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hypertension in adolescents & children

Staging: - > 130/80 stage 1 - > 140/90 stage 2 Etiology: - also see hypertension - endocrine - pheochromocytoma - hyperthyroidism - Cushing syndrome, glucocorticoid use - increased intracranial pressure - obstructive sleep apnea - systemic lupus erythematosus - renal artery stenosis - coarctation of the aorta [4] - obesity Pathology: - higher systolic blood pressure from infancy across the early life is associated with higher carotid intima-media thickness in young adulthood [9] - contributions to carotid intima-media thickness aremapproximately equal from systolic blood pressure in infancy, preschool childhood, childhood, adolescence, young adulthood into mid-adulthood [9] Clinical manifestations: - tachycardia: pheochromocytoma, hyperthyroidism - moon facies: Cushing syndrome glucocorticoid use - papilledema: increased intracranial pressure - adenotonsillar hypertrophy: obstructive sleep apnea - malar rash: systemic lupus erythematosus - renal bruit: renal artery stenosis - BP in upper > lower extremities: coarctation of the aorta Laboratory: - basic metabolic panel - serum glucose - renal function tests [1] Special laboratory: - ambulatory blood pressure monitoring for 24 hours to confirm diagnosis & periodically to monitor therapy [2] - home BP monitoring should not be used for diagnosis [3] - lower extremity blood pressure - rule out coarctation of the aorta [4] - funduscopy (retinal exam) [1] - sleep study not routinely recommended for obesity [4] Radiology: - echocardiography recommended prior to drug therapy [3] - renal ultrasonography [1] Complications: - men with blood pressure > 140/90 mm Hg at age 18 years have higher risk of cardiovascular events by 68 years of age [8] Management: - first line - healthy diet (low sodium, high potassium) [1], DASH diet [3] - regular exercise - weight reduction - monitor blood pressure, weight - antihypertensive agent if 1st line intervention inadequate - ACE inhibitor 1st line [1]

Specific

early onset hypertension with severe exacerbation in pregnancy

General

hypertension (HTN, high blood pressure, HBP)

References

  1. Ingelfinger JR The Child or Adolescent with Elevated Blood Pressure N Engl J Med 2014; 370:2316-2325. June 12, 2014 PMID: 25207779 http://www.nejm.org/doi/full/10.1056/NEJMcp1001120
  2. Rao G Diagnosis, epidemiology, and management of hypertension in children. Pediatrics 2016 Jul 12. Review. PMID: 27405770
  3. Stapleton FD AAP Updates Guidelines for Pediatric Hypertension. NEJM Journal Watch. Aug 21, 2017 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Flynn JT, Kaelber DC, Baker-Smith CM et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017 Aug 21 PMID: 28827377
  4. NEJM Knowledge+ Question of the Week. Hune 12, 2018 https://knowledgeplus.nejm.org/question-of-week/4893/
  5. Flynn JT, Kaelber DC, Baker-Smith CM et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017 Sep;140(3). pii: e20171904. PMID: 28827377
  6. Weaver DJ. Hypertension in children and adolescents. Pediatr Rev 2017 Aug; 38:369. PMID: 28765199
  7. Moyer VA et al. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics 2013 Nov; 132:907-914. PMID: 24101758 Free Article
  8. Rietz H et al. Blood pressure level in late adolescence and risk for cardiovascular events: A cohort study. Ann Intern Med 2023 Sep 26; [e-pub] PMID: 37748182 https://www.acpjournals.org/doi/10.7326/M23-0112
  9. Meng Y, Sharman JE, Koskinen JS et al Blood Pressure at Different Life Stages Over the Early Life Course and Intima-Media Thickness. JAMA Pediatr. Published online December 4, 2023 PMID: 38048127 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2812150