Pediatric Hypertension

By: Anthony Botte and Tyler Valente, PharmD Candidates c/o 2016

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Diseases which are prevalent within the pediatric population require distinct protocols for treatment accompanied by the utmost care and precision. Pediatric hypertension (HTN) is one disease state in particular that has come to the forefront of medical practice in the United States over the past decade. Reasons for this include an increase in the prevalence of cardiac abnormalities, improvements in diagnosing, and a rise in childhood obesity. It is estimated that 3% to 5% of the pediatric population is currently affected by this condition.¹

Children three years and older should have their blood pressures checked via auscultation at each visit to their healthcare provider and measured via sphygmomanometer if the readings appear elevated. Childhood HTN is diagnosed based on average systolic blood pressure and/or diastolic blood pressure readings that are greater than or equal to the 95th percentile on three or more consecutive office visits. An individual’s blood pressure percentile is calculated based on his/her sex, age, and height.²

Pediatric HTN causes immediate harm to a child, but also has implications on his/her health in the future. Critical concerns for treating pediatric HTN include avoidance of some non-specific symptoms such as headache, vertigo, nasal bleeding, nausea, and vomiting triggered by hypertensive urgency, and preventing target organ insufficiency. Among the long-term consequences of not treating pediatric hypertension are adult HTN, cardiovascular disease, and insulin resistance.^{2, 3}

      Non-pharmacologic treatments such as lifestyle modifications can be effective at lowering blood pressure and decreasing risks of cardiovascular disease. The Dietary Approach to Stop Hypertension (DASH) diet is commonly considered for pediatric patients (12 months of age and older) with HTN. DASH encourages a diet regimen that consists of fruits, vegetables, non-fat dairy products, fiber, and low amounts of daily sodium consumption. Besides dietary modifications, weight loss for overweight patients, as well as physical exercise for all patients, is recommended. A pediatric patient can stay active by walking, biking, playing sports, and completing household chores.^{4, 5}

Pharmacologic interventions appear to be the most effective forms of treating pediatric HTN. Since there is limited data regarding the long-term effects of antihypertensive drugs on children’s growth and development, clear-cut indications should be established before initiating therapy. These indications include symptomatic HTN, secondary HTN, established hypertensive target-organ damage, and failure of nonpharmacologic measures.² Since all classes of antihypertensive drugs have been shown to lower blood pressure in children, the physician’s judgment dictates which medication should be used to initiate therapy. No matter which class of medication is selected, treatment is initiated at the lowest recommended dose and titrated upward until optimal blood pressure is achieved. After the highest possible dose has been reached, or if the patient experiences adverse effects from the medication, a drug from another class is added onto the regimen. The most commonly prescribed anti-hypertensive drugs for pediatric patients fall into four main classes: Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Blockers, Calcium Channel Blockers, and Beta-Blockers. Among the four classes, Angiotensin-Converting Enzyme Inhibitors have the most evidence supporting their use in the pediatric population when treating HTN.⁶ Although diuretics are commonly used to treat pediatric HTN, no large studies have been performed to date.

Pharmacists can play a large role in the detection and treatment of pediatric HTN. They can record blood pressure, promote healthy lifestyles, collaborate with the physician to select the best course of treatment, and verify pediatric doses.⁵

 

SOURCES:

1. Redwine KM, Acosta AA, Poffenbarger T, et al. Development of hypertension in adolescents with prehypertension. J Pediatr. 2012;160:98-103.
2. 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;114:555-576.
3. Skrzypczyk P, Roszkowska-Blaim M, Daniel M. Pol Merkur Lekarski. 2013. Hypertensive crisis in children and adolescents. Dec;35(210):379-84. Review. Polish
4. Torrance B, McGuire KA, Lewanczuk R, McGavock J. Overweight, physical activity and high blood pressure in children: a review of the literature. Vasc Health Risk Manag. 2007;3:139-149
5. Hylick, Ericka V., “Pediatric Hypertension.” USPharmacist.com. U.S. Pharmacist, 19 Feb. 2014. Web. 24 June 2014. <http://www.uspharmacist.com/content/c/46726/>.
6. Meyers RS, Siu A. Pharmacotherapy review of chronic pediatric hypertension. Clin Ther. 2011;33:1331-1356.

[pubmed_related keyword1=”pediatric” keyword2=”hypertension” keyword3=”pressure”]