
 it is widely accepted among pediatric health care providers that the risks of developing coronary artery disease ( cad ) start in early life .
hypertension ( ht ) is a major modifiable risk factor in the development of cad .
identification of ht at an early age may allow early intervention to prevent future end organ damage . despite ample literature studying ht in animals and humans , our understanding of pediatric ht
many questions regarding the long - term effects of antihypertensive therapy on growth and development remain unanswered . until recently , normal blood pressure ( bp ) values have been scarce especially in the very young due to the relative difficulty of measuring bp in this age group . the wide availability of oscillometric bp devices have made bp measurement more feasible especially in young children . furthermore , several normative bp values are now available .
thus , the measurement of bp in infants and children at the office and hospital should now be easier and more reproducible .
hypertension is a hemodynamic manifestation of total vascular resistance ( tvr ) , and cardiac output ( co )   tvr is a function blood vessel wall elasticity , myocardial contractility , and cardiac afterload .
cardiac output is the product of cardiac stroke volume ( sv ) and rate ( hr ) . both myocardial contractility and hr are regulated by sympathetic nerve activity .
sv depends on myocardial contractility and preload . during the early stages of hypertension , co is often increased . as hypertension progresses , tvr increases and co normalizes . in a certain group of patients ,
hypertension develops primarily due to a decrease in the cross - sectional area of peripheral arterioles leading to an increase in resistance to flow .
tvr is controlled by the interaction of vasodilators such as prostaglandins and bradykinins and vasoconstrictors such as platelet - derived growth factor ( pdgf ) , thromboxane , and angiotensin ii .
this group includes patients with renal disease , african american children , and certain genetic forms of hypertension .
a prevalent operational designation of hypertension is bp elevation above the 95% percentile for either age , height , or tanner stage and gender , using standardized measurement techniques on at least three separate occasions .
the normative sporadic bp values were updated in 2004 by the fourth report on the diagnosis , evaluation , and treatment of high blood pressure in children and adolescents from the united states of america ( us ) .
this task force has incorporated previous data from us children and added new data from the 1999 to 2000 national health and nutrition examination survey ( nhanes ) .
blood pressure values are based on gender , age , and height , and 50th , 90th , 95th , and 99th percentiles are provided . while this data is accepted and used worldwide normative data from other regions of the world is available .
some regional normative data significantly vary from us data , stressing the ethnic variability in bp .
the joint national committee on prevention , detection , evaluation , and treatment of high bp ( jnc7 ) further stratified hypertension in adults into prehypertension and 2 stages . in 2004 , the fourth report recommended childhood classification .
stage 1 htn is defined as being from the 95th to the 99th percentile plus 5  mmhg .
stage 2 htn is 5  mmhg or more above the 100th percentile and represents a level of bp that requires prompt evaluation .  
actual bp measurement among 10 19-year - old school children , shows that the prevalence of hypertension is close to the predicted rate at 4.5% .
risk factors associated with hypertension include gender ( males ) , ethnicity ( african americans and hispanics ) , and increased bmi can increase the prevalence of hypertension among certain high risk groups .
the prevalence of hypertension among obese children is much higher estimated to be as high as 11% .
children with hypertension have 2.5 times the risk of becoming adults with hypertension . from these studies
one may conclude that prevention of risk factors for the development of hypertension , such as obesity , may delay or prevent adult hypertension .
  symptoms of hypertension in childhood can vary depending upon the severity and duration of hypertension .
mild to moderate hypertension is often asymptomatic , while severe hypertension can present with encephalopathy and acute loss of vision ( posterior reversible encephalopathy syndrome , pres ) .
determining the duration of hypertension at presentation is of clinical consequence as it helps narrow down the list of differential diagnosis . establishing the duration of hypertension starts by obtaining a comprehensive history .
such interview should focus on symptoms associated with hypertension such as poor sense of well - being , poor sleep , restlessness , poor growth , nose bleed , all with the potential to suggest chronic hypertension .
frequent headaches , blurred vision , chest pain , symptoms of congestive heart failure , and encephalopathy seizure all could point to an acute onset of hypertension .   as most clinical conditions in pediatrics , etiology of hypertension is age specific , table 1 , as we and others have previously shown . as such ,
neonatal period , prematurity low birth weight , prolonged oxygen therapy , and history of umbilical artery catheters may provide clues as to the etiology of hypertension . also history of urinary tract infection in infancy
glomerulonephritis and in adolescent females , history of urinary tact infections or dysfunctional voiding may suggest a cause for hypertension .
symptoms of systemic illness also could include pallor , flushing , joint pains , rash , edema , gross hematuria , excessive weight gain or loss , or decreased height growth which may suggest vasculitis or glomerulonephritis .
triad of flushing , palpitations and , hypertension are often suggestive of pheochromocytoma , a rare cause of hypertension in this age group . in adolescents history
history should question the occurrence of headaches , sleep disturbance , visual symptoms , nosebleeds , palpitations , and episodic rapid pulse .
sleep disorder , snoring fatigue could be associated with obstructive sleep apnea , a condition overlooked in older children .
excessive intake of sodium or caffeinated beverages , and energy drinks is associated with hypertension .
a medication history should include specific questions about over - the - counter drugs like pseudoephedrine or herbal preparations like ephedra , st .
adolescents should be questioned in private to obtain a history of substance abuse or the possibility of pregnancy .
history of current or recent prescription medications such as decongestants , corticosteroids , and nonsteroidal anti - inflammatory could all suggest a cause for hypertension .  
office hypertension also known as white coat effect is not an uncommon cause of referral for evaluation to the specialist .
studies have shown that repeated bp measurement can lower the incidence of office hypertension . a complete physical exam should focus on signs associated with the disease process that caused hypertension and signs of end organ damage associated with hypertension .  
an infant with hypertension abdominal mass could suggest congenital kidney disease , and pulmonary findings could suggest bronchopulmonary dysplasia . in older children ,
four extremities bp check is an essential part of a physical exam of a child with hypertension to evaluate for coarctation of the aorta .
caf - au - lait spots could suggest neurofibromatosis often associated with hypertension either due to pheochromotocytoma or renal artery stenosis .
signs of cv disease as a complication of hypertension include gallop , tachycardia , rales , decreased breath sounds , and so forth . in severe hypertension , lethargy , loss of vision ( pres ) , and signs of stroke
signs of excessive steroids such as cushing syndrome , for example , truncal obesity , buffalo hump , round moon faces , and hirsutism .
height and weight to calculate bmi is an essential part of the physical exam when evaluating a child with hypertension .
basic laboratory tests including basic chemistries , cbc , urinalysis , and renal sonogram are what the practioner should request in children who have stage 1 hypertension ; please refer to table 3 for details . if the child is symptomatic or show signs of end organ damage or symptoms of secondary causes of hypertension the gp should promptly refer the child to the specialist .
end organ damage are often rare in children but can include concentric hypertrophy of left ventricular , proteinuria , microalbuminuria , and retinopathy .
the younger was the age at presentation with hypertension , the higher are the chances that we find its secondary cause .  
table 4 lists some of the biochemical and imaging tests often recommended to evaluate a child with hypertension .  
pharmacological therapy when employed should aim to control elevated blood pressure with the lowest dose and minimal number of drugs , thus minimizing potential toxicity , expense and simplifying the therapeutic regimen .
the level to which elevated blood pressure is to be lowered in children and adults remains an arbitrary clinical decision . in adults
, the relationship between diastolic blood pressure and the risk of cardiovascular mortality appears to be j - shaped , that is , the risk of developing cardiovascular mortality declines with lowering diastolic blood pressure up to a nadir beyond which further drop in blood pressure will increase morbidity .
it is often desired to drop diastolic blood pressure to levels between 80 and 90th percentiles for age .
there are two accepted modalities to treat hypertension in pediatrics , namely , nonpharmacological and drug therapies .
the type of therapy used often depends on the age of onset , duration , and the severity of ht .
it is generally accepted that borderline hypertension ( 9095th percentile for age ) with no evidence of end - organ damage can be treated with nonpharmacological remedies .
stage 2 hypertension the other hand ( above 99th percentile ) often requires admission to hospital for comprehensive management .
the safest therapeutic intervention to manage mild ht is the use of nonpharmacological remedies . evidence for the efficacy of this type of intervention in children is not yet established .
nonpharmacological intervention has traditionally been focused on the reduction in dietary sodium intake along with high potassium ( if there is no clinical contraindication ) and on weight loss when the patient is obese .
while there are no strong evidence in children about the effect of avoidance of tobacco , alcohol , and stress on bp control , these are desirable practices should be promoted through pediatric counseling .  
it should be instituted whenever ht is severe or when nonpharmacological intervention alone fails to control the bp in mild to moderate ht .
major questions with regard to the long - term effects of antihypertensive drug treatment on growth and cognitive function in children remain unresolved .
in addition , the absence of adequate information regarding drug interaction , volume of distribution , protein binding , metabolic degradation , and renal and hepatic excretion introduces additional concerns when treating ht in children . as such most antihypertensive drugs , however , carry a disclaimer relating to their use in children . a large number of antihypertensive agents with various sites and mechanisms of action are commercially available .
each drug has undergone extensive evaluation in adult volunteers in pre- and postmarketing clinical trials .  
the availability of newer drugs allows us to make a rational choice of antihypertensive therapy .
the first step in the treatment of hypertension involves a small dose of a single drug , usually a diuretic , the dose is increased until bp goals are achieved , side effects appear , or a maximum dosage is reached . if the bp is not controlled , in spite of adequate compliance , a second and even a third drug is then added .
recently , a different approach to antihypertensive treatment has become increasingly popular where therapy is  individualized . 
while vasodilators can lower high bp of almost any etiology , understanding pathophysiologic mechanisms leading to the bp elevation helps in selecting targeted therapy aimed at better control of ht .
table 3 provides guidelines for the selection of antihypertensive drugs based on our knowledge of the pathogenesis of ht in an individual child . using these guidelines
, we often initiate therapy with a calcium channel blocker agent , an ace - i or a beta - adrenergic antagonist .
these drugs are available in once - a - day dosage and have few side effects , both features reflecting positively on adherence .
if monotherapy with angiotensin converting enzyme inhibitors , beta - blockers or calcium channel blockers fail to correct bp within two weeks , a diuretic or a mild vasodilator like hydralazine or prazosin are often second line therapy .
a final step is to use a potent vasodilator like minoxidil or a centrally acting agent like clonidine .
often , combination therapy from different antihypertensive classes is required to achieve control of bp .
treatment of severe ht , on the other hand , requires admission to the hospital for frequent bp monitoring . for more detailed review of medications used for treatment of hypertension ,
while treatment 's potential to alter long - term outcome of hypertension in children sounds intuitive , clear evidence is lacking .
what is certain is that children with hypertension require frequent monitoring for end - organ damage from hypertension as well as the potential complication of antihypertensive therapy .
it is then rather instinctive that prevention of risk factors associated with hypertension in childhood , such as obesity , may delay or prevent adult hypertension .
furthermore , the development of cardiovascular disease and renal disease later in life is also suspected to be associated with childhood hypertension .
hence , it can not be overemphasized that early detection of hypertension by routine measurement of bp is an essential part of any office visit .
 over the past several decades , childhood hypertension has undergone a considerable conceptual change , as hypertension is a predictor of future development of cardiovascular disease in adults . 
 childhood hypertension has distinctive features that distinguish it from hypertension in adults . 
 pediatric hypertension is often secondary . 
 it is widely believed that therapeutic intervention at an early age favorably modifies the long - term outcome of hypertension . despite its significance as a cause for morbidity , 
 childhood hypertension is underdiagnosed and less studied with many basic issues remaining contentious . 
1. Overview
2. Clinical Presentation
3. Management
4. Long-Term Followup 
5. Summary from a General Practioner's Perspective