hypertension and blood pressure management guidelines in
TRANSCRIPT
Hypertension And Blood Pressure Management Guidelines In
ChildrenAuthor(s) Ann Ratcliffe (registrar) Jan Dudley, Carol
Inward (Consultant Paediatric Nephrologists)
Page 1 of 12
SETTING Bristol Royal Hospital for Children (BRHC) and Neonatal wards, St Michael’s Hospital
FOR STAFF Medical and nursing staff caring for children with suspected hypertension
PATIENTS Children with suspected hypertension
_____________________________________________________________________________
GUIDANCE Definitions of hypertension
1. Systolic or diastolic blood pressure > 95th centile for BP by sex, age and height with an appropriately sized cuff, measured on three occasions. [1]
2. ‘Hypertensive crisis’ is the term used to describe acute elevation in blood pressure that can
rapidly cause end-organ damage. Can be further subdivided into hypertensive urgency where patients with an acutely elevated blood pressure may manifest symptoms (headache and nausea etc.) but have no evidence of acute target-organ injury. Or hypertensive emergency which is associated with evidence of acute target-organ injury. Hypertensive crisis requires urgent investigation and management and will commonly require IV anti- hypertensives to safely lower the blood pressure. [2]
3. Prehypertension: Mean systolic or diastolic ≥ 90th percentile but ≤ 95th percentile (or 120/80mmHg, even if BP below the 90th percentile for sex, age and height) [1]
Measurement of blood pressure in children
1. Children over 3 years of age should have their blood pressure measured at least once during every hospital admission [1, 3]
2. Children under the age of 3 years should have their blood pressure measured as clinically indicated. [1, 3]
3. A range of cuff sizes from newborn to large adult should be available (see table 1) [1]
4. Blood pressure should be measured with the weight of the arm supported after the child has
been sitting quietly for at least 3 minutes using an appropriately sized cuff
5. The appearance of Korotkoff sound (K1) should be used to define the systolic blood pressure and the disappearance of Korotkoff sounds (K5) should be used to define the diastolic blood pressure when auscultation is used to measure blood pressure [3]
Clinical Guideline
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 2 of 12
6. If an automated oscillometric device is used to measure blood pressure and it is found to be elevated then manual measurements should be obtained. [4]
7. Centile charts should be available to allow interpretation of blood pressure measurement (appendix 1) [1, 5]
8. Elevated blood pressure should be confirmed on at least 3 occasions before characterising a child as having hypertension. The appropriate time interval depends on the clinical circumstances. Reactive causes of hypertension for example emotion, activity or pain should be excluded.
9. Consider ambulatory BP monitoring [6, 7, 8]. This may be helpful in cases of uncertainty, where three BP measurements are borderline or anxiety cannot be excluded.
Neonatal Blood Pressure
Normal blood pressure in newborn babies depends on a variety of factors (gestational age, postnatal age, and birth weight).
The incidence of hypertension in healthy newborn babies is very low (estimated 0.2%) and routine screening is not recommended. [9]
Hypertension is more common in ‘at-risk’ newborns (those admitted to NICU) and incidence ranges from 0.7-2.5%. [9]
The Care Quality Commission have recommended that NHS England ask NICE to develop national guidance on which babies require blood pressure monitoring and the frequency of observations.[19]
There is no current definitive national or international reference ranges of ‘normal’ neonatal blood pressure. Tables of estimated BP values after 2 weeks of age have been synthesised from current available date.(see appendix 2) [9]
Aetiology of Hypertension
Secondary hypertension is more common than primary hypertension in children under 10 and the younger the child the more likely that a definable cause will be identified. Primary hypertension is more likely in children over 10 years especially if they are overweight, obese of there is a family history of hypertension. [4]
Table 1 [1]: Available cuff
sizes
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 3 of 12
Underlying causes of secondary hypertension (Appendix 3) [10]: 1. Renal disease (80%). [4] 2. Reno-vascular disease (10%). [4] 3. Cardiovascular (Coarctation of the aorta should be excluded) 4. Endocrine causes 5. Central Nervous System 6. Genetic 7. Autoimmune 8. Miscellaneous
Investigations First line:
pulse and blood pressure • Fundoscopy • Consider stigmata of underlying cause
• Urinalysis and early morning urine for protein:creatinine ratio and albumin:creatinine ratio.
• Urine for MC+S if suggestive history of Urinary Tract Infection (UTI) or abnormal urinalysis
• Urea &Electrolytes /Bicarbonate/Bone profile / Magnesium / Full Blood Count /Thyroid Function/Random Glucose/Random Lipids (with fasting if results indicate)
• Ultrasound of abdomen and renal tract with doppler imaging of renal vessels • Consider ambulatory BP monitoring (ABPM). Interpretation needs comparison with
an appropriate reference range; reference values provided by the German Working Group on Paediatric Hypertension are currently considered the best available data for paediatric ABPM [11, 12]
• Further assessment of end organ damage ECG/ECHO/CXR • Ophthalmology
Second Line: For indication, discuss with Paediatric Nephrologist
• DMSA (radionuclide scan using dimercaptosuccinic acid) • Renin and aldosterone (consider whether any current medications could influence
result). Ideally collect after patient has been awake for 2 hours and seated for 5-15 minutes.
• Suspected Cushings disease (reduced linear growth with increased weight): 24 hour urine free cortisol (at least 2 tests) or dexamethasone suppression test on liason with endocrinology.
• Suspected phaeochromocytoma: Urinary catecholamines (ideally 24 hour collection but random sample if not). High clinical suspicion – plasma metanephrines
• Suspected neuroblastoma: Urine VMA (Vanillylmandelic acid) and HVA (Homovanillic acid). • Urine steroid profile – very rarely indicated and requires discussion with consultant
nephrologists and biochemistry. (indications are suspected apparent mineralocorticoid excess or congenital adrenal hyperplasia)
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 4 of 12
• MRA/Renal angiography/MRI Non-pharmacological management
Lifestyle changes are recommended for children with established hypertension and pre- hypertension. Consider addressing the following:
• Sodium restriction • Weight loss • Exercise • Attention to other cardiovascular risk factors: Control of blood lipids, glycaemic control
in diabetes
Oral maintenance treatment
Aim to maintain BP <95th centile in children with uncomplicated primary hypertension with no
evidence of end organ damage and <90th centile in children with renal impairment (Chronic Kidney Disease [CKD] ≥ stage 2), diabetes or evidence of end organ damage. [1, 13]
Choice of oral agents (see Specific considerations for treatment of hypertension):
1. Angiotensin converting enzyme inhibitors (ACEI; e.g. enalapril/lisinopril) or angiotensin II receptor antagonists (ARB; losartan, irbesartan)
a. May cause hyperkalaemia. Monitor serum potassium; check levels within 7 days of starting or increasing dose
b. Avoid if renal artery stenosis suspected c. Avoid in the early period after renal transplantation
2. Beta blockers: Metoprolol has selective blockade and non-renal excretion. a. Use if concerns about the possibility of renal artery stenosis or ACEI/ARB
contraindicated 3. Calcium channel blockers: Amlodipine/ nifedipine 4. Consider diuretics if fluid overload is contributing
Once daily dosing schedules improve compliance
Emergency management of Hypertensive Crisis: Discuss with paediatric nephrologist
• Patients may require management on PICU/renal ward or appropriate HDU setting • Slow reduction over 72 hours to avoid sudden drop in perfusion pressure which may cause
catastrophic cerebral ischaemia. Aim to drop by no more than 25% of the overall planned BP reduction over the first eight hours of treatment [14]. Avoid mydriatics for fundoscopy so pupillary responses can be monitored
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 5 of 12
• Site 2 IV cannulae. One is used to deliver IV antihypertensive agent and the second to
deliver a 10ml/kg 0.9% sodium chloride bolus if the blood pressure falls significantly.
• The choice of IV agent should be the one with which the clinician is most familiar with and can include the following: Labetalol / Nicardipine / Sodium Nitroprusside. These agents should be administered using a sliding scale to titrate dose administered with BP, measured every 15 minutes (usually monitored via arterial line in patients on PICU) – liaise with nephrologist for details
Once control has been established with parenteral agents, convert to oral agents as above.
Specific considerations for treatment of hypertension
1. Following renal transplantation there is no evidence that any antihypertensive agent is better than any other but the use of angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists are not generally used in the first 3 months post transplant. [15] Calcium channel blockers are a sensible choice and there is evidence that use of these agents in the peri-operative period reduce the incidence of post-transplant acute tubular necrosis [16].
2. Phaeochromocytoma. This is characterised by episodic hypertension/palpitations and
sweating. Control of hypertension is required before surgery generally using alpha and then beta blockade.[17] This should be discussed with a consultant anaesthetist pre-operatively.
3. Renovascular disease. This is characterised by very high renin levels and may be secondary to renal artery stenosis or obstruction to vessels by cysts in polycystic kidney disease. In this situation, intra-glomerular pressure depends on efferent arteriolar constriction and therefore ACE inhibitors or angiotensin II receptor antagonists must be used with caution as these agents cause efferent arteriolar dilatation. Investigations may include: MRA/Angiography. Treatment: metoprolol / amlodipine / other.
4. Rare single gene disorders GRA (glucocorticoid remedial hyperaldosteronism), Gordons,
Liddle syndrome [18] and AME (apparent mineralocorticoid excess) are characterised by hypertension due to interruption of the renin-aldosterone axis. They are often associated with hypo- or hyperkalaemia and diagnosis is with a urine steroid profile. Treatment includes the use of potassium sparing diuretics.
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 6 of 12
References
1. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics (2004)114: 555-576
2. Patel NH, Romero SK , Kaelber DC. Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies. Open Access Emergency Medicine (2012); 4:85–92.
3. Lurbe, Empar, Cifkova, et al. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. Journal of Hypertension Sep 2009 vol 27: issue 9: p 1719-1742
4. Ingelfinder J. The Child or Adolescent with Elevated Blood Pressure. N Engl J Med 2014; 370: 2316-25
5. Jackson LV, Thalange NK, Cole TJ. Blood pressure centiles for Great Britain. Arch Dis Child (2007) 92: 298-303
6. Soergel M, Kirschstein M, Busch C, et al. Oscillometric twenty-four-hour ambulatory blood pressure values in healthy children and adolescents: a multicenter trial including 1141 subjects. J Pediatr (1997) 130: 178-184
7. Flynn JT. Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertension (2012); 14: 372-82
8. Butani L, Morgenstern BZ. Are pitfalls of oscillometric blood pressure monitoring preventable in children? Pediatr Nephrol (2003) 18: 313-8
9. Dionne J, Abitbol C, Flynn JT. Hypertension in Infancy: Diagnosis, management and outcome. Pediatr Nephrol (2012) 27: 17-32
10. Singh D, Akingbola O et al. Emergency Management of Hypertension in Children (2012). International Journal of Nephrology: Article ID 420247, 15 pages
11. Flynn JT, Daniels SR Update: Ambulatory Blood Pressure Monitoring in Children and Adolescents. A Scientific Statement From the American Heart Association. Hypertension. 2014; 63: 1116-1135.
12. Wühl E, Witte K, et al. German Working Group on Pediatric Hypertension. Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions. J Hypertens (2003); 21:2205-2206
13. National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NFK KDOQI) - Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease
14. Flynn JT, Tallus K. Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatr Nephrol. 2009;24(6):1101
15. Post operative care of the renal transplant recipient (2011). The Renal Association. 16. Shilliday I, Sherif M (2007) Calcium channel blockers for preventing acute tubular
necrosis in kidney transplant recipients. Cohrane Database Syst Rev 4: CD003421 17. S. G. Waguespack, T. Rich et al. A Current Review of the Etiology, Diagnosis, and
Treatment of Pediatric Pheochromocytoma and Paraganglioma (2011). JCEM; 95: 5 18. Warnock DG. Liddle syndrome: an autosomal dominant form of human hypertension.
Kidney Int (1998) 53: 18-24 19. Care Quality Commission Report July 2016: Identifying and managing clinical risks in
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 7 of 12
_____________________________________________________________________________
None
SAFETY Children with hypertensive crises should be managed in a suitable environment e.g. renal unit/HDU/PICU by experienced staff Blood Pressure should not be allowed to fall abruptly in hypertensive crisis and therefore short acting nifedipine should be avoided as its absorption and efficacy is unpredictable. These guidelines were produced in good faith by the authors reviewing available evidence. They were designed for use by medical and nursing staff at the Bristol Royal Hospital for Children for children under their care. Responsibility for use of these guidelines lies with the individuals caring for the patients.
QUERIES Contact the on-call Paediatric Nephrology registrar on bleep 2938 if any queries or to make a referral
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 8 of 12
Appendix 1: BP percentiles in children and adolescents [1] (based on mercury sphygomanometry)
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 9 of 12
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 10 of 12
Appendix 2: Estimated BP values after 2 weeks of age in infants from 26 to 44 weeks post conceptual age. [9]
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 11 of 12
Renal
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 12 of 12
Genetic
Page 1 of 12
SETTING Bristol Royal Hospital for Children (BRHC) and Neonatal wards, St Michael’s Hospital
FOR STAFF Medical and nursing staff caring for children with suspected hypertension
PATIENTS Children with suspected hypertension
_____________________________________________________________________________
GUIDANCE Definitions of hypertension
1. Systolic or diastolic blood pressure > 95th centile for BP by sex, age and height with an appropriately sized cuff, measured on three occasions. [1]
2. ‘Hypertensive crisis’ is the term used to describe acute elevation in blood pressure that can
rapidly cause end-organ damage. Can be further subdivided into hypertensive urgency where patients with an acutely elevated blood pressure may manifest symptoms (headache and nausea etc.) but have no evidence of acute target-organ injury. Or hypertensive emergency which is associated with evidence of acute target-organ injury. Hypertensive crisis requires urgent investigation and management and will commonly require IV anti- hypertensives to safely lower the blood pressure. [2]
3. Prehypertension: Mean systolic or diastolic ≥ 90th percentile but ≤ 95th percentile (or 120/80mmHg, even if BP below the 90th percentile for sex, age and height) [1]
Measurement of blood pressure in children
1. Children over 3 years of age should have their blood pressure measured at least once during every hospital admission [1, 3]
2. Children under the age of 3 years should have their blood pressure measured as clinically indicated. [1, 3]
3. A range of cuff sizes from newborn to large adult should be available (see table 1) [1]
4. Blood pressure should be measured with the weight of the arm supported after the child has
been sitting quietly for at least 3 minutes using an appropriately sized cuff
5. The appearance of Korotkoff sound (K1) should be used to define the systolic blood pressure and the disappearance of Korotkoff sounds (K5) should be used to define the diastolic blood pressure when auscultation is used to measure blood pressure [3]
Clinical Guideline
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 2 of 12
6. If an automated oscillometric device is used to measure blood pressure and it is found to be elevated then manual measurements should be obtained. [4]
7. Centile charts should be available to allow interpretation of blood pressure measurement (appendix 1) [1, 5]
8. Elevated blood pressure should be confirmed on at least 3 occasions before characterising a child as having hypertension. The appropriate time interval depends on the clinical circumstances. Reactive causes of hypertension for example emotion, activity or pain should be excluded.
9. Consider ambulatory BP monitoring [6, 7, 8]. This may be helpful in cases of uncertainty, where three BP measurements are borderline or anxiety cannot be excluded.
Neonatal Blood Pressure
Normal blood pressure in newborn babies depends on a variety of factors (gestational age, postnatal age, and birth weight).
The incidence of hypertension in healthy newborn babies is very low (estimated 0.2%) and routine screening is not recommended. [9]
Hypertension is more common in ‘at-risk’ newborns (those admitted to NICU) and incidence ranges from 0.7-2.5%. [9]
The Care Quality Commission have recommended that NHS England ask NICE to develop national guidance on which babies require blood pressure monitoring and the frequency of observations.[19]
There is no current definitive national or international reference ranges of ‘normal’ neonatal blood pressure. Tables of estimated BP values after 2 weeks of age have been synthesised from current available date.(see appendix 2) [9]
Aetiology of Hypertension
Secondary hypertension is more common than primary hypertension in children under 10 and the younger the child the more likely that a definable cause will be identified. Primary hypertension is more likely in children over 10 years especially if they are overweight, obese of there is a family history of hypertension. [4]
Table 1 [1]: Available cuff
sizes
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 3 of 12
Underlying causes of secondary hypertension (Appendix 3) [10]: 1. Renal disease (80%). [4] 2. Reno-vascular disease (10%). [4] 3. Cardiovascular (Coarctation of the aorta should be excluded) 4. Endocrine causes 5. Central Nervous System 6. Genetic 7. Autoimmune 8. Miscellaneous
Investigations First line:
pulse and blood pressure • Fundoscopy • Consider stigmata of underlying cause
• Urinalysis and early morning urine for protein:creatinine ratio and albumin:creatinine ratio.
• Urine for MC+S if suggestive history of Urinary Tract Infection (UTI) or abnormal urinalysis
• Urea &Electrolytes /Bicarbonate/Bone profile / Magnesium / Full Blood Count /Thyroid Function/Random Glucose/Random Lipids (with fasting if results indicate)
• Ultrasound of abdomen and renal tract with doppler imaging of renal vessels • Consider ambulatory BP monitoring (ABPM). Interpretation needs comparison with
an appropriate reference range; reference values provided by the German Working Group on Paediatric Hypertension are currently considered the best available data for paediatric ABPM [11, 12]
• Further assessment of end organ damage ECG/ECHO/CXR • Ophthalmology
Second Line: For indication, discuss with Paediatric Nephrologist
• DMSA (radionuclide scan using dimercaptosuccinic acid) • Renin and aldosterone (consider whether any current medications could influence
result). Ideally collect after patient has been awake for 2 hours and seated for 5-15 minutes.
• Suspected Cushings disease (reduced linear growth with increased weight): 24 hour urine free cortisol (at least 2 tests) or dexamethasone suppression test on liason with endocrinology.
• Suspected phaeochromocytoma: Urinary catecholamines (ideally 24 hour collection but random sample if not). High clinical suspicion – plasma metanephrines
• Suspected neuroblastoma: Urine VMA (Vanillylmandelic acid) and HVA (Homovanillic acid). • Urine steroid profile – very rarely indicated and requires discussion with consultant
nephrologists and biochemistry. (indications are suspected apparent mineralocorticoid excess or congenital adrenal hyperplasia)
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 4 of 12
• MRA/Renal angiography/MRI Non-pharmacological management
Lifestyle changes are recommended for children with established hypertension and pre- hypertension. Consider addressing the following:
• Sodium restriction • Weight loss • Exercise • Attention to other cardiovascular risk factors: Control of blood lipids, glycaemic control
in diabetes
Oral maintenance treatment
Aim to maintain BP <95th centile in children with uncomplicated primary hypertension with no
evidence of end organ damage and <90th centile in children with renal impairment (Chronic Kidney Disease [CKD] ≥ stage 2), diabetes or evidence of end organ damage. [1, 13]
Choice of oral agents (see Specific considerations for treatment of hypertension):
1. Angiotensin converting enzyme inhibitors (ACEI; e.g. enalapril/lisinopril) or angiotensin II receptor antagonists (ARB; losartan, irbesartan)
a. May cause hyperkalaemia. Monitor serum potassium; check levels within 7 days of starting or increasing dose
b. Avoid if renal artery stenosis suspected c. Avoid in the early period after renal transplantation
2. Beta blockers: Metoprolol has selective blockade and non-renal excretion. a. Use if concerns about the possibility of renal artery stenosis or ACEI/ARB
contraindicated 3. Calcium channel blockers: Amlodipine/ nifedipine 4. Consider diuretics if fluid overload is contributing
Once daily dosing schedules improve compliance
Emergency management of Hypertensive Crisis: Discuss with paediatric nephrologist
• Patients may require management on PICU/renal ward or appropriate HDU setting • Slow reduction over 72 hours to avoid sudden drop in perfusion pressure which may cause
catastrophic cerebral ischaemia. Aim to drop by no more than 25% of the overall planned BP reduction over the first eight hours of treatment [14]. Avoid mydriatics for fundoscopy so pupillary responses can be monitored
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 5 of 12
• Site 2 IV cannulae. One is used to deliver IV antihypertensive agent and the second to
deliver a 10ml/kg 0.9% sodium chloride bolus if the blood pressure falls significantly.
• The choice of IV agent should be the one with which the clinician is most familiar with and can include the following: Labetalol / Nicardipine / Sodium Nitroprusside. These agents should be administered using a sliding scale to titrate dose administered with BP, measured every 15 minutes (usually monitored via arterial line in patients on PICU) – liaise with nephrologist for details
Once control has been established with parenteral agents, convert to oral agents as above.
Specific considerations for treatment of hypertension
1. Following renal transplantation there is no evidence that any antihypertensive agent is better than any other but the use of angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists are not generally used in the first 3 months post transplant. [15] Calcium channel blockers are a sensible choice and there is evidence that use of these agents in the peri-operative period reduce the incidence of post-transplant acute tubular necrosis [16].
2. Phaeochromocytoma. This is characterised by episodic hypertension/palpitations and
sweating. Control of hypertension is required before surgery generally using alpha and then beta blockade.[17] This should be discussed with a consultant anaesthetist pre-operatively.
3. Renovascular disease. This is characterised by very high renin levels and may be secondary to renal artery stenosis or obstruction to vessels by cysts in polycystic kidney disease. In this situation, intra-glomerular pressure depends on efferent arteriolar constriction and therefore ACE inhibitors or angiotensin II receptor antagonists must be used with caution as these agents cause efferent arteriolar dilatation. Investigations may include: MRA/Angiography. Treatment: metoprolol / amlodipine / other.
4. Rare single gene disorders GRA (glucocorticoid remedial hyperaldosteronism), Gordons,
Liddle syndrome [18] and AME (apparent mineralocorticoid excess) are characterised by hypertension due to interruption of the renin-aldosterone axis. They are often associated with hypo- or hyperkalaemia and diagnosis is with a urine steroid profile. Treatment includes the use of potassium sparing diuretics.
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 6 of 12
References
1. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics (2004)114: 555-576
2. Patel NH, Romero SK , Kaelber DC. Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies. Open Access Emergency Medicine (2012); 4:85–92.
3. Lurbe, Empar, Cifkova, et al. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. Journal of Hypertension Sep 2009 vol 27: issue 9: p 1719-1742
4. Ingelfinder J. The Child or Adolescent with Elevated Blood Pressure. N Engl J Med 2014; 370: 2316-25
5. Jackson LV, Thalange NK, Cole TJ. Blood pressure centiles for Great Britain. Arch Dis Child (2007) 92: 298-303
6. Soergel M, Kirschstein M, Busch C, et al. Oscillometric twenty-four-hour ambulatory blood pressure values in healthy children and adolescents: a multicenter trial including 1141 subjects. J Pediatr (1997) 130: 178-184
7. Flynn JT. Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertension (2012); 14: 372-82
8. Butani L, Morgenstern BZ. Are pitfalls of oscillometric blood pressure monitoring preventable in children? Pediatr Nephrol (2003) 18: 313-8
9. Dionne J, Abitbol C, Flynn JT. Hypertension in Infancy: Diagnosis, management and outcome. Pediatr Nephrol (2012) 27: 17-32
10. Singh D, Akingbola O et al. Emergency Management of Hypertension in Children (2012). International Journal of Nephrology: Article ID 420247, 15 pages
11. Flynn JT, Daniels SR Update: Ambulatory Blood Pressure Monitoring in Children and Adolescents. A Scientific Statement From the American Heart Association. Hypertension. 2014; 63: 1116-1135.
12. Wühl E, Witte K, et al. German Working Group on Pediatric Hypertension. Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions. J Hypertens (2003); 21:2205-2206
13. National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NFK KDOQI) - Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease
14. Flynn JT, Tallus K. Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatr Nephrol. 2009;24(6):1101
15. Post operative care of the renal transplant recipient (2011). The Renal Association. 16. Shilliday I, Sherif M (2007) Calcium channel blockers for preventing acute tubular
necrosis in kidney transplant recipients. Cohrane Database Syst Rev 4: CD003421 17. S. G. Waguespack, T. Rich et al. A Current Review of the Etiology, Diagnosis, and
Treatment of Pediatric Pheochromocytoma and Paraganglioma (2011). JCEM; 95: 5 18. Warnock DG. Liddle syndrome: an autosomal dominant form of human hypertension.
Kidney Int (1998) 53: 18-24 19. Care Quality Commission Report July 2016: Identifying and managing clinical risks in
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 7 of 12
_____________________________________________________________________________
None
SAFETY Children with hypertensive crises should be managed in a suitable environment e.g. renal unit/HDU/PICU by experienced staff Blood Pressure should not be allowed to fall abruptly in hypertensive crisis and therefore short acting nifedipine should be avoided as its absorption and efficacy is unpredictable. These guidelines were produced in good faith by the authors reviewing available evidence. They were designed for use by medical and nursing staff at the Bristol Royal Hospital for Children for children under their care. Responsibility for use of these guidelines lies with the individuals caring for the patients.
QUERIES Contact the on-call Paediatric Nephrology registrar on bleep 2938 if any queries or to make a referral
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 8 of 12
Appendix 1: BP percentiles in children and adolescents [1] (based on mercury sphygomanometry)
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 9 of 12
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 10 of 12
Appendix 2: Estimated BP values after 2 weeks of age in infants from 26 to 44 weeks post conceptual age. [9]
Extended until May 2022
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 11 of 12
Renal
Author(s) Ann Ratcliffe (registrar) Jan Dudley, Carol Inward (Consultant Paediatric Nephrologists)
Page 12 of 12
Genetic