Transcript Hypertonia in childhood - PTE KK

Hypertonia in childhood
Dénes Molnár
Dept Pediatr
Univ Pécs
Recommended literature
Fourth Report on the Diagnosis,
Evaluation, and Treatment of High
Blood Pressure in Children and
Adolescents. Pediatrics 114: 555-76,
2004
Definition
• Hypertension: Average SBP and/or DBP that is
>= 95th percentile for age, gender and height on
>= 3 occasions
• Prehypertension: average SBP or DBP levels that
are >= 90th percentile but < 95th percentile
• A patient with BP levels > 95th percentile in a
physician’s office or clinic, who is normotensive
outside a clinical setting, has „white-coat
hypertension”. ABPM is required to make the
diagnosis
Prevalence
• Not exactly known
• In neonates, infants and toddlers usually
secondary (renal 70%)
• In adolescents the essential
hypertension is the most frequent
• The younger the child is and the higher
the blood pressure is the more likely that
the hypertonia is secondary
In childhood blood pressure
correlates better with height
than with either body weight or
age
A height is taken into
account in the childhood
blood pressure
standards
When should BP be measured?
• In children >3 years old who are seen in a
medical setting should have their BP
measured
• Children <3 years old should have their BP
measured in special circumstances
Conditions under which children
<3 years old should have BP
measured
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Prematurity, neonatal compl. Requiring intensive care
Cong. Heart dis.
Recurrent UTI, hematuria or proteinuria
Known renal dis
Family hist. of cong renal dis
Solid organ transplant
Malignancy or bone marrow transplant
Drugs known to raise BP
Systemic illness associated with hypertension
Evidence of incr. intracranial pressure
How to measure BP – the device
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Flush method
Mercury manometer
Aneroid manometer
Oscillometric devices
ABPM
How to measure BP – the cuff
• The appropriate cuff size is important!!!
The cuff bladder should cover
80-100% of the
circumference of the arm
40% of the arm between
the olecranon and
acromion should be
covered by the inflatable
bladder
The standard method of BP
measurement is auscultation
above the brachial artery
How to measure BP
• Avoid the use of stimulant drugs, food,
strenuous exercise before BP measurement
• The child should rest for at least 5 min
before BP measurement
• Measure BP in sitting position, with the
back supported, feet on the floor and right
arm supported, cubital fossa at the heart
level
Hypertension is a risk factor for cardiovascular
diseases
• Stroke
- continuous positive relationship with SBP and
DBP
- 5 mmHg decrease of DBP causes 35-40 %
decrease of risk
• Coronary heart dis
- strong pos. Relationship (2/3 of that of stroke)
• Cardiac failure
- 5 mmHg decrease in DBP decreases the risk of
heart failure with 25% in renal diseases
Clinical signs of hypertension
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Headache
Nausea, vomiting
hypertensive encepalopathy
Polyuria, polydypsia
Vison disturb.
Irritability, tiredness
Cardiac failure
Facial paresis
Nasal bleeding
30 %
13 %
11 %
7,4 %
5,2 %
4,5 %
4,5 %
3,4 %
3,0 %
Diagnosis - history
- Hypertension in the family, heart disease, hyperlipidemia
drug treatment
- Umbilical cannulation, cranial or abdominal trauma
- Previous diseases
- Diabetes mellitus, hyperlipoproteinemia, renal disease
phacomatosis, endocrine dis. Vasculitis, weight gain or
loss.
Diagnosis – physical examination
• Obesity
• Rickets
• Virilization
• Café au lait spots
• Cushing signs
• Soft, weak femoral pulse
Diagnosis - lab
blood:
CN, creatinine, Na, K, Cl, uric acid, pH, pCO2,
fasting blood sugar, cholesterol, triglyceride, hgb. htc
urine:
rutine, pH, urine culture, GFR
hormones:
urine and plasma catecholamines,
peripheral renin activity, plasma aldosterone
Diagnosis - imaging
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ECG, echo-cardiography
Abdominal US, renal Doppler US,
MAG3 scintigraphy
DMSA scintigraphy
cystourethrography (!?)
angiography
Abdominal CT
Diagnosis – rare investigations
• Selective renal vein catheterization – renin
activity measurement at diff. levels of the
vena cava
• Kidney biopsy
Causes of hypertension
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Renoparenchymal
Renovascular
Vascular
Endocrine
Central nervous syst.
Essential
Other
Causes of hyprtension in function of age
• Neonate: Thrombosis of the renal artery opr sten.,
cong. renal malformations,
bronchopulmonary dysplasia
• < 6 yr:
Renoparenchymal dis., coarctation of the
aorta, stenosis of the renal artery
• 6-10 yr: stenosis of the renal artery,
renoparenchymal dis., essential hypertonia
• >10 yr: essential hypertonia, renoparenchymal dis.
Lack of circadian rhythm
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Diabetic nephropathy
autonom neuropathy
Chronic renal failure
pheochromocytoma
After kidney transplant
mineralocorticoid overproduction, Cushing
syndrome
• sleep apnoe syndr.
Hypertension caused by drugs,
toxines
Sympathomimetic drugs (ephedrine)
Steroids, ACTH
Oral contraceptives
Vitamin -D intoxiccation
Cyclosporin
Heavy metal intox.
Cocain, amphetamines
Prevalence of hypertension in children
according to BMI percentiles
Sorof & Daniels Hypertension 40: 441-7, 2002
The association between blood pressure
and gestational age
Special characteristics of
blood pressure of neonates
Lack of circadian rhythm
It is mainly ultradian
Its periodicity is mainly associated with
sucking
Physiologic change of blood pressure
1st week
+1-2 mmHg/day
1 - 6 weeks
+1 mmHg/week
Later the SBP increases with 1,5
mmHg/yr
DBP hardly changes until the age of 56 yrs then it increases continuously at
a speed of 0,7 mmHg/yr
Northem Neonatal Nursing Initiative
Arch Dis Child 80: F38-F42, 1999
If the average of 3 independent, occasional blood
pressure values exceeds the 95th percentile value
then ABPM is recommended
Javallat:
•Diagnosis of hyper/hypo-tension
•White-coat hypertension
•To judge the diurnal rhythm
•To test the effectivity of the treatment
Pediatrics 1996; 98: 649-658
Normálértékek gyermekkori ABPM-méréshez
(Soergel és mtsai 1997 )
Magasság
24 órás átlag
nappali átlag
éjszakai átlag
----------------------------------------------(cm) (n)
50p 95p
50p
95p
50p
95p
-----------------------------------------------------------------------------------Fiúk (572)
120
130
140
150
160
170
180
(33)
(62)
(102)
(108)
(115)
(83)
(69)
105/65
105/65
105/65
109/66
112/66
115/67
120/67
Leányok (569)
120
130
140
150
160
170
180
(40)
(58)
(70)
(111)
(156)
(109)
(25)
103/65
106/66
108/66
110/66
111/66
112/66
113/66
113/72
117/75
121/77
124/78
126/78
128/77
130/77
112/73
113/73
114/73
115/73
118/73
121/73
124/73
123/85
125/85
127/85
129/85
132/85
135/85
137/85
95/55
96/55
97/55
99/55
102/56
104/56
107/56
104/63
107/65
110/67
113/67
116/67
119/67
122/67
113/73
117/75
120/76
122/76
124/76
124/76
124/76
111/72
112/72
114/72
115/73
116/73
118/74
120/74
120/84
124/84
127/84
129/84
131/84
131/84
131/84
96/55
97/55
98/55
99/55
100/55
101/55
103/55
107/66
109/66
111/66
112/66
113/66
113/66
114/66
Hypertension and
obesity
Odds ratio of cardiovascular risk factors
in children with BMI > 95%
8
Odds ratio
6
4
Compared to children with BMI < 85%
Freedman DS et al. Pediatrics 103: 1175, 1999
insulin
SBP
HDL-ch
LDL-ch
Triglyceride
0
Total ch
2
Association of hypertension with BMI in
German children
Reich et al. IJO 27: 1459-64, 2003
The frequency of cardiovascular risk factors in obese
and control children
Obese
Male (103)
Control
Female (77)
Male (155)
Female (84)
Hypertension
40%
42%
5%
4%
Hyperinsulinaemia
54%
53%
9%
5%
Hyperchol.
24%
26%
5%
2%
Hypertrigl.
45%
27%
6%
8%
Low HDL
8%
1%
3%
1%
IGT
28%
27%
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Csábi et al. Eur J Pediatr 159: 91-4, 2000
Heart rate based on weight and blood pressure
status in adolescents
Sorof & Daniels Hypertension 40: 441-7, 2002
Plasma Renin
+-SD
Control
NHT obese
HT obese
#
Csábi et al.Eur J Pediatrr 155: 895-7, 1996
Plasma Aldosterone
#
*
+-SD
Control
NHT obese
HT obese
#
Csábi Csábi et al.Eur J Pediatrr 155: 895-7, 1996
Na excretion
+-SD
Control
NHT obese
HT obese
p < 0.05 HT vs NHT
Csábi et al.Eur J Pediatrr 155: 895-7, 1996
Plasma Norepinephrine
+-SD
Control
NHT obese
HT obese
*
#
Csábi et al.Eur J Pediatrr 155: 895-7, 1996
Treatment of hypertension
(conservative)
Konzervatív kezelés
• Weight reduction if applicable
• Regular physical activity
• Reduced salt intake
Treatment of hypertension
(first line drugs)
• Béta blockers
• ACE inhibitors
• Angotensine receptor blockers
• Diuretics
Treatment of hypertension
(second line drugs)
• Calcium channel blockers
• Peripheral alpha antagonists
• Vasodilators
Hypertonia, kifejezett diurnális ritmus
Súlyos hypertonia
Circadian blood pressure rhythm
in obese children
60
50
40
% 30
20
10
0
Dippers
Molnár D preliminary results
Non-dippers