How is hypertension managed in a pediatric patient?

Hypertension Management in a 4-Year-Old Female

Blood Pressure Classification

For this 4-year-old with height 107cm, blood pressure should be measured at each routine visit and compared to age-, sex-, and height-specific percentile tables to determine if hypertension is present. 1

• Elevated BP is defined as systolic or diastolic BP ≥90th percentile for age, sex, and height 1
• Stage 1 hypertension is BP ≥95th percentile but <95th percentile + 12 mmHg 1
• Stage 2 hypertension is BP ≥95th percentile + 12 mmHg 1
• Hypertension must be confirmed on three separate occasions before diagnosis 1

Initial Management Approach

Lifestyle Modifications First

All children with elevated BP or hypertension should begin with lifestyle modifications, including weight management if overweight, dietary sodium restriction, increased physical activity, and a DASH-style eating pattern emphasizing fruits and vegetables. 1

• Dietary modifications should include sodium restriction and increased consumption of fruits and vegetables 1
• Regular physical activity should be encouraged 1, 2
• If the child is overweight (≥85th percentile), weight management through a family-centered behavioral approach is essential 1
• Follow-up visits should occur every 3-6 months when using lifestyle modifications alone to reinforce adherence and reassess need for medication 1

Pharmacologic Therapy Indications

Pharmacologic treatment should be initiated in children with Stage 2 hypertension, symptomatic hypertension, left ventricular hypertrophy on echocardiography, or Stage 1 hypertension that fails to respond to 3-6 months of lifestyle modifications. 1

First-Line Medication Choices

The preferred initial antihypertensive agents are ACE inhibitors, ARBs, long-acting calcium channel blockers, or thiazide diuretics. 1

• ACE inhibitors or ARBs are specifically recommended as first-line therapy in children with chronic kidney disease, proteinuria, or diabetes mellitus 1
• For African American children, consider a higher initial ACE inhibitor dose or alternatively start with a thiazide diuretic or long-acting calcium channel blocker, as response to ACE inhibitors may be less robust 1
• β-blockers are NOT recommended as initial treatment due to expanded adverse effect profile and lack of association with improved outcomes compared to other agents 1

Critical Contraindication

ACE inhibitors and ARBs are absolutely contraindicated in pregnancy and females of childbearing potential due to fetal injury and death risk; alternative medications (calcium channel blockers, β-blockers) should be considered in adolescent females. 1

Medication Titration and Monitoring

Patients should be seen every 4-6 weeks for dose adjustments until BP is normalized, with medication titrated every 2-4 weeks using home BP measurements. 1

• If BP is not controlled with a single agent at maximal dose, add a second agent from a different class 1
• After BP control is achieved, follow-up visits can be extended to every 3-4 months 1
• Home BP monitoring should be used to assess treatment effectiveness between visits 1
• Laboratory monitoring (electrolytes if on diuretics, renal function) should be performed at each follow-up visit 1

Evaluation for Secondary Causes

Before initiating pharmacologic therapy, evaluate for secondary causes of hypertension, particularly in young children, including renal disease, coarctation of the aorta, and endocrine disorders. 1

• Obtain urinalysis and renal function tests 1
• Consider echocardiography to assess for left ventricular hypertrophy and coarctation 1
• Evaluate for target organ damage before starting treatment 1

Treatment Goals

The goal of treatment is to achieve BP consistently below the 90th percentile for age, sex, and height. 1

• In children with chronic kidney disease or diabetes, more aggressive BP targets may be warranted 1
• Ambulatory BP monitoring (ABPM) may be used to assess treatment effectiveness, especially when clinic or home measurements suggest insufficient response 1

Common Pitfalls to Avoid

• Do not diagnose hypertension based on a single elevated reading; confirm on three separate days 1
• Do not use β-blockers as first-line therapy 1
• Do not prescribe ACE inhibitors or ARBs to adolescent females without reproductive counseling 1
• Do not delay evaluation for secondary causes in young children with significant hypertension 1