Treatment of arterial hypertension in children

The goal of treating arterial hypertension in children is to achieve a steady normalization of blood pressure to reduce the risk of early cardiovascular disease and mortality. The objectives of treatment include the following:

• reaching the target level of blood pressure, which should be less than the 90th percentile for a given age, sex, and height;
• improving the quality of life of the patient;
• prevention of target organ damage or reverse development of existing changes;
• prophylaxis of hypertensive crises.

General principles of conducting children and adolescents with arterial hypertension have been developed.

• If a child or adolescent has blood pressure that corresponds to the notion of "high normal blood pressure", drug therapy is not performed; recommend non-drug treatment and supervision.
• If the child's or adolescent's blood pressure is identified, which corresponds to the notion of "grade I hypertension," medication is prescribed if the non-drug treatment is ineffective within 6-12 months.
• If a second-degree arterial hypertension is detected in a child or adolescent, drug treatment is prescribed concomitantly with non-drug therapy.
• If a teenager 16 years of age and older is diagnosed with a high risk group, drug therapy is prescribed concomitantly with non-drug therapy, regardless of the degree of hypertension.
• Before the start of drug treatment it is desirable to conduct daily monitoring of blood pressure: if it is found that the time index of hypertension in the day or night exceeds 50%, this serves as an indication for the conduct of drug treatment; if the hypertension time index does not exceed 50%, it is advisable to continue non-pharmacological therapy.
• The choice of the drug is carried out taking into account the individual characteristics of the patient, age, concomitant conditions (obesity, diabetes, the state of the autonomic nervous system, myocardial hypertrophy of the left ventricle, the functional state of the kidneys, etc.).
• Treatment begins with a minimum dose of a single drug to reduce adverse side effects; if an insufficient hypotensive effect is noted with good tolerability of the drug, it is advisable to increase its dose.
• In the absence of an antihypertensive effect or a poor tolerance of the drug, a replacement for a drug of another class is carried out.
• It is desirable to use long-acting drugs that provide blood pressure control for 24 hours with a single dose.
• If the monotherapy is ineffective, it is possible to use combinations of several drugs, preferably in small doses.
• Evaluation of the effectiveness of the antihypertensive drug is carried out 8-12 weeks after the start of treatment.
• The optimal duration of drug therapy is determined individually in each case; the minimum duration of drug treatment is 3 months, preferably treatment for 6-12 months.
• With adequately selected therapy after 3 months of continuous treatment, it is possible to gradually reduce the dose of the drug until it is completely canceled, with the continuation of non-drug treatment with a stable normal blood pressure; control over the effectiveness of non-pharmacological treatment is carried out once in 3 months.

Non-drug treatment of hypertension in children

Until now, the issue of the need for regular medication in the labile course of the disease, the most characteristic of childhood and adolescence, remains debated. According to the conclusion of WHO experts, non-pharmacological methods for treating the labile form of arterial hypertension in children and adolescents can be recommended as the main and even the only methods of treatment of arterial hypertension in children and adolescents.

Non-drug treatment should begin with the normalization of the regimen of the day. Mandatory components of the regime of the day should be morning exercises, alternating mental load with exercise, walks at least 2-3 hours a day, night sleep not less than 8-10 hours. It is necessary to limit the viewing of television programs and classes on the computer (up to 30-40 minutes in day). It is recommended to increase the physical activity of the child, include swimming, skiing, skating, cycling, outdoor games.

Arterial hypertension I degree in the absence of organic lesions or concomitant cardiovascular diseases can not be an obstacle to participation in sports. Every 2 months, blood pressure should be measured to assess the effect of exercise on its level.

Restrictions on sports and other activities should concern only a small number of people with hypertension of the second degree. With arterial hypertension II degree, the participation of children and adolescents in sports competitions is limited.

Treatment of autonomic dysfunction begins with phyto- and physiotherapy.

Phytotherapy includes sedative herbs (sage, hawthorn, motherwort, valerian, St. John's wort, ledum, peony), marsh swine, leaf of euchemia and sculpin, diuretic herbs (cranberry leaf, bearberry, birch buds). Phytotherapy courses are prescribed for 1 month each quarter.

Assign physiotherapeutic procedures with sedative, hypotensive, spasmolytic effects: galvanization, diathermy of the sinocarotid zone, Vermel's electrophoresis (with 5% sodium bromide solution, 4% magnesium sulfate, 2% aminophylline solution, 1% papaverine solution), electrosleep with pulse frequency 10 Hz. It is possible to designate one of the above procedures or use two in sequence. Use massage, magnetotherapy of the collar zone.

Water procedures include carbonic, sulfide baths (with sympathicotonia), salted-coniferous baths (with vagotonia), Charcot douche, fan, circular shower (for normalization of vascular tone).

With ineffectiveness of the normalization of the regimen of the day and non-pharmacological methods of treatment of hypertension, the purpose of basic vegetotropic therapy, including vascular and nootropic drugs, is indicated.

Nootropic, or GABA-ergic, drugs affect the brain's y-aminobutyric acid system and are effective as neurotropic drugs.

Gamma-aminobutyric acid (aminalon, 1 t = 0.25 g) eliminates cerebral circulation disorders, improves the dynamics of the nervous processes in the brain, improves thinking, memory, and has a mild psycho-stimulating effect. Assign 1 tablet 3 times a day.

Aminophenylbutyric acid (phenibut, 1 t = 0.25 g) has tractivizing activity, reduces tension, anxiety, improves sleep. Assign 1 t 2-3 times a day.

Hopanthenic acid (pantogam, 1 t - 0.25 g) improves metabolic processes, increases resistance to hypoxia, has an antihypertensive effect, reduces motor excitability, activates mental activity, physical performance. Assign 1 tablet 3 times a day.

Preparations are prescribed as monotherapy for at least 1 month, alternation of drugs is possible for 1 month, combination with vascular agents is more effective. The courses are held 2 times a year.

Preparations that improve cerebral hemodynamics, eliminate headache, dizziness, memory loss. Prescribe courses as monotherapy for at least 1 month, alternating drugs for 1 month.

Methods of prescribing drugs that improve cerebral hemodynamics

A drug	Form of issue	Dose	Multiplicity of reception per day
Oxibrall	Syrup 60 or 120 ml Retard Capsules 30 mg	5-10 ml syrup 1 capsule retard	3 1
Ginkgo biloba leaves extract (bilobyl)	Tablets of 40 mg	1 tablet	3
Vinpocetine (Cavinton)	Tablets of 5 mg each	1 tablet	?
Cinnarizine	Tablets of 25 mg	1 tablet	2

Medical treatment of hypertension in children

Indications for drug-induced hypotensive therapy in adolescents depend on the degree of hypertension. Arterial hypertension II degree - an absolute indication for the appointment of antihypertensive therapy.

With arterial hypertension I degree hypotensive therapy is prescribed in the following situations:

• there are symptoms of target organ damage;
• Non-pharmacological therapy is ineffective for more than 6 months;
• the symptoms of a high risk of developing cardiovascular diseases (dyslipoproteinemia, insulin resistance, obesity, hereditary predisposition to hypertension, hypertensive crises) have been identified.

A large but insufficiently investigated problem is the possibility of using modern antihypertensive drugs used to treat adult patients with hypertension in childhood. Currently, numerous clinical studies conducted in adults with hypertension have shown that regular use of antihypertensive drugs reduces mortality and the risk of myocardial infarction, stroke, heart failure. At present, there are no results of long-term follow-up of children with high blood pressure who could demonstrate how high blood pressure in childhood affects mortality in adulthood. For the treatment of hypertension in childhood, five main groups of antihypertensive drugs are used, most effective in adults: diuretics, beta-blockers. ACE inhibitors, slow calcium channel blockers, angiotensin II receptor antagonists. Over the past five years, several clinical studies have been carried out on the potential for use of antihypertensive drugs in childhood. Safety and efficacy have been shown to reduce the blood pressure of such drugs as irbesartan, enalapril, felodipine. Multicenter trials on the safety and efficacy of the use of ACE inhibitors (fosinopril), angiotensin II receptor antagonists (losartan) in adolescents have been completed.

Beta-adrenoblockers are divided into nonselective, blocking beta1 and beta2-adrenoreceptors, for example propranolol (obzidan, inderal), and selective, blocking only beta1-adrenergic receptors. Some beta-blockers are characterized by their own (internal) sympathicomimetic activity, manifested along with beta-blocking action by a weak agonistic effect on the same receptors. Depending on the internal sympathicotonic activity, beta-blockers are divided into two subgroups:

• without internal sympathicomimetic activity, they include metoprolol, atenolol, betaxolol (lokren);
• with internal sympathicomimetic activity.

Beta-adrenoblockers have negative chrono-, dromo-, batmo-, and inotropic properties, increase the sensitivity of the baroreflex, reduce OPSS, inhibit the activity of the sympathetic nervous system, reduce renin secretion in the kidney, inhibit the formation of angiotensin II in the vascular wall, enhance the secretion of the atrial natriuretic factor, inhibit secretion of T ₄, insulin.

Methods for assigning major beta-blockers

Preparations	Dose for children	Dose for teenagers	Initial dose per day	The maximum dose per day	Multiplicity of reception per day
Atenolol	0,8-1,0 mg / kg	0.8 mg / kg	0.5-1.0 mg / kg	From 2.0 mg / kg to 100 mg	2
Metoprolol (betalk)	-	50-100 mg	1.0-2.0 mg / kg	From 6.0 mg / kg to 200 mg	2
Propranolol (inderal, obzidan)	0.5-1.0 mg / kg	0.5-1.0 mg / kg	1.0-2.0 mg / kg	From 4.0 mg / kg to 200 mg	3
Bisoprolol (Concor)	-	0.1 mg / kg	2.5 mg	10 mg	1

The main indications for the appointment of beta-blockers are a stable form of arterial hypertension combined with hyperkinetic type of hemodynamics, tachycardia, excessive sympathicotonic influences.

The purpose of the drugs requires the control of the level of glucose, lipids in the blood, ECG monitoring every 4 weeks after the start of treatment. A regular assessment of the patient's emotional state and muscle tone is necessary.

The main side effects of beta adrenoblockers are bradycardia, AV blockade, depression, emotional lability, insomnia, memory impairment, fatigue, bronchospastic reactions, hyperglycemia, hyperlipidemia, muscle weakness, impaired potency in young men.

Beta-adrenoblockers are contraindicated in obstructive lung diseases, conduction disorders, depression, hyperlipidemia, diabetes mellitus. In addition, their use is undesirable in hypertension in athletes and physically active patients, in sexually active young men.

ACE inhibitors block the conversion of angiotensin I into angiotensin II in blood and tissues, inhibit the breakdown of bradykinin, stimulate the synthesis of vasodilating prostaglandins, endothelial factors, reduce the activity of the sympathetic nervous system and the level of aldosterone in the blood, and act on the pressor natriuretic hormone. The pharmacodynamic effects of ACE inhibitors include an antihypertensive effect due to dilated arteries and veins (with no effect on heart rate and cardiac output), increased sodium excretion by the kidneys (associated with renal vasodilation), decreased pre- and post-loading on the heart, improved diastolic function of the left ventricle, influence on growth factors, reduction of left ventricular hypertrophy, vascular wall hypertrophy. Drugs improve the quality of life, withdrawal syndrome is not typical for them.

Indications for the appointment of ACE inhibitors: hypokinetic type of hemodynamics, increased plasma renin activity, systolic-diastolic arterial hypertension, diabetes mellitus.

Methods of administration of the main inhibitors of angiotensin converting enzyme

Preparations	Dose for children	Dose for teenagers	Initial dose	The maximum dose per day	Multiplicity of reception per day
Captopril	0.05-0.1 mg / kg	37.5-75 mg	0,3-0,5 mg / kg per reception	6 mg / kg	3
Enalapril	0.1-0.2 mg / kg	5-40 mg	From 0.08 mg / kg to 5 mg per day	From 0.6 mg / kg to 40 mg	1-2
Fosinopril	0.05-0.1 mg / kg	5-20 mg	From 0.1 mg / kg to 10 mg per day	40 mesh	1
Lizinopril (diroton)	-		From 0.07 mg / kg to 5 mg per day	From 0.6 mg / kg to 40 mg	1-2

The main side effects of drugs are the occurrence of "first-dose hypotension", hyperkalemia, the appearance of dry cough, it is extremely rare for the appearance of azotemia, Quincke edema. Contraindications to the appointment of drugs - pregnancy, hyperkalemia, stenosis of the renal arteries.

Blockers of slow calcium channels - a large group of drugs, very heterogeneous in chemical structure and pharmacological properties, which have a competitive effect on the potential-dependent calcium channels. According to their chemical structure, they are divided into three groups: phenylalkylamine derivatives (verapamil, gallopamil), benzothiazepine derivatives (diltiazem, kleshnazem), dihydropyridine derivatives (nifedipine, amlodipine, felodipine).

At the present time in the treatment of hypertension in children and adolescents use dihydro-pyridine drugs. They differ in vasoselectivity, they do not have a negative inotoropic and dromotropic effect. At the heart of the antihypertensive effect of blockers of slow calcium channels lies their ability to cause vasodilation as a result of inactivation of the potential-dependent calcium channels of the vascular wall and a decrease in OPSS. Among the preparations of dehydropyridine blockers of slow calcium channels, vasoselectivity is highly amlodipine, isradipine / felodipine.

Indications for the appointment of blockers of slow calcium channels - low renin activity, the need for a combination of antihypertensive therapy with NSAIDs, ineffectiveness of ACE inhibitors, contraindications to the appointment of beta-blockers. Blockers of slow calcium channels are the drugs of choice for patients with dyslipoproteinemia and impaired renal function. The main side effects are dizziness, facial hyperemia, peripheral edema, bradycardia, AV blockade (nondihydropyridine), gastrointestinal disorders. Contraindications to the appointment of blockers of slow calcium channels - conduction disorders.

Two forms of nifedipine are available: with rapid release and sustained release. Nifedipine (10 mg tablets) with rapid release begins to act very quickly, but is characterized by a short half-life in blood plasma (2-7 hours), which makes it difficult to use for long-term therapy. It is advisable to use the drug for cupping crises (single dose of 10 mg). Nifedipine (osmadalate - 10 mg tablets) with sustained release has a significantly longer half-life of the drug in plasma (12 to 24 hours), and therefore it is used for the therapy of hypertension.

Methods for assigning major slow calcium channel blockers

A drug	Initial dose per day	The maximum dose per day	Multiplicity of appointment per day
Amlodipine (norvasc)	2.5-5 mg	5 mg	1 reception for children> 6 years
Felodipine (captive)	2.5 mg	10 mg	1
Isradipine	0,15-0,2 mg / kg	From 0.8 mg / kg to 20 mg	2
Nifedipine (osmo-adalate)	0,25-0,5 mg / kg	From 3 mg / kg to 120 mg	1-2

The mechanism of action of angiotensin II receptor antagonists is associated with angiotensin blockade regardless of the pathway of its formation, which ensures their high efficacy and good tolerability. Unlike the administration of ACE inhibitors, the administration of these drugs is not accompanied by a side effect such as coughing. The drugs are prescribed in case of side effects with the use of ACE inhibitors. Intolerance drugs of other groups. Side effects: dizziness, headache, weakness, recurrent swelling. Contraindications: hypersensitivity, hyperkalemia, dehydration, pregnancy. Patients with liver disease should be given smaller doses. With caution apply for bilateral renal artery stenosis or renal artery stenosis of the only kidney (increased risk of renal dysfunction), with moderate and severe renal dysfunction, congestive heart failure.

Methods of administration of the main antagonists of angiotensin II receptors

A drug	Initial dose per day	The maximum dose per day	Multiplicity of reception per day
Irbesartan (for children over 6 years old)	75-150 mg	150-300 mg (for patients older than 13 years)	1
Losartan	From 0.7 mg / kg to 50 mg	From 1.4 mg / kg to 100 mg	1

The hypotensive effect of diuretics is due to a decrease in OPSS, a vascular reaction to vasoactive substances. As hypotensive agents, thiazide and thiazide-like diuretics are used in low doses, effective and most cost-effective antihypertensives, which can be used both for monotherapy and in combination with other drugs. High doses are not used because of the possibility of developing complications and side effects. The main side effects of diuretics - hypokalemia, hyperuricemia, hyperlipidemia, hyperglycemia, a violation of potency in young men, orthostatic hypotension. Special indications for the appointment of diuretics: metabolic syndrome (MS), obesity, diabetes mellitus, increased sensitivity to table salt, left ventricular myocardial hypertrophy, systolic hypertension. The following are the recommended drugs.

• Hydrochlorothiazide (hypothiazide) - a tablet of 25 mg. Children are prescribed 1-3 mg / kg per day inside in 2 doses; adolescents - 12.5-25 mg orally 1-2 times a day. It should be used with caution in connection with the possibility of side effects, it is necessary to control the level of potassium, glucose, blood lipids, ECG monitoring every 4 weeks of treatment. Low doses of the drug (6.25 mg once a day) increase the effectiveness of other antihypertensive drugs without undesirable metabolic effects.
• Indapamide (1.5 mg tablets) with sustained release (arifon retard). Older children and adolescents are prescribed 1.5 mg orally once a day. Do not increase the dose. It is necessary to control the level of potassium in the blood, ECG monitoring every 8 weeks of treatment.
• Loop diuretics (furosemide) are used only in the treatment of hypertensive crises and with concomitant renal failure. Newborns are prescribed 1-4 mg / kg orally 1-2 times a day or 1-2 mg / kg intravenously or intramuscularly 1-2 times a day; children - 1-3 mg / kg per day (up to 40 mg per day) orally 1-2 times or 1-2 mg / kg intravenously or intramuscularly 1-2 times a day; adolescents - 20-40 mg orally once a day.

Prognosis of hypertension

The stability of arterial pressure indices allows one to predict how much the values of the elevated blood pressure detected in children and adolescents can be extrapolated to the level of arterial pressure in adults. Information on the stability of the blood pressure level is provided by long (prospective) studies.

When observing the level of arterial pressure in more than 6,600 children for 6 years with an interval of 2 years, the low stability of blood pressure indicators was established. The stability factor (the correlation between the blood pressure value during the first and subsequent measurements) for systolic blood pressure was 0.25, for diastolic blood pressure -0.18. In this regard, a single increase in blood pressure can not be considered as an arterial hypertension and a risk factor for coronary heart disease, it is necessary to observe in dynamics. When comparing the blood pressure level measured at 9 years and 30 years, SBP resistance was observed only in men, and DBP resistance was absent in both men and women. At the same time, with a 10-year observation of children with arterial hypertension, the resistance coefficient was significantly higher: for SBP it was 0.32, for DBP - 0.53.

Arterial pressure remains elevated in 33-42% of adolescents, in 17-25% of hypertension acquires a progressive course, i.e. Every third child with hypertension may develop hypertension in the future.

When observing the natural course of juvenile arterial hypertension for 33 years, spontaneous normalization of arterial pressure was noted only in 25% of cases. Thus, there is a dissociation between the low stability of normal blood pressure values and the higher stability of elevated blood pressure values. In this regard, it is necessary to have a long-term follow-up of children with repeated increases in blood pressure in order to prevent the development of hypertension and its transformation into hypertensive disease.