Hypertension in Childhood

Leonard G. Feld, MD, PhD* 2. Howard Corey, MD† 1. *Editorial Board 2. †Director, Pediatric Nephrology, Goryeb Children's Hospital, Atlantic Health System, Morristown, NJ After completing this article, readers should be able to: 1. Describe the practical approach to confirming the diagnosis of hypertension. 2. Delineate the differential diagnosis and diagnostic approach for a child who has significant hypertension. 3. Discuss the role of the pediatrician in advising the parents and child/adolescent on the nonpharmacologic approach to treating hypertension. 4. List the primary classes of antihypertensive medications to treat hypertension in childhood. David is a 10-year-old boy who complains of frequent headaches. He generally is healthy, but he is overweight and has an anxiety disorder. There is a strong family history of hypertension. On physical examination, the seated blood pressure (BP) using a child-size cuff and an automated noninvasive blood pressure monitor is 140/85 mm Hg. Suspecting hypertension as the cause of the headache, his physician refers David to a pediatric nephrologist for additional investigation . On the initial physical examination, the seated BP reading using an adult-size cuff and a manual aneroid manometer is 135/80 mm Hg. A second reading, taken 15 minutes later, is 122/72 mm Hg. His body mass index (BMI) exceeds the 95th percentile for age. The remainder of the physical examination findings are unremarkable . Subsequently, a 24-hour ambulatory blood pressure monitor (ABPM) reveals that 35% of the daytime readings exceed the 95th percentile for age, sex, and height, confirming the diagnosis of hypertension. Echocardiography reveals mild left ventricular hypertrophy (LVH), but otherwise shows normal results, as do blood chemistries, urinalysis, plasma renin activity, catecholamine measurement, and renal ultrasonography. However, the plasma uric acid concentration is mildly elevated at 6.6 mg/dL (0.39 mmol/L) . In the 3 decades since the first Report of the Task Force on Blood Pressure Control in Children , the guidelines for pediatric hypertension have been clarified, diagnostic evaluation has been refined, and therapeutic options have been expanded. Increasing …