Arterial hypertension (hypertension) in children

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

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

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

The problem of prevention and treatment of arterial hypertension in children and adolescents occupies a central place in pediatric cardiology. This is due to the high prevalence of arterial hypertension, as well as the possibility of its transformation into ischemic and hypertensive diseases - the main causes of disability and mortality in the adult population. It should be emphasized that prevention and treatment of arterial 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 on the basis of three separate measurements, is equal to or exceeds the 95th percentile of the blood pressure distribution curve in the population for the corresponding age, sex and height. A distinction is made between primary (essential) and secondary (symptomatic) arterial hypertension.

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

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

Cardiologists in our country in most cases put an equal sign between the terms “primary (essential) arterial hypertension” and “hypertension”, which denote an independent disease, the main clinical manifestation of which is a chronic increase in systolic or diastolic blood pressure of unknown etiology.

ICD-10 code

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

Causes of arterial hypertension in children

In children under 10 years of age, increased blood pressure is most often caused by renal pathology. In older children, blood pressure increases during puberty (at 12-13 years for girls and at 13-14 years for boys), with obesity, the presence of autonomic dysfunction, left ventricular hypertrophy, and elevated cholesterol and triglyceride levels.

The cuff size for measurement should be approximately half the arm circumference or 2/3 of its length. For arm circumferences over 20 cm, use a standard cuff measuring 13 x 26 or 12 x 28 cm. For children under 10 years of age, a cuff measuring 9 x 17 cm can be used. B. Man et al. (1991) recommend one cuff for all children - measuring 12 x 23 cm.

Arterial hypertension should be considered as blood pressure values that are in the 95th percentile corridor, and when using sigma criteria - exceeding the norm by 1.5 a. Children usually complain of headaches, pain in the heart area, a feeling of shortness of breath, rapid fatigue, dizziness.

Causes of arterial hypertension in children and adolescents

Diseases	Nosological form, syndrome
Kidney diseases	Glomerulonephritis, pyelonephritis, renal structural abnormalities, hemolithin uremic syndrome (HUS), tumors, injuries, etc.
CNS pathology	Intracranial hypertension, hematomas, tumors, injuries, etc.
Vascular diseases	Coarctation of the aorta, renal artery anomalies, renal vein thrombosis, vasculitis, etc.
Endocrine diseases	Hyperthyroidism, hyperparathyroidism, Cushing's syndrome, primary hyperaldosteronism, etc.
Others	Functional hypertension 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)? Pathogenesis of arterial hypertension Classification of arterial hypertension Diagnosis of arterial hypertension

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Symptoms of arterial hypertension in children

A sudden and significant increase in blood pressure, which is accompanied by a vivid clinical picture, is usually called a hypertensive crisis. Neurological symptoms in the form of headache, "flies" or veils before the eyes, paresthesia, nausea, vomiting, weakness, transient paresis, aphasia and diplopia often dominate.

It is customary to distinguish between neurovegetative crisis (type 1, adrenal) and water-salt crisis (type 2, noradrenal). Type 1 crisis is characterized by sudden onset, agitation, hyperemia and moisture of the skin, tachycardia, frequent and profuse urination, predominantly increased systolic blood pressure with an increase in pulse. Type 2 crisis is characterized by gradual onset, drowsiness, adynamia, disorientation, pallor and puffiness of the face, general edema, predominantly increased diastolic blood pressure with a decrease in pulse.

A crisis accompanied by convulsions is also called eclampsia. Patients initially complain of a pulsating, sharp, bursting headache, psychomotor agitation, repeated vomiting without relief, sudden deterioration of vision, loss of consciousness and generalized tonic-clonic convulsions. Such an attack can end with a cerebral hemorrhage and the death of the patient. Such attacks are usually recorded in malignant forms of glomerulonephritis and in the terminal stage of chronic renal failure.

Symptomatic arterial hypertension

Methodology for determining and assessing blood pressure

Blood pressure is usually measured using a sphygmomanometer (mercury or aneroid) and a phonendoscope (stethoscope). The division value of the sphygmomanometer scale (mercury or aneroid) should be 2 mm Hg. The readings of the mercury manometer are assessed by the upper edge (meniscus) of the mercury column. Determining blood pressure using a mercury manometer is considered the "gold standard" among all methods of measuring blood pressure using other devices, since it is the most accurate and reliable.

High blood pressure is detected during preventive medical examinations in an average of 1-2% of children under 10 years of age and in 4.5-19% of children and adolescents aged 10-18 years (E. I. Volchansky, M. Ya. Ledyaev, 1999). However, hypertension develops later in only 25-30% of them.

Epidemiology of arterial hypertension (hypertension)

Treatment of arterial hypertension in children

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

For essential hypertension (including vegetative-vascular dystonia), the following can be prescribed:

• anaprilin - 0.25-1.0 mg/kg orally;
• isoptin (verapamil) - 5-10 mg/kg/day) orally in divided doses;
• nifedipine (corinfar) sublingually - 0.25-0.5 mg/kg (10 mg per tablet), can be chewed;
• amlodipine (Norvasc) - part of a 5 mg tablet;
• lasix (furosemide) - 0.5-1.0 mg/kg or hypothiazide - 1-2 mg/kg orally;
• reserpine (rauvazan and other drugs from the rauwolfia group) - 0.02-0.07 mg/(kg per day); adelfan is possible (part of a tablet);
• captopril (Capoten, etc.) orally - 0.15-0.30 mg/kg every 8-12 hours, enalapril (enap, ednit, etc.) - part of a tablet 1-2 times a day;
• you can combine capoten and corinfar, adding hypothiazide (in the absence of acute renal failure) or a beta-blocker; there are combined antihypertensive drugs containing a diuretic (adelfan ezidrex, cristepin, etc.);
• Sometimes dibazol, papaverine at a dose of 2-4 mg/kg orally, intramuscularly, intravenously, magnesium sulfate - 5-10 mg/kg 2-3 times a day intravenously or intramuscularly are used.

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

Treatment for hypertensive crisis in children

In an acute attack of arterial hypertension (crisis), it is necessary to reduce blood pressure within 1-2 hours to the "working" pressure (only in eclampsia can the rate of blood pressure reduction be increased, although this is also unsafe). Due to the threat of orthostatic collapse, patients need 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% solution of pyrroxane subcutaneously, intramuscularly or 10-20 mg orally;
• sedative therapy with tranquilizers (diazepam, etc.) is mandatory;
• diazoxide - 2-5 mg/kg intravenously by slow jet stream, can be repeated after 30 minutes (has a counter-insular effect);
• arfonad - 10-15 mg/(kg min) intravenously by drip under blood pressure monitoring;
• apressin (hydralazine) - 0.1-0.4 mg/kg intravenously, can be repeated after 4-6 hours;
• clonidine (clonidine) - 3-5 mcg/kg orally, or 0.25-1.0 mcg/kg intravenously by slow jet stream, or 0.05-0.1 mcg/(kg min) as an infusion; 1 ml of 0.01% clonidine (hemiton) solution contains 100 mcg;
• sodium nitroprussin (naniprus) - 0.1-2.0 mcg/(kg min) intravenously by drip or perlinganit - 0.2-2.0 mcg/(kg min) intravenously by drip.

In the neurovegetative form of crisis, atenolol (1 mg/kg) or clonidine (clonidine, etc.) at a dose of 10 mcg/kg orally, diazepam (0.2-0.5 mg/kg) and furosemide, lasix (0.5-1.0 mg/kg) orally or intramuscularly are used. In the water-salt form of crisis, lasix (2 mg/kg) or hypothiazide are used. In severe cases, sodium nitroprusside infusion (from 0.5 mcg/kg per minute) can be added to lasix. In case of loss of consciousness, convulsions, euphyllin can be additionally used - 4-6 mg/kg slowly intravenously and lasix (2 mg/kg). Potassium substitution should be carried out against the background of diuretic therapy.

Treatment for pheochromocytoma

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

In case of eclampsia against the background of acute renal failure or chronic renal failure, the following is prescribed:

• nifedipine - 0.5 mg/kg sublingually;
• diazoxide - 2-4 mg/kg intravenously over 30 sec;
• apressin (hydralazine) - 0.1-0.5 mg/kg intravenously by jet stream;
• anaprilin - 0.05 mg/kg intravenously by jet stream (to prevent reflex tachycardia with a sharp decrease in blood pressure);
• clonidine (clonidine) - 2-4 mcg/kg intravenously slowly (!) until the effect (1 ml of 0.01% solution contains 100 mcg);
• Lasix - 2-5 mg/kg intravenously.

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

In most cases, when blood pressure increases in children, the doctor has enough time to select the most effective drug, assessing its effect. Urgent measures are required when a threat of development or obvious symptoms of eclampsia (hypertension + convulsive syndrome) are detected in patients. But even in this case, the entire range of drugs listed should not be used at once. Taking into account the assessment of the results of previous therapeutic interventions, the doctor builds a program based on the "step by step" principle, striving to reduce blood pressure not to the notorious "norm", but to the most acceptable value in recent times, to which the patient has adapted during the course of the disease. It is important to remember that a sharp drop in blood pressure (by 2 times or more) can cause cerebral ischemia, kidneys and a new round of hypertension, which can cause acute heart failure.