The European Society of Hypertension has issued guidelines for managing high blood pressure in children and adolescents. The guidance was issued to fill a gap left by the exclusion of the topic in the latest adult guidelines from the ESH and the European Society of Cardiology, according to a committee led by Empar Lurbe, MD, of the University of Valencia in Spain.
Although many of the recommendations are made on the basis of expert consensus, owing to the lack of randomized data, they said "it would be unethical to neglect giving due attention to this medically and socially important problem." They said the guidelines, published in the September issue of the Journal of Hypertension, "should encourage public policymakers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents."
Normal blood pressure for children younger than 18 was defined as less than the 90th percentile according to age, sex, and height. This should be the target for treatment for most children with elevated blood pressure, according to the guidelines. A child is considered hypertensive with measurements in the 95th percentile or higher on at least three occasions. Measurements between the 90th and 95th percentiles are considered high-normal.
According to the guidelines, the auscultatory method should be used to measure blood pressure, which should be done in all children older than 3 and in younger children when special circumstances place them at risk for high blood pressure.
The authors said 24-hour ambulatory blood pressure monitoring should be used to confirm a diagnosis of hypertension before initiating treatment. The first steps following a diagnosis should involve the recording of a family and clinical history, a physical examination, a cardiovascular examination, and a neurological examination, they said. This should be followed by routine blood tests and tests for plasma renin activity, plasma aldosterone concentration, urine and plasma catecholamines or metanephrines, and urinary free cortisol, as well as a Tc99 dimercaptosuccinic acid scan.
In addition, children should be evaluated for organ damage, specifically in the heart, great vessels, kidneys, central nervous system, and retina, the authors said. This process will help identify any secondary causes of hypertension that require treatment.
The guidelines contained the following additional recommendations for managing a pediatric patient with hypertension:
First target the risk factors for elevated blood pressure, including overweight, increased salt intake, and low physical activity. Body mass index should be kept below the 85th percentile.
- Regular exercise and a well-balanced diet are recommended. These measures should be continued even when drug treatment is started.
- Pharmacological treatment should be started when patients have symptomatic hypertension, hypertensive target organ damage, secondary hypertension, or diabetes at the time of presentation.
- For children with chronic kidney disease, blood pressure should be lowered below the 75th percentile if they do not have proteinuria, and below the 50th percentile if they do have proteinuria. Combination drug treatment might be necessary.
- When initiating drug treatment, start with a low dose of a single drug. If there is no response within a few weeks, increase to a full dose.
- If the initial drug does not work, try a drug in a different class. In pediatric studies, all drug classes resulted in similar blood pressure reductions, but ACE inhibitors and angiotensin receptor blockers are the most widely used.
The authors acknowledged that there was little data from randomized clinical trials guiding the recommendations and said there was an urgent need for studies establishing doses and addressing the advantages and disadvantages of individual agents in pediatric patients.
In addition, they called for further research to obtain reference values for office, home, and ambulatory blood pressure, to collect information about early organ damage in hypertensive children, and to provide information about when to initiate pharmacologic treatment and which targets to meet.
Source: Medical News Europe / Journal of Hypertension
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