Hypertension in children and adolescents

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Overview.

  • The systolic and/or diastolic blood pressure of people under the age of 18 is higher than that of more than 95% of people of the same age and gender.
  • Most patients have no symptoms in the early stages of the disease, but some may experience headache, dizziness, palpitations, and fatigue.
  • Nearly half of the patients can develop adult hypertension, and those with good blood pressure control can survive for a long time.
  • The disease does not usually resolve spontaneously, but some children’s blood pressure may return to normal with weight loss and improved stress.

    • Definition

  • Because normal blood pressure varies by age and gender in children and adolescents, hypertension in children and adolescents is defined as a condition in which a teenager or young adult (defined as a person younger than 18 years of age) has a systolic and/or diastolic blood pressure that is higher than that of more than 95% of people of the same age and gender.
  • It is usually recommended to measure blood pressure from the age of 3 years, and the standard blood pressure values can be specifically referred to the blood pressure standards corresponding to each year of age and height of children aged 3 to 17 years in China, and there are some differences in the standard blood pressure values for children and adolescents of different ages, genders, and heights.
  • Specific blood pressure normal value comparison is cumbersome, the current clinical more simplified version of children and adolescents hypertension screening standards, the presence of abnormalities and then calculated according to the specific blood pressure reference standard [1-3].
    • Gender Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)Male 100+2*age 65+ageMale

    100+2*age

    65+age

    Female 100+1.5*age 65+age

    Female

    100+1.5*age

    65+age

    Typing

  • The disease can be categorized into the following two types according to its etiology.
  • Primary hypertension in children and adolescents

    • Primary hypertension refers to elevated blood pressure due to a combination of multiple risk factors under genetic susceptibility and is diagnosed after excluding the possibility of secondary hypertension.

    Secondary hypertension in children and adolescents

  • Secondary hypertension is defined as an elevation of blood pressure secondary to a condition that is clearly due to a disease, which may be due to renal artery stenosis, glomerulonephritis, aortitis, aortic constriction, primary aldosteronism, cerebral hemorrhage, and cerebral edema.
  • Morbidity
  • According to the 2010 National Student Physical Fitness Survey, the prevalence of hypertension among primary and secondary school students in China was 14.5%, with boys having a higher prevalence than girls (16.1% vs. 12.9%).

    • The prevalence of hypertension in children is 4% to 5%, obtained through multi-temporal blood pressure measurements.

    Etiology

    Causes

    Hypertension is categorized into primary and secondary hypertension, with primary hypertension referring to elevated blood pressure caused by a combination of risk factors in the context of genetic predisposition, and secondary hypertension referring to elevated blood pressure secondary to a condition that is clearly due to a disease.

    Primary hypertension in children and adolescents may be due to genetic factors, obesity, and the mother’s pregnancy status.

    Secondary hypertension in children and adolescents may be due to renal artery stenosis, glomerulonephritis, aortitis, aortic constriction, primary aldosteronism, cerebral hemorrhage, and cerebral edema.

    Pathogenesis

  • The pathogenesis of primary hypertension is a multifactorial neurohumoral-endocrine abnormality that leads to abnormal cardiac or vascular regulation, which in turn leads to an increase in blood pressure; whereas the pathogenesis of secondary hypertension is different depending on the primary disease, e.g., glomerulonephritis can lead to sodium and water retention, and renal artery stenosis can lead to activation of the RAAS system, etc. [2-4].
  • Symptoms

    • Main symptoms

  • Most patients do not have any symptoms in the early stage of elevated blood pressure. With the continuous elevation of blood pressure, headache, dizziness, palpitation, and fatigue may occur.
  • Complications

    • Left ventricular hypertrophy

  • Left ventricular hypertrophy is the most common form of target organ damage. Chronic poor blood pressure control can further lead to heart enlargement and heart failure.
  • Early left ventricular hypertrophy may have no clinical manifestations, and in late stage of insufficiency, patients may experience symptoms of dyspnea, chest tightness, and fatigue.

    • Cerebral hemorrhage

    Some of the people with rapid increase of blood pressure may cause cerebral blood vessel rupture and cerebral hemorrhage.

    Patients may have headache, hemiplegia and loss of consciousness.

    Kidney Insufficiency

    Prolonged poor control of blood pressure can lead to glomerular interstitial damage, and prolonged condition can lead to renal failure.

    Patients may present with oliguria, anuria, nausea, fatigue, etc. [5-6].

    Consultation

    Department of Medicine

    Cardiovascular medicine

    If the resting blood pressure is repeatedly higher than the 95% quartile for the same age group, it is advisable to consult a cardiovascular physician.

    Emergency Medicine

    If you experience a sudden increase in blood pressure, headache, chest pain, or oliguria, we recommend that you consult the Emergency Department.

    Preparation

    Consultation: registration, preparation of documents, common problems

  • Consultation Tips
  • Sudden headache, dizziness for a long time without obvious relief, fainting, suddenly fall to the ground and do not wake up, sudden numbness of the limbs or speech impediment, etc., it is recommended to go to the hospital immediately, or call 120 emergency.
  • During the process of calling the emergency number, you should accurately describe the location, the current state of the patient and other key information, and listen to the instructions of the first-aiders.
    • Medical Preparation Checklist
  • Symptom Checklist
  • Especially focus on the time of onset of symptoms, special manifestations, etc.
    • Are there symptoms of dizziness, headache, palpitations, weakness? When do they usually occur? How long do they last?

    When did the dizziness or headache occur, how long did it last, and how was it relieved?

  • Is there any combination of antecedent symptoms, duration of syncope, any twitching of limbs, etc.?
  • Medical History Checklist
  • Is there any family history of this disease and is there a relative in the family with hypertension? If so, what was the age of onset?
  • Have you ever had a syncope? If so, were there any specific symptoms prior to the syncope?
  • Checklist
    • Test results for the last six months, which can be brought to the doctor’s office

    Results of recent blood pressure measurements

  • Recent electrocardiograms (both routine and ambulatory)
  • Echocardiogram

    • Funduscopic examination results

    Kidney function test results

    Medication list

  • Medication use in the last 3 months, if available in boxes or packages, carry with you to the doctor’s office
  • Calcium channel blockers: amlodipine, nifedipine, etc;

    • ACEI/ARB drugs: Benadryl, valsartan, etc.

    Diagnosis
  • Diagnosis is based on
  • Medical history
    • The child may have a family history of hypertension and the mother may have a history of gestational hypertension.
  • The child may have a history of obesity.
  • Clinical manifestations
  • Symptoms

    • Some patients may be asymptomatic.

    Some patients may have dizziness, headache, palpitations, fatigue and other symptoms.
  • Physical signs
  • Irregular pulse rhythm may be present.
    • Measurement of blood pressure is elevated.
  • Cardiac auscultation may show a murmur, or a diminished sound of the heartbeat.
  • Laboratory Tests

    • BNP (cardiac natriuretic peptide)

    Check for the presence and severity of heart failure.
  • Poorly controlled blood pressure over a long period of time may progress to heart failure and is used to establish the diagnosis and determine the severity of the condition.
  • Blood biochemistry
    • To check liver function, kidney function, electrolytes, blood glucose, cholesterol, triglycerides.
  • Usually used to determine the patient’s baseline and general condition.
  • Imaging

    • Echocardiography

  • To check the structure and function of the heart.
  • It can clarify whether there is ventricular hypertrophy, the degree of ventricular hypertrophy, and whether there is heart failure.

    • CT scan of the brain

  • CT scanning can detect cerebral infarction foci, cerebral hemorrhage foci, and so on.
  • It can clarify the location, scope, and severity of the lesion and provide information for further examination or formulation of a treatment plan.

    • Electrocardiogram

  • It can check the rhythm, structure and function of the heart.
  • It can clarify the rhythm of the heart, the presence of left ventricular hypertrophy, myocardial ischemia and other conditions.
  • Funduscopic examination
  • Funduscopic examination may reveal arteriosclerosis, hemorrhage, and other signs of vascular involvement of the fundus.

    • Precautions: Dilated pupils may be required and should be performed under the supervision of a physician.

    Diagnostic criteria, grading and staging

    Individual diagnosis of hypertension in children is based on three measurements taken on non-simultaneous days, with two measurements taken more than 2 weeks apart. Hypertension can only be diagnosed if the systolic and/or diastolic blood pressure of all three measurements is higher than 95% of the blood pressure values of the population of the same age and sex.

    A blood pressure that is higher than 90% but lower than 95% of the population of the same age and sex is called normal high blood pressure.

    Grade 1 hypertension is defined as blood pressure within the range of +5 mmHg above 95% but below 99% of the population of the same sex.

    Grade 2 hypertension is defined as a blood pressure that is higher than 99% of the population of the same age and sex + 5 mmHg [4].

    Differential diagnosis

    White coat hypertension

    Similarities: both may present with elevated in-office blood pressure.

  • Differences: patients with white coat hypertension have home self-measured blood pressure or 24-hour ambulatory blood pressure in the normal range.
  • Treatment
  • Aim of treatment: Control blood pressure and reduce the degree of target organ damage.

    • Treatment principle: patients with secondary hypertension actively treat the primary disease, patients with primary hypertension on the basis of lifestyle control combined with drug therapy if necessary.

    Secondary hypertension

    The core treatment of secondary hypertension is to actively control the primary disease.

    For patients with renal artery stenosis, stent implantation or balloon dilatation can be performed.

    For aortic stenosis, surgery or endoluminal intervention can be performed.

    For patients with primary aldosteronism, partial adrenalectomy can be performed if the patient meets the surgical indications.

    Primary hypertension

    Lifestyle improvement

    Obese patients need to lose weight.

    Drug treatment

    Pharmacologic therapy is indicated when lifestyle modification is not effective.

    Angiotensin converting enzyme inhibitors (ACEI)

    One of the most commonly used antihypertensive medications for children, the only approved medication for children is captopril.

    Diuretics

    Approved medications for children are aminopterin, chlorthalidone, hydrochlorothiazide, and furosemide.

    Dihydropyridine Calcium Channel Blockers

    Approved medications for children include amlodipine.

  • Adrenoceptor blockers
  • Approved medications for children are propranolol, atenolol, and prazosin.
  • Prognosis
  • Cure

    • The vast majority of adolescents and children with hypertension can achieve blood pressure control with aggressive treatment and have a good prognosis, but if left untreated, about 40% of patients will carry on into adulthood and require lifelong treatment.

    Hazards

    Delayed progression of the disease can lead to ventricular hypertrophy, heart enlargement, and heart failure.

  • A rapid rise in blood pressure can lead to acute cerebrovascular events such as cerebral hemorrhage.
  • Long-term poor control of the disease can lead to atherosclerosis of the fundus of the eye and hemorrhage of the fundus of the eye.
  • Chronic poor control of the disease can lead to renal insufficiency.

    • Daily

  • Daily management
  • Daily management

    • Go to bed early and get up early, avoid staying up late.

  • Avoid over-exertion and moderate exercise under the guidance of physician.
  • Avoid coffee, strong tea, and alcoholic beverages.

    • Dietary management

    Avoid overeating, try to eat small and frequent meals, and try to eat soft and easy to digest food.

    Minimize the intake of high salt and high fat foods, such as salted vegetables, fatty meat, fried foods, etc.

    Emotion Management

    Avoid bad emotions such as tension, anxiety, anger and depression.

  • Keep a good mindset and face life positively.
  • Weight management

    • Obese children need to formulate a weight loss program under the guidance of physicians, and blood pressure is expected to be controlled normally after successful weight loss.

  • Disease monitoring
  • If there is dizziness, headache, chest pain, etc., which cannot be relieved for a long time, you need to go to the emergency room as soon as possible. If there is sudden loss of consciousness, fainting, etc., you need to go to the emergency room immediately.
  • Follow-up and review
  • Regular monitoring of blood pressure is a very critical tool. Adolescents with prehypertension should have their blood pressure levels assessed every 6 months for better monitoring of blood pressure and intensification of non-pharmacological treatment. Patients with grade 1 hypertension can have their blood pressure assessed every 3 to 4 months when their blood pressure is well controlled. For patients with grade 2 hypertension, blood pressure should be assessed every 2 to 3 weeks at first, and then every 3 to 4 months when their blood pressure stabilizes.
  • For patients with progressive disease, blood pressure monitoring, 24-hour ambulatory blood pressure monitoring, and transthoracic echocardiography can be performed in a timely manner. This disease requires regular review of ambulatory blood pressure, echocardiography, electrocardiogram, as well as blood glucose, blood lipids, liver and kidney functions, etc., and adjustments to the treatment program should not be made without a long-term review of the disease.
  • Prevention
  • Improve diet, ensure balanced nutrition, avoid overeating, and maintain appropriate body weight.
  • Avoid diets high in salt, fat, sugar and calories, and try to avoid pickled, smoked, barbecued and fried foods. Avoid stimulating foods such as chili peppers, coffee and strong tea.