medical area

The group “Child” wants to provide a diagnostic - therapeutic guide for pediatricians who practice either in hospitals or in family practises and for physicians of different medical specializations,
the group “Child “ has drawn the following recommendations in order to:

• define categories at risk
• identify the correct methods of high blood pressure detection
• make the correct standard reference
• describe an adequate diagnostic procedure
• provide therapeutic indications

1. blood pressure must be measured at least once during infancy, school age, and adolescence.
2. blood pressure must be measured at least once a year in children and adolescents who belong to the categories that are at risk.
3. subjects with high blood pressure must be screened for all forms of secondary hypertension.
4. hypertension in children is defined as BP > 95 centile in three non consecutive measurements obtained with an proper releavation with an appropriate instrument.
5. the correct measurement of BP should be carried out on the non dominant arm, with an appropriate cuff size (that covers 2/3 of the length of the arm) maintaining that the arm at the heart level , while the patient rests for at least 3 minutes.
6. in all cases of hypertensionit  is important to detect  BP on both arms and one of two lower extremities: a difference of BP > 20 mmHg in favor of arms can be considered diagnostic for Coarctiation of Aorta.
7. the monitoring unit of  BP is extremely useful (to make a diagnosis of hypertension in the first place and to monitor the efficiency  of  antihypertensive  therapy). Pressure values recorded with the ABPM are reported to the standard  values of the ABPM. 
8. the clinical evaluation of the child with hypertension is intended to:
   1. determine  entity of hypertension and its circadian variability;
   2. examine the secondary causes of the hypertension;
   3. make evident  the presence of    target organ damage (i.e. hearth, brain and kidney);
   4. begin  anti hypertension  therapy and plan  a cardiologic follow-up. 
9. in patients with moderate or significant hypertension, the first approach considered is non- pharmacological treatment. Patients with  secondary or severe hypertension  must undergoe pharmacologic  treatments.
10. the treatment of hypertension in children should always include the following measures : reduction of weight, reduction of the use of sodium in the diet, interruption of isometric  exercise, abolition of abusing of stimulating substances. 
11. dynamic  physical activity is effective in reducing hypertension. Physical activity is not contraindicated in children with high blood pressure, but requires frequent blood pressure measurements. The only contraindication is agonistic  isometric physical activity in the subjects with severe hypertension  not controlled by pharmacologic therapy or  subjects with end-organ damage.
12. the following medicines are  considered to be the  first choice in the treatment of hypertension in children:
    1. the medications that block renin;
    2. angiotensin system (ACE - inhibitors and sartanics [= inhibitors of type 1 receptor of angiotensin  II]), beta;
    3. blockers, calcium channel blockers, diuretics (thiazide, loop,  and potassium sparing diuretics) .
13. in everyday practice is considered :
    1. use of medicines with a duration of  action of 24 hours or more , use of medications that may be administered once daily . In toddlers and pre-school children you should avoid medical formulation –retard- which pharmacokinetic is not known ;
    2. no use of monotherapy that often does not control high BP adequately  . In fact, in adults  has been prooved  that only the association of four medicines has an synergistic effect: acronym (A+B) / (C+D) represents  the 4 advantageous associations (A) for medication that blocks the renin - angiotensin system; (B) for Beta - blocking, (C) for calcium antagonist and (D) for diuretic: a drug written as numerator can be associated only with a drug indicated as denominator, and vice versa;
    3. use an appropriate somministration of medicines and avoid frequent therapeutical changes. The  maximum effect on BP is  reached after one or two months from the start of the treatment; -  Use a limited number of medicines to develop a specific experience.  
14. hypertension emergency is defined as: hypertension  that  is accompanied by acute symptoms of end – organ damage,  risk of life or serious complications for a patient in a short time  period (minutes or hours). Especially when it is called upon to deal with a hypertensive emergency in very young  children with low weight , or in children with serious pathologies  and / or hypertensive children that are resistent to pharmacologic treatment (with no specific formulation registered);  it is important  to form  a multidisciplinary team between physicians , pharmacists and nurses to achieve optimal results with a highly personalized pharmacologic treatment.
15. All children with a diagnosis of significant (95 - 99th percentile) and severe  hypertension (> 99th percentile) should be examined with the  ECG and the  echocardiogram.
16. The cardiologic follow-up of subjects with hypertension should  include:
    1. for ages under  24 months: very close control – every two weeks up to 2 months of life; monthly after  2 months up to one month after  the achievement of therapeutical  control; then  the control should be   from 4 times to twice a year;
    2. for ages above 24 months with severe hypertension (centile > 99th), who are  not controlled by pharmacologic therapy or assocted with eniad – organ damage: control is are  every six months; for ages above 24 months with hypertension that has been    controlled by pharmacologic treatment  without end – organ damage: control should occurre  once a year, and then once every two years.
17. hypertension in term neonates is defined as  BP > 90 / 60 mmHg. For the premature neonates it  is essential to refer pressure values to the  birth weight.
18. in  children with hypertension the first thing to be  excluded must be  kidney disease.  The target of PAS and PAD in patients with kidney disease and/or  diabetic nephropathy,  is to maintain pressure values  < 90 ° centile. The initial pharmacological treatment   considered is with ACE - inhibitors (or  sartanics).  
19. hypertension in children undergoing   renal replacement therapy  (dialysis), especially if refractory to pharmacological  treatments, should always be considered due to volume overload.  Hypertension In children with kidney transplantation should be considered  a side effect of immunosuppressive therapy or vascular stenosis.