Hypertension in children and adolescents

Introduction

Hypertension in children is defined as an average systolic and/or diastolic blood pressure that is 2 95th percentile for gender, age, and height on 3 or more separate occasions taken in the right arm (in view of possibility of coarctation of aorta).
An appropriate cuff size that covers two thirds () of the length of the arm (between shoulder and elbow) and encircling the whole arm, should be used.
In general, a blood pressure of > 110/70 mmHg in children aged 2-5 years and > 115/76 mmHg in those aged 6-12 years and more than 128/82 mmHg in adolescents is considered abnormal and would require a referral to, and evaluation by a paediatrician.
Most adolescent and childhood hypertension, especially in infants and younger children, is due to secondary causes (See section on ‘Hypertension in Adults’). Adolescents, however, may have early onset primary hypertension.

Causes of hypertension in children and adolescents

The following are the causes of hypertension in children and adolescents

  1. Renal e.g. chronic pyelonephritis, hydronephrosis.
  2. Vascular e.g. coarctation of aorta, renal artery stenosis
  3. Endocrine e.g. phaeochromocytoma, Cushing’s syndrome, adrenal disorders
  4. Obesity
  5. Primary hypertension

Symptoms of hypertension in children and adolescents

  1. Chest pain
  2. Headaches
  3. Dyspnoea on exertion
  4. Excessive sweating
  5. Leg swelling
  6. Palpitations
  7. Haematuria
  8. Unconsciousness (hypertensive encephalopathy)

Signs of hypertension in children and adolescents

The signs of hypertension in children and adolescents include the following:

  1. BP > 110/70 mmHg in children aged 2-5 years
  2. >115/76 mmHg in children aged 6-12 years
  3. >128/82 mmHg in adolescents
  4. Signs pointing to a specific cause for secondary hypertension

Investigations

(See ‘Hypertension in Adults‘)

Treatment

Objectives

The treatment objectives of hypertension in children and adolescents include the following:

  1. To reduce blood pressure (BP) to a target of < 95th percentile for age, gender and height in the absence of end organ-damage (to < 90th percentile if end organ damage present)
  2. To prevent complications.
  3. To manage underlying secondary cause
  4. To encourage weight reduction in obese and overweight children

Non-pharmacological treatment

Therapeutic lifestyle changes

  • weight control
  • regular exercise
  • low fat intake
  • low sodium diet
  • regular fruit and vegetable intake

Pharmacological treatment

Evidence Rating: [A]

Angiotensin-converting enzyme (ACE) inhibitors

Enalapril, oral,
Children

  • 12-18 years; initially 2.5 mg daily (increased to max. 10 – 20 mg daily in 1-2 divided doses)
  • 1 month-12 years; initially 100 micrograms per kg daily (increased to max. 1 mg/kg daily in 1-2 divided doses)
  • Neonate: 10 microgram/kg daily (increased to max. 500 microgram/kg daily in 1-3 divided doses)

Diuretics

Bendroflumethiazide, oral,
Children:

  • 12-18 years; 2.5 mg daily
  • 2-12 years; 50-100 microgram/kg daily
  • 1 month-2 years; 50-100 microgram/kg daily

Beta blockers

Propranolol, oral,
Children

  • 12-18 years; 80-160 mg 12 hourly
  • 1 month-12 years; 250 μg -1 mg/kg 8 hourly
  • Neonate; 250 μg/kg 8 hourly

Or

Atenolol, oral,

  • Children 0.5-1 mg/kg daily (max. 2 mg/kg daily)

Calcium channel blockers

Nifedipine, oral,
Children

  • 12-18 years; 5-20 mg 8 hourly
  • 1 month-12 years; 200-300 microgram/kg 8 hourly (max. 100 mg daily)

Or

Amlodipine, oral,
Children

  • 12-18 years; 5-10 mg daily
  • 1 month-12 years; 100-400 microgram /kg daily (max. 10 mg daily)

Vasodilators

Hydralazine, oral,
Children

  • 12-18 years; 25 mg 12 hourly increased to usual max. 50 to 100 mg 12 hourly
  • 1 month-12 years; 250-500 microgram/kg 8-12 hourly increased as necessary to max. 7.5 mg/kg daily (not exceeding 200 mg)
  • Neonate: 250-500 microgram/kg 8-12 hourly increased as necessary to max. 2-3 mg/kg every 8 hours
    • IV, 250-500 microgram/kg diluted in 10 ml normal saline given over 20 minutes, then 100-200 microgram/kg 4-6 hourly (max 3 mg/kg in 24 hours)

Angiotensin-receptor blockers

Losartan, oral,
Children

  • Initial dose; 0.7 mg /kg daily (max. 50 mg)
  • Maintenance dose; 1.4 mg/kg daily (max. 100 mg)

Referral Criteria

Refer all cases of hypertension in children and adolescents to a specialist for investigation and further treatment.