Hypertension: Evaluation and Management.

Hypertension in children is increasing over the years, prevalence being 4% worldwide with peak at adolescence. While secondary causes predominate, essential hypertension is not uncommon, especially after 5–6 y of age, associated with overweight or family history. Among secondary causes, renal parenchymal and renovascular etiologies are most common. As per the Clinical Practice Guidelines, 2017, of American Academy of Pediatrics, hypertension is defined as blood pressure above the 95th percentile for age, gender and height of the child, being classified as Stage 1 up to 12 mm above 95th percentile, and Stage 2 beyond this limit. It is recommended to begin screening of asymptomatic children for hypertension after three years of age, advocating lifestyle modifications when blood pressure is abnormal. Persistence of elevated blood pressure or Stage 1 hypertension for 6-12 mo requires confirmation by ambulatory blood pressure monitoring (ABPM) and evaluation, followed by pharmacological treatment. In secondary hypertension, antihypertensives are to be started at the outset, along with evaluation. ABPM is strongly recommended for monitoring in secondary hypertension to identify masked hypertension and absence of nocturnal dipping, both of which are significant prognostic markers of cardiovascular morbidity. While first-line anti-hypertensives include calcium channel blockers, angiotensin-converting-enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), and thiazide diuretics, specific management and targeted antihypertensives may be required for the underlying cause in secondary hypertension. For acute severe hypertension intravenous agents such as sodium nitroprusside or labetalol are preferred, keeping a short-term goal of 95th centile of blood pressure, with an initial controlled reduction.