In children under 10, high BP is usually secondary to an underlying disease or condition. Primary hypertension increasingly recognised in older, obese children.
Do repeated measurements, ideally automated home BP monitoring, before diagnosing hypertension. Check manually as well as with automated device. Beware “white coat effect”, even if not clearly anxious.
Use appropriate cuff size – cuff should cover at least 75% of the upper arm from the acromion to the olecranon (should be sufficient space at the antecubital fossa to apply stethoscope!) . An inappropriately small cuff will overestimate BP.
Long list of causes, so follow the clues.
- Cardiac – coarctation of aorta.
- Renal – chronic pyelonephritis, dysplastic, glomerulonephritis, Acute kidney injury, polycystic kidney disease, renal artery stenosis or renal vein thrombosis etc
- Intracranial hypertension!
- Endocrine – hyperthyroidism, phaeochromocytoma, neuroblastoma, congenital adrenal hyperplasia
- Drugs, esp for ADHD, depression, immunosuppression
Family history important, of course.
Examination
So needs thorough history and examination, including:
- Fundi
- Bruits, radiofemoral delay
- Neck for goitre
Complications
Consider then end organ effects –
- Proteinuria, high creatinine
- Retinopathy
- Left ventricular hypertrophy, cardiac failure
- Abnormal tone and reflexes, cranial nerve deficits if severe
Management
Depends on how high, whether other risk factors (diabetes, chronic kidney disease), symptoms and evidence of end organ damage.
Initially low salt diet, weight loss (if obese). Remember other morbidities related to obesity.
Acute hypertension might need frusomide and/or nifedipine.
Long term treatment is only going to be started if no improvement with lifestyle measures. Target BP depends on risk factors, as above.
[2016 European Society for Hypertension guidelines]