Arterial hypertension (hypertension) in children

Currently, the pathology of the cardiovascular system - coronary heart disease and hypertension, called "diseases of civilization", firmly occupy the first place in the structure of morbidity and mortality in economically developed countries.

Arterial hypertension in children is the main risk factor for coronary heart disease, heart failure, brain diseases, renal failure, which is confirmed by the results of large-scale epidemiological studies.

Most researchers share the view that the conditions for the occurrence of cardiovascular diseases in adults exist already in childhood and adolescence. In connection with the insufficient effectiveness of preventive programs in adults, it is necessary to search for new preventive measures and to conduct them in younger age groups.

The problem of prevention and treatment of arterial hypertension in children and adolescents holds the main place in pediatric cardiology. This is due to the high prevalence of hypertension, as well as the possibility of its transformation into ischemic and hypertensive disease - the main causes of disability and mortality of the adult population. It should be emphasized that the prevention and treatment of hypertension in childhood is more effective than in adults.

Arterial hypertension is a condition in which the mean value of systolic blood pressure (SBP) and / or diastolic blood pressure (DBP) calculated from three separate measurements equals or exceeds the 95th percentile of the blood pressure distribution curve in the population for the corresponding age, sex and growth. There are primary (essential) and secondary (symptomatic) arterial hypertension.

Primary, or essential, arterial hypertension is an independent nosological unit. The main clinical symptom of this disease is an increase in SBP and / or DBP for unknown reasons.

Hypertensive illness in children is a chronic disease manifested by the syndrome of hypertension. The causes of which are not associated with specific pathological processes (in contrast to symptomatic arterial hypertension). This term was proposed by G.F. Lang, and corresponds to the notion of "essential arterial hypertension" used in other countries.

Cardiologists in our country in most cases equate the terms "primary (essential) arterial hygiene" and "hypertonic disease", denoting an independent disease whose main clinical manifestation is a chronic increase in systolic or diastolic arterial pressure of unknown etiology.

ICD-10 code

• 110 Essential (primary) hypertension.
• 111 Hypertensive heart disease (hypertensive disease with predominant heart disease).
  • 111.0 Hypertensive (hypertensive) disease with predominant heart involvement with (congestive) heart failure.
  • 111.9 Hypertensive (hypertensive) disease with predominant heart damage without (congestive) heart failure.
• 112 Hypertensive (hypertensive) disease with predominant kidney damage.
  • 112.0 Hypertensive (hypertensive) disease with primary renal damage with renal insufficiency.
  • 112.9 Hypertensive (hypertensive) disease with predominant renal involvement without renal failure.
• 113 Hypertensive (hypertensive) disease with predominant involvement of the heart and kidneys.
  • 113.0 Hypertensive (hypertensive) disease with predominant heart and kidney damage with (congestive) heart failure.
  • 113.1 Hypertensive (hypertensive) disease with primary renal damage and renal insufficiency.
  • 113.2 Hypertensive (hypertensive) disease with predominant heart and kidney damage with (congestive) heart failure and renal insufficiency.
  • 113.9 Hypertensive (hypertensive) disease with predominant involvement of the heart and kidneys, unspecified. 115 Secondary hypertension.
• 115.0 Renovascular hypertension.
• 115.1 Hypertension secondary to other renal lesions.
• 115.2 Hypertension secondary to endocrine diseases.
• 115.8 Other secondary hypertension.
• 115.9 Secondary hypertension, unspecified.

Causes of hypertension in children

In children under 10 years, increased arterial pressure is more often due to renal pathology. In older children, blood pressure rises during puberty (at 12-13 years in girls and at 13-14 years in boys), with obesity, autonomic dysfunction, left ventricular hypertrophy, elevated cholesterol and triglycerides.

The cuff size for measurement should be about half the circumference of the shoulder or 2/3 of its length. With a shoulder circumference of more than 20 cm, a standard cuff of 13 x 26 or 12 x 28 cm is used. In children under 10 years old, a cuff of 9x17 cm size can be used. B. Mann et al. (1991) recommend for all children one cuff - 12 x 23 cm in size.

To arterial hypertension should be attributed to the values of blood pressure, located in the 95th percentile corridor, and when using sigmal criteria - exceeding the norm by 1.5 a. Children at the same time usually complain of a headache, pain in the heart, a sense of lack of air, quick fatigue, dizziness.

The causes of hypertension in children and adolescents

Diseases	Nosological form, syndrome
Kidney Diseases	Glomerulonephritis, pyelonephritis, kidney structure anomalies, hemolytic-uremic syndrome (HUS), tumors, trauma, etc.
Pathology of the central nervous system	Intracranial hypertension, hematomas, tumors, trauma, etc.
Diseases of blood vessels	Coarctation of the aorta, abnormalities of the renal arteries, thrombosis of the renal veins, vasculitis, etc.
Endocrine diseases	Hyperthyroidism, hyperparathyroidism, Cushing's syndrome, primary hyperaldosteronism, and others.
Other	Functional AH Neuroses, psychogenic and neurovegetative disorders

Cuff width for children (WHO recommendation)

Age, years	Cuff size, cm
Up to 1	2.5
1-3	5-6
4-7	8-8.5
8-9	9
10-13	10
14-17	13

What causes arterial hypertension (hypertension)? The pathogenesis of hypertension Classification of arterial hypertension Diagnosis of arterial hypertension

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Symptoms of arterial hypertension in children

Sudden and significant increase in blood pressure, which is accompanied by a bright clinical picture, is usually called a hypertensive crisis. Most often, neurological symptoms predominate in the form of headache, "flies" or shroud before the eyes, paresthesias, nausea, vomiting, weakness, passing paresis, aphasia and diplopia.

It is accepted to distinguish between neurovegetative crisis (type 1, adrenal) and water-salt (2 nd type crisis, noradrenal). For a crisis of type 1, a sudden onset, excitation, hyperemia and skin moisture, tachycardia, rapid and profuse urination, a predominant increase in systolic blood pressure with an increase in pulse pressure are characteristic. At the 2nd type of crisis, there is a gradual onset, drowsiness, adynamia, disorientation, pale and puffy face, general puffiness, a predominant increase in diastolic blood pressure with a decrease in pulse.

Crisis, which is accompanied by convulsions, is also called eclampsia. Patients at first complain of a pulsating, acute, bursting headache, there are psychomotor agitation, repeated vomiting without relief, sudden deterioration of vision, loss of consciousness and generalized tonic-clonic convulsions. End such an attack can be a hemorrhage in the brain, the death of the patient. Usually, such seizures are recorded in malignant forms of glomerulonephritis and in the terminal stage of CRF.

Symptomatic arterial hypertension

The procedure for determining and assessing the value of blood pressure

Arterial pressure is usually measured with a sphygmomanometer (mercury or aneroid) and a phonendoscope (stethoscope). The scale of the sphygmomanometer scale (mercury or aneroid) should be 2 mm Hg. The mercury manometer reading is evaluated on the upper edge (meniscus) of the mercury column. The determination of blood pressure using a mercury manometer is considered a "gold standard" among all methods of measuring blood pressure using other devices, since it is the most accurate and reliable.

Elevated blood pressure is revealed in preventive medical examinations on average in 1-2% of children under 10 years of age and in 4.5-19% of children and adolescents aged 10-18 years (EI Volchanskii, M. Ya. Ledyaev , 1999). However, hypertensive disease develops later only in 25-30% of them.

Epidemiology of arterial hypertension (hypertensive disease)

Treatment of arterial hypertension in children

The main antihypertensive drugs are diuretics, beta-adrenoblockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II antagonists and a-adrenergic blockers. 

With essential hypertension (including vegetovascular dystonia), you can designate: 

• anaprilin - 0.25-1.0 mg / kg orally; 
• isoptin (verapamil) - 5-10 mg / kgs) inside fractional;
• nifedipine (Corinfar) under the tongue - 0,25-0,5 mg / kg (in the tablet 10 mg), can be chewed;
• amlodipine (norvask) - part of the tablet 5 mg; 
• Lasix (furosemide) 0.5-1.0 mg / kg or hypothiazide 1-2 mg / kg orally; 
• reserpine (rauvazan and other preparations from the rauwolfia group) - 0,02-0,07 mg / (kg day); can be adelphan (part of the pill); 
• captopril (kapoten, etc.) inside - 0,15-0,30 mg / kg every 8-12 hours, enalapril (enap, ednit, etc.) - part of the pill 1-2 times a day; 
• it is possible to combine hood and corinfar by adding hypothiazide (in the absence of arrester) or beta-blocker; there are combined antihypertensive drugs containing a diuretic (adelfan ezidreks, kristepin, etc.); 
• sometimes apply dibazol, papaverine in a dose of 2-4 mg / kg orally, intramuscularly, intravenously, sulfurous magnesia - 5-10 mg / kg 2-3 times a day, intravenously or intramuscularly. 

Treatment of arterial hypertension Treatment of hypertensive crisis Prevention of arterial hypertension

Treatment for hypertensive crisis in children

In case of an acute attack of arterial hypertension (crisis), it is necessary to lower blood pressure within 1-2 h to "working" pressure (only with eclampsia, the rate of blood pressure reduction may be increased, although this is unsafe). Due to the threat of orthostatic collapse, patients need a strict bed rest for at least 2 hours after the administration of one of the following drugs: 

• You can start with beta-blockers (atenolol at a dose of 0.7 mg / kg orally); - for older children 1-2 ml of 1% pyrrolean solution subcutaneously, intramuscularly or 10-20 mg orally; 
• Sedation therapy with tranquilizers (diazepam, etc.) is mandatory; 
• diazoxide - 2-5 mg / kg intravenously struino slowly, can be repeated after 30 minutes (has a counterinsular effect); 
• arfonade - 10-15 mg / (kg min) intravenously drip under the monitored blood pressure control; 
• apressin (hydralazine) - 0.1-0.4 mg / kg intravenously, can be repeated after 4-6 hours; 
• clonidine (clonidine) 3-5 μg / kg or 0.25-1.0 μg / kg intravenously, slowly, or 0.05-0.1 μg / (kg min) as an infusion; in 1 ml of a 0.01% solution of clonidine (hemithon) contains 100 μg; 
• nitropruss sodium (naniprus) 0.1-2.0 μg Dkgmin) intravenously drip or perlignanite 0.2-2.0 μg / (kg min) intravenously drip.

Neurovegetative form of the crisis uses atenolol (1 mg / kg) or clonidine (clonidine, etc.) at a dose of 10 μg / kg orally, diazepam (0.2-0.5 mg / kg) and furasemide, lasix (0.5- 1.0 mg / kg) orally or intramuscularly. In the water-salt form of the crisis, lasix (2 mg / kg) or hypothiazide is used. In severe course, a sodium nitroprusside infusion (from 0.5 μg / kg per minute) can be added to the lasix. With loss of consciousness, seizures, you can additionally use euphyllin - 4-6 mg / kg slowly intravenously and lasix (2 mg / kg). Against the backdrop of diuretic therapy should be subsidized potassium. 

Treatment with pheochromocytoma

• prazosin - 1-15 mg / kg or phenethylamine - 0.1 mg / kg (maximum 5 mg / day) intravenously. 

In case of eclampsia, on the background of acute renal failure or chronic renal failure, 

• nifedipine - 0.5 mg / kg under the tongue; 
• diazoxide - 2-4 mg / kg intravenously for 30 seconds; 
• apressin (hydralazine) - 0.1-0.5 mg / kg intravenously sprayed; 
• anaprilin - 0.05 mg / kg intravenously struino (to prevent reflex tachycardia with a sharp decrease in blood pressure); 
• clonidine (clonidine) - 2-4 μg / kg intravenously slowly (!) to the effect (in 1 ml of 0.01% solution contains 100 μg); 
• Lasix - 2-5 mg / kg intravenously.

If there is no effect, urgent hemofiltration, hemodialysis is necessary.

In most cases, with a rise in blood pressure in children, the doctor has enough time to choose the most effective drug, assessing its effect. Immediate measures are required if patients develop a threat of development or obvious symptoms of eclampsia (hypertension + convulsive syndrome). But in this case, do not immediately apply the entire range of drugs listed. Taking into account the evaluation of the results of previous medical effects, the doctor builds the program on a "step by step" basis, aiming to lower BP not to the notorious "norm", but to the most acceptable value for the patient to which the patient adapted in the course of the disease. It is important to remember that a sharp fall in blood pressure (by 2 times or more) can cause brain, kidney and cerebral ischemia, which can cause OCH.