Pediatric Primary Care (74 page)

F.  Differential diagnosis.

1.  Secondary hypertension.

2.  Renal vascular disease, renal parenchymal disease.

3.  About 60-80% of secondary hypertension in childhood is due to renal causes.

4.  Coarctation of aorta (Turner syndrome).

5.  Endocrine and adrenal causes: hyperthyroidism, Cushing's syndrome.

6.  Systemic diseases: systemic lupus erythematosus, tuberous sclerosis.

7.  Pharmacologic effect: steroids, amphetamine or sympathomimetics, oral contraceptives, illicit drugs.

8.  CNS manifestations: increased intracranial pressure, intracranial mass.

G.  Treatment.

1.  Treatment goal is to achieve blood pressure <95th percentile, or < 90th percentile if concurrent conditions present.

2.  Nonpharmacologic treatment first-line therapy.

a.  Weight loss if obese; prevention of obesity if normal weight.

b.  Increase physical activity.

c.  Dietary modifications.

d.  Family-based interventions.

e.  Tobacco cessation; avoid drugs of abuse, particularly cocaine.

f.  Reevaluation of blood pressure.

3.  Pharmacologic treatment indicated if symptoms present, target organ damage present, type 1 or 2 diabetes present, or failure of nonpharmacologic treatment with lifestyle modifications.

4.  Single drug therapy preferred. Provider preference since no studies show absolute long-term benefit of any class or drug.

a.  Angiotensin converting enzyme inhibitors (preferred if diabetes or proteinuria).

b.  Angiotensin receptor blockers (preferred if diabetes or proteinuria).

c.  Beta blockers (preferred if patient experiences migraine headaches).

d.  Calcium channel blockers (preferred if patient experiences migraine headaches).

e.  Diuretics.

5.  Add second class of medication if maximum dose achieved or side effects experienced before blood pressure control achieved.

6.  Consider gradual withdrawal of medication if target blood pressure achieved for long period of time.

H.  Follow up.

1.  Continued monitoring of blood pressure.

2.  Encouragement of and follow up on lifestyle changes.

3.  Refer back to pediatrician or specialist if treatment goals not achieved with lifestyle changes, current medication regime.

I.  Complications.

1.  End-organ dysfunction.

2.  Hypertensive crisis.

J.  Education.

1.  Essential hypertension.

a.  Chronicity of disease, likely long-term morbidity, end-organ damage if not controlled.

b.  Potential improvements with dietary, lifestyle changes and medications if necessary.

c.  Need for continuous follow up.

d.  Adherence to medication regime if prescribed.

e.  Encourage patients to return to prescriber if side effects unacceptable because many classes of medications are available for blood pressure control.

f.  Goals of therapy.

2.  Suspected or known secondary hypertension.

a.  Thorough evaluation of cause, may be extensive testing.

b.  Follow up with specialists.

c.  Adherence to treatment or medication regimen.

III. INNOCENT HEART MURMURS

A.  Etiology.

1.  Innocent murmur is abnormal heart sound caused by turbulent blood flow not associated with structural heart disease, also called functional or nonorganic murmur.

B.  Occurrence.

1.  Cardiac murmurs are noted in 50-70% of children who are asymptomatic.

2.  Vast majority of murmurs heard in infants and children are innocent in nature.

C.  Clinical manifestations.

1.  Innocent murmur is typically found on routine physical exam.

2.  Presence of other clinical manifestations: concern for congenital, acquired heart disease.

3.  Any murmur, innocent or organic, is typically louder with fever, anemia, other high cardiac output states.

D.  Physical findings.

1.  Absence of physical findings other than murmur should be expected if innocent murmur is suspected. Innocent murmurs often more prominent during high cardiac output states such as fever, anemia, pregnancy.

2.  Physical exam findings of congenital or acquired heart disease that follow should specifically be evaluated.

a.  Known or suspected syndrome or genetic or chromosomal abnormality.

b.  Failure to grow.

c.  Easily fatigued.

d.  Tachypnea, increased work of breathing, retractions, flaring, grunting.

e.  Diaphoresis particularly with exertion, feeding in the infant.

f.  Cyanosis, central or peripheral.

g.  Clubbing of digits.

h.  Tachycardia.

i.  Edema, particularly periorbital and facial in infant.

j.  Active precordium.

k.  Palpable thrill.

l.  Weak pulses, delayed capillary refill, hypotension, or other signs of shock.

m.  Differential between upper and lower extremity pulses or blood pressures.

n.  Hepatomegaly or splenomegaly.

o.  Murmur of grade IV (see
Box 25-1
)
or higher in intensity.

p.  Diastolic murmur.

3.  Careful consideration of murmur description.

a.  Location.

•  Where murmur is heard best, described by location over cardiac structures or location on chest.

Box 25-1
Grading of Cardiac Murmurs

Grade I/VI: soft, difficult to hear unless room quiet and child cooperative.

Grade II/VI: soft but heard immediately.

Grade III/VI: easily heard, moderately loud, no thrill associated.

Grade IV/VI: loud, can palpate the thrill of turbulent flow on chest wall.

Grade V/VI: loud, has thrill, able to hear murmur with stethoscope barely off chest wall.

Grade VI/VI: loud, has thrill, able to hear murmur with stethoscope off chest wall

•  Most common areas to auscultate innocent murmurs are left upper sternal border and left lower sternal border.

b.  Radiation.

•  Descriptor of where else murmur can be heard.

•  Innocent murmurs rarely radiate to distant parts of chest.

c.  Timing: where in the cardiac cycle the murmur is heard.

•  Systole: between Si and S
₂
.

•  Diastole: between S
₂
and S
₁
.

•  Continuous: starts in systole, continues into diastole, does not need to continue throughout cardiac cycle, but has same sound for duration of murmur.