Arterial hypertension in children: causes and diagnosis

General information about the disease

Arterial hypertension (AH) affects a significant portion of the world's population (1 billion people, according to WHO).

Arterial hypertension is divided into two groups.

Essential (primary) hypertension

This is an independent pathology that develops against the background of the patient’s general good health. Causes:

• heredity;
• lack of physical activity;
• passive lifestyle;
• improper study and rest regime;
• constant stress, which develops against the background of increased psychological stress (poor relationships with peers, poor performance despite great effort, etc.);
• disrupted metabolic processes. Source: I.P. Bryazgunov Primary arterial hypertension in children and adolescents // Issues of modern pediatrics, 2003, vol. 2, no. 3, pp. 68-71

Essential hypertension usually develops after 6 years of age. Often the impetus for the development of the disease is stress at school, problems in the family, or a strong quarrel. Children who have this disease are prone to increased anxiety, depression, and fearfulness.

Hypertension also occurs in adolescents who start smoking and drinking alcohol.

Symptomatic (secondary) hypertension

This form of pathology manifests itself against the background of:

• kidney diseases;
• disturbances in the functioning of the endocrine system;
• taking medications that interfere with maintaining blood pressure at the desired level and/or raise it;
• neurological disorders.

The disease is dangerous due to many complications, including:

• hypertensive crisis (can lead to loss of consciousness);
• blood clots in blood vessels;
• heart failure;
• stroke;
• myocardial infarction;
• deterioration of vision due to damage to the blood vessels of the fundus;
• renal failure.

In the vast majority of cases, children develop hypertension of the second type - symptomatic . Its main cause at an early age is kidney pathologies (anomalies in vascular development, autoimmune pathologies, underdeveloped kidneys, Wilms tumor). Also common in children are: bronchopulmonary dysplasia, obstructive sleep apnea syndrome (stopping for 10 seconds or more or a sharp slowdown in breathing during sleep against the background of snoring), closure or narrowing of the aortic lumen. Source: N.N. Arkhipova Secondary arterial hypertension in children // Practical Medicine, 2011, No. 5(53), pp. 20-24

Among the youngest children at risk are children with diseases of the ENT organs (chronic tonsillitis, adenoids), obesity, and pathologies of the skull. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860989/ Anusha Uddaraju and C. Venkata S. Ram Hypertension in children, not a “small” problem // Indian Heart J. 2013 Sep; 65(5): 501–503.

Often in children and adolescents, blood pressure rises sharply, which can be accompanied by convulsions, headache, nausea and vomiting. Such an attack can easily be confused with a migraine, which the child may “outgrow,” so parents are not always vigilant enough. It is very important to measure blood pressure at such times.

Figures of increased systolic pressure at different ages

Remember that a home blood pressure monitor does not give accurate results. Therefore, if you have symptoms, you should consult a doctor, and in case of a severe attack, call an ambulance.

ARTERIAL HYPERTENSION IN CHILDREN

ANTsygin, Research Institute of Pediatrics, Russian Academy of Medical Sciences Definition

Arterial hypertension (AH) in children is understood as a persistent increase in blood pressure (BP) above the 95th percentile for a specific age and gender of the child. This indicator is assessed using special tables or nomograms, however, to a certain extent, normal blood pressure indicators depend on the height and weight of the child. It is easier to establish the presence of hypertension using the criteria proposed by the Second Task Force in Blood Pressure Control in Children; 1987 Table 1) [1].

In some children, elevated blood pressure is a consequence of psycho-emotional stress when visiting a medical facility and is transient in nature. In this regard, at least three ambulatory blood pressure monitoring is recommended, and it should be measured in a calm environment, with the child in a comfortable sitting or lying position. According to various sources, hypertension is registered in 1–3% of all children.

Causes of hypertension in children

In most cases, hypertension in children is secondary to kidney disease, cardiovascular, renovascular, and endocrine diseases. However, in adolescents, in the absence of signs of these diseases, a diagnosis of essential hypertension can be made, especially if a moderate increase in blood pressure is combined with excess body weight and/or a family predisposition to hypertension. More severe hypertension, as a rule, indicates a causative role of kidney damage. The main causes of secondary hypertension in childhood are listed below [2].

Kidney diseases Renovascular:

renal artery stenosis;
renal artery thrombosis; renal vein thrombosis. Parenchymal:
acute glomerulonephritis;
chronic glomerulonephritis; chronic pyelonephritis; reflux-nephropathy; polycystic kidney disease; kidney hypoplasia; hemolytic-uremic syndrome; Wilms tumor; hydronephrosis; systemic lupus erythematosus; condition after kidney transplantation. Cardiovascular diseases:
coarctation of the aorta;
Takayasu's disease (aortoarteritis). Endocrine diseases:
pheochromocytoma;
neuroblastoma; hyperthyroidism; congenital adrenal hyperplasia; primary hyperaldosteronism; Cushing's syndrome (endogenous or exogenous). Diseases of the central nervous system:
increased intracranial pressure.
Use of medications:
sympathomimetics; oral contraceptives.

Essential hypertension

The structure of the causes of hypertension in children has age-related characteristics (Table 2), taking into account which can help determine adequate diagnostic and treatment tactics. During the neonatal period, increased blood pressure is most often a consequence of congenital anomalies or thrombosis of the renal vessels caused by complications of umbilical catheterization [3].

In early and preschool age, hypertension can be a manifestation of inflammatory kidney diseases (glomerulonephritis, reflux nephropathy) and Wilms tumor. At the age of 6–10 years, hypertension develops mainly due to parenchymal diseases of the kidneys, accompanied by impaired renal function. During this period and in adolescence, essential hypertension begins to appear. Endocrine diseases in all age groups are quite rarely the cause of hypertension.

Mechanisms of development of hypertension

The blood pressure level is determined by two main factors: vascular tone and the volume of extracellular fluid (ECF) [4]. In the early stages of increased blood pressure, an increase in arteriolar smooth muscle tone may be mediated by activation of the sympatheticoadrenal system through stimulation of postsynaptic α1 receptors and presynaptic β receptors by circulating adrenaline, followed by the release of norepinephrine. Subsequently, circulating (angiotensin II, vasopressin, endogenous digoxin-like factor) and local (endothelin) vasoconstrictor hormones are involved in the process, the action of which is opposed by vasodepressor systems (prostaglandins, endothelial relaxing factor, nitric oxide system - L-arginine) [5].

The leading role in the regulation of the EF belongs to the kidneys. The retention of sodium and water by the kidneys, leading to an increase in blood pressure, is induced by the following factors. • Reduction in the number of functioning nephrons: in parenchymal kidney diseases, loss of renal parenchyma leads to a decrease in the filtering surface, and perfusion pressure compensatory increases to maintain sufficient excretion of sodium and water. • Renal vasoconstrictors (angiotensin II, adrenaline, norepinephrine), which also promote tubular reabsorption of sodium. • Factors promoting tubular reabsorption of sodium (aldosterone, deoxycorticosterone). • Activation of renal sympathetic innervation leading to renal vasoconstriction and increased tubular sodium reabsorption. • Presence of a pressure gradient between the central arteries and renal perfusion pressure in renal artery stenosis. In hypertension of any origin, a combination of these factors can be observed, which does not exclude the leading role of one of them. In essential hypertension, the central role in pathogenesis is played by an increase in the intracellular concentration of free ionized calcium in the smooth muscle cells of arterioles, leading to an increase in their tone. In renovascular hypertension in the initial stages, the cause of increased blood pressure is the activation of the renin-angiotensin-aldosterone system. With long-term persistence of hypertension, factors that increase the activity of the sympathetic nervous system, suppress the activity of vasodepressor renal substances, and impair the autoregulation of peripheral vascular tone begin to predominate. Hypertension in renal parenchymal diseases is largely associated with impaired excretion of sodium and water.

Approaches to diagnosing hypertension in children

In case of severe hypertension, it is necessary to reduce blood pressure to a safe level before starting diagnostic measures. The initial examination of a child with hypertension should include a complete blood count, urine tests, urine testing for bacteriuria, serum testing for urea, creatinine, electrolytes, ultrasound examination of the kidneys, ECG recording and chest radiography. If possible, two-dimensional echocardiography, nephroscintigraphy, excretory urography (in the absence of severe renal failure), determination of aldosterone and plasma renin activity are performed. In most cases, based on the data obtained, it is possible to determine the most likely group of diseases that caused an increase in blood pressure, as well as obtain information about the duration of hypertension based on the degree of left ventricular myocardial hypertrophy.

Further diagnostic tactics may be more targeted: if there are signs of a urinary tract infection, its possible connection with vesicoureteral reflux (VUR) or urinary tract obstruction is clarified. For this purpose, an X-ray urological examination is carried out, and first of all, voiding cystourethrography is performed, since up to 40% of cases of recurrent urinary tract infection are associated with VUR, and reflux nephropathy is, according to large hospitals, a causative factor in 50% of cases of hypertension in childhood . If glomerular diseases are suspected, in addition to standard clinical and biochemical tests, it is advisable to test serum for antistreptolysin-O (ASL-O) to exclude acute post-streptococcal glomerulonephritis and for markers of systemic lupus erythematosus. Determination of hepatitis B virus (HBV) antigen is carried out to exclude secondary glomerulonephritis, most often of the membranous type, in HBV infection. Nephrobiopsy is very informative, allowing not only to determine the type of glomerular lesion, but also to assess the degree of preservation of the renal parenchyma and the intensity of nephrosclerosis. Diagnosis of renovascular diseases as a cause of hypertension is based on Doppler ultrasound, which is used as a screening method, followed by radioisotope and x-ray examination. If asymmetry in the size of the kidneys is detected on urograms (one of them is smaller than the contralateral one by more than 20%), as well as in cases where contrasting of one of the kidneys and the subsequent removal of the contrast agent are delayed, a suspicion arises of renal artery stenosis, the most common cause of which is children is fibromuscular hyperplasia. With isotope renography, in these cases, a flatter curve is noted on the side of the stenosis; with a test with captopril, the curvature increases. The diagnosis is definitively confirmed by aortography or selective renal arteriography. If possible, determine the activity of plasma renin in the blood flowing through the renal veins. A pathognomonic sign is its increase on the side of the stenosis.

Examination plan for arterial hypertension in children

Primary:

complete blood count, urea and electrolytes, creatinine, urine analysis and culture;
Chest X-ray, ECG, kidney ultrasound. Desirable additions:
plasma renin activity, plasma aldosterone, two-dimensional echocardiography, 99Tc DMSA nephroscintigraphy, excretory urography.

Further research

Suspicion of reflux or obstructive nephropathy:

plain radiography of the abdominal cavity;
voiding cystourethrography; excretory urography or nephroscintigraphy with 99Tc DMSA; renin activity in the renal veins. Suspicion of glomerular diseases:
autoantibodies, ANF, antibodies to DNA;
C3, C4 and immunoglobulin levels; ASL-O titer; HBV surface antigen; nephrobiopsy. Suspicion of renovascular diseases:
Doppler echography; aortography or selective arteriography; determination of renin in the renal veins; cerebral arteriography (in the presence of neurological symptoms). In the absence of signs of the listed groups of diseases, it becomes necessary to exclude endocrine diseases, which are extremely rarely the cause of hypertension. For this purpose, it is recommended to determine the daily excretion of catecholamines, electrolytes, aldosterone levels and plasma renin activity. The latter not only has diagnostic value, but also allows for a more differentiated approach to the prescription of antihypertensive drugs. Thus, for low-renin hypertension, diuretics are more effective, and for high-renin hypertension, b-blockers and angiotensin-converting enzyme inhibitors (ACEIs) are more effective.

Treatment of hypertension in children

When choosing antihypertensive therapy, it should be taken into account that the symptoms of hypertension inversely correlate with the duration of the increase in blood pressure and directly correlate with its degree in acutely developed hypertension. At the same time, sudden normalization of blood pressure with severe hypertension is associated with the risk of developing cerebral and cardiovascular complications of a collapsed nature. An initial reduction in blood pressure of 30% from the initial level is considered safe. If there is an excessive decrease in blood pressure, intravenous administration of an isotonic solution of sodium chloride is indicated, and if this measure is ineffective, the use of sympathomimetics (mesaton). It is advisable to begin emergency treatment of hypertension with parenteral administration of drugs [6] due to the possible disruption of their absorption in the gastrointestinal tract. Once adequate blood pressure control is achieved, oral antihypertensive therapy should be promptly switched to avoid the risk of hypotension and to facilitate drug dosing. For emergency treatment, sublingual administration of the calcium channel blocker nifedipine is also possible (Table 3). Therapy for moderately severe hypertension should begin with non-drug interventions, the main of which are limiting the consumption of table salt, dietary correction to reduce excess body weight, physical therapy under the supervision of a specialist, and smoking cessation in adolescents. When choosing drugs for oral antihypertensive therapy [7], it is recommended to take into account the etiology of hypertension. Thus, for hyperaldosteronism, spironolactone (veroshpiron) is very effective. For vasorenal hypertension, ACEIs are most effective, but when taken, transient acute renal failure may develop in cases of bilateral renal artery stenosis, extreme unilateral stenosis, or stenosis of the artery of a single kidney or renal transplant. In case of crisis of hypertension, which is based on the release of catecholamines, it is advisable to use a-blockers (prazosin). Hypertension in pheochromocytoma is most sensitive to phentolamine. In the case of renal parenchymal hypertension, accompanied by sodium and water retention, diuretics are the drugs of choice. Oral therapy (Table 4) should be started with small doses to avoid excessive reduction in blood pressure. It is not recommended to use drugs with the same mechanism of action at the same time, as this may lead to increased adverse reactions. Monotherapy is preferred. If, upon reaching the therapeutic dose of one drug, it is not possible to control blood pressure, move on to combination therapy. Until the last decade, antihypertensive drugs were prescribed to children in the following sequence: diuretic, beta-blocker, peripheral vasodilator. Treatment was started with a diuretic, usually a thiazide, except in cases of elevated serum creatinine and when a loop diuretic (furosemide) was used. If there was no effect, a b-blocker (propranolol) was added. If this did not lead to adequate blood pressure control, an additional peripheral vasodilator (hydralysine) was prescribed. In most cases, this approach gives satisfactory results, but the incidence of side effects is very high. Currently, calcium channel blockers and ACE inhibitors are increasingly used, which have actually become the drugs of choice, since they can improve the quality of life of patients due to the relatively low frequency of adverse reactions and high efficiency. The simultaneous use of b-blockers and calcium channel blockers is undesirable, since drugs of both groups reduce myocardial contractility, which can lead to congestive heart failure. Ganglion blockers and the central α-adrenergic agonist clonidine are rarely used in childhood, which is associated with relatively low effectiveness and side effects (clonidine), the most serious of which is considered to be the phenomenon of “rebound” hypertension against the background of abrupt withdrawal. The ultimate goal of treatment of hypertension in older children is a sustained reduction in diastolic blood pressure to a level not exceeding 80–90 mmHg. Art. One of the main criteria for effectiveness in this case is the regression of left ventricular myocardial hypertrophy, which is most facilitated by beta-blockers and ACE inhibitors. The latter also have antiproteinuric properties, thereby providing a nephroprotective effect in glomerulonephritis and diabetic nephropathy. For a number of forms of hypertension, surgical treatment is effective. Thus, in case of renovascular hypertension, the revascularization procedure eliminates the renal ischemia underlying hypertension. If revascularization is impossible or if there is a marked decrease in the function of the kidney supplied by the stenotic artery, nephrectomy is performed. Surgical treatment is used for coarctation of the aorta, Wilms tumor, and renin-secreting tumors. Of course, hypertension is an important pediatric problem. Given its high prevalence, the need for screening should be emphasized. Every teenager should have their blood pressure levels determined at least once, even in the absence of signs of any disease. Identified cases of hypertension require extensive research to establish the cause of increased blood pressure and determine adequate therapeutic tactics aimed at preventing damage to vital organs and systems.

Literature:

1. Report of the Second Task Force on Blood Pressure Control in Children. Pediatrics 1987;79:1–25. 2. Mendoza SA. Hypertension in infants and children. Nephron 1990;54:289–95. 3. Loggie JMH. Hypertension in children. Heart disease and stroke 1994;3:147–54. 4. Ching GWK., Beevers DG. Hypertension. Postgrad Med. J 1991;67:230–46. 5. Preston RA., Singer I, Epstein M. Renal parenchymal hypertension: Current concept of pathogenesis and management. Arch Intern Med. 1996;156:602–11. 6. Houston MC. Pathophysiology, clinical aspects and treatment of hypertensive crises. Progress in Cardiovasc. Dis. – 1989. –v. 32. – p. 99–148. 7. Dillon MJ. Drug treatment of hypertension. In: Holliday MA, Barratt TM, Vernier RL. (Eds.) Pediatric Nephrology. Williams and Wilkins, Baltimore (1987). – p. 758–765.

Alarming symptoms

If blood pressure is slightly higher than normal, then general health is satisfactory. External manifestations may include irritability and fatigue.

If the blood pressure numbers are very high, then the child feels unwell, he has pain and dizziness, the heart rate increases, pain occurs in the chest, and memory often deteriorates.

There is also malignant AD. In this form, the pressure is very high, and treatment is often ineffective. The risk to health and life is extremely high.

However, the most dangerous situation is the absence of symptoms, which delays diagnosis and treatment.

As you age, your blood pressure may remain above average or rise steadily.

Treatment of hypertension

A moderate form of the disease does not require serious intervention. Usually no medications are prescribed for it. To eliminate symptoms and improve well-being, stress is eliminated from the child’s life both at home and at school, parents monitor and, if necessary, adjust sleep and nutritional patterns. As for nutrition, with hypertension you need to minimize the consumption of salty foods.

One of the reasons for high blood pressure is obesity in any form. In this case, a weight loss diet is selected.

For any type of hypertension, light physical activity will be beneficial: exercise therapy, swimming, walking.

If you notice that your child has started drinking alcohol and smoking, you must immediately eliminate these bad habits.

If the form of the disease is more severe or there is no effect from non-drug treatment, then drugs identical to those prescribed for adults are used. First, the child should take them in small doses, and if the response is insufficient, in higher doses. Every six months, the child needs to be examined by a therapist and/or a pediatric cardiologist. Specialists will adjust the therapy if necessary.

Dear patients!

Arterial hypertension (AH) is currently the greatest non-infectious pandemic in human history, determining the structure of morbidity and mortality in the adult population, and its origins are usually found in adolescence.

Hypertension is an independent disease and one of the main risk factors contributing to the development of coronary heart disease, myocardial infarction, stroke and, ultimately, disability and mortality.

The appearance of high blood pressure in adolescence is fraught with the risk of its persistence in subsequent years and an unfavorable prognosis for the occurrence of the above-mentioned cardiovascular diseases.

According to the World Health Organization, arterial hypertension affects more than 1 billion people worldwide, in Europe – about 44% of the population. This problem is also relevant for Belarus. In children and adolescents, hypertension is relatively uncommon and ranges from 2.4 to 18% with age.

Normal blood pressure (BP) is taken to be the values ​​of systolic and diastolic blood pressure corresponding to the gender, age and physical development of the child, determined using special tables. For children and adolescents, it fluctuates and changes depending on age. For example, in a 14-year-old boy with a height of 165 cm, blood pressure can fluctuate within the following limits: systolic blood pressure - from 102 to 125 mm. rt. Art., diastolic blood pressure – from 61 to 78 mm. rt. Art.

The formation of hypertension in children and adolescents can be caused by various factors and causes.

Hypertension can be primary (essential) and secondary (symptomatic).

Primary hypertension is an independent disease. Its cause may be:

hereditary predisposition;

psychosocial stress (increased nervous mental stress);

sedentary lifestyle;

inadequate work and rest regime;

smoking, alcohol abuse;

physiological mechanisms (complex disorders of metabolic processes in the body).

Secondary hypertension in children in most cases occurs against the background of certain diseases:

kidneys (about 70%);

endocrine system (Itsenko-Kushirnga syndrome, thyrotoxicosis, pheochromocytoma, etc.);

cardiovascular system (aortic caorctation, aortic stenosis, aortic valve insufficiency, patent ductus arteriosus), etc.

The main symptom of hypertension is increased blood pressure. Patients may complain of headaches, pain in the heart, poor health, irritability, fatigue, sweating, dizziness, tinnitus, flashing spots before the eyes, nausea, vomiting, nosebleeds.

To avoid untimely detection of hypertension in children, it is recommended to measure blood pressure at the age of 3 years (before entering a nursery school, kindergarten), 1 year before school (5-6 years), immediately before school (6-7 years ), after finishing 1st grade (7-8 years old), at the ages of 10, 12, 14-15, 16 and 17 years old.

Correct measurement of blood pressure is important not only to diagnose hypertension, but also to avoid its overdiagnosis. With a daily dynamic study of blood pressure, measurements should be taken at the same hours, preferably in the morning before meals. The height of the table should be such that the middle of the cuff placed on the shoulder is at the level of the child’s heart. Before determining blood pressure, the child should sit quietly on a chair with a straight back next to the table for at least 5 minutes. Blood pressure is measured on the right arm (in left-handers on the left), three times at 2-3-minute intervals.

To more accurately determine the level of blood pressure, the severity of hypertension and its prognosis, a method for assessing the daily blood pressure profile is used - daily blood pressure monitoring (ABPM). ABPM is indicated for significant fluctuations in blood pressure during one or more visits to the doctor, or if hypertension is suspected. When a disease is detected, treatment is prescribed.

The main goal of hypertension treatment is to achieve sustainable normalization of blood pressure, which reduces the risk of developing early cardiovascular diseases. For children and adolescents, this means achieving a target blood pressure level that is appropriate for age, gender and height.

Treatment of a child with hypertension can be non-drug and medicinal, complex and long-term. In children and adolescents, non-drug therapy is of enormous importance.

The main methods of non-drug therapy in childhood are:

lifestyle changes;

measures to reduce excess body weight;

physical activity;

change in diet and quality of food.

It is known that reducing the calorie content of food through the consumption of animal fats and easily digestible carbohydrates leads to a decrease in body weight, especially

in combination with an increase in physical activity carried out through dynamic loads - swimming, running, team sports. It is necessary to eliminate unfavorable psychological factors if it is possible to find out (conflicts in the family, school). Psychotherapeutic approaches to the treatment of children with hypertension should concern all family members.

The diet used for high blood pressure must meet the following requirements:

it is necessary to limit table salt to 3-7 grams per day;

reduce the consumption of easily digestible carbohydrates (sugar, jam, honey, sweets);

limit animal fats (at least 1/3 of the amount of fats should be vegetable fats);

exclude strong tea, coffee, cocoa, alcoholic drinks, spicy, salty snacks, canned food, spices, smoked foods, fatty meats, fish;

add vitamins A, B1, B2, B6, C, PP to food;

eat food 5-6 times a day;

include foods rich in potassium and magnesium in your diet: nuts, dried fruits, baked potatoes, pumpkin, zucchini, beans, beans, peas, cauliflower, broccoli, bananas, grapes, apricots, peaches, seafood, as well as cottage cheese, hard cheeses, oatmeal.

Drug therapy is prescribed only when all non-drug treatment methods have been used and there is no effect from them. But you should also know that there are conditions that are an absolute indication for the prescription of drug therapy in children with hypertension: secondary hypertension, target organ damage (left ventricular hypertrophy, retinopathy - non-inflammatory degenerative changes occurring in the retina, etc.).

It is necessary to consult a cardiologist if there is any deviation in blood pressure in children, and only a doctor will prescribe a set of examinations, give recommendations on the regimen, diet, determine non-drug or drug treatment and thereby prevent serious illnesses in the future.

Prevention of arterial hypertension

Measures to prevent this serious disease come down to lifestyle adjustments:

• reduction and maintenance of normal body weight;
• proper, balanced nutrition according to the regime, reducing the amount of salty, smoked foods, pickled vegetables in the diet;
• light physical activity of half an hour every day;
• avoidance of stress, conflicts and other heavy psycho-emotional stress;
• timely diagnosis and treatment of pathologies that cause increased blood pressure. Source: V.P. Bulatov, T.P. Makarova, D.I. Sadykova, G.M. Farkhutdinova, R.T. Ganieva Arterial hypertension in children and adolescents // Kazan Medical Journal, 2006, v. 87, no. 4, pp. 300-303

Advantages of contacting SM-Clinic

Our clinic employs some of the best pediatric cardiologists and pediatricians in the Northern capital. We have modern diagnostic equipment that allows us to accurately and quickly make diagnoses. Based on the results of the examinations, the specialist will prescribe effective therapy for your child, which will restore good health and eliminate risks in the future.

Sources:

1. N.N. Arkhipova. Secondary arterial hypertension in children // Practical Medicine, 2011, No. 5(53), pp. 20-24
2. I.P. Bryazgunov. Primary arterial hypertension in children and adolescents // Issues of modern pediatrics, 2003, vol. 2, no. 3, pp. 68-71.
3. V.P. Bulatov, T.P. Makarova, D.I. Sadykova, G.M. Farkhutdinova, R.T. Ganieva. Arterial hypertension in children and adolescents // Kazan Medical Journal, 2006, v. 87, no. 4, pp. 300-303.
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860989/
   Anusha Uddaraju and C. Venkata S. Ram. Hypertension in children, not a “small” problem // Indian Heart J. 2013 Sep; 65(5): 501–503.

The information in this article is provided for reference purposes and does not replace advice from a qualified professional. Don't self-medicate! At the first signs of illness, you should consult a doctor.

Diagnosis and treatment of arterial hypertension in childhood

Arterial hypertension (AH) is a major socioeconomic and medical problem, remaining the main risk factor for coronary heart disease and brain diseases, the share of mortality from which in the structure of overall mortality exceeds 50%.

Numerous clinical and epidemiological studies have established that the “origins” of hypertension are in childhood and adolescence. Hypertension is registered in 4% to 18% of children, depending on the age group and selected diagnostic criteria. In the absence of timely prevention and adequate therapy, hypertension transforms into hypertension in 30–40% of cases [1, 2, 3].

In accordance with the recommendations of the American Working Group on High Blood Pressure in Children and Adolescents, experts from the All-Russian Scientific Society of Cardiologists, the Association of Pediatric Cardiologists of Russia and the Russian Medical Society for Arterial Hypertension, the normal level of blood pressure (BP) in children is considered to be the value of systolic blood pressure (SBP) and diastolic Blood pressure (DBP) is less than the 90th percentile for the corresponding age, sex and height (see table on pages 34–35) “SBP and DBP levels in boys aged 1 to 17 years depending on the height percentile distribution” and “SBP and DBP levels in girls aged 1 to 17 years depending on the height percentile distribution”). To indicate a SBP or DBP level between the 90th and 95th percentile, or greater than 120/80 mmHg. Art., but not exceeding the 95th percentile, the concept of “high normal blood pressure” was introduced. Blood pressure values ​​exceeding the 95th percentile are taken as hypertension [4, 5].

In establishing the diagnosis of hypertension in pediatrics, special tables are used based on the results of population studies, and the diagnostic process itself consists of the following stages:

• determination of the height percentile corresponding to the patient’s sex and age using special tables (

  
  ) [6];

• calculation of average SBP and DBP values ​​based on three blood pressure measurements taken at intervals of several minutes;
• comparison of the average values ​​of the patient's SBP and DBP, obtained from the results of three measurements of blood pressure at one visit, with the 90th and 95th percentiles of blood pressure corresponding to the patient's gender, age and height percentile;
• comparison of the average values ​​of SBP and DBP recorded for the patient at three visits with an interval between visits of 10–14 days, with the 90th and 95th percentiles of blood pressure corresponding to the patient’s sex, age and height percentile [5].

If three average values ​​of SBP and DBP, determined at three visits with an interval of 10–14 days, meet the criteria for normal BP, high normal BP or hypertension, an appropriate diagnosis is established [4].

In children and adolescents, it is advisable to distinguish two stages of hypertension:

1. Stage I - average SBP and/or DBP levels are in the range from the 95th percentile to the 99th percentile plus 5 mmHg. Art. for the corresponding sex, age and height percentile.
2. Stage II - average levels of SBP and/or DBP are more than 5 mm Hg above the 99th percentile. Art., for the corresponding sex, age and height percentile [5].

The stage of hypertension is established by a higher value of systolic or diastolic blood pressure and is determined in patients not receiving antihypertensive therapy.

The classification of hypertension is based on the identification of primary or essential hypertension and secondary or symptomatic forms of high blood pressure. The latter are caused by renal, endocrine, neurogenic and cardiovascular etiology, and in their therapy the treatment of the underlying disease comes to the fore. The most common known causes of hypertension, in order of their relative prevalence in different age periods, are presented in

[7]. Approximately 60–80% of secondary hypertension are caused by parenchymal renal diseases [7]. According to most experts, the term essential hypertension is a misnomer, implying that high blood pressure is somehow an essential component of the patient's life. Due to its imprecision, this term is not currently used.

Correct diagnosis and differential diagnosis of the disease is based on a thorough history taking, detailed clinical examination and the use of modern laboratory and instrumental research methods.

When collecting anamnesis, you should pay attention to the following information:

• complaints (headache, vomiting, sleep disturbances);
• blood pressure level and duration of hypertension;
• pathology of pregnancy and childbirth;
• traumatic brain injury and abdominal injury;
• premature sexual development (appearance of secondary sexual characteristics in girls under 8 years old, in boys under 10 years old);
• pyelonephritis (can be assumed by episodes of unmotivated increase in body temperature, a history of leukocyturia, dysuria);
• previous antihypertensive therapy;
• excessive consumption of table salt (tendency to add salt to already cooked food), changes in body weight, level and nature of physical activity;
• drinking alcohol, smoking;
• family history of hypertension, other cardiovascular diseases, diabetes mellitus (the presence of these diseases in parents aged <55 years);
• psychological and environmental factors: the nature of study and work, the atmosphere in the family, the socio-economic indicators of the family, living conditions, the nature of the parents’ work, the level of mutual understanding [4].

The physical examination should begin with weight and height. Obesity is an important risk factor for hypertension. Regardless of the child's age, blood pressure should be measured in at least one leg to rule out coarctation of the aorta. Normally, blood pressure in the legs is 10–20 mm higher than in the arms.

Many children have normal clinical examination results, which may require additional laboratory tests. During instrumental and laboratory examinations, the child’s age, medical history, results of physical examination and the severity of increased blood pressure must be taken into account. Diagnostic procedures recommended for children with hypertension are listed in

[8].

Special and specific studies are carried out if appropriate data from the anamnesis, physical examination and screening tests are available. For example, the level of thyroid hormones is determined if the child has corresponding symptoms of thyroid pathology.

The evaluation of a child with hypertension would not be complete without testing the target organs of hypertension. Should be excluded: left ventricular hypertrophy, hypertensive nephropathy, microalbuminuria and thickening of the walls of the carotid arteries [9, 10, 11, 12]. If these disorders are observed, the child should receive antihypertensive therapy.

All children with hypertension should undergo echocardiography and fundus examination. 24-hour blood pressure monitoring is increasingly used in children to detect white-coat hypertension [13]. The obtained data, in combination with anamnesis and physical examination, allow us to determine the severity of hypertension, which is necessary for treatment planning and monitoring [14].

There is no doubt that the prevention and treatment of hypertension is more effective in the early stages of its development, i.e. in childhood, and not at the stage of stabilization and organ damage. The goal of hypertension treatment is to achieve sustainable normalization of blood pressure to reduce the risk of developing early cardiovascular diseases.

Objectives of treatment of hypertension:

• achieving the target blood pressure level, which should be <90th percentile for a given age, sex and height;
• improving the patient's quality of life;
• prevention of damage to target organs or reverse development of changes in them;
• prevention of hypertensive crises [4].

Therapeutic tactics in the management of children with high blood pressure are determined by the level of blood pressure, its persistence, and data from additional studies indicating the involvement of other organs in the process or the absence thereof.

Treatment of hypertension in children and adolescents should begin primarily with non-drug methods of influencing high blood pressure.

Of the variety of non-medicinal methods used in practical healthcare, only scientifically based methods are used. These include:

• dietary correction of excess body weight, water-salt metabolism, a significant reduction in table salt consumption (less than 5 g per day) and sufficient potassium intake (3-5 g per day);
• optimization of physical activity: brisk walking and/or running, swimming, inclusion of physical activity in leisure hours and daily activities;
• normalization of the daily routine, rational distribution of free time;
• rational psychotherapy, self-improvement, auto-training, development of resistance to stressful situations;
• therapeutic massage: in the area of ​​the spine and cervical-collar area, segmental, 15–20 procedures per course;
• physiotherapy (electrophoresis with Eufillin, magnesium, calcium, bromine, electrosleep, inductothermy, sinusoidally modulated currents to the sinocarotid zone). The purpose of physiotherapy: to improve the central regulation of vascular tone, general and regional hemodynamics, normalize the functional state of the autonomic nervous system, reduce blood pressure, peripheral vascular resistance, increase the level of compensatory and adaptive processes;
• Spa treatment.

In case of grade I hypertension without left ventricular hypertrophy, obesity, dyslipoproteinemia and carbohydrate metabolism disorders, non-drug correction of high blood pressure can be recommended as the main and even the only method of treating hypertension in children and adolescents. Drug therapy is prescribed if non-drug treatment is ineffective within 6 months.

Prescribing medications for high normal blood pressure is also inappropriate.

If a child or adolescent is diagnosed with stage I high-risk hypertension (left ventricular hypertrophy, obesity, dyslipoproteinemia, impaired carbohydrate metabolism) or grade II hypertension, drug treatment is prescribed simultaneously with non-drug therapy [4]. In case of established hypertension, non-drug methods of treatment and prevention are not an alternative to drug treatment, but an integral component of complex treatment. Its advantages are obvious from the point of view of physiology, simplicity, accessibility, cost-effectiveness, absence of undesirable effects, etc. The introduction of non-drug methods for correcting high blood pressure provides the child and his parents with an active role in promoting health, which, from the point of view of the whole organism, makes it possible to more fully comply with the basic principles of medicine: to treat not the disease, but the patient and do no harm.

So, if non-drug intervention is ineffective within 6 months, and in patients with stage II hypertension or high-risk stage I hypertension, drug treatment is immediately prescribed. In this case, the least number of drugs should be used and in small doses while continuing non-drug treatment and lifestyle changes.

The choice of drug is carried out taking into account the individual characteristics of the patient, age, concomitant conditions: obesity, diabetes mellitus, functional state of the kidneys, dysfunction of the autonomic nervous system and others. In the presence of manifestations of hypersympathicotonia, emotional disorders (neurotic and psychopathic personality development, neurosis, psycho-emotional stress), sedatives are prescribed (preparations of valerian, hawthorn, motherwort; herbal collection - valerian, motherwort, hawthorn, sage, wild rosemary, St. John's wort) and/or nootropic drugs , anxiolytics (Phenibut, Pantogam). These drugs reduce tension, anxiety, fear, improve sleep, which makes them prescribed to patients with asthenoneurotic complaints. The duration of therapy is from 1 to 3 months [8].

In the treatment of autonomic disorders, physiotherapeutic procedures are used: galvanization, diathermy of the sinocarotid zone; electrophoresis according to Vermeule (with 5% sodium bromide solution, 4% magnesium sulfate, 2% Eufillin solution, 1% papaverine solution); electrosleep with a pulse frequency of 10 Hz, massage, acupuncture, water treatments (carbon dioxide, sulfide, pearl baths; Charcot shower, circular shower). Drug treatment of dysfunction of the autonomic nervous system includes drugs that improve cerebral hemodynamics (Vinpocetine, Cinnarizine). The drugs are prescribed in courses lasting at least 1 month. Courses are held 2 times a year.

Read more in the next issue.

L. I. Agapitov , Candidate of Medical Sciences, Research Institute of Pediatrics and Pediatric Surgery of Rosmedtekhnologii , Moscow

Prices