03/19/2010 Recognizing and managing the hypertensive child

Resident: Hencler
Date: 03/19/2010
Article title: Recognizing and managing the hypertensive child
Author: Flynn, MD, MS
Year: 2003
Major topic: Hypertension (HT)

Key points in the article discussion:
Awareness of childhood HT among the med community and the general public has increase. As a result, a greater number of children with HT have come to med attention. It is important to know the child’s height percentile b/f determining if BP is normal. Overall, most childhood HT is secondary to an underlying disorder, which in most cases, is renal disease. Today, obesity is a common cause of childhood HT. HT in children can also have a genetic basis although the role of genetic mutations in the pathophysiology of HT remains unknown. To obtain an accurate BP reading the bladder of the cuff should encircle 80%-100% of the circumference of the upper arm and it’s width should be 40%. The child should be seated quietly for at least 5 mins b/f BP reading and the arm should be supported at heart level. Once a child is found to have HP and thorough H & P, med and family hx should be conducted. Look for underlying symptoms of another disorder such as renal disease. B/c many children w/ HT have an otherwise normal physical exam, laboratory testing (full blood work up) is very important. Also assess the presence of hypertensive target-organ damage such as left vent hypertrophy or hypertensive retinopathy. Endocardiogrphy may also be required. Management is multifaceted including a comprehensive approach incorporating patient and family education, nonpharm measures, and anti-HT meds as well as monitoring med side effects and tx response. Encourage wieghtloss through diet modification and exercise. When prescribing anti-HT for children, the “stepped care” approach has been recommended. The dose of the initial agent chosen is increased until either, the BP is controlled, the max dose is reached, or side effects appear, then if BP not controlled a second agent is from a different class is added. Drug choice is up to doctor. Many pediatric authorities recommend against using diuretics as first line agents. The optimal BP goal of tx in a child w/ HT remains unknown. The lack of HT-related endpoints perhaps explains the lack of consensus on tx goals for HT children.

Summary:
Increased awareness of HT in children, coupled with an increase in risk factors for HT such as obesity, means that many more children will be found to have elevated BP.
Careful measurement of BP and evaluation of children with sustained HT should ID those for tx
Although outcome data for childhood HT does not yet exist, there has been a rapid increase in information regarding anti-HT drugs, making children easier to tx.
A combo of pharm and non-pharm measure will result in satisfactory control of childhood HT while allowing quality of life.

Assessment of article:
Useful information and very pertinent to anyone tx children.