Our orders are delivered strictly on time without delay
Our orders are delivered strictly on time without delay
discuss the following:
You see a 3-year-old with hypertension (documented on three different visits) in your primary care clinic.
Describe the workup, differential diagnoses, assessment, and management.
How would your plan of care be different if the child were 10 years old?
What risk factor counseling and advice would you include?
That's a critical clinical scenario. Identifying and managing hypertension in a child requires a systematic approach, as it often signals an underlying secondary cause.
Hypertension in a child under 6 years old is much more likely to be secondary (caused by an identifiable underlying medical problem) rather than primary (essential) hypertension.
The initial workup is focused on ruling out the most common secondary causes:
Initial Lab Studies:
Basic Metabolic Panel (BMP): Assess serum electrolytes (especially potassium), blood urea nitrogen (BUN), and creatinine to evaluate renal function.
Urinalysis (UA) with Urine Culture: Screen for proteinuria, hematuria, and signs of chronic kidney infection.
Lipid Panel and Fasting Glucose: Establish baseline and screen for metabolic syndrome, though less common as a primary cause in this age group.
Thyroid-Stimulating Hormone (TSH): Rule out thyroid dysfunction.
Plasma Renin Activity (PRA) and Aldosterone: Evaluate for mineralocorticoid excess (e.g., primary hyperaldosteronism).
Imaging and Diagnostic Studies:
Renal Ultrasound with Doppler: This is crucial. It assesses kidney size, structure (ruling out congenital anomalies, tumors, or hydronephrosis), and checks for renal artery stenosis (using Doppler).
Echocardiogram: Assesses for target-organ damage (e.g., left ventricular hypertrophy, LVH) and structural heart defects.
Four-Extremity Blood Pressure (BP): Check BP in all four limbs (right arm, left arm, right leg, left leg) to screen for Coarctation of the Aorta (CoA), indicated by a significant difference (typically $\geq 10-20$ mmHg) between upper and lower extremity pressures.
| Differential Diagnosis | Rationale (Likelihood in a 3-year-old) |
|---|---|
| 1. Renal Parenchymal Disease (Chronic Kidney Disease) | HIGH. This is the most common cause of secondary hypertension in young children. It includes congenital anomalies of the kidney and urinary tract (CAKUT), reflux nephropathy, and inherited conditions. |
| 2. Renal Artery Stenosis | HIGH. A form of renovascular hypertension often caused by fibromuscular dysplasia or neurofibromatosis in children. Decreased blood flow to the kidney triggers the Renin-Angiotensin-Aldosterone System (RAAS). |
| 3. Coarctation of the Aorta (CoA) | HIGH. A narrowing of the aorta that increases blood pressure proximal to the narrowing (upper body) and decreases it distally (lower body). Often missed if a four-limb BP screen wasn't done at birth. |
| 4. Endocrine Disorders | MODERATE. Includes hyperaldosteronism, Cushing syndrome, or rare catecholamine-secreting tumors like pheochromocytoma or neuroblastoma. Should be ruled out with targeted labs (e.g., PRA/Aldosterone, urine catecholamines). |