ten years old. Because of that treatment would be more targeted in not just managing hypertension with medication. However, the focus would also be on preventing other complications related to hypertension such as high cholesterol, heart disease, arterial plaque formation, renal disease, endocrine disorders such as diabetes and other condition as well.
What risk factor counseling and advice would you include?
Unfortunately, long-term hypertension leads to cardiovascular issues such as an increase in left ventricular mass, increased carotid intimal medial thickness, and coronary artery calcification, especially if combined with overweight, lipid and lipoprotein abnormalities. Patient education would be mainly focus on good nutrition, prevention of overweight, medication management, stress management, constant monitoring of blood pressure and follow the healthcare provider’s regimen closely.
References
Burns, C. E., Dunn, A. M., Brady, M. A., Blosser, C. G., Starr, N. B., & Garzon, D. L. (2017). Pediatric Primary Care. Elsevier Gezondheidszorg.
McCrindle, B. W. (2010). Assessment and management of hypertension in children and adolescents. Nature Reviews Cardiology, 7(3), 155–163. https://doi.org/10.1038/nrcardio.2009.231
Rabi, D. M., McBrien, K. A., Sapir-Pichhadze, R., Nakhla, M., Ahmed, S. B., Dumanski, S. M., Butalia, S., Leung, A. A., Harris, K. C., Cloutier, L., Zarnke, K. B., Ruzicka, M., Hiremath, S., Feldman, R. D., Tobe, S. W., Campbell, T. S., Bacon, S. L., Nerenberg, K. A., Dresser, G. K., . . . Daskalopoulou, S. S. (2020). Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Canadian Journal of Cardiology, 36(5), 596–624. https://doi.org/10.1016/j.cjca.2020.02.086
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