Diagnosis
Definition of HTN in children and adolescents reviewed with the patient.
The goal of initial diagnostic evaluation will be to 1) Identify children with curable HTN who may have a curable disease, 2) Identify other comorbid risk factors (eg, obesity and dyslipidemia) for CVD) or diseases associated with an increased risk for CVD (eg, diabetes mellitus).
H&P
Common presentation.
-High BP in childhood commonly leads to HTN in adulthood. Discussed seriousness with this patient.
–Risk factors for primary HTN in children and adolescents reviewed.
-Will evaluate for causes of secondary HTN since they are more common in this population than in adults. Renal parenchymal disease and renovascular disease are the most common in the pediatric population.
-Will screen for other risk factors for cardiovascular disease, including diabetes mellitus and hyperlipidemia and also evaluate for target organ damage with a retinal examination and echocardiography.
Treatment
-Home BP cards provided with instructions to bring home BP for confirmation.
-Will order: CBC, CMP(BUN, Cr, electrolytes), urinalysis, Fasting blood glucose or A1C, fasting lipid panel, calcium, uric acid, renal U/S with doppler flow, Urine drug screen. Polysomnography to r/o OSA.
-Will start with lifestyle modification. Education provided.
-Will initiate antihypertensive pharmacotherapy for symptomatic hypertension, secondary hypertension, target organ damage, diabetes, or persistent hypertension despite nonpharmacologic therapy.
-ACT – ACEI / ARBs, CCB, & Thiazide diuretics will be used since they safe, effective, and well tolerated in children. BB if a compelling indication is present.
-Will consider referring the patient to get end-organ damage evaluation: Retinal evaluation, Echocardiography (to evaluate left ventricular mass).
-Will refer to sleep medicine for polysomnography as needed.
-Will refer to a pediatric nephrologist as needed.
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All children with confirmed HTN should be evaluated for secondary causes of HTN because they are more likely in them.
Why order calcium and uric acid for hypertensive child or adolescent?
High urinary excretion of uric acid combined with high excretion of calcium links kidney stone disease to familial hypertension (see Nephrol Dial Transplant (2002) 17 (2): 253-259.)
References:
Am Fam Physician. 2012 Apr 1;85(7):693-700. http://www.aafp.org/afp/2012/0401/p693.html
Nephrol Dial Transplant (2002) 17 (2): 253-259. https://www.ncbi.nlm.nih.gov/pubmed/11812875