Symptoms of hypertension in childhood can vary depending upon the severity and duration of hypertension. Mild to moderate hypertension is often asymptomatic, while severe hypertension can present with encephalopathy and acute loss of vision (posterior reversible encephalopathy syndrome, PRES).
2.1. Past Medical History
Determining the duration of hypertension at presentation is of clinical consequence as it helps narrow down the list of differential diagnosis. Establishing the duration of hypertension starts by obtaining a comprehensive history. Such interview should focus on symptoms associated with hypertension such as poor sense of well-being, poor sleep, restlessness, poor growth, nose bleed, all with the potential to suggest chronic hypertension. Frequent headaches, blurred vision, chest pain, symptoms of congestive heart failure, and encephalopathy seizure all could point to an acute onset of hypertension.
As most clinical conditions in pediatrics, etiology of hypertension is age specific, , as we and others have previously shown [8
]. As such, history taking should be focused depending on the age of the child. Neonatal period, prematurity low birth weight, prolonged oxygen therapy, and history of umbilical artery catheters may provide clues as to the etiology of hypertension. Also history of urinary tract infection in infancy may predispose to renal scars and may suggest renal anomalies. In older children glomerulonephritis and in adolescent females, history of urinary tact infections or dysfunctional voiding may suggest a cause for hypertension. Symptoms of systemic illness also could include pallor, flushing, joint pains, rash, edema, gross hematuria, excessive weight gain or loss, or decreased height growth which may suggest vasculitis or glomerulonephritis. Triad of flushing, palpitations and, hypertension are often suggestive of pheochromocytoma, a rare cause of hypertension in this age group. In adolescents history is often nonspecific as the prevalence of idiopathic hypertension often increases. History should question the occurrence of headaches, sleep disturbance, visual symptoms, nosebleeds, palpitations, and episodic rapid pulse. Sleep disorder, snoring fatigue could be associated with obstructive sleep apnea, a condition overlooked in older children.
Causes of hypertension in children by age group (percentage).
2.2. Dietary and Medication History
Detailed dietary history is important when deciphering the etiology of hypertension. Excessive intake of sodium or caffeinated beverages, and energy drinks is associated with hypertension. A medication history should include specific questions about over-the-counter drugs like pseudoephedrine or herbal preparations like ephedra, St. John's Wort, or licorice as well as prescription drugs. Adolescents should be questioned in private to obtain a history of substance abuse or the possibility of pregnancy. History of current or recent prescription medications such as decongestants, corticosteroids, and nonsteroidal anti-inflammatory could all suggest a cause for hypertension.
2.3. Physical Exam
BP is a variable that depends on many factors including anxiety. Office hypertension also known as white coat effect is not an uncommon cause of referral for evaluation to the specialist. Studies have shown that repeated BP measurement can lower the incidence of office hypertension. A complete physical exam should focus on signs associated with the disease process that caused hypertension and signs of end organ damage associated with hypertension.
The prevalence of secondary hypertension is high in children. An infant with hypertension abdominal mass could suggest congenital kidney disease, and pulmonary findings could suggest bronchopulmonary dysplasia. In older children, presence of edema or rash could suggest glomerulonephritis or vasculitis. Four extremities BP check is an essential part of a physical exam of a child with hypertension to evaluate for coarctation of the aorta. Café-au-lait spots could suggest neurofibromatosis often associated with hypertension either due to pheochromotocytoma or renal artery stenosis. Signs of CV disease as a complication of hypertension include gallop, tachycardia, rales, decreased breath sounds, and so forth. In severe hypertension, lethargy, loss of vision (PRES), and signs of stroke are all signs of hypertension. Signs of excessive steroids such as Cushing syndrome, for example, truncal obesity, buffalo hump, round moon faces, and hirsutism. Height and weight to calculate BMI is an essential part of the physical exam when evaluating a child with hypertension. A high BMI points to obesity as a possible cause for hypertension.