Paediatric hypertension

What?

A twelve-year-old girl presents to the Emergency Department (ED) having had a fall at school, she is diagnosed with a sprain to her left wrist and minor head injury (contusion to her forehead). During the episode of care her physiological parameters are measured on a number of occasions and an incidental finding of persistently raised blood pressure is discovered (observations shown in table 1).

She is noted to be obese, weighing = 70Kg, height = 1.6 Metres, and Body Mass Index (BMI) = 27.3.

Table 1 – Paediatric Early Warning Score (PEWS) 5-12 years

PEWS
Respiratory rate 19 bpm 0
Respiratory distress nil 0
Oxygen Saturations (SaO2) 100% (on air) 0
Heart rate 88 bpm 0
Blood pressure 130/87mmHg 2
Capillary Refill Time (CRT) <3 seconds 0
Total = 2

So What?

In childhood, hypertension is increasing in both rate and prevalence (Luma & Spiotta 2006). Perhaps, not least because of the associated increase in childhood obesity and the growing awareness of this condition.

Hypertension in childhood can be defined as an average systolic and/or diastolic blood pressure ≥95th percentile for gender, age and height on three or more separate occasions (Faulkner & Daniels 2004, Luma & Spiotta 2006).

Table 2. Classification of childhood blood pressure (adapted from Falkner & Daniels 2006).

Classification Centile
Normotension =50th – <90th
Prehypertension ≥90th  –  <95th
Stage 1 Hypertension ≥95th
Stage 2 Hypertension ≈12mmHg or more above 95th

Primary (or essential) hypertension, is more commonly found in adolescents (85-95% of cases) and often includes a positive family history of the condition or related cardiovascular disease (Bridger 2009). Additional associated risk factors include a history of metabolic syndrome or symptoms of sleep disorder e.g. obstructive sleep apnoea (Bridger, 2009). Obesity is an important additional feature, where high BMI has shown a strong association between increasing weight gain and earlier expression of primary hypertension (Falkner & Daniels 2006).

For the majority of pre-adolescent children (10 years or less), a presentation of hypertension is generally secondary to underlying renal parenchymal disease (60-70%), with other causes including endocrine disease (e.g. diabetes) and drug therapies or substance abuse (Luma & Spiotta 2006).

Experience from adult populations demonstrates that poorly controlled blood pressure can lead to coronary heart disease (Bridger 2009). Where children presenting with evidence of end organ damage in the form of left ventricular hypertrophy (present in 41% of cases of childhood hypertension), pharmacological intervention may be required (Luma & Spiotta 2006). Likewise, exclusion of aortic coarctation should be undertaken by assessment and comparison of upper and lower limb blood pressure recordings, along with examination of the retina.

Although physical examination may be grossly normal, children with severe cases of hypertension are at increased risk of hypertensive encephalopathy, seizure, cerebrovascular accident and congestive heart failure.

Table 3 – Symptoms and potential etiologies of hypertension (adapted from Luma & Spiotta 2006)

Symptom Etiology
Chest pain

Palpitations

Dyspnoea (on exertion)

Oedema

Cardiovascular disease
Diaphoresis (abnormal)

Failure to thrive

Weight or appetite changes

Heat or cold intolerance

Endocrinology
Enuresis

Haematuria

Recurrent UTI

Neonatal hypovolaemia/shock

Umbilical artery catherisation

Renovascular disease/renal scarring
Headaches

Snoring or sleep apnoea

Primary hypertension
Joint pain or swelling

Myalgia

Recurrent rash

Rheumatological disorders

Now What?

The Department of Health’s (2013-2016) Public Health Outcomes Framework provides an outline for objectives which focus on health improvement. These objectives include aiding healthy lifestyles, healthy choices and reducing health inequalities, with the aim of preventing serious illness and premature death.

Routine screening as part of attendance to emergency services or other healthcare facilities including general practice should aid early recognition of the disease in this population (Falkner & Daniels 2006). Identifying children and young people at greater risk, particularly those suspected of high BMI (Luma & Spiotta 2006), and initiating what can be uncomfortable conversations for the less experienced practitioner about weight, diet, exercise, and lifestyle choices, should be undertaken at every opportunity.

Follow-up for continued health assessment and blood pressure monitoring should be arranged with the patients General Practitioner (GP). Where cases are associated with obesity, referral for dietetic support should be considered, as a reduction in weight (and support to eat healthily) are lifestyle changes required to reduce the likelihood of a requirement for drug therapy. Other lifestyle changes should be recommended including an increase in exercise (NICE 2011). It should be remembered however that for any lifestyle change to be effective, particularly involving children and young people, the influence of the family dynamic should not be underestimated.

Pharmacological intervention is required for those children and young people who present with symptomatic hypertension, evidence of end organ damage and where there has been no reduction in blood pressure in response to lifestyle changes.

 

Shiela Pantrini

 

References

Bridger, T. (2009) Childhood Obesity and Cardiovascular Disease. Paediatric Child Health 14(3):177-82.

Department of Health (2013-2016) Public Health Outcomes Framework. [on-line] https://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency (accessed 3/10/16).

Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.

Falkner B, & Daniels, S.R. (2004) Summary of the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Hypertension 44(4):387-8.

Luma, G.B. & Spiotta, R.T. (2006) Hypertension in children and adolescents. American Family Physician 73(9):1558-68.

National Institute for Clinical Excellence (2011) Physical activity guidelines for children and young people aged 5-18 years. [on-line] https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213739/dh_128144.pdf (accessed 3/10/16).

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