The following simple table to identify children and adolescents needing further evaluation of blood pressure
Any reading equal to or above the readings in the simplified table indicates potentially abnormal blood pressures in one of three ranges: pre-hypertension; stage 1 hypertension; or stage 2 hypertension and identifies blood pressures that requires additional evaluation.
BP Centile Charts
Note: BP measurements repeated on several different occasions are required to diagnose hypertension. The cuff bladder should cover at least 3/4 of the child’s arm length, and the child should be quiet and calm.
Obesity may complicate the accurate measurement of blood pressure and be a contributing factor.
Renal (75%) – post-infectious glomerulonephritis, chronic glomerulonephritis, obstructive uropathy, reflux nephropathy, reno-vascular, haemolytic uraemic syndrome, polycystic kidney disease
Cardiovascular (15%) – coarctation of the aorta
Endocrine (5%) – phaeochromocytoma, hyperthyroidism, congenital adrenal hyperplasia, primary hyperaldosteronism, Cushing syndrome
Other (5%) – neuroblastoma, neurofibromatosis, steroid therapy, raised intracranial pressure.
Appearance – Cushingoid, obese
Height and weight
Upper and lower limb BP measurement
Skin: Cafe-au-lait spots, neurofibromas, hirsutism, vasculitis
Fundoscopy: hypertensive retinopathy
CVS examination: left ventricular hypertrophy, murmurs (particularly interscapular)
Abdomen: renal / adrenal masses, renal bruits
Full neurological examination
Initially: urine analysis, urine microscopy, urea and electrolytes, creatinine,
Further investigations may include: 24 hours urinary catecholamines, chest X-ray, ECG, renal ultrasound, plasma renin activity, plasma aldosterone, thyroid function tests, Cortisol, 17-hydroxy progesterone, renal Doppler scan, renal angiography.
No treatment required acutely. Investigate and manage as out-patient.
Acute severe hypertension
These patients require admission to ICU for urgent treatment.
Hypertensive encephalopathy presents as severe headache, visual disturbance and vomiting, progressing to focal neurological deficits, seizures and impaired conscious state, with grossly elevated BP, papilloedema and retinal haemorrhages. These patients almost always have chronic renal disease and are on dialysis. The differential diagnosis includes uraemic encephalopathy and metabolic disturbance. BP should be lowered in a controlled fashion, with anticonvulsants given for seizures.
Choice includes (list not exhaustive):
Sublingual / oral nifedipine:
tabs – 0.5 – 1.0 mg/kg/dose (max. 40 mg) 12-hourly
Side effects include tachycardia, flushing and fluid retention.
0.2 mg/kg initially; later 0.4 mg/kg by slow push every 10 min up to 3 – 4 mg/kg (max. 100 mg) total dose. Avoid if there is heart failure, asthma or bradycardia.
0.1 – 0.2 mg/kg (max. 10 mg) stat, then 4 – 6 micrograms/kg/min (max 300micrograms/min). Hydralazine may cause tachycardia, nausea and fluid retention.
- mg/kg initially, increasing to a maximum of 1 mg/kg (max. 50 mg).Thereafter 0.1-1.0 mg/kg/dose 8-hourly. Captopril is usually effective within 30 – 60 min