Hypertension in Children

Key Points

• Hypertension in children is 3 or more BP readings above 90^th percentile for age
• Ensure proper technique. Elevated BP measurements taken by oscillometric machines should be confirmed by manual BP readings
• Most children and adolescents have primary hypertension. Suspect secondary etiology in children younger than 6 years with hypertension or any children with stage 2 hypertension
• History and physical examination can aid in the identification of secondary etiologies
• Diagnostic evaluation can identify end-organ injury and comorbid conditions or confirm a secondary etiology
• Lifestyle modification is the first line of therapy in the management of primary hypertension
• Antihypertensive medications are indicated in patients who have persistent elevated BPs despite lifestyle modification, symptomatic hypertension, stage 2 hypertension without modifiable risk factor, or hypertension associated with CKD or diabetes mellitus
• First line medications include CCBs, ACE inhibitors, ARBs, and thiazide diuretics

Alarm Signs and Symptoms

• Symptoms of hypertensive emergency require prompt attention. These include hypertension and any of the following symptoms:
  • Headache
  • Chest pain
  • Shortness of breath
  • Blurry vision
  • Nausea/abdominal pain
  • Dizziness
• Admit patients with hypertensive emergency to ICU for controlled and monitored lowering of BP over 48 hours as these patients are at risk for brain ischemia if BP is lowered too rapidly

Terminology

• Normal BP (blood pressure) is defined as SBP (systolic BP) and DBP (diastolic BP) values less than 90th percentile based on age, sex, and height percentiles for children younger than age 13 years and less than 120/80 for those older than 13 years¹ (Table 1)
• Elevated BP for children younger than 13 years is defined as SBP and DBP values between 90^th and 95^th percentile based on age, sex, and height percentiles¹
• Elevated BP for adolescents (age older than 13 years) is defined as BP ranges ≥ 120/< 80 mm Hg to 129/< 80 mm Hg¹
• Stage 1 hypertension: 95^th percentile to 95^th percentile + 12 mm Hg up to age 13 years, or > 130-139/80-89 for ages older than 13 years¹
• Stage 2 hypertension: greater than 95^th percentile + 12 mm Hg up to age 13, or > 140/90 for ages 13 and older¹
• To be classified as hypertension, BP measurements should be above the cutoffs on 3 or more separate occasions
• Primary hypertension (sometimes called essential or idiopathic hypertension) is the most common cause of hypertension in children. Primary hypertension typically presents in children who are older than 6 years, have family history of hypertension, are overweight or obese, and have no history or physical findings suggestive of secondary causes
• Secondary hypertension is defined as hypertension secondary to other disease
• WCH (white coat hypertension) is defined as BP in 95th percentile or greater in the office or clinical setting but less than 95^th percentile outside office or clinical setting¹
• Hypertensive urgency is a condition in which BP is severely elevated without signs of acute end-organ damage. Patients may be asymptomatic or have symptoms such as headache or nausea
• Hypertensive emergency (severe symptomatic hypertension) is a condition where BP is severely elevated with acute end-organ damage and is a life-threatening condition
• In both hypertensive emergency and hypertensive urgency, BP is severely elevated¹
  • Age younger than 13 years: 30 mm Hg or more above 95^th percentile for age
  • Age 13 years and older: ≥ 180/120

• Table 1. Definitions of normal and abnormal BP.

  DBP, diastolic blood pressure; SBP, systolic blood pressure.

  *Based on age, sex, and height percentiles.

  Data from Thomas J et al. Pediatric hypertension: review of the definition, diagnosis, and initial management. Int J Ped Adol Med. 2022;(9)1:1-6, Table 1; and Flynn JT et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904, Table 3.

  Age	SBP*	DBP*
  Normal BP
  < 13 years	< 90th percentile	< 90th percentile
  ≥ 13 years	< 120	< 80
  Elevated BP
  < 13 years	Between 90th and 95th percentile	Between 90th and 95th percentile
  ≥ 13 years	≥ 120-129	< 80
  Stage 1 hypertension
  < 13 years	95th percentile to 95th percentile + 12 mm Hg	95th percentile to 95th percentile + 12 mm Hg
  ≥ 13 years	> 130-139	> 80-89
  Stage 2 hypertension
  < 13 years	> 95th percentile + 12 mm Hg	> 95th percentile + 12 mm Hg
  ≥ 13 years	> 140	> 90

Epidemiology

• Prevalence of hypertension and elevated BP in children in the United States is approximately 3.5%¹
• With the obesity epidemic, the incidence of pediatric hypertension is on the rise²
• In the United States, hypertension is more common among Black and Hispanic children^3,4,5
• Hypertension is more likely in boys than girls⁵
• Children with higher BPs were more likely to have hypertension as adults⁶
• Primary hypertension is the most common cause of hypertension in children and adolescents. Children with primary hypertension:
  • Are usually older than 6 years
  • Have family history of hypertension
  • Are often overweight/obese. Children with obesity are 2 times more likely to develop hypertension⁷
• In primary hypertension, it is more common to have SBP versus DBP elevation
• Secondary hypertension is uncommon and should be suspected in children younger than 6 years and in children with stage 2 hypertension

Etiology and Risk Factors

Approach to Diagnosis

• Identify patients at risk for elevated BP and hypertension including those with risk factors for primary hypertension. Screening BP values for children requiring additional workup are listed in Table 2
• Confirm BP reading is elevated on 3 separate occasions with proper technique
  • BP should be properly measured. Improper positioning can falsely elevate BP
    • Obtain in upper extremities in a quiet environment after the patient has relaxed for at least 5 minutes
    • The urinary bladder should be empty, and the patient should not be talking
    • The patient should be sitting, with back supported and uncrossed feet flat on the ground, and the arm should be resting on supported surface at the level of the heart
    • The right arm is the preferred location to measure BP as BP in the left arm may be falsely reassuringly low in the setting of aortic coarctation
    • The correct size of cuff includes a bladder width that covers at least 40% of the arm length and the bladder length should allow it to cover more than 80% of the arm circumference. The lower end of the cuff should be 2 to 3 cm above the antecubital fossa
  • Oscillometric BP measurement can be used for screening, but elevated BPs should be re-evaluated with a manual BP reading
  • The first Korotkoff sound should be used to determine SBP and the fifth Korotkoff sound should be used as the DBP. If no fifth Korotkoff sound is heard, the fourth Korotkoff sound (muffling) can be used as DBP
  • Avoid overinflation. Inflate the cuff 20 to 30 mm Hg above the pressure at which the radial pulse is no longer palpable
• Evaluate patients meeting criteria for hypertension for underlying etiologies as well as end-organ damage
• A thorough history and physical examination can identify risk factors and signs of underlying etiologies for secondary hypertension
• ABPM (ambulatory blood pressure monitoring) can be helpful in excluding patients with WCH. ABPM may also be beneficial in identifying patients who have BPs that vary throughout the day
• Laboratory studies can help in the identification of end-organ damage as well as potential underlying etiologies. These can include complete blood count, basic metabolic panel, calcium, phosphorus, uric acid, urinalysis, lipid panel, and drug screen
• Additional laboratory studies may be indicated if history and examination suggest renal or endocrine disease such as 24-hour urine, hormone levels, renin, aldosterone, catecholamines
• Obtain imaging to identify renal structural and vascular abnormalities. Studies may include renal ultrasonography, CTA (computed tomography angiography), or MRA (magnetic resonance angiography)
• Patients with abnormal sleep such as snoring require a sleep study to confirm sleep apnea as a secondary etiology
• To identify end-organ injury, echocardiogram as well as retinal examination may be included

• Table 2. Screening BP values requiring further evaluation.*

  DBP, diastolic blood pressure; SBP, systolic blood pressure.

  *Reflects BP values for the 90th percentile BP for age and sex for children at the 5th percentile of height.

  Data from Flynn JT et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.

  Age (years)	SBP (mm Hg)	DBP (mm Hg)
  Boys
  1	98	52
  2	100	55
  3	101	58
  4	102	60
  5	103	63
  6	105	66
  7	106	68
  8	107	69
  9	107	70
  10	108	72
  11	110	74
  12	113	75
  ≥ 13	120	80
  Girls
  1	98	54
  2	101	58
  3	102	60
  4	103	62
  5	104	64
  6	105	67
  7	106	68
  8	107	69
  9	108	71
  10	109	72
  11	111	74
  12	114	75
  ≥ 13	120	80

Diagnostic Criteria

• See Table 1 for BP definitions
• Tables 3 and 4 list normal BP values for children
• For neonates and children younger than 1 year, there are separate tables of normal values and specific recommendations for diagnosis and management (Figure 1)

• Table 3. Normal BP values in boys.*

  DBP, diastolic blood pressure; SBP, systolic blood pressure.

  *Represents BP values of normal weight boys by age and height categorized by percentiles.

  Data from Flynn JT et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.

  Age (years)	BP percentile	Height percentile or measured height
  		5%	10%	25%	50%	75%	90%	95%
  1	Height (in)	30.4	30.8	31.6	32.4	33.3	34.1	34.6
  	Height (cm)	77.2	78.3	80.2	82.4	84.6	86.7	87.9
  	SBP (mm Hg)
  	50th	85	85	86	86	87	88	88
  	90th	98	99	99	100	100	101	101
  	95th	102	102	103	103	104	105	105
  	95th + 12 mm Hg	114	114	115	115	116	117	117
  	DBP (mm Hg)
  	50th	40	40	40	41	41	42	42
  	90th	52	52	53	53	54	54	54
  	95th	54	54	55	55	56	57	57
  	95th + 12 mm Hg	66	66	67	67	68	69	69
  2	Height (in)	33.9	34.4	35.3	36.3	37.3	38.2	38.8
  	Height (cm)	86.1	87.4	89.6	92.1	94.7	97.1	98.5
  	SBP (mm Hg)
  	50th	87	87	88	89	89	90	91
  	90th	100	100	101	102	103	103	104
  	95th	104	105	105	106	107	107	108
  	95th + 12 mm Hg	116	117	117	118	119	119	120
  	DBP (mm Hg)
  	50th	43	43	44	44	45	46	46
  	90th	55	55	56	56	57	58	58
  	95th	57	58	58	59	60	61	61
  	95th + 12 mm Hg	69	70	70	71	72	73	73
  3	Height (in)	36.4	37	37.9	39	40.1	41.1	41.7
  	Height (cm)	92.5	93.9	96.3	99	101.8	104.3	105.8
  	SBP (mm Hg)
  	50th	88	89	89	90	91	92	92
  	90th	101	102	102	103	104	105	105
  	95th	106	106	107	107	108	109	109
  	95th + 12 mm Hg	118	118	119	119	120	121	121
  	DBP (mm Hg)
  	50th	45	46	46	47	48	49	49
  	90th	58	58	59	59	60	61	61
  	95th	60	61	61	62	63	64	64
  	95th + 12 mm Hg	72	73	73	74	75	76	76
  4	Height (in)	38.8	39.4	40.5	41.7	42.9	43.9	44.5
  	Height (cm)	98.5	100.2	102.9	105.9	108.9	111.5	113.2
  	SBP (mm Hg)
  	50th	90	90	91	92	93	94	94
  	90th	102	103	104	105	105	106	107
  	95th	107	107	108	108	109	110	110
  	95th + 12 mm Hg	119	119	120	120	121	122	122
  	DBP (mm Hg)
  	50th	48	49	49	50	51	52	52
  	90th	60	61	62	62	63	64	64
  	95th	63	64	65	66	67	67	68
  	95th + 12 mm Hg	75	76	77	78	79	79	80
  5	Height (in)	41.1	41.8	43.0	44.3	45.5	46.7	47.4
  	Height (cm)	104.4	106.2	109.1	112.4	115.7	118.6	120.3
  	SBP (mm Hg)
  	50th	91	92	93	94	95	96	96
  	90th	103	104	105	106	107	108	108
  	95th	107	108	109	109	110	111	112
  	95th + 12 mm Hg	119	120	121	121	122	123	124
  	DBP (mm Hg)
  	50th	51	51	52	53	54	55	55
  	90th	63	64	65	65	66	67	67
  	95th	66	67	68	69	70	70	71
  	95th + 12 mm Hg	78	79	80	81	82	82	83
  6	Height (in)	43.4	44.2	45.4	46.8	48.2	49.4	50.2
  	Height (cm)	110.3	112.2	115.3	118.9	122.4	125.6	127.5
  	SBP (mm Hg)
  	50th	93	93	94	95	96	97	98
  	90th	105	105	106	107	109	110	110
  	95th	108	109	110	111	112	113	114
  	95th + 12 mm Hg	120	121	122	123	124	125	126
  	DBP (mm Hg)
  	50th	54	54	55	56	57	57	58
  	90th	66	66	67	68	68	69	69
  	95th	69	70	70	71	72	72	73
  	95th + 12 mm Hg	81	82	82	83	84	84	85
  7	Height (in)	45.7	46.5	47.8	49.3	50.8	52.1	52.9
  	Height (cm)	116.1	118	121.4	125.1	128.9	132.4	134.5
  	SBP (mm Hg)
  	50th	94	94	95	97	98	98	99
  	90th	106	107	108	109	110	111	111
  	95th	110	110	111	112	114	115	116
  	95th + 12 mm Hg	122	122	123	124	126	127	128
  	DBP (mm Hg)
  	50th	56	56	57	58	58	59	59
  	90th	68	68	69	70	70	71	71
  	95th	71	71	72	73	73	74	74
  	95th + 12 mm Hg	83	83	84	85	85	86	86
  8	Height (in)	47.8	48.6	50	51.6	53.2	54.6	55.5
  	Height (cm)	121.4	123.5	127	131	135.1	138.8	141
  	SBP (mm Hg)
  	50th	95	96	97	98	99	99	100
  	90th	107	108	109	110	111	112	112
  	95th	111	112	112	114	115	116	117
  	95th + 12 mm Hg	123	124	124	126	127	128	129
  	DBP (mm Hg)
  	50th	57	57	58	59	59	60	60
  	90th	69	70	70	71	72	72	73
  	95th	72	73	73	74	75	75	75
  	95th + 12 mm Hg	84	85	85	86	87	87	87
  9	Height (in)	49.6	50.5	52	53.7	55.4	56.9	57.9
  	Height (cm)	126	128.3	132.1	136.3	140.7	144.7	147.1
  	SBP (mm Hg)
  	50th	96	97	98	99	100	101	101
  	90th	107	108	109	110	112	113	114
  	95th	112	112	113	115	116	118	119
  	95th + 12 mm Hg	124	124	125	127	128	130	131
  	DBP (mm Hg)
  	50th	57	58	59	60	61	62	62
  	90th	70	71	72	73	74	74	74
  	95th	74	74	75	76	76	77	77
  	95th + 12 mm Hg	86	86	87	88	88	89	89
  10	Height (in)	51.3	52.2	53.8	55.6	57.4	59.1	60.1
  	Height (cm)	130.2	132.7	136.7	141.3	145.9	150.1	152.7
  	SBP (mm Hg)
  	50th	97	98	99	100	101	102	103
  	90th	108	109	111	112	113	115	116
  	95th	112	113	114	116	118	120	121
  	95th + 12 mm Hg	124	125	126	128	130	132	133
  	DBP (mm Hg)
  	50th	59	60	61	62	63	63	64
  	90th	72	73	74	74	75	75	76
  	95th	76	76	77	77	78	78	78
  	95th + 12 mm Hg	88	88	89	89	90	90	90
  11	Height (in)	53	54	55.7	57.6	59.6	61.3	62.4
  	Height (cm)	134.7	137.3	141.5	146.4	151.3	155.8	158.6
  	SBP (mm Hg)
  	50th	99	99	101	102	103	104	106
  	90th	110	111	112	114	116	117	118
  	95th	114	114	116	118	120	123	124
  	95th + 12 mm Hg	126	126	128	130	132	135	136
  	DBP (mm Hg)
  	50th	61	61	62	63	63	63	63
  	90th	74	74	75	75	75	76	76
  	95th	77	78	78	78	78	78	78
  	95th + 12 mm Hg	89	90	90	90	90	90	90
  12	Height (in)	55.2	56.3	58.1	60.1	62.2	64	65.2
  	Height (cm)	140.3	143	147.5	152.7	157.9	162.6	165.5
  	SBP (mm Hg)
  	50th	101	101	102	104	106	108	109
  	90th	113	114	115	117	119	121	122
  	95th	116	117	118	121	124	126	128
  	95th + 12 mm Hg	128	129	130	133	136	138	140
  	DBP (mm Hg)
  	50th	61	62	62	62	62	63	63
  	90th	75	75	75	75	75	76	76
  	95th	78	78	78	78	78	79	79
  	95th + 12 mm Hg	90	90	90	90	90	91	91
  13	Height (in)	57.9	59.1	61	63.1	65.2	67.1	68.3
  	Height (cm)	147	150	154.9	160.3	165.7	170.5	173.4
  	SBP (mm Hg)
  	50th	103	104	105	108	110	111	112
  	90th	115	116	118	121	124	126	126
  	95th	119	120	122	125	128	130	131
  	95th + 12 mm Hg	131	132	134	137	140	142	143
  	DBP (mm Hg)
  	50th	61	60	61	62	63	64	65
  	90th	74	74	74	75	76	77	77
  	95th	78	78	78	78	80	81	81
  	95th + 12 mm Hg	90	90	90	90	92	93	93
  14	Height (in)	60.6	61.8	63.8	65.9	68.0	69.8	70.9
  	Height (cm)	153.8	156.9	162	167.5	172.7	177.4	180.1
  	SBP (mm Hg)
  	50th	105	106	109	111	112	113	113
  	90th	119	120	123	126	127	128	129
  	95th	123	125	127	130	132	133	134
  	95th + 12 mm Hg	135	137	139	142	144	145	146
  	DBP (mm Hg)
  	50th	60	60	62	64	65	66	67
  	90th	74	74	75	77	78	79	80
  	95th	77	78	79	81	82	83	84
  	95th + 12 mm Hg	89	90	91	93	94	95	96
  15	Height (in)	62.6	63.8	65.7	67.8	69.8	71.5	72.5
  	Height (cm)	159	162	166.9	172.2	177.2	181.6	184.2
  	SBP (mm Hg)
  	50th	108	110	112	113	114	114	114
  	90th	123	124	126	128	129	130	130
  	95th	127	129	131	132	134	135	135
  	95th + 12 mm Hg	139	141	143	144	146	147	147
  	DBP (mm Hg)
  	50th	61	62	64	65	66	67	68
  	90th	75	76	78	79	80	81	81
  	95th	78	79	81	83	84	85	85
  	95th + 12 mm Hg	90	91	93	95	96	97	97
  16	Height (in)	63.8	64.9	66.8	68.8	70.7	72.4	73.4
  	Height (cm)	162.1	165	169.6	174.6	179.5	183.8	186.4
  	SBP (mm Hg)
  	50th	111	112	114	115	115	116	116
  	90th	126	127	128	129	131	131	132
  	95th	130	131	133	134	135	136	137
  	95th + 12 mm Hg	142	143	145	146	147	148	149
  	DBP (mm Hg)
  	50th	63	64	66	67	68	69	69
  	90th	77	78	79	80	81	82	82
  	95th	80	81	83	84	85	86	86
  	95th + 12 mm Hg	92	93	95	96	97	98	98
  17	Height (in)	64.5	65.5	67.3	69.2	71.1	72.8	73.8
  	Height (cm)	163.8	166.5	170.9	175.8	180.7	184.9	187.5
  	SBP (mm Hg)
  	50th	114	115	116	117	117	118	118
  	90th	128	129	130	131	132	133	134
  	95th	132	133	134	135	137	138	138
  	95th + 12 mm Hg	144	145	146	147	149	150	150
  	DBP (mm Hg)
  	50th	65	66	67	68	69	70	70
  	90th	78	79	80	81	82	82	83
  	95th	81	82	84	85	86	86	87
  	95th + 12 mm Hg	93	94	96	97	98	98	99

• Table 4. Normal BP in girls.*

  DBP, diastolic blood pressure; SBP, systolic blood pressure.

  *Represents BP values of normal weight girls by age and height categorized by percentiles.

  Data from Flynn JT et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.

  Age (years)	BP percentile	Height percentile or measured height
  		5%	10%	25%	50%	75%	90%	95%
  1	Height (in)	29.7	30.2	30.9	31.8	32.7	33.4	33.9
  	Height (cm)	75.4	76.6	78.6	80.8	83	84.9	86.1
  	SBP (mm Hg)
  	50th	84	85	86	86	87	88	88
  	90th	98	99	99	100	101	102	102
  	95th	101	102	102	103	104	105	105
  	95th + 12 mm Hg	113	114	114	115	116	117	117
  	DBP (mm Hg)
  	50th	41	42	42	43	44	45	46
  	90th	54	55	56	56	57	58	58
  	95th	59	59	60	60	61	62	62
  	95th + 12 mm Hg	71	71	72	72	73	74	74
  2	Height (in)	33.4	34	34.9	35.9	36.9	37.8	38.4
  	Height (cm)	84.9	86.3	88.6	91.1	93.7	96	97.4
  	SBP (mm Hg)
  	50th	87	87	88	89	90	91	91
  	90th	101	101	102	103	104	105	106
  	95th	104	105	106	106	107	108	109
  	95th + 12 mm Hg	116	117	118	118	119	120	121
  	DBP (mm Hg)
  	50th	45	46	47	48	49	50	51
  	90th	58	58	59	60	61	62	62
  	95th	62	63	63	64	65	66	66
  	95th + 12 mm Hg	74	75	75	76	77	78	78
  3	Height (in)	35.8	36.4	37.3	38.4	39.6	40.6	41.2
  	Height (cm)	91	92.4	94.9	97.6	100.5	103.1	104.6
  	SBP (mm Hg)
  	50th	88	89	89	90	91	92	93
  	90th	102	103	104	104	105	106	107
  	95th	106	106	107	108	109	110	110
  	95th + 12 mm Hg	118	118	119	120	121	122	122
  	DBP (mm Hg)
  	50th	48	48	49	50	51	53	53
  	90th	60	61	61	62	63	64	65
  	95th	64	65	65	66	67	68	69
  	95th + 12 mm Hg	76	77	77	78	79	80	81
  4	Height (in)	38.3	38.9	39.9	41.1	42.4	43.5	44.2
  	Height (cm)	97.2	98.8	101.4	104.5	107.6	110.5	112.2
  	SBP (mm Hg)
  	50th	89	90	91	92	93	94	94
  	90th	103	104	105	106	107	108	108
  	95th	107	108	109	109	110	111	112
  	95th + 12 mm Hg	119	120	121	121	122	123	124
  	DBP (mm Hg)
  	50th	50	51	51	53	54	55	55
  	90th	62	63	64	65	66	67	67
  	95th	66	67	68	69	70	70	71
  	95th + 12 mm Hg	78	79	80	81	82	82	83
  5	Height (in)	40.8	41.5	42.6	43.9	45.2	46.5	47.3
  	Height (cm)	103.6	105.3	108.2	111.5	114.9	118.1	120
  	SBP (mm Hg)
  	50th	90	91	92	93	94	95	96
  	90th	104	105	106	107	108	109	110
  	95th	108	109	109	110	111	112	113
  	95th + 12 mm Hg	120	121	121	122	123	124	125
  	DBP (mm Hg)
  	50th	52	52	53	55	56	57	57
  	90th	64	65	66	67	68	69	70
  	95th	68	69	70	71	72	73	73
  	95th + 12 mm Hg	80	81	82	83	84	85	85
  6	Height (in)	43.3	44	45.2	46.6	48.1	49.4	50.3
  	Height (cm)	110	111.8	114.9	118.4	122.1	125.6	127.7
  	SBP (mm Hg)
  	50th	92	92	93	94	96	97	97
  	90th	105	106	107	108	109	110	111
  	95th	109	109	110	111	112	113	114
  	95th + 12 mm Hg	121	121	122	123	124	125	126
  	DBP (mm Hg)
  	50th	54	54	55	56	57	58	59
  	90th	67	67	68	69	70	71	71
  	95th	70	71	72	72	73	74	74
  	95th + 12 mm Hg	82	83	84	84	85	86	86
  7	Height (in)	45.6	46.4	47.7	49.2	50.7	52.1	53
  	Height (cm)	115.9	117.8	121.1	124.9	128.8	132.5	134.7
  	SBP (mm Hg)
  	50th	92	93	94	95	97	98	99
  	90th	106	106	107	109	110	111	112
  	95th	109	110	111	112	113	114	115
  	95th + 12 mm Hg	121	122	123	124	125	126	127
  	DBP (mm Hg)
  	50th	55	55	56	57	58	59	60
  	90th	68	68	69	70	71	72	72
  	95th	72	72	73	73	74	74	75
  	95th + 12 mm Hg	84	84	85	85	86	86	87
  8	Height (in)	47.6	48.4	49.8	51.4	53	54.5	55.5
  	Height (cm)	121	123	126.5	130.6	134.7	138.5	140.9
  	SBP (mm Hg)
  	50th	93	94	95	97	98	99	100
  	90th	107	107	108	110	111	112	113
  	95th	110	111	112	113	115	116	117
  	95th + 12 mm Hg	122	123	124	125	127	128	129
  	DBP (mm Hg)
  	50th	56	56	57	59	60	61	61
  	90th	69	70	71	72	72	73	73
  	95th	72	73	74	74	75	75	75
  	95th + 12 mm Hg	84	85	86	86	87	87	87
  9	Height (in)	49.3	50.2	51.7	53.4	55.1	56.7	57.7
  	Height (cm)	125.3	127.6	131.3	135.6	140.1	144.1	146.6
  	SBP (mm Hg)
  	50th	95	95	97	98	99	100	101
  	90th	108	108	109	111	112	113	114
  	95th	112	112	113	114	116	117	118
  	95th + 12 mm Hg	124	124	125	126	128	129	130
  	DBP (mm Hg)
  	50th	57	58	59	60	60	61	61
  	90th	71	71	72	73	73	73	73
  	95th	74	74	75	75	75	75	75
  	95th + 12 mm Hg	86	86	87	87	87	87	87
  10	Height (in)	51.1	52	53.7	55.5	57.4	59.1	60.2
  	Height (cm)	129.7	132.2	136.3	141	145.8	150.2	152.8
  	SBP (mm Hg)
  	50th	96	97	98	99	101	102	103
  	90th	109	110	111	112	113	115	116
  	95th	113	114	114	116	117	119	120
  	95th + 12 mm Hg	125	126	126	128	129	131	132
  	DBP (mm Hg)
  	50th	58	59	59	60	61	61	62
  	90th	72	73	73	73	73	73	73
  	95th	75	75	76	76	76	76	76
  	95th + 12 mm Hg	87	87	88	88	88	88	88
  11	Height (in)	53.4	54.5	56.2	58.2	60.2	61.9	63
  	Height (cm)	135.6	138.3	142.8	147.8	152.8	157.3	160
  	SBP (mm Hg)
  	50th	98	99	101	102	104	105	106
  	90th	111	112	113	114	116	118	120
  	95th	115	116	117	118	120	123	124
  	95th + 12 mm Hg	127	128	129	130	132	135	136
  	DBP (mm Hg)
  	50th	60	60	60	61	62	63	64
  	90th	74	74	74	74	74	75	75
  	95th	76	77	77	77	77	77	77
  	95th + 12 mm Hg	88	89	89	89	89	89	89
  12	Height (in)	56.2	57.3	59	60.9	62.8	64.5	65.5
  	Height (cm)	142.8	145.5	149.9	154.8	159.6	163.8	166.4
  	SBP (mm Hg)
  	50th	102	102	104	105	107	108	108
  	90th	114	115	116	118	120	122	122
  	95th	118	119	120	122	124	125	126
  	95th + 12 mm Hg	130	131	132	134	136	137	138
  	DBP (mm Hg)
  	50th	61	61	61	62	64	65	65
  	90th	75	75	75	75	76	76	76
  	95th	78	78	78	78	79	79	79
  	95th + 12 mm Hg	90	90	90	90	91	91	91
  13	Height (in)	58.3	59.3	60.9	62.7	64.5	66.1	67
  	Height (cm)	148.1	150.6	154.7	159.2	163.7	167.8	170.2
  	SBP (mm Hg)
  	50th	104	105	106	107	108	108	109
  	90th	116	117	119	121	122	123	123
  	95th	121	122	123	124	126	126	127
  	95th + 12 mm Hg	133	134	135	136	138	138	139
  	DBP (mm Hg)
  	50th	62	62	63	64	65	65	66
  	90th	75	75	75	76	76	76	76
  	95th	79	79	79	79	80	80	81
  	95th + 12 mm Hg	91	91	91	91	92	92	93
  14	Height (in)	59.3	60.2	61.8	63.5	65.2	66.8	67.7
  	Height (cm)	150.6	153	156.9	161.3	165.7	169.7	172.1
  	SBP (mm Hg)
  	50th	105	106	107	108	109	109	109
  	90th	118	118	120	122	123	123	123
  	95th	123	123	124	125	126	127	127
  	95th + 12 mm Hg	135	135	136	137	138	139	139
  	DBP (mm Hg)
  	50th	63	63	64	65	66	66	66
  	90th	76	76	76	76	77	77	77
  	95th	80	80	80	80	81	81	82
  	95th + 12 mm Hg	92	92	92	92	93	93	94
  15	Height (in)	59.7	60.6	62.2	63.9	65.6	67.2	68.1
  	Height (cm)	151.7	154	157.9	162.3	166.7	170.6	173
  	SBP (mm Hg)
  	50th	105	106	107	108	109	109	109
  	90th	118	119	121	122	123	123	124
  	95th	124	124	125	126	127	127	128
  	95th + 12 mm Hg	136	136	137	138	139	139	140
  	DBP (mm Hg)
  	50th	64	64	64	65	66	67	67
  	90th	76	76	76	77	77	78	78
  	95th	80	80	80	81	82	82	82
  	95th + 12 mm Hg	92	92	92	93	94	94	94
  16	Height (in)	59.9	60.8	62.4	64.1	65.8	67.3	68.3
  	Height (cm)	152.1	154.5	158.4	162.8	167.1	171.1	173.4
  	SBP (mm Hg)
  	50th	106	107	108	109	109	110	110
  	90th	119	120	122	123	124	124	124
  	95th	124	125	125	127	127	128	128
  	95th + 12 mm Hg	136	137	137	139	139	140	140
  	DBP (mm Hg)
  	50th	64	64	65	66	66	67	67
  	90th	76	76	76	77	78	78	78
  	95th	80	80	80	81	82	82	82
  	95th + 12 mm Hg	92	92	92	93	94	94	94
  17	Height (in)	60.0	60.9	62.5	64.2	65.9	67.4	68.4
  	Height (cm)	152.4	154.7	158.7	163.0	167.4	171.3	173.7
  	SBP (mm Hg)
  	50th	107	108	109	110	110	110	111
  	90th	120	121	123	124	124	125	125
  	95th	125	125	126	127	128	128	128
  	95th + 12 mm Hg	137	137	138	139	140	140	140
  	DBP (mm Hg)
  	50th	64	64	65	66	66	66	67
  	90th	76	76	77	77	78	78	78
  	95th	80	80	80	81	82	82	82
  	95th + 12 mm Hg	92	92	92	93	94	94	94

Staging or Classification

• See Table 1 for classification definitions

History

• Perinatal history can identify risk factors that are associated with high BP. These include:
  • Maternal hypertension
  • Low birth weight
  • Preterm delivery. Gestational age inversely associated with hypertension risk¹³
  • Complications
  • Umbilical artery catheterization suggests renal artery stenosis
• Nutritional history
  • High dietary sodium increases risk for hypertension, especially in children with obesity¹⁴
  • High consumption of sugary beverages and fast foods increases the risk of obesity and subsequent risk for hypertension¹⁵
  • Fruit and vegetable intake decreases risk for hypertension¹
• Physical activity
  • Regular exercise decreases risk for hypertension
• Psychosocial stressors
  • Identify adverse experiences as they are associated with hypertension in adults
  • Identify signs of depression or anxiety, which may include bullying and poor body image
• Poor sleep or obstructive sleep apnea increases the likelihood of hypertension. Symptoms can include:
  • Snoring
  • Daytime fatigue
• Family history of hypertension
  • Risk factor for primary hypertension
  • Rare causes of monogenic hypertension
• Medication history can highlight drugs that can cause hypertension
  • Herbal supplements
  • Cough and cold medicines
  • Prescription medicines such as oral contraceptives, stimulants
• A detailed past medical history should include assessment for secondary etiologies of hypertension
• History of frequent urinary tract infection suggests the possibility of renal causes

Physical Examination

• Weight and height measurements as well as calculated BMI aid in differentiating primary hypertension from secondary causes
  • Growth retardation suggests the possibility of CKD
  • Obesity, particularly central, could suggest Cushing syndrome or insulin resistance syndrome
• Goiter suggests thyroid disease
• Measurement of BP in both arms and 1 leg¹
  • Second visit with elevated BP or stage 1 hypertension
  • First visit with stage 2 hypertension
  • BP readings taken in the legs that are lower than those taken in the arms (difference of more than 20 mm Hg in arms) suggest aortic coarctation
  • Absence of femoral pulses are also suggestive of aortic coarctation and require further evaluation
  • Brachial-femoral delay suggests coarctation of the aorta
• Signs suggestive of other secondary causes:
  • Abnormal facies
    • Elfin suggests Williams syndrome (OMIM #194050)
    • Moon facies suggest Cushing syndrome
  • Proptosis suggests hyperthyroidism
  • Tonsillar hypertrophy suggests poor sleep or sleep apnea as an etiology
  • Unexplained tachycardia with or without flushing suggests pheochromocytoma, neuroblastoma, hyperthyroidism, or drug use
  • Heart murmurs suggest cardiac lesions such as coarctation
  • Skin findings
    • Café au lait spots suggest neurofibromatosis. These patients are at risk for renal artery stenosis and pheochromocytoma¹⁶
    • Acanthosis nigricans suggests insulin resistance as can be seen in type 2 diabetes and obesity
  • Abdominal masses suggest polycystic kidney disease, malignancies such as neuroblastoma or Wilms tumor
  • Abnormal genitalia suggest congenital adrenal hyperplasia
• Signs of end-organ damage secondary to hypertension
  • Retinal changes

Laboratory Tests

• The aim of laboratory tests is to assess for end-organ damage and for causes of secondary hypertension
• Studies recommended in all pediatric patients with high BP measurements:
  • Urinalysis
    • RBCs suggest renal disease
    • WBCs/casts suggest urinary tract infection, interstitial nephritis, chronic pyelonephritis
  • Basic metabolic panel
    • Hypokalemia and alkalosis suggest mineralocorticoid hypertension or monogenic causes of hypertension
    • Elevated creatinine suggests renal disease
  • Lipid profile
    • Hyperlipidemia suggests metabolic syndrome as an etiology for hypertension
  • Hemoglobin A1C
    • Elevated levels suggest diabetes
  • ALT and AST and fasting lipid profile
    • Elevated levels can suggest fatty liver
• Additional studies to consider in patients with signs and symptoms of specific secondary etiologies include:
  • Fasting blood glucose
    • In overweight patients with clinical suspicion for diabetes (eg, acanthosis nigricans)
  • TSH
    • In patients with proptosis, tachycardia, sweating
  • Drug screening
    • In patients with concerns for recreational drug use or abuse
  • Sleep study
    • In patients with signs and symptoms of sleep apnea (eg, daytime sleepiness, snoring)
  • Plasma renin and aldosterone activity
    • Elevated levels indicate mineralocorticoid disease or renal artery stenosis
    • Low levels might suggest monogenic causes of hypertension
  • Plasma and urine catecholamines
    • Elevated levels indicative of pheochromocytoma
  • Genetic testing for monogenic hypertension syndromes (eg, Liddle syndrome [OMIM #177200], Gordon syndrome [OMIM #614495], congenital adrenal hyperplasia type V)

Imaging Studies

• Renal ultrasonography
  • Recommended for children younger than 6 years with hypertension as an initial evaluation
  • Recommended for all children with:
    • Abnormal urinalysis
    • Renal function impairment
  • Routine duplex ultrasonography is not recommended for evaluation of renovascular hypertension in most children because of its low sensitivity and specificity
• Renovascular imaging by MRA or CTA
  • Obtain in children with suspicion of renal artery stenosis
    • Features or family history of neurofibromatosis
    • Abdominal bruit on examination
    • History of umbilical artery catheterization
    • Young children (younger than 6 years) with stage 2 hypertension with unclear secondary cause
• Angiography
  • In cases where renal artery stenosis is strongly suspected, angiography may be needed as even MRA and CTA are not fully sensitive to detect all cases
• Echocardiography
  • Recommended when antihypertensive treatment is started
  • Assess left ventricular mass, geometry, and function

Diagnostic Tools

• The gold standard for diagnosis of hypertension is 24-hour ABPM
  • Useful in ruling out WCH or BP differences throughout the day
  • This is typically performed by a specialist in patients with BP elevation on repeated clinic visits
  • ABPM measures BP for 24 hours using a small digital device that checks BP every 20 to 30 minutes during the day and night
  • Confirmation of hypertension
    • Children and adolescents with elevated office BP measurements for 1 year or more
    • Children with stage 1 hypertension over 3 clinic visits
  • ABPM use is limited to children older than 5 years who can tolerate the procedure
  • Table 5 lists ABPM classification¹⁷
• ECG is not a sensitive tool for identifying left ventricular hypertrophy and is not a recommended diagnostic modality¹

• Table 5. Revised classification for ambulatory BP studies in pediatric patients.

  BP, blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure; WCH, white coat hypertension.

  *Including 24-hour, wake, and sleep BP.

  From Flynn JT et al. Ambulatory blood pressure monitoring in children and adolescents: 2022 update: a scientific statement from the American Heart Association. Hypertension. 2022;79(7):e114-e124; Table 1.

  Category	Clinic SBP or DBP*		Mean ambulatory SBP or DBP
  	< 13 years of age	≥ 13 years of age	< 13 years of age	≥ 13 years of age
  Normal BP	< 95th percentile	< 130/80 mm Hg	< 95th percentile OR adolescent cut points*	< 125/75 mm Hg 24-h AND < 130/80 mm Hg wake AND < 110/65 mm Hg sleep
  WCH	≥ 95th percentile	≥ 130/80 mm Hg
  Masked hypertension	< 95th percentile	< 130/80 mm Hg	≥ 95th percentile OR adolescent cut points*	≥ 125/75 mm Hg 24-h OR ≥ 130/80 mm Hg wake OR ≥ 110/65 mm Hg sleep
  Ambulatory hypertension	≥ 95th percentile	≥ 130/80 mm Hg

Approach to Treatment

• The goal for treatment of hypertension in children and adolescents is to maintain BP in a range that reduces the risk for target organ damage in childhood and related complications in adulthood
  • BP less than 90^th percentile or less than 130/80 mm Hg, whichever is lower¹
• Lifestyle modification can help with better control of hypertension and reduced cardiometabolic complications
  • Dietary changes. DASH diet (Dietary Approach to Stop Hypertension)
  • Regular physical activities
  • Stress reduction
  • Maintenance of ideal body weight
• Indications for medical therapy¹
  • Failure of lifestyle modification
  • Symptomatic hypertension
  • Stage 2 hypertension without modifiable risk factor
  • Hypertension is associated with CKD or diabetes mellitus
• Treatment to be initiated with a single medication. The dose can be titrated up every 2 to 4 weeks until BP is controlled (less than 90^th percentile)
• A second agent should be added if BP is not controlled with a single medication
• In children with CKD, a lower BP target (24-hour mean arterial pressure less than 50^th percentile on ABPM) decreases risk for progression of CKD
• Hypertensive urgency and emergency require prompt management. These patients present with severely elevated BP (for children younger than 13 years with BP greater than 30 mm Hg above 95^th percentile and for children 13 years or older with BP greater than 180/120) with or without symptoms
  • Requires IV medication/drip in ICU
  • Because of risk for ischemic organ injury, it is recommended to lower the BP over 48 hours and to limit lowering to 25% of goal in first 8 hours³³

Nondrug and Supportive Care

• Lifestyle modifications are important elements in the treatment of hypertension
• DASH diet includes:
  • Low salt (less than 2300 mg/24 hours)
  • Abundance of fruits and vegetables
  • Low-fat dairy
  • Whole grains
  • Nuts
  • Fish, poultry, lean red meats
  • Limit sugar and sweets
• Regular physical exercise is recommended along with DASH diet. At least 3 to 5 days per week of moderate to vigorous physical activity for 30 to 60 minutes for each session is helpful to reduce BP³⁴
• Weight loss therapy including regular, daily physical activities is helpful to control hypertension associated with obesity³⁵
• Stress reduction approaches that may also be helpful:³⁶
  • Breathing awareness meditation
  • Hatha yoga

Drug Therapy

• Choice of antihypertensive (Table 8)
  • In general, initiate therapy with 1 of 3 classes of antihypertensive medications
    • Long-acting CCBs (calcium channel blockers)
    • ACE inhibitors or ARBs (angiotensin receptor blockers)
    • Thiazide diuretics
  • Some classes of antihypertensive medications may be contraindicated in populations with specific comorbid conditions
  • In some populations, specific medications may have additional benefits
  • No data in pediatric populations comparing classes of medications¹
• CCBs
  • Peripheral arterial vasodilation via relaxation of vascular smooth muscle thereby reducing peripheral vascular resistance and BP
  • Divided into 2 classes: DHP (dihydropyridine) and non-DHP
  • DHP subclass is preferable as first line therapy
  • Examples include amlodipine, isradipine, extended-release nifedipine
  • Contraindication: hypersensitivity to CCB
  • Common adverse effects: flushing, dizziness, and peripheral edema
  • Use with caution in patients with aortic stenosis, heart failure, hypertrophic cardiomyopathy (as it can depress ventricular function), and hepatic impairment (associated with hepatic injury)
  • Titrate the dose up every 7 to 14 days
• ARBs
  • Blocks angiotensin II receptor
    • Inhibits vasoconstriction
    • Inhibits salt and water retention in the kidney
  • Examples include losartan, candesartan, valsartan, irbesartan, and olmesartan
  • Recommended as first line therapy in:
    • CKD
    • Diabetes mellitus
    • Proteinuria
  • Does not cause cough and angioedema because it does not inhibit bradykinin metabolism
  • Do not use in conjunction with ACE inhibitor
  • Contraindicated in pregnancy given the risk of fetal toxicity
  • Adverse effects include hyperkalemia and acute kidney injury
• ACE inhibitor
  • Inhibits conversion of angiotensin I to angiotensin II, which is a potent vasoconstrictor, thereby lowering BP
  • Examples include enalapril, captopril, lisinopril, ramipril, fosinopril, quinapril, and benazepril
  • Recommended for children with CKD, proteinuria, left ventricular hypertrophy, or diabetes
  • Contraindicated in:
    • Pregnancy because of increased risk of fetal damage and death
    • Children with angioedema
  • Do not use in conjunction with ARBs
  • Common adverse effects: headache, cough, and dizziness
  • Severe adverse effects: hyperkalemia, angioedema, and acute kidney injury
• Thiazide and thiazide-like diuretics
  • Induces sodium and fluid loss resulting in lower BP
  • Use in patients with CKD
  • Low doses are preferred to minimize metabolic complications, prevent renin-angiotensin system activation, and maintain antihypertensive response
  • Preferred in patients with edema, osteoporosis, or calcium nephrolithiasis with hypercalciuria
  • Examples include chlorthalidone, indapamide, and hydrochlorothiazide
  • Contraindicated if patient is anuric
  • Common adverse effects: dizziness, hypokalemia
  • Severe adverse effects: cardiac arrhythmias, cholestatic jaundice and pancreatitis
• β-Blocker
  • Use in patients in which hypertension does not respond to 2 or more first line agents
  • Given potential adverse effects without associated improved outcomes, not recommended as first line therapy¹
  • Examples include atenolol, metoprolol, propranolol, and bisoprolol
• Vasodilators
  • Relaxes arteriolar smooth muscle
  • Examples include minoxidil and hydralazine

• Table 8. Drug therapies for management of hypertension in children.

  ARBs, angiotensin receptor blockers; CCBs, calcium channel blockers; CKD, chronic kidney disease; DHP, dihydropyridine; GFR, glomerular filtration rate.

  Category	Mechanism	Indication	Contraindication	Adverse effects	Examples
  First line therapies
  CCBs DHP subclass	Vasodilation of peripheral arteries by relaxation of vascular smooth muscle	Primary or secondary hypertension	Hypersensitivity to CCB	Flushing Dizziness Peripheral edema	Amlodipine Isradipine Extended-release nifedipine
  ARBs	Blocks angiotensin II receptor Inhibits vasoconstriction Inhibits salt and water retention in kidney	CKD Diabetes mellitus Proteinuria	Pregnancy Patients taking ACE inhibitor	Reduced GFR can impair renal function Hyperkalemia Acute kidney injury	Losartan Candesartan Valsartan Irbesartan Olmesartan
  ACE inhibitors	Inhibits conversion of angiotensin I to angiotensin II, preventing vasoconstriction	CKD Proteinuria Diabetes mellitus	Pregnancy Angioedema Patients taking ARBs	Reduced GFR can impair renal function Headache, cough, dizziness Severe: hyperkalemia, angioedema, acute kidney injury	Enalapril Captopril Lisinopril Ramipril Fosinopril Quinapril Benazepril
  Thiazides	Induces sodium and fluid loss	Edema Osteoporosis Calcium nephrolithiasis	Anuric	Dizziness Hypokalemia Severe: arrhythmias, cholestatic jaundice, pancreatitis	Chlorthalidone Indapamide Hydrochlorothiazide
  Second line therapies
  β-Blockers	Decreased renin Decreased cardiac output	Use in patients whose hypertension does not respond to 2 or more first line agents	Asthmatics	Dizziness Severe: chest pain, shortness of breath	Atenolol Metoprolol Bisoprolol
  Vasodilators	Relaxes arteriolar smooth muscle	Use in refractory hypertension	Pericardial effusion	Palpitations Nausea Headache Nausea/vomiting	Minoxidil Hydralazine

Treatment Procedures

• Percutaneous transluminal angioplasty is performed to treat hypertension secondary to renal artery stenosis, usually due to fibromuscular dysplasia
  • Generally done by interventional radiology
  • Technical success rate as high as 90%³⁷
  • Clinical improvement or resolution of hypertension in 64%³⁷

Persistent or Recurrent Disease

• While not specifically defined in children, resistant hypertension in adults is defined as persistently elevated BP despite using 3 different antihypertensive agents including diuretics at their maximum doses. Treatment includes:
  • Assessment of medication adherence
  • Reinforcement of low-salt diet
  • Reevaluation of possible undiagnosed secondary causes of hypertension
  • Addition of another agent such as spironolactone, which is helpful in the treatment of hyperaldosteronism seen commonly with resistant hypertension
• Some controversy in the literature as to whether this a true entity in children³⁸

Admission Criteria

• Hypertensive urgency and hypertensive emergency require ICU management to lower BP in controlled fashion
  • Severely elevated BP (for children younger than 13 years with BP greater than 30 mm Hg above 95^th percentile and for children 13 years or older with BP greater than 180/120) with or without symptoms
  • American Academy of Pediatrics guidelines recommend enteral therapy if the patient can tolerate oral administration¹
  • May require IV medication/drip that may include labetalol, esmolol, or nicardipine³³
  • Continuous cardiac monitoring
  • Because of risk for cerebral ischemia, it is recommended to lower the BP over 48 hours and to limit lowering to 25% of goal in first 8 hours³³

Premature and Low-Birth-Weight Infants

• Higher risk for developing hypertension later in life as compared to their term counterparts³⁹
• These patients may also be at additional risk for CKD, which can be exacerbated by hypertension⁴⁰
• Recommend early evaluation and long-term follow-up for development and subsequent management of hypertension¹³

CKD

• Higher risk of masked hypertension whereby BP in clinic is lower than at home⁴¹
• Evaluate by ABPM to diagnose masked hypertension
• Increased risk of cardiovascular disease⁴²
• Treat with ACE inhibitors (eg, enalapril, lisinopril, ramipril) or ARBs (eg, losartan, candesartan, valsartan, irbesartan, olmesartan)

Sickle Cell Disease

• Higher risk for masked hypertension as patients can have abnormal circadian BPs⁴³
• Evaluate these patients by ABPM to identify those patients with masked hypertension
• High BPs confer additional risk in sickle cell patients for cardiovascular and neurovascular complications⁴⁴

Polycystic Kidney Disease

• Higher risk of masked hypertension
• Evaluate by ABPM to diagnose masked hypertension

Diabetes

• Lower threshold for starting antihypertensive therapy as coexisting untreated hypertension can exacerbate vascular complications⁴²
  • First line medications include ACE inhibitors (eg, enalapril, captopril, lisinopril, ramipril, fosinopril, quinapril, benazepril) or ARBs (eg, losartan, candesartan, valsartan, irbesartan, olmesartan)

Monitoring

• Home BP monitoring is recommended to determine treatment efficacy
  • In older children or adolescents, commercially available oscillometric devices may be used
• If home and clinic BPs do not show adequate improvement, BPs should be monitored with ABPM
• After initiation of antihypertensive medication, check BP every 2 to 4 weeks at home; dose of medication can be titrated if necessary¹
• Follow up in clinic every 4 to 6 weeks until BP has normalized. When target BP is reached, follow up every 3 to 6 months. Home BP can be used for follow-up¹
• Assess for end-organ damage at 6- to 12-month intervals¹
• Regular microalbumin measurements are not routinely recommended in children and adolescents with primary hypertension
• Echocardiography may be repeated to monitor for end-organ damage every 1 to 2 years, especially in patients with:
  • Uncontrolled hypertension despite treatment
  • Secondary hypertension
  • Stage 2 hypertension
• Refer patients with evidence of left ventricular hypertrophy or low left ventricular ejection fraction on echocardiogram to cardiology

Complications

• Hypertension is associated with significant cardiovascular, renal, and neurologic complications
• Cardiovascular complications include left ventricular hypertrophy, heart failure
• Hypertension can cause CKD and end-stage renal disease
• Although they are uncommon, intracranial hemorrhage, stroke, and posterior reversible encephalopathy syndrome can result from uncontrolled hypertension
• Hypertensive retinopathy is the most common eye complication of hypertension

Prognosis

• Earlier onset of hypertension increases risk of cardiovascular disease likely representing lifetime burden of elevated BPs⁴⁵
• Research suggests that hypertension diagnosed during childhood is associated with worse cardiovascular outcomes in middle-aged adults⁴⁶

Referral

• Pediatric hypertension is ideally managed by a pediatric nephrologist or preventative cardiologist
• Refer patients with left ventricular hypertrophy and low ejection fraction to pediatric cardiology
• Refer patients with suspected secondary endocrine etiology, such as Cushing disease or hypothyroidism, to pediatric endocrinology for their hypertension
• Refer to a registered dietitian for help with dietary advice and nutritional strategies for weight control. When available, multidisciplinary weight management clinics can be helpful

Screening

• For children without risk factors to develop hypertension, begin measuring BP at each annual well-child visit starting at age 3 years
• For children with risk factors, start BP measurements before age 3 years at each well-child visit. These risk factors include preterm birth (less than 32 weeks of gestation), low birth weight, CKD, solid organ transplant, and overweight or obesity

Prevention

• Preventive measurements that aim to modify the risk factors for hypertension include lifestyle modification and monitoring for hypertension earlier in those at highest risk
• Maintain healthy weight and regular exercise
• For those at highest risk, encourage DASH diet and discourage sedentary lifestyle
• Regular well-child care with monitoring of BP