The Indian Journal of Pediatrics

, Volume 78, Issue 5, pp 569–575 | Cite as

Hypertensive Emergencies in Children

  • Pankaj Hari
  • Aditi Sinha
Symposium on PICU Protocols of AIIMS


Hypertensive emergencies, though uncommon in children, are potentially life threatening. While targeting blood pressure reduction to below the 90th percentile for age, gender and height, mean arterial blood pressure should be gradually lowered by one-fourth of the planned reduction over 8–12 h, a further fourth over the next 8–12 h, and the final 50% over the 24 h after that. Frequent invasive or non-invasive blood pressure monitoring is essential, as is monitoring for sensorial alteration and loss of papillary reflexes. Few antihypertensive agents have been examined in children. Continuous intravenous infusions of short acting drugs such as nitroprusside, labetalol and nicardipine are preferred to intravenous boluses of hydralazine or diazoxide. If severe symptoms are absent, oral agents such as nifedipine, clonidine, minoxidil, hydralazine, labetalol, captopril, and prazosin may be used. Nicardipine and labetalol are particularly suited in emergencies with intracranial bleeding or ischemic stroke, while furosemide, sodium nitroprusside and nitroglycerine are useful in congestive cardiac failure. Therapy with oral antihypertensive drugs should be instituted within 6–12 h of parenteral therapy, and the latter gradually withdrawn over the next 12–48 h. Oral agents have limited application as primary therapy, except when administration of intravenous infusion is likely to be delayed. This article provides a summary of the clinical approach to evaluation and management of severe symptomatic hypertension in children.


Hypertensive crisis Pediatric Antihypertensive 


  1. 1.
    Fivush B, Neu A, Furth S. Acute hypertensive crises in children: emergencies and urgencies. Curr Opin Pediatr. 1997;9:233–6.PubMedCrossRefGoogle Scholar
  2. 2.
    National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555–76.CrossRefGoogle Scholar
  3. 3.
    Belsha CW. Pediatric hypertension in the emergency department. Ann Emerg Med. 2008;51:S21–3.PubMedCrossRefGoogle Scholar
  4. 4.
    Flynn JT, Tullus K. Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatr Nephrol. 2009;24:1101–12.PubMedCrossRefGoogle Scholar
  5. 5.
    Zampaglione B, Pascale C, Marchisio M, et al. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension. 1996;27:144–7.PubMedGoogle Scholar
  6. 6.
    Martin JF, Higashiama E, Garcia E, et al. Hypertensive crisis profile. Prevalence and clinical presentation. Arq Bras Cardiol. 2004;83:125–36.CrossRefGoogle Scholar
  7. 7.
    Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension. 1995;25:305–13.PubMedGoogle Scholar
  8. 8.
    Marquez-Contreras E, Coca A, de la Figuera von Wichmann M, et al. Cardiovascular risk profile of uncontrolled hypertensive patients. The Control-Project study. Med Clin (Barc). 2007;128:86–91.CrossRefGoogle Scholar
  9. 9.
    Hari P, Bagga A, Srivastava RN. Sustained hypertension in children. Indian Pediatr. 2000;37:268–74.PubMedGoogle Scholar
  10. 10.
    Flynn JT, Daniels SD. Pharmacologic treatment of hypertension in children and adolescents. J Pediatr. 2006;149:746–54.PubMedCrossRefGoogle Scholar
  11. 11.
    Porto I. Hypertensive emergencies in children. J Pediatr Health Care. 2000;14:312–9.PubMedGoogle Scholar
  12. 12.
    Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 1. Am J Health-Syst Pharm. 2009;66:1343–52.PubMedCrossRefGoogle Scholar
  13. 13.
    Deal JE, Barratt TM, Dillon MJ. Management of hypertensive emergencies. Arch Dis Child. 1992;67:1089–92.PubMedCrossRefGoogle Scholar
  14. 14.
    Hoffman BB. Therapy of hypertension. In: Brunton LL, Lazo JS, Parker KL, editors. Goodman & Gilman’s the pharmacological basis of therapeutics. 11th ed. New York: McGraw-Hill; 2006. p. 845–68.Google Scholar
  15. 15.
    Bunchman TE, Lynch RE, Wood EG. Intravenously administered labetalol for treatment of hypertension in children. J Pediatr. 1992;120:140–4.PubMedCrossRefGoogle Scholar
  16. 16.
    Flynn JT, Pasko DA. Calcium channel blockers: pharmacology and place in therapy of pediatric hypertension. Pediatr Nephrol. 2000;15:302–16.PubMedCrossRefGoogle Scholar
  17. 17.
    Adamson PC, Rhodes LA, Saul JP, et al. The pharmacokinetics of esmolol in pediatric subjects with supraventricular arrhythmias. Pediatr Cardiol. 2006;27:420–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Murphy MB, Murray C, Shorten GD. Fenoldopam—a selective peripheral dopamine-receptor agonist for the treatment of severe hypertension. N Engl J Med. 2001;345:1548–57.PubMedCrossRefGoogle Scholar
  19. 19.
    Nordlander M, Sjöquist P-O, Ericsson H, Rydén L. Pharmacodynamic, pharmacokinetic and clinical effects of clevidipine, an ultrashort-acting calcium antagonist for rapid blood pressure control. Cardiovasc Drug Rev. 2004;22:227–50.PubMedCrossRefGoogle Scholar
  20. 20.
    Woisetschläger C, Bur A, Vlcek M, Derhaschnig U, Laggner AN, Hirschl MM. Comparison of intravenous urapidil and oral captopril in patients with hypertensive urgencies. J Hum Hypertens. 2006;20:707–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Wells TG, Bunchman TE, Kearns GL. Treatment of neonatal hypertension with enalaprilat. J Pediatr. 1990;117:664–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Burton TJ, Wilkinson IB. The dangers of immediate-release nifedipine in the emergency treatment of hypertension. J Hum Hypertens. 2008;22:301–2.PubMedCrossRefGoogle Scholar
  23. 23.
    Calvetta A, Martino S, von Vigier RO, Schmidtko J, Fossali E, Bianchetti MG. What goes up must immediately come down! Which indication for short-acting nifedipine in children with arterial hypertension? Pediatr Nephrol. 2003;18:1–2.PubMedCrossRefGoogle Scholar
  24. 24.
    Yiu V, Orrbine E, Rosychuk RJ, et al. The safety and use of short-acting nifedipine in hospitalized hypertensive children. Pediatr Nephrol. 2004;19:644–50.PubMedCrossRefGoogle Scholar
  25. 25.
    Sica DA. Centrally acting antihypertensive agents: An update. J Clin Hypertens (Greenwich). 2007;9:399–405.CrossRefGoogle Scholar
  26. 26.
    Strife CF, Quinlan M, Waldo FB, et al. Minoxidil for control of acute blood pressure elevation in chronically hypertensive children. Pediatrics. 1986;78:861–5.PubMedGoogle Scholar
  27. 27.
    Aggarwal M, Khan IA. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin. 2006;24:135–46.PubMedCrossRefGoogle Scholar
  28. 28.
    Flanigan JS, Vitberg D. Hypertensive emergency and severe hypertension: what to treat, who to treat, and how to treat. Med Clin North Am. 2006;90:439–51.PubMedCrossRefGoogle Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2011

Authors and Affiliations

  1. 1.Division of Nephrology, Department of PediatricsAll India Institute of Medical SciencesNew DelhiIndia

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