Chapter 43

High-Yield Facts

• Hypertension is defined as blood pressures ≥90th percentile for age- and height-matched normal values. Stage 2 hypertension (≥99th percentile) requires urgent evaluation and treatment.

• The differential diagnosis of hypertension changes with the age of the patient; the clinician should focus on the cause of hypertension and evaluate the patient for signs of end-organ damage.

• Initiation of oral antihypertensive agents should be done in conjunction with the physician who will be following up with the patients.

• Patients with a hypertensive emergency should be aggressively treated and admitted to a pediatric nephrologist or other hypertension specialist.

Hypertension is an unusual finding in younger pediatric patients while becoming more common in teenagers. When present, it must be quickly recognized and treated to avoid damage to the renal, cardiovascular, and neurologic systems. In the emergency department (ED) setting, it is not common practice to routinely take blood pressures of children younger than 3 years of age. Hypertension is more common in obese teenagers and may be more like adult hypertension or be secondary to other causes. Blood pressures must be measured accurately and abnormal values confirmed before initiating an evaluation. The normal ranges for blood pressure change with age and height, and not all elevated pressures require immediate treatment. An understanding of the etiologies of and a stepwise approach to hypertensive children ensures that patients will receive appropriate management.

Measuring Blood Pressure

Management of hypertension in children requires an accurate measurement of blood pressure. Accuracy requires a seated and relaxed patient as well as selection of the appropriate-size cuff. Cuffs that are too large will yield an erroneously low blood pressure and conversely, cuffs that are too small will yield a high reading. The bladder width should be approximately 40% of the circumference of the width of the arm at mid-point between the acromion and the olecranon process. The length of the bladder should reach around 80% to 100% of the circumference of the arm.1

Many EDs utilize automated oscillometric devices that can be very accurate at all age ranges as long as they are calibrated regularly. Any abnormal reading must be repeated by manual sphyngomanometry. In addition, abnormally high readings should be correlated with blood pressure measurements obtained from both upper extremities as well as at least one lower extremity.

Defining Hypertension

Although there has been some debate over the years as to defining pediatric hypertension, the National High Blood Pressure Education Program (NHBPEP) put forth the following definitions of hypertension in the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents: hypertension is either a systolic (sBP) or diastolic pressure (dBP) ≥95th percentile of age- and height-matched normal values and prehypertension is between the 90th and 95th percentile (Fig. 43-1). Hypertension is then further broken down into two stages: stage 1 hypertension ...

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