Headache in Children - It could be 'Secondary Hypertension'

Headache in Children - It could be 'Secondary Hypertension'

I was always suspicious of children complaining of headache ( thinking of my days, when headache was the most common excuse to get away from studies )...but that changed during my pediatric rotation when the vitals revealed a high BP in a 7 yr old who was admitted to be investigated for TB meningitis since 2 members in his family had Kochs. Further investigation led to the uncovering of an aortic coarctation for which he was operated and is doing well ( 2 years down the line ).

Of note is the fact that a BP of 120 / 80 is hypertension for children below 12 years...which we sometimes forget.

Also most of us don't know the normal range in the pediatric population and hence don't bother to check and the other issue is that we may not have a dedicated pediatric bp cuff.

Most books give an intimidating chart based on percentiles and height which compounds our reluctance to regularly check the bp in the pediatric population.

So i am keeping a very simple table..which should serve as a rough guide

[TABLE="class: grid, width: 500"]
[TR]
[TD][/TD]
[TD]systolic
[/TD]
[TD]dystolic
[/TD]
[/TR]
[TR]
[TD]1 - 3 months
[/TD]
[TD]75 +/- 5
[/TD]
[TD]50 +/- 5[/TD]
[/TR]
[TR]
[TD]4 - 12 months
[/TD]
[TD]85 +/- 5
[/TD]
[TD]65 +/- 5[/TD]
[/TR]
[TR]
[TD]1 - 8 years
[/TD]
[TD]95 +/- 5[/TD]
[TD]65 +/- 5
[/TD]
[/TR]
[TR]
[TD]9 - 14 years
[/TD]
[TD]105 +/- 5[/TD]
[TD]65 +/- 5[/TD]
[/TR]
[/TABLE]


Blood pressure Cuff Size

Infants - 5 cm
1 - 8 yrs - 9.5 cm
> 9 years - 12.5 cm

On first visit measure BP in both upper limbs and at least one lower limb.

Some common non-specific complaints can be - restlessness, irritability, fatigue, headache, blurred vision...all of which should also prompt us to think of hypertensive encephalopathy in the pediatric age group...and the reason i am taking this effort to make this post.

Fundoscopic and detailed urine analysis should be part of the workup.

Causes of hypertension in Pediatric age group

- renal : parenchymal causes ( glomrulonephritis, pyelonephritis, tumors, cysts, trauma, SLE ) ; vascular causes ( arterial stenosis, venous stenosis, thrombosis, AV malformation )

- endocrine : Pheochromocytoma, Ganlioneuroma, Cushing, Cong. Adrenal hyperplasia, hypethyroidism, hyperparathyrodism

- iatrogenic - steroid therapy

- miscellaneous : coarctation of aorta, raised ICT due to various etiologies, heavy metal toxicity ( Pb, Cd and Hg poisoning )

Some causes of transient hypertension in ped. age group

- renal : acute GN, HUS, Henoch Schonlein purpura
- CNS : encephalitis, myelitis, GBS
- drugs : steroids, oral contraceptives, vit D toxicity, sympathomimetics



(Y)

 

Related Self Assessment Question

[FONT=&quot]A 4-year-old boy, whose past medical history is positive for three urinary tract infections, presents with a blood pressure of 135/90 mm Hg. He is likely to exhibit which of the following symptoms or signs?[/FONT]
[FONT=&quot]
A. Multiple cranial nerve palsy[/FONT]

[FONT=&quot]B. Headache[/FONT]
[FONT=&quot]C. Hyporeflexia[/FONT]
[FONT=&quot]D. Increased urine output[/FONT]
[FONT=&quot]E. Right ventricular hypertrophy[/FONT]
[FONT=&quot] [/FONT]
[FONT=&quot]EXPLANATION: [/FONT]

[FONT=&quot]
Blood pressures in children must be interpreted in relation to the child's age and height. Nomograms are available to assist in all general texts and on governmental websites. Routine BP measurement is performed on children of age 3 and beyond and for subgroups of children at younger ages, including children who were premature, had frequent urinary tract infection, had umbilical artery catheters, and so on. Hypertension is usually asymptomatic, but with marked hypertension (that which is demonstrated by this 4-year-old) children can develop headache, dizziness, visual disturbances, irritability, and nocturnal wakening. Hypertensive encepha-lopathy can be preceded or accompanied by vomiting, hyperreflexia, ataxia, and focal or generalized seizures. Isolated facial nerve palsy can be the sole manifestation of severe hypertension. Isolated left ventricular hypertrophy, decreased urine output, and abdominal bruits are possible. When marked fundoscopic changes are present or when there are signs of vascular compromise, emergency treatment of the accompanying hypertension is warranted. Such hypertensive persons require immediate hospitalization for diagnosis and therapy.

[/FONT]

[FONT=&quot]The answer is B.


[/FONT]

 

good and excellent remark thank you (Y)