Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Measurement of Blood Pressure Normal Blood Pressure When should BP be measured? Definition of Hypertension Signs & Symptoms Causes of Transient Hypertension Causes of Sustained Hypertension Investigation of the Hypertensive Child Hypertensive Urgency Hypertensive Emergency Management of the Hypertensive Emergency Management of Primary Hypertension Recommended Reading Appendix 1 – Tables of Blood Pressure Levels for Age & Height Appendix 2 – Neonatal BP Values Appendix 3 - Oral antihypertensive drugs for management of hypertension in children References An elevated blood pressure level in childhood can predict an increased cardiovascular risk in adult life. The increasing prevalence of childhood obesity necessitates regular surveillance of blood pressure to detect abnormal blood pressure and hence increased cardiovascular risk. Identifying hypertension in children allows for treatment, assessment of target organ damage and investigation of aetiology. Measurement of Blood Pressure Devices The most common methods are: (1) Aneroid sphygmomanometry (manual blood pressure) (2) Oscillometry using automated devices such as DINAMAP (Critikon). Mercury manometers are no longer in routine clinical use. Aneroid devices are not as accurate as mercury manometers and require regular calibration. Oscillometry detects arterial pulsations by transducer. The mean arterial pressure is measured, and systolic and diastolic recordings are calculated from a mathematical formula. There is good agreement between DINAMAP readings and blood pressures obtained by invasive central aortic measurements. DINAMAP values are generally 6-7 mm Hg higher for systolic and 2-4 mm Hg lower for diastolic. DINAMAP recordings have the potential for less variability, less error and greater reproducibility. DINAMAP measurements may be inaccurate in low birth weight or preterm infants where it may overestimate BP. Ambulatory blood pressure monitoring is also available for investigation of those with suspected hypertension, those at risk of developing hypertension or difficult to mange blood pressure. Appropriate Cuff Size This refers to the size of the inflatable bladder. The correct size is based on the diameter (thickness) of the arm, not the age of the child. Length is not as important. The widest cuff that can be applied to the arm should be used, with the bladder covering at least two thirds of the upper arm, and the length of the cuff should completely encircle the arm. Small cuffs result in a spuriously high BP, whereas the risk of a spuriously low blood pressure from too large a cuff is minimal. It is better to use a cuff which too large than one that is too small. Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 1 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) The cuff should be at heart level. Blood pressure should be measured on the arm only. There are no significant differences in BP between supine and erect as long as the cuff is at heart level and the child is volume replete. Technique The child should be seated in a quiet room for at least 5 minutes before taking the blood pressure. The right arm is preferred for consistency and because of the possibility of aortic coarctation (falsely low recording in the left arm.) Blood pressure should not be measured routinely on the leg as this may result in a false high reading. Definition of Systolic and Diastolic BP Systolic BP = 1st Korotkoff sound (K1). Diastolic BP = K5 in young children, K4 in adolescents. Use K4 (muffling of the sounds) in young children if K5 is very low, in which case record both. Variables Affecting the Measurement of BP Several variables can affect BP measurement including: Patient behaviour (anxiety, cooperation) Medications (beta-agonists, steroids) Observer variability (detection of Korotkoff sounds) Cuff size (as above). There are significant variations in published normal measurements due to these differences. Normal Blood Pressure Current normative data is based on auscultation and there is no normative blood pressure data that is based on recordings measured from oscillometric devices. There is limited data available on infants and young children. There is no significant difference between sexes in the first 5 years of life. Blood pressures rise gradually from 2 to 5 yrs of age, at a rate of approximately 1 mm Hg per year, and at a rate of 1.5 mm Hg per year from 7 to 11 years of age. In older children a wide variation of "normal values" are reported. Approximately 40% of the variability of BP in children is related to height, weight, triceps skin fold thickness, and arm circumference. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents presents new data and the reader is advised to consult this extensive report. See Appendix for BP tables When Should BP be Measured? It should be an integral part of the physical examination. Measure it 4 to 5 times in early school age, after which only children with "high" BP (>75th centile) need following. Measure BP more often in "high risk" children: IDDM, obesity, hyper-lipoproteinemia (child or parent), periodically high BP, risk factors in a parent (severe hypertension, early stroke or MI), renal disease, syndromes known to be associated with hypertension. Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 2 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Definition of Hypertension A single moderately elevated measurement does not indicate hypertension. There must be repeated evaluation under basal conditions, over time. A very high blood pressure measurement requires urgent evaluation and treatment. The 4th report definitions are as follows: Pre hypertension (previously borderline hypertension) is defined as an average SBP and/or average DBP between 90th and 95th centile. This group is considered at increased risk for hypertension. Hypertension Average systolic and/or diastolic BP > 95th centile for age, sex and height obtained on at least 3 occasions. Stage 1 hypertension average SBP ± DBP 95 to 99% for age and sex with no end organ damage. Stage 2 hypertension: average SBP ± DBP ³ 99% ± end organ damage. A patient with BP levels >95th centile in a clinic setting, who is normotensive outside the clinic setting has “white coat” hypertension If a statistical definition of hypertension is used, then potentially 5% of children have hypertension, a prevalence which is not supported in clinical studies where 1-2% of children have hypertension. Signs and Symptoms of Hypertension The signs and symptoms of hypertension vary enormously. The underlying disease causing hypertension may also have symptoms. Neonates: Respiratory distress, sweating, irritability, pallor/cyanosis, failure to thrive, sepsislike picture, cardiac failure, apnoea, vomiting, seizures Older children: Fatigue, encephalopathy, headache, heart murmur, blurred vision, anorexia, nausea, epistaxis, weakness (facial palsy), weight loss / gain, polydipsia / polyuria, tiredness, enuresis, abdominal pain, haematuria, short stature. Acute hypertension in older children may be heralded by, Bell’s palsy, headaches, seizures, sudden visual loss, epistaxis or abdominal pain. Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 3 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Causes of Transient Hypertension Acute glomerulonephritis, Henoch-Schonlein nephritis, haemolytic uraemic syndrome, other causes of acute renal failure. Post urologic surgery or renal transplantation. Acute hypovolaemia (nephrotic relapse, burns, adrenal + GI saline depletion). Acute hypervolaemia (excessive administration of blood, saline or plasma). CNS disease (tumour, infection, seizures, injury). Guillain-Barre syndrome. Hypercalcaemia. Lead Poisoning. Medications (steroids, sympathomimetics, contraceptive pill). Causes of Sustained Hypertension Coarctation of aorta. Renin-dependent hypertension: o Renovascular o Renal parenchymal: coarse renal scarring (reflux nephropathy, obstructive uropathy, neuropathic bladder), glomerulonephritis, polycystic kidney disease, hemolytic uraemic syndrome. o Renal tumour. o Catecholamine-excess hypertension (pheochromocytoma, neuroblastoma). Corticosteroid excess (Congenital adrenal hyperplasia, Cushing’s or Conn’s syndrome). Essential hypertension. Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 4 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Investigation of the Hypertensive Child The level and urgency of investigation depend on the rapidity of onset, severity, and age. The younger the child, and the more severe the hypertension, the more likely there is an underlying cause. Initial investigation is focussed on the kidneys, as 80% have a renal abnormality. You must also search for evidence of end organ damage. First line Investigations Medical history (symptoms of hypertension, medications, trauma, growth) Family history (renal or CVS disease, endocrine tumours, phakomatoses) Examination - Mental state and coma score (Encephalopathy). - Optic Fundi (papillodema, haemorrhage, exudates). - Visual acuity and pupillary responses (Visual impairment). - Tone, power and reflexes (Hemiparesis, Bell’s palsy). - Tachycardia, gallop rhythm, hepatomegaly, crackles(Congestive heart failure). - Abdominal masses or bruits (Renal enlargement ,R Art stenosis). - Signs of virilisation or cushingoid habitus (CAH, Cushing’s syndrome). - Skin (neurofibromatosis) Urinalysis (urinary sediment, microscopy and culture) Cardiac investigations (CXR, ECG, echocardiogram) Renal function (U&E, creatinine, chloride, acid base, FBC, GFR estimation) Renal Ultrasound including Doppler study of renal arteries Second Line Investigations Further imaging of the urinary tract (DMSA scan, MCU) Imaging of renal vasculature (CT angiography or MR. Angiography) Urine catecholamines Plasma renin and aldosterone ESR and ANA Other Investigations (on advice from renal team) Renal vein renin sampling, arteriography, isotope scan for pheochromocytoma NOTE: A normal ECG does not exclude left ventricular hypertrophy Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 5 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Hypertensive urgency Hypertensive urgency is defined as a significant elevation of blood pressure without evidence of end organ injury. Patients are symptomatic with headaches or nausea but without end organ involvement. The patient is clinically stable. Treatment with oral hypotensive agents is indicated if BP is above the 99th centile for age, height and gender, on three occasions 30 minutes apart. See Appendix for BP tables. The choice of agents are: Beta blockers (labetolol, atentolol) Vasodilators (isradipine, felodipine, amlodipine, minoxidil) Angiotensin converting enzyme inhibitors (captopril, lisinopril, enalapril) Diuretic if volume overload is evident. Sublingual nifedipine is unpredictable and should be avoided. Suggested drugs: Oral Isradapine: 0.1 mg/kg/dose q 6- 8h. Hospital only. Will need to be changed to a different medication if patient requires outpatient antihypertensive therapy. NOT TO BE USED AS A MAINTENANCE MEDICATION Labetalol: - See dosing table Appendix 2 Enalapril: - See dosing table Appendix 2 Intravenous Hydralazine: 0.15mg/kg iv q 3-4 hourly. Short acting rapid onset medication. Should not be used as maintenance medication. This can be given on the ward. Longer acting drugs such as amlodipine, lisinopril may be started but will not provide acute control of blood pressure Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 6 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Hypertensive Emergency Defined as a severe elevation of blood pressure associated with a clinical picture of rapid and progressive central nervous system, visual, myocardial, haematological or renal deterioration. Fibrinoid necrosis of arterioles with retinal exudates and haemorrhages occur. Congestive heart failure may occur, with infants being particularly prone to this complication. There is no specific level of BP that constitutes a hypertensive emergency. It is defined as a blood pressure high enough to cause acute injury to target organs Heart Brain Kidney Eye - left ventricular failure hypertensive encephalopathy (9 - 33% of children) renal failure retinopathy The most common causes in children are renal scarring from reflux nephropathy, and acute nephritis. Children are more prone to hypertensive encephalopathy than adults, and you must differentiate this from stroke or subarachnoid haemorrhage. Management of the Hypertensive Emergency Admit the child to PICU. Consult paediatric nephrologist and intensivist on call Acute severe hypertension requires urgent treatment to prevent end organ damage. In chronic severe hypertension, slow smooth BP reduction is strongly recommended. It is often difficult to know whether hypertension is acute or chronic at the first presentation. Signs of end organ damage are more likely in chronic hypertension (eyes, heart, kidney), and less likely to be present in acute severe hypertension. There is a high risk of neurological sequelae (spinal infarction, blindness) if anti-hypertensive drugs cause a precipitous fall in blood pressure. Sublingual nifedipine is unpredictable and should be avoided if the duration of hypertension is unclear and there are signs of end organ damage. Reduce blood pressure urgently. Secure IV access before commencing therapy Monitor BP and pupillary responses frequently during therapy Use continuous intra-arterial pressure monitoring. Dinamap is a second option in children aged over 5 years Aim to reduce blood pressure by one third of the total planned reduction in the first 24 hours, and the remaining 2/3 over the next 48 to 72 hours Formatted: Bullets and Numbering Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 7 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) The choice of intravenous antihypertensive drug is at the discretion of the treating physician. These need to given in ICU. o IV Labetalol: a bolus of 0.2 - 1 mg/kg, followed by a constant infusion (1 mg / ml in 0.9% NaCl). Begin infusion at 1 mg/kg/hour. Increase the infusion rate at 10 -15 minute intervals until there is an effect. If there is no effect at a dose of 2.5 mg/kg/hour, choose another agent. o IV Sodium nitroprusside infusion (0.5-10micrograms/kg/min) may be used as a second option. In this case, intra-arterial blood pressure monitoring is mandatory o IV Hydralazine as per above If BP falls too rapidly, give boluses of normal saline Avoid using ACE inhibitors until a renovascular cause has been excluded Management of Primary Hypertension Weight reduction is the mainstay in obesity related hypertension. Dietary modification with emphasis on sodium intake reduction is strongly encouraged in those who have blood pressures in the prehypertensive range as well those with established hypertension. Lifestyle changes are integral to the successful treatment of hypertension. Pharmacological therapy is indicated when primary interventions are unsuccessful. Single agents which are suitable for daily dosing is preferred. Examples are ACE inhibitors, calcium channel blockers, blockers. The goal for pharmacological therapy is reduction of blood pressure to <90% percentile. Recommended Reading: Goonasekera CDA, Dillon MJ. Measurement and interpretation of blood pressure. Arch Dis Child. 2000;82:261-265. Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood in Children and Adolescents Pediatrics. 2004;114:555-576. de Man SA, André JL, Bachmann H, et al. Blood pressure in childhood: pooled findings of six European studies. Journal of Hypertension. 1991;9:109-114. Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 8 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Appendix 1 – Table of Blood Pressure Levels for Age & Height Adapted from The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents. TABLE 1 BOYS. BP Levels for BOYS by Age and Height Percentile Systolic BP (mmHg) Height percentile Age (years) 1 2 3 4 5 7 9 11 13 15 17 Author: Editor: Diastolic BP (mmHg) BP Percentile 5th 50th 95th 5th Height percentile 50th 95th 50th 90th 95th 99th 80 94 98 105 85 99 103 110 89 103 106 114 34 49 54 61 37 52 56 64 39 54 58 66 50th 90th 95th 99th 84 97 101 109 88 102 106 113 92 106 110 117 39 54 59 66 42 57 61 69 44 59 63 71 50th 90th 95th 99th 86 100 104 111 91 105 109 116 95 109 113 120 44 59 63 71 46 61 65 73 48 63 67 75 50th 90th 95th 99th 88 102 106 113 93 107 111 118 97 111 115 122 47 62 66 74 50 65 69 77 52 67 71 79 50th 90th 95th 99th 90 104 108 115 95 108 112 120 98 112 116 123 50 65 69 77 53 68 72 80 55 70 74 82 50th 90th 95th 99th 92 106 110 117 97 111 115 122 101 115 119 126 55 70 74 82 57 72 76 84 59 74 78 86 50th 90th 95th 99th 95 109 113 120 100 114 118 125 104 118 121 129 57 72 76 84 60 75 79 87 62 77 81 89 50th 90th 95th 99th 99 113 117 124 104 117 121 129 107 121 125 132 59 74 78 86 61 76 80 88 63 78 82 90 50th 90th 95th 99th 104 117 121 128 108 122 126 133 112 126 130 137 60 75 79 87 62 77 81 89 64 79 83 91 50th 90th 95th 99th 109 122 126 134 113 127 131 138 117 131 135 142 61 76 81 88 64 79 83 91 66 81 85 93 50th 90th 95th 99th 114 127 131 139 118 132 136 143 122 136 140 147 65 80 84 92 67 82 87 94 70 84 89 97 Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 9 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) TABLE 2 - GIRLS: BP Levels for Girls by Age and Height Percentile: Systolic BP (mmHg) Age (years) 1 2 3 4 5 7 9 11 13 15 17 Diastolic BP (mmHg) BP Percentile 5th Height Percentile 50th 95th 5th Height Percentile 50th 95th 50th 90th 95th 99th 50th 90th 95th 99th 83 97 100 108 85 98 102 109 86 100 104 111 88 101 105 112 90 103 107 114 91 105 109 116 38 52 56 64 43 57 61 69 40 54 58 65 45 59 63 70 42 56 60 67 47 61 65 72 50th 90th 95th 99th 86 100 104 111 89 103 107 114 93 106 110 117 47 61 65 73 49 63 67 74 51 65 69 76 50th 90th 95th 99th 88 101 105 112 91 104 108 115 94 108 112 119 50 64 68 76 52 66 70 77 54 68 72 79 50th 90th 95th 99th 89 103 107 114 93 106 110 117 96 109 113 120 52 66 70 78 54 68 72 79 56 70 74 81 50th 90th 95th 99th 93 106 110 117 96 109 113 120 99 113 116 124 55 69 73 81 57 71 75 82 59 73 77 84 50th 90th 95th 99th 96 110 114 121 100 113 117 124 103 116 120 127 58 72 76 83 59 73 77 84 61 75 79 87 50th 90th 95th 99th 100 114 118 125 103 117 121 128 107 120 124 131 60 74 78 85 61 75 79 87 63 77 81 89 50th 90th 95th 99th 104 117 121 128 107 121 124 132 110 124 128 135 62 76 80 87 63 77 81 89 65 79 83 91 50th 90th 95th 99th 107 120 124 131 110 123 127 134 113 127 131 138 64 78 82 89 65 79 83 91 67 81 85 93 50th 90th 95th 99th 108 122 125 133 111 125 129 136 115 128 132 139 64 78 82 90 66 80 84 91 68 82 86 93 * The 90th percentile is 1.28 SD, the 95th percentile is 1.65 SD, and the 99th percentile is 2.33 SD above the mean Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 10 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Appendix 2 – Neonatal Blood Pressure Values Estimated BP values after 2 weeks of age in infants from 26 to 44 weeks postconceptional age Reproduced with permission from Joseph Flynn (Pediatr Nephrol (2000) 14:332–341). 50th percentile 95th percentile 99th percentile SBP DBP MAP 55 30 38 72 50 57 77 56 63 SBP DBP MAP 60 38 45 75 50 58 80 54 63 SBP DBP MAP 65 40 48 80 55 65 85 60 69 SBP DBP MAP 68 40 48 83 55 62 88 60 69 SBP DBP MAP 70 40 50 85 55 65 90 60 70 SBP DBP MAP 72 50 57 87 65 72 92 70 71 SBP DBP MAP 77 50 59 92 65 74 97 70 79 SBP DBP MAP 80 50 60 95 65 75 100 70 80 SBP DBP MAP 85 50 62 98 65 76 102 70 81 SBP DBP MAP 88 50 63 105 68 80 110 73 85 Post-conceptional age 26 weeks 28 weeks 30 weeks 32 weeks 34 weeks 36 weeks 38 weeks 40 weeks 42 weeks 44 weeks SBP = systolic blood pressure DBP = diastolic blood pressure MAP = mean arterial pressure Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 11 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) Appendix 3 - Oral antihypertensive drugs for management of hypertension in children 1-17 years old Class Drug Dose Frequency Comments ACE inhibitors Captopril Initial: 0.1-0.5mg/kg/dose Max: 6mg/kg per day Three times daily Enalapril Initial: 0.1mg/kg/day up to 5mg/day Max: 1mg/kg/day up to 40mg/day Initial: 0.1-0.2mg/kg/day up to 5mg/day Max: 1mg/kg/day up to 40mg/day Initial: 0.7mg/kg/day up to 50mg/day Max: 1.4mg/kg/day up to 100mg/day Initial: 4mg/day Max: 32mg/day Initial: 4mg/kg/day in divided doses Max: 20/kg/day up to 1200mg/day Initial: 0.5-1mg/kg/day Max: 2mg/kg/day up to 100mg/day Initial: 0.1-0.2mg/kg/day Max: 0.4mg/kg/day up to 20mg/day Once or twice daily Once daily Liquid proprietary 5mg/ml Liquid manufactured 1mg/ml. Requires HEC for discharge if proprietary liquid not available. Liquid manufactured 1mg/ml Liquid requires HEC for discharge Round doses to tablet size, can halve tablets. Soluble in water Special authority required Soluble in water. Special authority required. 2 to 4 times daily Liquid manufactured 10mg/ml Once or twice daily Liquid manufactured 10mg/ml Once daily Liquid manufactured 1mg/ml Liquid requires HEC for discharge Funded tablet does not disperse well, use liquid if need part doses. Extended release tablets, do not crush Lisinopril Angiotensinreceptor blocker Losartan Candesartan and -blocker Labetalol -blocker Atenolol Calcium channel blocker Amlodipine (as mesylate) Felodipine Isradipine Vasodilator Minoxidil Initial: 0.2mg/kg/day Max: 0.5mg/kg/day up to 20mg/day Initial: 0.1mg/kg/dose Max: 0.8mg/kg/day up to 20mg/day Once daily Once daily Once or twice daily 3 to 4 times daily Initial: 0.1-0.2mg/kg/day Max: 1mg/kg/day Twice daily Liquid manufactured 1mg/ml – switch to alternative agent before discharge Immediate release tablets are S29 – unlicensed in NZ Tablets can be crushed and dissolved Not funded. Not licensed in NZ, can supply from hospital via DCS (discretionary community supply). Should be used with a diuretic and blocker Patients requiring more than one antihypertensive agent, or treatment with angiotensin receptor blockers (ARBs) or minoxidil, should be discussed with a Paediatric Nephrologist. Funding: All medicines listed above are fully funded as tablets/capsules unless specified. Availability of liquid formulations is listed where possible with strength used at ADHB, including any additional funding requirements. References: Flynn JT. Neonatal hypertension: diagnosis and treatment. Pediatr Nephrol (2000) 14:332–341. Kemp A, McDowell JM, editors. Paediatric Pharmacopoeia. 13th edition. Melbourne: Pharmacy Dept Royal Children’s Hospital; 2002 Guy’s, St Thomas’ and Lewisham Hospitals. Paediatric formulary. 5th Edition. London: Guy’s and St Thomas’ Hospitals Trust; 1999. Mehta DK, Exec editor. BNF for children 2007. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2007 Strauser LM, Groshang T, Tobias JD. Initial experience with isradipine for treatment of hypertension in children. Southern Medical Journal 2000; 93(3): 289-93. Takemoto C, Hodding J, Krauss D. Pediatric Dosage Handbook 15th Edition; Lexicomp 2008 Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 12 of 13 Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer. HYPERTENSION (Blood Pressure in Childhood) The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents, Pediatrics. 2004; 114: 555-576 Author: Editor: Dr William Wong Dr Raewyn Gavin Hypertension (Blood Pressure in Childhood) Service: Reviewed: Nephrology December 2009 Page: 13 of 13
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