Accurately measure the blood pressure (BP) in all pediatric patients older than age 3 and in youngerhigh-risk patients
Accurately measure the blood pressure (BP) in all pediatric patients older than age 3 and in youngerhigh-risk patients: Excerpt from Avoiding Common Pediatric Errors
Author:
Jennifer Maniscalco, MD
What to Do - Gather Appropriate Data
Hypertension during childhood is not rare, with an estimated prevalence
ranging from 1% to 5.8%. Children with hypertension may develop early
abnormalities in target organs systems, even in the absence of signs and
symptoms. Furthermore, childhood hypertension is a strong risk factor for
adult hypertension. An aggressive surveillance system to detect hypertension in children can lead to prompt diagnosis and management, prevention
of target organ damage, and a reduced risk of adult hypertension. Recent
guidelines suggest that all children older than 3 years should have their BP
checked. Younger children should have their BP checked if risk factors for
hypertension are present (Table 138.1 ).
Hypertension in the pediatric population is defined as an average systolic blood pressure (SBP) or diastolic blood pressure (DBP) >=95% for age,
gender, and height, measured on at least three separate occasions. Appropriate technique in BP measurement is required to diagnose hypertension
accurately.Auscultationusingmercurysphygmomanometryisthegoldstandard, but many oscillometric devices have been validated for use in children.
Regardless of the device employed, the correct cuff size is essential for the
accurate measurement of BP. The width of the cuff bladder should be approximately 40% of the arm circumference measured at the midpoint of the
upper arm. The length of the cuff bladder should be 80% to 100% of the
arm circumference.
Hypertension in children can be classified as primary or secondary.
Primary hypertension, also called essential hypertension, does not have an
identifiable cause, but rather results from a combination of genetic and environmental factors. It occurs more commonly in adolescents than younger
children, and it is associated with overweight, obesity, and other cardiovascular risk factors. Individuals with primary hypertension are often asymptomatic and without evidence of target organ damage at presentation.
Secondary hypertension is more common in younger children and results from an underlying disease process. At presentation, these children are
more likely to have dramatic elevations of BP, symptoms of hypertension,
and evidence of target organ damage. The most common cause of secondary
hypertension is renal disease. Renal parenchymal disease is more common
than renovascular disease. Other causes of secondary hypertension include
cardiac diseases such as coarctation of the aorta, medications, and poorly
controlled pain. Primary endocrine disorders are rare and include hyperthyroidism, Cushing disease, and endocrine tumors such aspheochromocytoma
and neuroblastoma. Table 138.2 provides the common causes of hypertension by age group.
Table 138.1 Conditions Under Which the Child Younger than Age 3 Should Have their Blood Pressure Checked
• History of prematurity, very low birth weight, umbilical artery catheter placement, or other neonatal condition requiring intensive care
• Congenital heart disease
• Recurrent urinary tract infections, hematuria, or proteinuria
• Known renal disease or urologic malformation
• Family history of congenital renal disease
• Solid-organ transplant
• Malignancy or bone marrow transplant
• Treatment with drugs known to raise blood pressure
• Other systemic illnesses associated with hypertension
• Evidence of elevated intracranial pressure
Adapted from National High Blood Pressure Education Program Working Group on
High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis,
evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics.
2004;114(2 Suppl):555–576.
The evaluation of a child with hypertension begins with a thorough history and physical exam. The focus should be on the signs and symptoms of
diseases thatcausehypertensionaswell ascomorbidconditionsandevidence
of target organ damage. For older children and adolescents, family history
should focus on hypertension and its comorbid conditions. The social history should address diet, physical activity, smoking, and recreational drug
use. Laboratory evaluation of children with hypertension should include
complete blood count, chemistries, blood urea nitrogen, creatinine, complete urinalysis, and urine culture. A renal ultrasound should be obtained.
Specialized tests such as renin, steroid and catecholamine levels, and renovascular imaging may be obtained as the clinical situation dictates. Evidence
of target organ damage should be documented. Ophthalmologic consultation may reveal retinal changes, and echocardiography may reveal left ventricular hypertrophy. Comorbid conditions, such as dyslipidemia, glucose
intolerance, and hyperuricemia, should be sought in children who are overweight or who have essential hypertension.
Suggested Readings
Bartosh SM, Aronson AJ. Childhood hypertension. An update on etiology, diagnosis, and
treatment. Pediatr Clin North Am. 1999;46:235–252.
National High Blood Pressure Education Program Working Group on High Blood Pressure in
Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment
of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl):555–576.
Varda NM, Gregoric A. A diagnostic approach for the child with hypertension. Pediatr Nephrol.
2005;20:499–506.
Pictures
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Hypertension
More Medical Textbooks Online about Hypertension
Review other book chapters online related to Hypertension:
Medical Books Excerpts
- Hypertension
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Hypertension
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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