Hypertension in Paediatrics, Renal Unit, Royal Hospital for Children

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1 CLINICAL GUIDELINE Hypertension in Paediatrics, Renal Unit, Royal Hospital for Children Please note: The following guidelines have not been assessed according to the AGREE (Appraisal of Guidelines for Research and Evaluation) criteria. This will take place at the next review of this guideline. A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments. Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty. If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient. Date of publication: 21/10/2016 Review date: 14/02/2019 Lead Author: Approval Group: David Hughes Paediatric Clinical Effectiveness & Risk Committee Version no. 2

2 Contents 1. Introduction Page 3 2. Definition of hypertension Page 3 3. Measurement of blood pressure Page 3 4. History Page 4 5. Examination Page 4 6. Causes of hypertension Page 5 7. Investigation of hypertension Page 6 8. Management of hypertension Page 7 Appendix I: BP reference ranges for males 1-17 years Page 9 Appendix II: BP reference ranges for females 1-17 years Page 10 Appendix III: drugs for outpatient management of hypertension in children 1-17 years Page 11 Hypertension in Paediatrics Version: 2 Page 2 of 12 2

3 1. Introduction The following guideline has been developed and is regularly reviewed by clinicians within the Renal Unit at the Royal Hospital for Children. These guidelines are based on current evidence and best practice relating to the investigation and management of hypertension in infants, children and adolescents (aged 1-17 years). A separate West of Scotland guideline exists for Hypertension in neonatal patients and this should be referred to if necessary. These guidelines are intended for use by clinicians and nursing staff. For further discussion of this guideline, please contact a member of the nephrology team based within the Renal Unit (On call Consultant through switchboard, Renal Registrar on page or or via Renal Hotdesk ). 2. Definition of hypertension Blood pressure rises throughout childhood relative to age and height. As with height and weight there are specific percentiles for blood pressure measurement available for both sexes. Published values for blood pressure for both sexes are included in the appendices (The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 2004;114;555). Definitions are as follows: Normotension systolic and diastolic pressures less than 90 th percentile for age, height and sex. Pre-hypertension (or high-normal blood pressure) systolic and diastolic pressures between 90 th and 95 th percentiles for age, height and sex. Stage 1 hypertension systolic and diastolic between the 95 th percentile and 5mmHg above the 99 th percentile. Stage 2 hypertension systolic and diastolic pressures are 5mmHg above the 99 th percentile. May be associated with systemic features due to target-organ damage (e.g. left ventricular hypertrophy, renal impairment, retinopathy). 3. Measurement of blood pressure The gold standard for blood pressure measurement is mercury sphygmomanometry and this should be used to confirm hypertension if it is suspected following use of an automated device. An appropriate sized cuff must be used. The width of the cuff should cover at least 75% of the upper arm from the acromion to the olecranon, leaving sufficient space at the antecubital fossa to allow application of the bell of the stethoscope. The diastolic blood pressure is recorded when the sounds disappear (5 th Korotkoff sound) for all ages. In some children Korotkoff sounds can be heard down to 0mmHg, which excludes diastolic hypertension. Measure the blood pressure with the child in a seated position and their arm gently supported, ideally after the child has been sitting quietly for 5 minutes (or lying supine for an infant). Confirm hypertension with an average of measurements on three separate days/visits. Measure height and plot on an appropriate gender-specific growth chart to establish the height percentile then refer to the blood pressure centile chart for the Hypertension in Paediatrics Version: 2 Page 3 of 12 3

4 appropriate gender. Infants and younger children may require admission to hospital for blood pressure monitoring in order to confirm the diagnosis as reliable blood pressure recordings can be difficult to obtain in this age group. 4. History It is important to ask about the following: Review of symptoms Neonatal history o Prematurity o Umbilical catheterization o Bronchopulmonary dysplasia o Patent ductus arteriosus Past history of renal disease and urinary tract infections Congenital heart disease and cardiovascular risk factors Family history o Primary hypertension o Systemic disease o Endocrine disorders Drug history including steroids, oral contraceptives, illicit drugs, tobacco, alcohol Diet including salt intake Nausea and/or vomiting Urinary symptoms including polyuria, oliguria/anuria and haematuria Neurological symptoms o Headaches o Visual disturbance o Behavioural change o Altered mental state o Drowsiness o Seizures Cardiac symptoms o Chest pain o Palpitations o Oedema (periorbital and peripheral) o Dyspnoea Weight faltering or weight loss 5. Examination Assess for: Signs of heart failure o Tachycardia o Gallop rhythm o Hepatomegaly Hypertension in Paediatrics Version: 2 Page 4 of 12 4

5 o Raised jugular venous pressure Absent of weak femoral pulses potentially indicative of coartaction of the aorta - if this is detected then measure four limb blood pressure Neurological deficit o Weakness o Hypotonia or hypertonia o Hyper-reflexia and clonus o Upgoing plantars o Cranial nerve deficits Papilloedema and/or retinal haemorrhages Organomegaly and/or abdominal masses Evidence of thyroid disease including goitre and eye signs Carotid, abdominal and/or femoral bruits Obesity and Cushingoid features 6. Causes of hypertension Most significant hypertension in children is secondary to an underlying cause. Primary (essential) hypertension is a diagnosis of exclusion. Primary (essential) hypertension Secondary hypertension in neonates and infants Secondary hypertension in children and adolescents Obesity Family history of hypertension or cardiovascular disease Renal causes Renal artery thrombosis after umbilical catheterization Congenital renal parenchymal disease Renal artery stenosis Cardiac causes Coarctation of the aorta Patent ductus arteriosus Bronchopulmonary dysplasia Raised intracranial pressure Previous extracorporeal membrane oxygenation (ECMO) Renal causes Renal parenchymal disease Renal artery stenosis Acute post-streptococcal glomerulonephritis Membranoproliferative glomerulonephritis Diffuse proliferative glomerulonephritis Lupus nephritis IgA nephropathy Haemolytic uraemic syndrome Nephrotic syndrome Reflux nephropathy Polycystic kidney disease Wilms tumour Cardiac causes Coarctation of the aorta Hypertension in Paediatrics Version: 2 Page 5 of 12 5

6 Endocrine causes Mineralocorticoid excess Hyperthyroidism Hyperparathyroidism Phaechromocytoma Neuroblastoma Hypercalcaemia Congenital adrenal hyperplasia Neurological causes Raised intracranial pressure Tumours Drug-related causes including immunosuppressants, NSAID s, sympathomimetics and antidepressants 7. Investigation of hypertension The extent to which hypertension is investigated depends on its severity and the information obtained from a careful history and examination. A family history of hypertension, renal disease or endocrine causes may help guide you in a particular direction. Clinical features of any of the aforementioned causes may be detected on examination thus helping focus your investigations. Initial investigations to consider: Urinalysis and urine culture U&E s, Bone profile, LFT s, CRP and FBC Glucose Lipid profile Thyroid function tests Chest X-ray ECG and echocardiogram Renal USS (± Doppler) Peripheral plasma renin and aldosterone (following 30 minutes of recumbancy and preferably off treatment; ideally taken first thing in the morning after waking) Urine catecholamines 24 hour ambulatory blood pressure monitoring Secondary investigations Secondary investigations are guided by the findings from the above preliminary investigations along with the clinical findings and include: Renal aetiology suspected o DMSA scan to look for renal scarring or loss of cortical function o Direct or indirect cystogram e.g. MCUG to look for vesico-ureteric reflux o Intravenous urography o Renal angiography to look for renal artery stenosis o Renal biopsy Catecholamine excess suspected o I 123 MIBG scan to look for phaeochromocytoma o CT/MRI Hypertension in Paediatrics Version: 2 Page 6 of 12 6

7 o Abdominal angiography with selective venous sampling Corticosteroid excess suspected o Urinary steroid profile o Steroid suppression tests o Adrenal CT/MRI o Selective adrenal venous steroid sampling 8. Management of hypertension N.B. Investigations should be undertaken prior to the commencement of treatment unless severity dictates immediate management. Therapeutic lifestyle changes Most patients will benefit from lifestyle changes irrespective of the aetiology of their hypertension. These include exercise, weight loss, low-salt or no-added-salt diets, and increased intake of fruit, vegetables, fibre and low-fat dairy products. Short-term treatment of acute hypertension The most common indication in this category would be the treatment of hypertension secondary to acute nephritis leading to salt and water retention causing volume overload. A well-tolerated combination would be a loop diuretic (e.g. furosemide) plus a vasodilating Ca 2+ channel blocker (e.g. nifedipine). Long-term treatment of chronic hypertension Pharmacological therapy is considered in patients who do not respond to lifestyle modifications or who have secondary hypertension, symptomatic hypertension or established target-organ damage. The aim is to use a single agent if possible and to select a long-acting once-daily agent to aid compliance. The choice of antihypertensive is dependent on the underlying aetiology. The goal for antihypertensive treatment in children should be a reduction in blood pressure to <95 th percentile unless concurrent conditions are present, in which case blood pressure should be lowered to <90 th percentile. Please see Appendix III for a more detailed list of potential pharmacological agents, including dosing regimens. Angiotensin-converting enzyme (ACE) inhibitors (e.g. enalapril, lisinopril) or angiotensin-receptor blockers (e.g. irbesartan, losartan). Relatively contraindicated in confirmed or suspected renal artery stenosis and to be used with caution in renal disease. Electrolyte monitoring is required whilst on treatment due to the risk of hyperkalaemia and azotemia. ACE inhibitors have a beneficial antiproteinuric effect and are therefore useful in nephrotic syndrome. Complications include ascending cholangitis. ACE inhibitors and ARB s are contraindicated in pregnancy, and females of childbearing age should use reliable contraception. β-blockers (e.g. propranolol, atenolol). Asthma and overt heart failure are contraindications. β-blockers should not be used in insulin-dependent diabetics. Ca 2+ channel blockers (e.g. amlodipine, nifedipine) Diuretics (e.g. furosemide) are useful in volume-dependent hypertension (as above). All patients treated with diuretics should have electrolytes monitored shortly after initiating therapy and periodically thereafter. Potassium-sparing diuretics (e.g. spironolactone, amiloride) may cause severe hyperkalaemia especially if given with Hypertension in Paediatrics Version: 2 Page 7 of 12 7

8 an ACE inhibitor or ARB. Treatment of severe, symptomatic hypertension Symptomatic hypertensive emergencies should be treated without delay to avoid further damage to vital organs. The aim is to lower blood pressure promptly but in a controlled manner. A sudden drop in blood pressure is associated with an increased risk of intracranial bleeding. Short-acting antihypertensives such as nifedipine should be avoided for this reason. The initial aim of therapy is to reduce the mean arterial pressure by approximately 25% over the first 24 hours. This is best done with intravenous antihypertensives. If blood pressure drops more rapidly on initiation of treatment then volume expansion with isotonic 0.9% sodium chloride must be considered. Any serious complications must be managed before, or as, hypertension is being treated (e.g. anticonvulsants should be administered to a seizing patient along with antihypertensive medications). Drugs used in hypertensive emergencies include: Sodium nitroprusside o Dose: 0.5 micrograms/kg/minute, by intravenous infusion o Onset: instantaneous o Duration of action: only during infusion o Side-effects: headache, chest and abdominal pain o Disadvantages: patients require close observation; potential exists for cyanide accumulation Hydralazine o Dose: micrograms/kg/hour (maximum 3 mg/kg in 24 hours for children >1 month), by intravenous infusion o Side-effects: tachycardia, headache, flushing, vomiting o Disadvantage: may require the introduction of a β-blocker Labetalol o Dose: mg/kg/hour adjusted every 15 minutes according to response to max. 3 mg/kg/hour o Side-effects: gastrointestinal upset, scalp tingling, headache, sedation o Disadvantage: may precipitate bronchospasm in children with a history of asthma Hypertension in Paediatrics Version: 2 Page 8 of 12 8

9 Appendix I: blood pressure reference ranges for males aged 1-17 by height percentile 1 Hypertension in Paediatrics Version: 2 Page 9 of 12 9

10 Appendix II: blood pressure reference ranges for females aged 1-17 by height percentile 1 Hypertension in Paediatrics Version: 2 Page 10 of 12 10

11 Appendix III: drugs for outpatient management of hypertension in children 1-17 years 1 Hypertension in Paediatrics Version: 2 Page 11 of 12 11

12 References: 1. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents Aug;114(2 Suppl 4th Report): Document author: Dr Douglas Stewart Paediatric trainee Other professionals consulted: Dr Ian Ramage Consultant Paediatric Nephrologist, Royal Hospital for Children Document title: Hypertension Guideline in Paediatrics Implementation date: 01/08/16 Review date: 01/08/21 Hypertension in Paediatrics Version: 2 Page 12 of 12 12

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