Pediatric Antihypertensive Medications
Key Points
- Treatment based on BP percentile for age, height, and gender
- Goal: Reduce BP to <90th percentile in uncomplicated HTN
- Consider underlying etiology when selecting medications
- Start low and titrate slowly
- Regular monitoring of BP and side effects essential
Indications for Treatment
- BP >95th percentile with symptoms
- BP >95th percentile with target organ damage
- Stage 2 hypertension (>99th percentile + 5mmHg)
- Persistent hypertension despite lifestyle modifications
- Hypertension with comorbidities (diabetes, CKD)
First-Line Medications
ACE Inhibitors
- Enalapril
- Initial: 0.08 mg/kg/day (max 5 mg/day)
- Maximum: 0.6 mg/kg/day (up to 40 mg/day)
- Frequency: Once or twice daily
- Specific indications: Proteinuria, diabetes, heart failure
- Lisinopril
- Initial: 0.07 mg/kg/day (max 5 mg/day)
- Maximum: 0.6 mg/kg/day (up to 40 mg/day)
- Frequency: Once daily
- Monitoring
- Serum creatinine and potassium
- First-dose hypotension
- Cough and angioedema
- Contraindicated in pregnancy
Calcium Channel Blockers
- Amlodipine
- Initial: 0.1 mg/kg/day (max 5 mg/day)
- Maximum: 0.6 mg/kg/day (up to 10 mg/day)
- Frequency: Once daily
- Advantages: Long acting, well-tolerated
- Side Effects
- Peripheral edema
- Gingival hyperplasia
- Flushing
- Headache
ARBs (Angiotensin Receptor Blockers)
- Losartan
- Initial: 0.7 mg/kg/day (max 50 mg/day)
- Maximum: 1.4 mg/kg/day (up to 100 mg/day)
- Frequency: Once or twice daily
- Valsartan
- Initial: 1.3 mg/kg/day
- Maximum: 2.7 mg/kg/day (up to 160 mg/day)
- Frequency: Once daily
Second-Line Medications
Beta Blockers
- Metoprolol
- Initial: 1-2 mg/kg/day
- Maximum: 6 mg/kg/day (up to 200 mg/day)
- Frequency: Twice daily
- Indications: Tachycardia, migraine, anxiety
- Propranolol
- Initial: 1-2 mg/kg/day
- Maximum: 4 mg/kg/day (up to 640 mg/day)
- Frequency: Two to three times daily
Diuretics
- Hydrochlorothiazide
- Initial: 1 mg/kg/day
- Maximum: 2 mg/kg/day (up to 50 mg/day)
- Frequency: Once or twice daily
- Chlorthalidone
- Initial: 0.3 mg/kg/day
- Maximum: 2 mg/kg/day (up to 50 mg/day)
- Frequency: Once daily
Hypertensive Emergency Management
IV Medications
- Nicardipine
- Initial: 0.5-1 μg/kg/min
- Maximum: 4-5 μg/kg/min
- Rapid onset and offset
- Labetalol
- Bolus: 0.2-1.0 mg/kg/dose
- Infusion: 0.25-3.0 mg/kg/hr
- Combined α and β blockade
- Sodium Nitroprusside
- Initial: 0.3-0.5 μg/kg/min
- Maximum: 8-10 μg/kg/min
- Monitor for thiocyanate toxicity
Special Considerations
Specific Conditions
- Chronic Kidney Disease
- Prefer ACEi/ARB for antiproteinuric effect
- Monitor renal function closely
- May need dose adjustment
- Diabetes
- ACEi/ARB first choice
- Target BP <90th percentile
- Monitor for orthostatic hypotension
- Heart Failure
- Beta blockers may be preferred
- Consider combination with ACEi
- Careful fluid management
Monitoring
- Regular BP Measurements
- Office readings
- Home monitoring when appropriate
- 24-hour ambulatory monitoring
- Laboratory Monitoring
- Electrolytes
- Renal function
- Drug-specific monitoring
- Target Organ Damage Assessment
- Echocardiogram
- Renal ultrasound
- Eye examination
Further Reading
