What is the appropriate disposition and workup for a pediatric patient with newly diagnosed hypertension?

From the Guidelines

The disposition and workup of a pediatric patient with newly identified hypertension should begin with confirmation of the diagnosis through repeated blood pressure measurements on at least three separate occasions, as recommended by the 2017 American Academy of Pediatrics clinical practice guideline 1. The diagnosis of hypertension in children is based on the blood pressure level that exceeds the 95th percentile on age-related blood pressure distribution curves.

• For children under 3 years, blood pressure measurement is not routine, but it should be measured if there is a history of neonatal complications, congenital heart disease, urinary/renal abnormality, solid-organ transplant, malignancy, drug prescription, or condition known to raise blood pressure or increase intracranial pressure, as stated in the expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents 1.
• For children between 3 to 11 years, annual blood pressure measurement is recommended, and if the blood pressure is ≥95th percentile, a basic work-up should be initiated, including urinalysis, complete blood count, electrolytes, blood urea nitrogen, creatinine, fasting glucose, lipid profile, and renal ultrasound.
• For children between 12 to 17 years, annual blood pressure measurement is also recommended, and if the blood pressure is ≥95th percentile, a thorough evaluation, including a complete history, physical examination, and laboratory testing, should be performed. Management depends on the severity of hypertension and presence of symptoms or target organ damage.
• For stage 1 hypertension without symptoms or target organ damage, lifestyle modifications, including weight management, increased physical activity, and dietary sodium restriction, should be initiated for 3-6 months before considering pharmacotherapy.
• For stage 2 hypertension or symptomatic hypertension, pharmacologic therapy should be started immediately, typically with ACE inhibitors, calcium channel blockers, or angiotensin receptor blockers. The goal is to reduce blood pressure to below the 90th percentile for age, sex, and height.
• Regular follow-up is essential to monitor blood pressure control, medication side effects, and target organ damage.
• Referral to a pediatric nephrologist or cardiologist is recommended for severe hypertension, suspected secondary hypertension, or when initial therapy is ineffective, as suggested by the 2017 AAP clinical practice guideline 1.

From the FDA Drug Label

Pediatric Patients 6 years of age and older with hypertension For pediatric patients with glomerular filtration rate > 30 mL/min/1.73m2, the recommended starting dose is 0. 07 mg per kg once daily (up to 5 mg total). Lisinopril tablets are not recommended in pediatric patients < 6 years or in pediatric patients with glomerular filtration rate < 30 mL/min/1.73m2

The disposition and work up of a pediatric patient with new hypertension should start with evaluating the patient's glomerular filtration rate.

• If the patient is 6 years of age or older and has a glomerular filtration rate > 30 mL/min/1.73m2, the recommended starting dose of lisinopril is 0.07 mg per kg once daily (up to 5 mg total) 2.
• If the patient is younger than 6 years or has a glomerular filtration rate < 30 mL/min/1.73m2, lisinopril is not recommended 2. In these cases, alternative treatments or further evaluation should be considered. Key considerations for pediatric patients with hypertension include:
• Evaluating glomerular filtration rate
• Assessing the need for alternative treatments or further evaluation if lisinopril is not recommended.

From the Research

Disposition and Workup of Pediatric Patient with New Hypertension

• The approach to a pediatric patient with new hypertension involves evaluation and management by a pediatric nephrologist, as childhood hypertension can track into adulthood and increase the risk of cardiovascular disease and renal disease progression 3.
• The etiology of hypertension in children and adolescents is varied, but primary hypertension is increasing in prevalence, making early identification and management crucial to prevent hypertensive end-organ disease 4.

Diagnostic Evaluation

• The 2017 American Academy of Pediatrics Clinical Practice Guidelines for the Screening and Management of High Blood Pressure in Children and Adolescents provide a comprehensive reference for evaluating and managing hypertension in this age group 4.
• Renal ultrasound and Doppler sonography can be used to evaluate morphological changes in kidney structure and patterns of renal and extrarenal vascularization, and can help diagnose early renal damage, acute or chronic nephropathies, and nephrovascular disease 5.

Laboratory Tests

• Urinary sodium and potassium measurements can be used to assess sodium intake and correlate with blood pressure, but the accuracy of spot urinary measurements compared to 24-hour urine collections is debated 6, 7.
• The relationship between urinary sodium excretion and blood pressure can vary depending on the method used to evaluate the completeness of 24-hour urine collections 7.

Management

• Early diagnosis and management of pediatric hypertension are essential to prevent long-term cardiovascular and renal complications, and a comprehensive approach involving lifestyle modifications and potential pharmacological interventions may be necessary 3, 4.