pediatrics
Hypertension in Children
Treatment of Hypertension in Children
Weight reduction Dietary modification (salt and calorie reduction) Exercise Sometimes drug treatment Treatment of hypertension in children includes a combination of weight reduction, diet, exercise, and sometimes drug treatment depending on the stage of hypertension. Children with stage 2 hypertension, or stage 1 hypertension with symptoms, evidence of end-organ damage, diabetes, or renal disease should be referred to a specialist to begin a more rapid and correct therapy. Treatment goalsare typically a BP of < 90th percentile or, in older children, < 130/80, whichever is lower; some centers have a treatment goal of < 120/80. For children with renal disease, the goal is a mean 24-hour BP below the 50th percentile. Lifestyle changesthat can help lower BP, including dietary modification and exercise, are started in all children with elevated BP. The keys to weight reduction in childhood are healthy eating habits and increased physical activity. A diet higher in fruits, vegetables, legumes, and low-fat dairy products and lower in salt, such as the DASH (Dietary Approaches to Stop Hypertension) diet, has been associated with lower BP. Dietary changes also should include a calorie limit based on activity level, age, and sex. Salt intake should be < 2300 mg/day in children over 13 years of age and < 2 to 3 mEq/kg/day in younger children. Children ages 6 to 17 years should be doing 30 to 60 minutes of moderate to vigorous physical activity each day or at least 3 to 5 days a week. Younger children should be physically active throughout the day. Drug treatment of hypertension in children is begun immediately in certain children and later in others if a trial of lifestyle changes fails to control BP. Immediate drug treatmentis typically started (along with lifestyle changes) for children with Symptomatic hypertension at any stage or level Stage 1 hypertension with any evidence of end-organ dysfunction or damage Stage 2 hypertension even with an obvious, modifiable risk factor (eg, obesity), which should be addressed while BP is being controlled Any stage of hypertension if they have chronic kidney disease, diabetes, or cardiac disease In children with high normal or borderline hypertension or stage 1 hypertension without symptoms or end-organ dysfunction, lifestyle changes are initiated, and if these do not sufficiently lower BP within about 6 months, drug treatment will be necessary. Generally, drug treatment should begin with a single drug at the low end of its dosing range and increased every 1 to 4 weeks until BP is controlled, the upper end of the dosing range is approached, or adverse effects develop that affect the use of the drug. At that point, if the BP goal has not been attained, a second drug can be added and titrated as with the initial drug. Classes of oral drugs used to treat hypertension include Adrenergic Modifiers (beta- and alpha-antagonist, alpha-2-agonist, beta-blocker) Angiotensin-Converting Enzyme (ACE) Inhibitors None Angiotensin II Receptor Blockers (ARBs) None Calcium Channel Blockers (CCBs) None Thiazide Diuretics None Vasodilators None For a more detailed discussion of each class and its specific drugs, see Drugs for Hypertension in Children . Oral therapyfor persistent hypertension in children should generally begin with an angiotensin-converting enzyme (ACE) inhibitor or a calcium channel blocker (CCB). (ARBs are equally effective and do not cause a cough, but there are more data in children on the use of ACE inhibitors.) Both classes of drugs can be given as a single daily dose and seem to be equally effective. ACE inhibitors should be used in patients with chronic kidney disease or diabetes because these drugs may also protect the kidneys. CCBs should be used in menstruating girls if there is risk of pregnancy because ACE inhibitors and ARBs have significant effects on a fetus. CCBs also have no significant effect on blood chemistries. Thiazide diuretics have been used as initial treatment, but salt intake in adolescents is usually so high that they are rarely effective. If initial therapy with a single drug does not achieve the target BP, a second drug should be added. If the first drug is an ACE inhibitor or ARB, thiazide diuretics have proved to work well as second drugs, but a CCB could be added instead. If the first drug is a CCB, an ACE inhibitor or an ARB usually works as a second drug, but if there is a risk of pregnancy, they need to be avoided, and a thiazide diuretic or other drug can be tried instead. If a thiazide diuretic is used,chlorthalidoneis the ideal one to use because it can be given once a day. Except in special conditions, vasodilators and alpha- and beta-blockers are 3rd-line drugs, which if needed should be used after consultation with a specialist. 