History inquiry should be carefully conducted, as it can offer hints on whether the hypertension is essential or secondary, as well as clues regarding its etiology, thus facilitating workup. Therefore, the physician must ask about the gestational age at birth, keeping in mind that prematurity is a well known risk factor for pediatric hypertension. Other perinatal conditions that fall into the same category include bronchopulmonary dysplasia and the need for umbilical artery catheterization. A family history of neurofibromatosis and arterial hypertension also draws attention to the need to actively screen for pediatric hypertension. In older children, the physician must ask about a personal history of pyelonephritis (single or recurrent episodes), personal habits like smoking, salt, caffeine, alcohol, illicit drugs and licorice consumption or use of medication known to elevate blood pressure, such as tricyclic antidepressants or steroids. Nocturnal snoring points to obstructive sleep apnea, another possible cause for hypertension.

Infants with arterial hypertension and fail to thrive, may be lethargic or irritable, may have signs of congestive heart failure or experience respiratory distress or seizures. Older children complain about intermittent claudication, sweating, flushing, blurred vision, headaches, chest pain, fatigability or recurrent epistaxis after physical effort or intense emotional stress. Facing a child with Bell palsy, always consider pediatric hypertension as a possible cause.

While performing the physical examination, the doctor should pay special attention to signs of secondary hypertension, because correctly identifying the cause of secondary hypertension can sometimes rapidly lead to curative and definitive treatment [1]. For instance, neurofibromatosis can be suspected in patients with café au lait spots, coarctation of the thoracic aorta is suggested by the existence of different blood pressures in the arms and legs, whereas abdominal aorta coarctation should be investigated in cases where the physician hears an epigastric or abdominal bruit. The same sound heard in the projection area of renal arteries can mean renal artery stenosis.

Abdominal palpation may reveal the presence of a mass, therefore workup should be pointed towards detecting a Wilms tumor or polycystic kidney disease. Chronic renal failure may manifest as growth retardation, whereas metabolic syndrome children have an increased body mass index and acanthosis nigricans. Children are tachycardic if suffering from pheochromocytoma, hyperthyroidism or neuroblastoma. Adrenal hyperplasia is suggested by virilization, while Turner syndrome, Bardet-Biedl syndrome, Williams syndrome and von Hippel-Lindau disease have their specific traits.

Children older than 3 years should have their blood pressure measured on a yearly basis, in a calm environment, using a proper cuff size. Blood pressure in both arms and both legs should be measured at least once, especially if the systolic pressure in one arm is higher than the one in one foot. Newborns, infants and children under 3 have their blood pressure measured using the oscillometric technique, at least until they are able to cooperate for manual blood pressure determination. A cuff bladder with a width-to-arm circumference ratio of 0.45 to 0.55 should be used and multiple readings should be obtained [2].

The values obtained after proper measurement should be confronted with chart values. If the average systolic or diastolic blood pressure exceeds the 95th percentile, the child is considered hypertensive. If the 90th percentile is exceeded, more measurements and active surveillance are needed.

• Fatigue

  Hypertension Drug: ramipril Phase 4 Detailed Description: In adults, common side effects include persistent dry mouth, dizziness, fatigue, and headache. Rare cases of angioedema have been reported. [clinicaltrials.gov]

  Occasionally if the blood pressure is significantly elevated symptoms such as chronic headaches, fatigue, and dizziness may result. Treatment of high blood pressure in children initially involves lifestyle changes. [pediatricheartspecialists.com]

  Symptoms : Shortness of breath, fainting, fatigue, turning blue, not growing appropriately. [pphnet.org]

  Hyperlipidemia Impaired glucose tolerance or type 2 diabetes mellitus Renal artery stenosis Prior umbilical artery catheterization Abdominal bruit Abnormal findings on renovascular imaging Renal parenchymal disease Enuresis Family history of renal disease Fatigue [aafp.org]

• Congestive Heart Failure

  […] exam, including heart and lung (congestive heart failure or structural disease), abdominal (masses or pregnancy, bruit for renal vascular disease), fundoscopic and neurological examination (end organ damage) Laboratory Tests Urinalysis (determine if [learn.pediatrics.ubc.ca]

  As one would anticipate from its mode of action, propranolol is contraindicated in patients with a history of congestive heart failure, asthma, or diabetes mellitus. [healio.com]

  Infants with arterial hypertension and fail to thrive, may be lethargic or irritable, may have signs of congestive heart failure or experience respiratory distress or seizures. [symptoma.com]

  Many retrospective studies have shown evidence of adult hypertension beginning in childhood. 5,6 Moreover, children and adolescents with severe elevation in blood pressure (stage II hypertension or above) have increased risk of seizures, congestive heart [ndnr.com]

• Respiratory Distress

  Infants with arterial hypertension and fail to thrive, may be lethargic or irritable, may have signs of congestive heart failure or experience respiratory distress or seizures. [symptoma.com]

  Para naman sa mga bagong panganak: Seizures Irritability Lethargy Respiratory Distress Kapag nararanasan mo ang mga sintomas na ito, inirerekomenda na kumonsulta agad sa doktor. [tgp.com.ph]

  Research output: Contribution to journal › Journal article › Research › peer-review Rapid test for lung maturity, based on spectroscopy of gastric aspirate, predicted respiratory distress syndrome with high sensitivity Verder, H., Heiring, C., Clark, [vbn.aau.dk]

• Vomiting

  Symptoms of very high blood pressure (headache, vomiting) or hypertensive emergency (seizures, altered mental state). Examination Examination is normal in most cases. [patient.info]

  Κατευθυντήριες οδηγίες (guidelines) για τον προληπτικό έλεγχο των λιπιδίων στα παιδιά Β’ Παιδιατρική Κλινική Πανεπιστημίου Αθηνών July 2014 Guidelines on the prevention of post-operative vomiting in children Association of Paediatric Anaesthetists of [e-child.gr]

  Hypertensive encephalopathy presents as severe headache, visual disturbance and vomiting, progressing to focal neurological deficits, seizures and impaired conscious state, with grossly elevated BP, papilloedema and retinal haemorrhages. [rch.org.au]

  Common symptoms: Headache (#1 complaint) Nausea & Vomiting Chest Pain / Left heart failure Dizziness Convulsions Status Epilepticus Coma Initial Evaluation Four Limb pulses and blood pressures CXR Chemistry panel Urinalysis Fundoscopic exam (papilledema [pedemmorsels.com]

  Severe hypertension may be symptomatic like headache, dizziness, nausea, vomiting, irritability, personality changes.. Occasionally with complications like neurological, CHF, Renal dysfunction, Stroke. 20. [slideshare.net]

• Nausea

  Hydralazine may cause tachycardia, nausea and fluid retention. Oral captopril: 0.1 mg/kg initially, increasing to a maximum of 1 mg/kg (max. 50 mg). Thereafter 0.1-1.0 mg/kg/dose 8-hourly. Captopril is usually effective within 30 - 60 min. [rch.org.au]

  Common symptoms: Headache (#1 complaint) Nausea & Vomiting Chest Pain / Left heart failure Dizziness Convulsions Status Epilepticus Coma Initial Evaluation Four Limb pulses and blood pressures CXR Chemistry panel Urinalysis Fundoscopic exam (papilledema [pedemmorsels.com]

  In rare cases, severe hypertension can cause headaches, visual changes, dizziness, nosebleeds, heart palpitations, and nausea. If your child has severe high blood pressure and has any of these symptoms, get medical care right away. [kidshealth.org]

  Severe hypertension may be symptomatic like headache, dizziness, nausea, vomiting, irritability, personality changes.. Occasionally with complications like neurological, CHF, Renal dysfunction, Stroke. 20. [slideshare.net]

• Hypertension

  In total, 314 patients were studied: 218 with primary hypertension and 96 with secondary hypertension. [ncbi.nlm.nih.gov]

  The rates of hypertension among children and adolescents are on the rise along with obesity. Having hypertension as a child or an adolescent can increase the risk of early development of cardiovascular disease later in life. [chp.edu]

  A family history of neurofibromatosis and arterial hypertension also draws attention to the need to actively screen for pediatric hypertension. [symptoma.com]

• Heart Disease

  Patients with left to right shunts are the main group who develop pulmonary vascular disease if not treated in the early infancy. Some cyanotic congenital heart diseases are also the causes of PAH. [go.gale.com]

  Cardiovascular risk factors for the development of early heart disease are increasing in childhood including high blood pressure and high cholesterol. [urmc.rochester.edu]

  Once the echo has suggested PAH or congenital heart disease, the child should be referred to a specialty center expert in PAH and congenital heart disease. This may require traveling out of town. [pulmonaryhypertensionrn.com]

  Related disorders : Congenital heart disease, scleroderma, lupus, sickle cell and other hematologic diseases, as well as genetic disorders can be related to PAH. For more information, please see the “ For Patients and Families ” page. [pphnet.org]

  Services we offer include: Clinical evaluation and consultation Ambulatory Blood Pressure Monitoring (ABPM) Nutritional evaluation and counseling Home blood pressure monitoring Medication management Risk factor testing for heart disease Access to diagnostic [universitychildrenshealth.com]

• Blurred Vision

  In the rare pediatric patient with malignant hypertension, severe headache, blurred vision, and seizures can occur, and the main underlying cause is renal parenchymal disorders. [ncbi.nlm.nih.gov]

  Elevated blood pressure may cause no symptoms or may manifest as headache, seizures, blurred vision or vomiting. [symptoma.com]

• Epistaxis

  Older children complain about intermittent claudication, sweating, flushing, blurred vision, headaches, chest pain, fatigability or recurrent epistaxis after physical effort or intense emotional stress. [symptoma.com]

• Kidney Failure

  […] not treated, it can lead to other medical problems, including heart failure, kidney failure and stroke. [mottchildren.org]

  Untreated hypertension may lead to heart disease, strokes, or kidney failure. Can hypertension in children be treated? Yes. [ufhealth.org]

  If high blood pressure is not treated, it can also damage the arteries in the kidneys causing them to narrow and decrease the blood supply to the kidneys. The kidneys cannot function normally and this may result in kidney failure. [cincinnatichildrens.org]

  […] and treatment of chronic renal failure and end-stage renal disease. [massgeneral.org]

• Renal Insufficiency

  CCAs can be safely used in children with renal insufficiency or failure and as a general rule there is no need to modify drug dosage in this population. CCAs are generally well tolerated; most adverse effects appear to be dose related. [ncbi.nlm.nih.gov]

  However, avoiding potassium depletion (eg, from diuretic therapy) and prescribing a potassium-rich diet in patients without renal insufficiency appear reasonable. [emedicine.medscape.com]

  Microalbuminuria is a powerful predictor of both renal insufficiency and cardiovascular morbidity and mortality in adults. 52 The prevalence of microalbuminuria among children diagnosed with hypertension is estimated to be 20%. [pediatrics.aappublications.org]

• Headache

  Although children with hypertension usually have few symptoms, the major complaint is headache, which is characteristically frontal and may be throbbing. [ncbi.nlm.nih.gov]

  Hypertension Drug: ramipril Phase 4 Detailed Description: In adults, common side effects include persistent dry mouth, dizziness, fatigue, and headache. Rare cases of angioedema have been reported. [clinicaltrials.gov]

  Pediatric hypertension is often asymptomatic, but some common symptoms may include headache, nosebleeds, irritability, and impaired academic and athletic performances. [learn.pediatrics.ubc.ca]

  It also can cause a variety of symptoms including headaches, chest pains, stomachaches and difficulty sleeping. The normal range for blood pressure depends on your child's sex, age and height. [ucsfbenioffchildrens.org]

• Seizure

  In the rare pediatric patient with malignant hypertension, severe headache, blurred vision, and seizures can occur, and the main underlying cause is renal parenchymal disorders. [ncbi.nlm.nih.gov]

  Elevated blood pressure may cause no symptoms or may manifest as headache, seizures, blurred vision or vomiting. [symptoma.com]

  BP should be lowered in a controlled fashion, with anticonvulsants given for seizures. [rch.org.au]

  Symptoms of very high blood pressure (headache, vomiting) or hypertensive emergency (seizures, altered mental state). Examination Examination is normal in most cases. [patient.info]

  Accurate assessment of blood pressure (BP) in every patient presenting with a seizure is essential, particularly when no seizure disorder has been established in that patient. [emedicine.medscape.com]

• Irritability

  Severe hypertension may be symptomatic like headache, dizziness, nausea, vomiting, irritability, personality changes.. Occasionally with complications like neurological, CHF, Renal dysfunction, Stroke. 20. [slideshare.net]

  Pediatric hypertension is often asymptomatic, but some common symptoms may include headache, nosebleeds, irritability, and impaired academic and athletic performances. [learn.pediatrics.ubc.ca]

  In younger children there may be irritability, poor feeding, failure to thrive or seizures, whereas older children may be able to report symptoms such as headache, vomiting, dizziness, visual changes or chest pain. [patient.info]

  Infants with arterial hypertension and fail to thrive, may be lethargic or irritable, may have signs of congestive heart failure or experience respiratory distress or seizures. [symptoma.com]

  Black tea: Leave to infuse for 10-15 minutes so that the tannic acid (which can irritate the bowel) is dissolved Green tea Chamomile tea (antibacterial) Strawberry or blackberry leaf tea (contain tannins, can be obtained from a pharmacy) Fennel tea or [aoporphan.com]

• Lethargy

  Para naman sa mga bagong panganak: Seizures Irritability Lethargy Respiratory Distress Kapag nararanasan mo ang mga sintomas na ito, inirerekomenda na kumonsulta agad sa doktor. [tgp.com.ph]

• Confusion

  Ang ilan sa mga sintomas na lalabas ay ang mga sumusunod: Severe Headaches Nausea Vomiting Fatigue or Confusion Dizziness Blurred or Double Vision Nosebleeds Chest Pains Heart Palpitations / Irregular Heartbeat Breathlessness Blood in Urine Para naman [tgp.com.ph]

Workup in pediatric hypertension aims towards detecting the cause of the disease, given that most children suffer from secondary hypertension and towards establishing whether secondary organ damage exists. A complete cell blood count may highlight the presence of anemia, a sign of chronic renal disease. It may be accompanied by proteinuria, hematuria, increased creatinine levels and decreased creatinine clearance. Hyperaldosteronism is suggested by low potassium levels. Pheocromocitoma is characterized by high values of catecholamines. Aldosterone and renin activity offer additional important information: hyperaldosteronism is characterized by increased aldosterone levels, while high plasma renin activity is suggestive for renal vascular hypertension, whereas low plasma renin activity point towards apparent mineralocorticoid excess, Liddle syndrome or glucocorticoid-remediable aldosteronism. Lipid panels are recommended in obese children. This category of patients can also benefit from oral glucose-tolerance tests, periodically performed in selected cases in order to diagnose diabetes and decreased glucose tolerance in a timely manner.

Positive urine cultures are found in chronic pyelonephritis. Catecholamines and their metabolites are found in large quantities in the urine in case of pheochromocytoma or neuroblastoma.

Echocardiography is an imaging method of foremost importance in pediatric hypertension. It is an essential tool in suspected aortic coarctation cases. The standard view is the one obtained from the suprasternal notch, showing flux acceleration in the descending aorta. Pulsed and continuous Doppler sampling will be applied to all segments of the aortic arch and the incipient portion of the descending aorta, confirming increased velocities [3]. In all other cases, the echocardiogram is used to assess left ventricular hypertrophy. If the parietal wall thickness is increased, the patient is definitely suffering from chronic hypertension (except for chronic hypertrophic cardiomyopathy patients), and treatment needs to urgently be started or intensified. The report should specify if the left ventricular hypertrophy is concentric or eccentric [4] and details about the indexed left ventricular mass [5], especially important in infants and young children because of their rapid growth.

The physician should also characterize left ventricular function by calculating the ejection fraction [6], which is more often decreased in acute and severe hypertension with heart failure.

Electrocardiography also offers information about left ventricular hypertrophy. This method is considered to have high specificity but poor sensitivity [7] and low positive predictive value [8].

Abdominal ultrasonography assesses kidney size (differences suggest renal dysplasia or renal artery stenosis) and renal arterial flow, as well as the presence of visible tumors. A renal mass can signify a Wilms tumor, while an extra renal tumor could be a neuroblastoma. If Doppler studies highlight the presence of asymmetric flow, a renal angiography may be in order. This method allows the physician to obtain accurate information about renal blood flow and to measure renin levels in the renal arteries and the aorta. Renal vascular hypertension is diagnosed when a renin activity ratio of 3:1 between the kidneys is observed.

The 24-hour ambulatory blood pressure monitoring is useful in diagnosing white coat hypertension and observing blood pressure variations associated with daily activity. The mean 24-hour systolic and diastolic blood pressure values are compared with percentiles tables [9]. Polysomnography is indicated when sleep disturbances are the suspected cause of childhood hypertension.

Other tests, like cardiac catheterization, computed tomography, magnetic resonance imaging and radionuclide imaging may be ordered in selected cases for a better characterization of suspected abnormalities [1]. Retinal examination provides information about vascular changes associated with severe and prolonged hypertension.

• Microalbuminuria

  One study found that childhood hypertension was significantly associated with microalbuminuria in black adults but not white adults. [uspreventiveservicestaskforce.org]

  Search for microalbuminuria is of particular relevance because it also holds in the first decades of life a relevant prognostic significance which is not affected (as it happens in adult hypertension) by the concomitant presence of comorbities. [escardio.org]

  […] thickness, an established surrogate marker for atherosclerosis, is abnormally increased in children with hypertension, even after adjusting for BMI. 14 Other target organ effects include impaired cognitive function, reduced glomerular filtration rate, microalbuminuria [mdedge.com]

  Microalbuminuria is a powerful predictor of both renal insufficiency and cardiovascular morbidity and mortality in adults. 52 The prevalence of microalbuminuria among children diagnosed with hypertension is estimated to be 20%. [pediatrics.aappublications.org]

In secondary hypertension cases, treatment should eliminate the cause of the disease, if possible. In essential hypertension patients and in children suffering from hypertension caused by irremediable causes, treatment usually begins with nonpharmacologic measures. Weight reduction is indicated regardless of the etiology of the hypertension in all overweight and obese children [10]. Unless blood pressure values are uncontrollable, patients benefit from aerobic and isotonic exercises, stress-reducing activities and low fat, low salt, potassium rich diet. Competitive and high static resistance sports should be avoided. In patients where these methods fail, as well as in those with diabetes, target-organ damage and uncontrolled symptoms, pharmacological therapy should be initiated. Clinical judgment must dictate which class of antihypertensive agents is appropriate for each patient. [1]. Angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors and calcium-channel blockers are widely used in the pediatric hypertensive population. The first two categories are optimum for patients with diabetes and microalbuminuria or renal disease, while beta blockers offer maximum benefit in migraine cases. Treatment starts with a low dose of one antihypertensive drug, subsequently titrated upwards if needed. If the blood pressure does not drop below accepted values for height, sex and age, a second class of medication will be added. A third drug should only be added after reconsidering and rejecting the possibility of secondary hypertension. Long-term monitorization for adverse effects must also be performed.

A hypertensive crisis is a pediatric emergency and should be promptly treated with intravenous agents, such as labetalol, sodium nitroprusside or nicardipine. It manifests as seizures, dyspnea, tachycardia or other signs that can be correlated with heart failure, cerebral or pulmonary edema or renal failure. Blood pressure reduction should be achieved gradually, with only 25% during the first 8 hours and return to normal values during the next 12 to 24 hours [11].

Severe aortic coarctation in newborns and infants should be operated on, while mild cases observed in older children benefit from balloon angioplasty and stent placement. Renal artery stenosis can also be treated this way. Surgery is required in patients suffering from pheochromocytoma, Wilms tumor, renal segmental hypoplasia or renal vascular hypertension.

The classical complications of hypertension, stroke and heart attack are expected to develop at some point during the life of an individual suffering from childhood hypertension, if blood pressure values are not properly controlled. The risk is even higher if the child is obese and/or diabetic [12]. 41% of hypertensive children have left ventricular hypertrophy [13].

Pediatric hypertension is usually secondary, but essential hypertension can also be encountered in this age group, especially after puberty [14]. Common causes of hypertension in infants include bronchopulmonary dysplasia, thrombosis of renal artery or vein [15], congenital renal anomalies and coarctation of the aorta, whereas older children, aged 7 to 12 may suffer from hypertension caused by renal parenchymal disease or renal artery stenosis, aortic coarctation or tumors like neuroblastoma or Wilms. Adolescent hypertension is essential or caused by endocrine disease (hyperthyroidism, congenital adrenal hyperplasia, Cushing syndrome, familial hyperaldosteronism type I, Liddle’s syndrome, pseudohypoaldosteronism type 2, congenital adrenal hyperplasia and syndrome of apparent mineralocorticoid excess) or renal parenchymal or vascular abnormalities [16].

Other causes include Takayasu arteritis, Henoch-Schonlein purpura, polycystic ovary syndrome, increased intracranial pressure, dysautonomia, Guillan-Barre’ syndrome, mid aortic hypoplasia, hypercalcemia, obstructive sleep apnea, chronic lung disease and medication like steroids, oral contraceptives, erythropoietin, cyclosporine or tacrolimus.

Pediatric hypertension becomes an increasingly more frequent disease, especially in obese children. 2 to 5% of children are estimated to be hypertensive [17]. Still, the exact incidence remains unknown. Furthermore, incidence varies from one country to another. Girls and boys aged less than 6 have approximately the same blood pressure. Values are slightly higher in girls form 6 to puberty. Adolescence reverses this ratio, with male adolescents being more frequently hypertensive than their female peers.

Pediatric hypertension is caused by the unbalance between cardiac output and vascular resistance. The first parameter is regulated by the effective circulating volume, the extracellular volume and influenced by baroreceptor information and the sympathetic nervous system. Vascular resistance depends on pressor factors (vasopressin, catecholamines, angiotensin II, intracellular calcium level and the sympathetic nervous system) and depressor factors (prostaglandin s E2 and I2, atrial natriuretic hormones, kinins and endothelial relaxing factors).

The disease cannot be fully prevented, but diminished natrium intake may be advisable in the pediatric population affected by risk factors. The complications of pediatric hypertension, however, should be prevented by carefully monitoring blood pressure and adjusting the therapeutic plan. Patients and parents should be informed about the potential side effects of medication being used.

Pediatric hypertension is divided into several degrees. Prehypertension is defined as blood pressure above the 90th percentile but below the 95th or above 120/80 mm Hg. Stage I hypertension is diagnosed when the blood pressure is above the 95th percentile but less than or equal to the 99th percentile plus 5 mm Hg, while stage II hypertension reflects a blood pressure above the 99th percentile plus 5 mm Hg. If discrepancies exist between the systolic and diastolic pressures, the higher value should be used to classify the degree of hypertension.

Workup and treatment plans are similar to those in adults, but the physician should always investigate a cause of the hypertension that is adapted to the child's age (see Etiology). Angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors and calcium-channel blockers are therapeutic measures preferred by many physicians, but should be prescribed after dietary and lifestyle changes have failed.

Definition of elevated blood pressure in children is made after thorough measurement and comparison to charts containing normal values for the child's height, age and gender. Some children suffer from elevated blood pressure of unknown cause, while others have vascular, renal or endocrine causes for their disease. Elevated blood pressure may cause no symptoms or may manifest as headache, seizures, blurred vision or vomiting. Hypertensive children should undergo lifestyle changes like diminished salt intake, weight and stress reduction and certain types of physical activity. If these fail, medical antihypertensive treatment or sometimes surgical treatment to address the cause of the hypertension is needed.

1. 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;114:555-76.
2. Duncan AF, Rosenfeld CR, Morgan JS, Ahmad N, Heyne RJ. Interrater reliability and effect of state on blood pressure measurements in infants 1 to 3 years of age. Pediatrics. 2008;122(3): e590-4.
3. Rao PS, Carey P. Doppler ultrasound in the prediction of pressure gradients across aortic coarctation. Am Heart J. 1989; 118(2):299-307.
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14. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA. 2004;291: 2107-13.
15. Flynn JT. Neonatal hypertension: diagnosis and management. Pediatr Nephrol. 2000;14:332-41.
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17. Ogden CL, Troiano RP, Briefel RR, et al. Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics1997; 99: E1.