ThisiscontentfromClinicalKey

    Hypertension in Children

    Sign up for your free ClinicalKey trial today!  Your first step in getting the right answers when you need them.

    Apr.19.2024

    Hypertension in Children

    Summary

    Key Points

    • Hypertension in children is 3 or more BP readings above 90th 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

    Basic Information

    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 90th and 95th 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: 95th percentile to 95th 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 95th 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 95th 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 95th 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.
      AgeSBP*DBP*
      Normal BP
      < 13 years< 90th percentile< 90th percentile
      ≥ 13 years< 120< 80
      Elevated BP
      < 13 yearsBetween 90th and 95th percentileBetween 90th and 95th percentile
      ≥ 13 years≥ 120-129< 80
      Stage 1 hypertension
      < 13 years95th percentile to 95th percentile + 12 mm Hg95th 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 children3,4,5
    • 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

    Etiology

    • Although a specific etiology for primary hypertension is not identified, the underpinnings are thought to be multifactorial including obesity, neurologic, immunologic, and metabolic abnormalities8
    • Secondary hypertension:
      • Renal causes make up about half of the pediatric patients with secondary hypertension (eg, renal artery stenosis, CKD [chronic kidney disease], postinfectious glomerulonephritis, monogenic causes of hypertension)2
      • Endocrine causes are the next most common category (5% to 10%) (eg, Cushing syndrome, pheochromocytoma, neuroblastoma, congenital adrenal hyperplasia, hypo- or hyperthyroidism, hyperparathyroidism)2
      • Cardiovascular (eg, aortic coarctation)
      • Drugs and toxins (eg, glucocorticoids, oral contraceptives, tacrolimus and cyclosporine, cold medicines)
      • Abdominal compartment syndrome
      • Alcohol intoxication and recreational drugs

    Risk Factors

    • Nonmodifiable risk factors for primary hypertension1
      • Race: Hispanic and non-Hispanic Black children are more likely to have high BP as compared to non-Hispanic White children
      • Sex: boys are more likely to have high BP as compared to girls
      • Family history:9 risk for hypertension in children is 2 times more likely if 1 parent has hypertension and 4 times as likely in children in which both parents have hypertension
      • Prenatal/perinatal1
        • Preterm and low-birth-weight infants are at risk for hypertension as adults
        • Low birth weight infants are also at risk for high BP in childhood
    • Modifiable risk factors
      • Increase risk of hypertension
        • High dietary sodium intake
        • Obesity
        • Metabolic syndrome
        • Tobacco exposure
        • Prenatal and perinatal factors
          • Children with a history of maternal hypertensive disease during pregnancy are at increased risk
          • Maternal smoking during pregnancy increases risk
          • Preterm and low birth weight increase risk
        • Adverse childhood experiences10
          • Abuse: physical, sexual, emotional
          • Neglect
          • Household dysfunction including substance use disorder, domestic violence, parental divorce, mental illness
        • Environmental exposures: lead, cadmium, mercury, phthalates
        • Sedentary lifestyle11
        • Obstructive sleep apnea12
      • Decrease risk of hypertension
        • Breastfed children
        • Healthy, well-balanced diet
        • Active lifestyle

    Diagnosis

    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
      19852
      210055
      310158
      410260
      510363
      610566
      710668
      810769
      910770
      1010872
      1111074
      1211375
      ≥ 1312080
      Girls
      19854
      210158
      310260
      410362
      510464
      610567
      710668
      810769
      910871
      1010972
      1111174
      1211475
      ≥ 1312080

    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 percentileHeight percentile or measured height
      5%10%25%50%75%90%95%
      1Height (in)30.430.831.632.433.334.134.6
      Height (cm)77.278.380.282.484.686.787.9
      SBP (mm Hg)
      50th85858686878888
      90th989999100100101101
      95th102102103103104105105
      95th + 12 mm Hg114114115115116117117
      DBP (mm Hg)
      50th40404041414242
      90th52525353545454
      95th54545555565757
      95th + 12 mm Hg66666767686969
      2Height (in)33.934.435.336.337.338.238.8
      Height (cm)86.187.489.692.194.797.198.5
      SBP (mm Hg)
      50th87878889899091
      90th100100101102103103104
      95th104105105106107107108
      95th + 12 mm Hg116117117118119119120
      DBP (mm Hg)
      50th43434444454646
      90th55555656575858
      95th57585859606161
      95th + 12 mm Hg69707071727373
      3Height (in)36.43737.93940.141.141.7
      Height (cm)92.593.996.399101.8104.3105.8
      SBP (mm Hg)
      50th88898990919292
      90th101102102103104105105
      95th106106107107108109109
      95th + 12 mm Hg118118119119120121121
      DBP (mm Hg)
      50th45464647484949
      90th58585959606161
      95th60616162636464
      95th + 12 mm Hg72737374757676
      4Height (in)38.839.440.541.742.943.944.5
      Height (cm)98.5100.2102.9105.9108.9111.5113.2
      SBP (mm Hg)
      50th90909192939494
      90th102103104105105106107
      95th107107108108109110110
      95th + 12 mm Hg119119120120121122122
      DBP (mm Hg)
      50th48494950515252
      90th60616262636464
      95th63646566676768
      95th + 12 mm Hg75767778797980
      5Height (in)41.141.843.044.345.546.747.4
      Height (cm)104.4106.2109.1112.4115.7118.6120.3
      SBP (mm Hg)
      50th91929394959696
      90th103104105106107108108
      95th107108109109110111112
      95th + 12 mm Hg119120121121122123124
      DBP (mm Hg)
      50th51515253545555
      90th63646565666767
      95th66676869707071
      95th + 12 mm Hg78798081828283
      6Height (in)43.444.245.446.848.249.450.2
      Height (cm)110.3112.2115.3118.9122.4125.6127.5
      SBP (mm Hg)
      50th93939495969798
      90th105105106107109110110
      95th108109110111112113114
      95th + 12 mm Hg120121122123124125126
      DBP (mm Hg)
      50th54545556575758
      90th66666768686969
      95th69707071727273
      95th + 12 mm Hg81828283848485
      7Height (in)45.746.547.849.350.852.152.9
      Height (cm)116.1118121.4125.1128.9132.4134.5
      SBP (mm Hg)
      50th94949597989899
      90th106107108109110111111
      95th110110111112114115116
      95th + 12 mm Hg122122123124126127128
      DBP (mm Hg)
      50th56565758585959
      90th68686970707171
      95th71717273737474
      95th + 12 mm Hg83838485858686
      8Height (in)47.848.65051.653.254.655.5
      Height (cm)121.4123.5127131135.1138.8141
      SBP (mm Hg)
      50th959697989999100
      90th107108109110111112112
      95th111112112114115116117
      95th + 12 mm Hg123124124126127128129
      DBP (mm Hg)
      50th57575859596060
      90th69707071727273
      95th72737374757575
      95th + 12 mm Hg84858586878787
      9Height (in)49.650.55253.755.456.957.9
      Height (cm)126128.3132.1136.3140.7144.7147.1
      SBP (mm Hg)
      50th96979899100101101
      90th107108109110112113114
      95th112112113115116118119
      95th + 12 mm Hg124124125127128130131
      DBP (mm Hg)
      50th57585960616262
      90th70717273747474
      95th74747576767777
      95th + 12 mm Hg86868788888989
      10Height (in)51.352.253.855.657.459.160.1
      Height (cm)130.2132.7136.7141.3145.9150.1152.7
      SBP (mm Hg)
      50th979899100101102103
      90th108109111112113115116
      95th112113114116118120121
      95th + 12 mm Hg124125126128130132133
      DBP (mm Hg)
      50th59606162636364
      90th72737474757576
      95th76767777787878
      95th + 12 mm Hg88888989909090
      11Height (in)535455.757.659.661.362.4
      Height (cm)134.7137.3141.5146.4151.3155.8158.6
      SBP (mm Hg)
      50th9999101102103104106
      90th110111112114116117118
      95th114114116118120123124
      95th + 12 mm Hg126126128130132135136
      DBP (mm Hg)
      50th61616263636363
      90th74747575757676
      95th77787878787878
      95th + 12 mm Hg89909090909090
      12Height (in)55.256.358.160.162.26465.2
      Height (cm)140.3143147.5152.7157.9162.6165.5
      SBP (mm Hg)
      50th101101102104106108109
      90th113114115117119121122
      95th116117118121124126128
      95th + 12 mm Hg128129130133136138140
      DBP (mm Hg)
      50th61626262626363
      90th75757575757676
      95th78787878787979
      95th + 12 mm Hg90909090909191
      13Height (in)57.959.16163.165.267.168.3
      Height (cm)147150154.9160.3165.7170.5173.4
      SBP (mm Hg)
      50th103104105108110111112
      90th115116118121124126126
      95th119120122125128130131
      95th + 12 mm Hg131132134137140142143
      DBP (mm Hg)
      50th61606162636465
      90th74747475767777
      95th78787878808181
      95th + 12 mm Hg90909090929393
      14Height (in)60.661.863.865.968.069.870.9
      Height (cm)153.8156.9162167.5172.7177.4180.1
      SBP (mm Hg)
      50th105106109111112113113
      90th119120123126127128129
      95th123125127130132133134
      95th + 12 mm Hg135137139142144145146
      DBP (mm Hg)
      50th60606264656667
      90th74747577787980
      95th77787981828384
      95th + 12 mm Hg89909193949596
      15Height (in)62.663.865.767.869.871.572.5
      Height (cm)159162166.9172.2177.2181.6184.2
      SBP (mm Hg)
      50th108110112113114114114
      90th123124126128129130130
      95th127129131132134135135
      95th + 12 mm Hg139141143144146147147
      DBP (mm Hg)
      50th61626465666768
      90th75767879808181
      95th78798183848585
      95th + 12 mm Hg90919395969797
      16Height (in)63.864.966.868.870.772.473.4
      Height (cm)162.1165169.6174.6179.5183.8186.4
      SBP (mm Hg)
      50th111112114115115116116
      90th126127128129131131132
      95th130131133134135136137
      95th + 12 mm Hg142143145146147148149
      DBP (mm Hg)
      50th63646667686969
      90th77787980818282
      95th80818384858686
      95th + 12 mm Hg92939596979898
      17Height (in)64.565.567.369.271.172.873.8
      Height (cm)163.8166.5170.9175.8180.7184.9187.5
      SBP (mm Hg)
      50th114115116117117118118
      90th128129130131132133134
      95th132133134135137138138
      95th + 12 mm Hg144145146147149150150
      DBP (mm Hg)
      50th65666768697070
      90th78798081828283
      95th81828485868687
      95th + 12 mm Hg93949697989899
    • 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 percentileHeight percentile or measured height
      5%10%25%50%75%90%95%
      1Height (in)29.730.230.931.832.733.433.9
      Height (cm)75.476.678.680.88384.986.1
      SBP (mm Hg)
      50th84858686878888
      90th989999100101102102
      95th101102102103104105105
      95th + 12 mm Hg113114114115116117117
      DBP (mm Hg)
      50th41424243444546
      90th54555656575858
      95th59596060616262
      95th + 12 mm Hg71717272737474
      2Height (in)33.43434.935.936.937.838.4
      Height (cm)84.986.388.691.193.79697.4
      SBP (mm Hg)
      50th87878889909191
      90th101101102103104105106
      95th104105106106107108109
      95th + 12 mm Hg116117118118119120121
      DBP (mm Hg)
      50th45464748495051
      90th58585960616262
      95th62636364656666
      95th + 12 mm Hg74757576777878
      3Height (in)35.836.437.338.439.640.641.2
      Height (cm)9192.494.997.6100.5103.1104.6
      SBP (mm Hg)
      50th88898990919293
      90th102103104104105106107
      95th106106107108109110110
      95th + 12 mm Hg118118119120121122122
      DBP (mm Hg)
      50th48484950515353
      90th60616162636465
      95th64656566676869
      95th + 12 mm Hg76777778798081
      4Height (in)38.338.939.941.142.443.544.2
      Height (cm)97.298.8101.4104.5107.6110.5112.2
      SBP (mm Hg)
      50th89909192939494
      90th103104105106107108108
      95th107108109109110111112
      95th + 12 mm Hg119120121121122123124
      DBP (mm Hg)
      50th50515153545555
      90th62636465666767
      95th66676869707071
      95th + 12 mm Hg78798081828283
      5Height (in)40.841.542.643.945.246.547.3
      Height (cm)103.6105.3108.2111.5114.9118.1120
      SBP (mm Hg)
      50th90919293949596
      90th104105106107108109110
      95th108109109110111112113
      95th + 12 mm Hg120121121122123124125
      DBP (mm Hg)
      50th52525355565757
      90th64656667686970
      95th68697071727373
      95th + 12 mm Hg80818283848585
      6Height (in)43.34445.246.648.149.450.3
      Height (cm)110111.8114.9118.4122.1125.6127.7
      SBP (mm Hg)
      50th92929394969797
      90th105106107108109110111
      95th109109110111112113114
      95th + 12 mm Hg121121122123124125126
      DBP (mm Hg)
      50th54545556575859
      90th67676869707171
      95th70717272737474
      95th + 12 mm Hg82838484858686
      7Height (in)45.646.447.749.250.752.153
      Height (cm)115.9117.8121.1124.9128.8132.5134.7
      SBP (mm Hg)
      50th92939495979899
      90th106106107109110111112
      95th109110111112113114115
      95th + 12 mm Hg121122123124125126127
      DBP (mm Hg)
      50th55555657585960
      90th68686970717272
      95th72727373747475
      95th + 12 mm Hg84848585868687
      8Height (in)47.648.449.851.45354.555.5
      Height (cm)121123126.5130.6134.7138.5140.9
      SBP (mm Hg)
      50th939495979899100
      90th107107108110111112113
      95th110111112113115116117
      95th + 12 mm Hg122123124125127128129
      DBP (mm Hg)
      50th56565759606161
      90th69707172727373
      95th72737474757575
      95th + 12 mm Hg84858686878787
      9Height (in)49.350.251.753.455.156.757.7
      Height (cm)125.3127.6131.3135.6140.1144.1146.6
      SBP (mm Hg)
      50th9595979899100101
      90th108108109111112113114
      95th112112113114116117118
      95th + 12 mm Hg124124125126128129130
      DBP (mm Hg)
      50th57585960606161
      90th71717273737373
      95th74747575757575
      95th + 12 mm Hg86868787878787
      10Height (in)51.15253.755.557.459.160.2
      Height (cm)129.7132.2136.3141145.8150.2152.8
      SBP (mm Hg)
      50th96979899101102103
      90th109110111112113115116
      95th113114114116117119120
      95th + 12 mm Hg125126126128129131132
      DBP (mm Hg)
      50th58595960616162
      90th72737373737373
      95th75757676767676
      95th + 12 mm Hg87878888888888
      11Height (in)53.454.556.258.260.261.963
      Height (cm)135.6138.3142.8147.8152.8157.3160
      SBP (mm Hg)
      50th9899101102104105106
      90th111112113114116118120
      95th115116117118120123124
      95th + 12 mm Hg127128129130132135136
      DBP (mm Hg)
      50th60606061626364
      90th74747474747575
      95th76777777777777
      95th + 12 mm Hg88898989898989
      12Height (in)56.257.35960.962.864.565.5
      Height (cm)142.8145.5149.9154.8159.6163.8166.4
      SBP (mm Hg)
      50th102102104105107108108
      90th114115116118120122122
      95th118119120122124125126
      95th + 12 mm Hg130131132134136137138
      DBP (mm Hg)
      50th61616162646565
      90th75757575767676
      95th78787878797979
      95th + 12 mm Hg90909090919191
      13Height (in)58.359.360.962.764.566.167
      Height (cm)148.1150.6154.7159.2163.7167.8170.2
      SBP (mm Hg)
      50th104105106107108108109
      90th116117119121122123123
      95th121122123124126126127
      95th + 12 mm Hg133134135136138138139
      DBP (mm Hg)
      50th62626364656566
      90th75757576767676
      95th79797979808081
      95th + 12 mm Hg91919191929293
      14Height (in)59.360.261.863.565.266.867.7
      Height (cm)150.6153156.9161.3165.7169.7172.1
      SBP (mm Hg)
      50th105106107108109109109
      90th118118120122123123123
      95th123123124125126127127
      95th + 12 mm Hg135135136137138139139
      DBP (mm Hg)
      50th63636465666666
      90th76767676777777
      95th80808080818182
      95th + 12 mm Hg92929292939394
      15Height (in)59.760.662.263.965.667.268.1
      Height (cm)151.7154157.9162.3166.7170.6173
      SBP (mm Hg)
      50th105106107108109109109
      90th118119121122123123124
      95th124124125126127127128
      95th + 12 mm Hg136136137138139139140
      DBP (mm Hg)
      50th64646465666767
      90th76767677777878
      95th80808081828282
      95th + 12 mm Hg92929293949494
      16Height (in)59.960.862.464.165.867.368.3
      Height (cm)152.1154.5158.4162.8167.1171.1173.4
      SBP (mm Hg)
      50th106107108109109110110
      90th119120122123124124124
      95th124125125127127128128
      95th + 12 mm Hg136137137139139140140
      DBP (mm Hg)
      50th64646566666767
      90th76767677787878
      95th80808081828282
      95th + 12 mm Hg92929293949494
      17Height (in)60.060.962.564.265.967.468.4
      Height (cm)152.4154.7158.7163.0167.4171.3173.7
      SBP (mm Hg)
      50th107108109110110110111
      90th120121123124124125125
      95th125125126127128128128
      95th + 12 mm Hg137137138139140140140
      DBP (mm Hg)
      50th64646566666667
      90th76767777787878
      95th80808081828282
      95th + 12 mm Hg92929293949494

    Staging or Classification

    • See Table 1 for classification definitions

    Workup

    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.
      CategoryClinic 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

    Differential Diagnosis

    • The differential diagnosis for elevated BP includes transient elevated BP, WCH, primary hypertension, secondary hypertension (Table 6)
    • Table 6. Considerations for differential causes of hypertension.BP, blood pressure; WCH, white coat hypertension.
      ConditionDescriptionDifferentiated by
      WCHBP ≥ 95th percentile in office or clinical setting but < 95th percentile outside office or clinical settingHome BPs are different than clinic BPs
      PrimaryHypertension without a specific underlying etiologyPatients are usually older than 6 years, have family history of hypertension, are overweight or obese
      SecondaryHypertension due to a specific etiologyPatients are usually younger than 6 years and/or have symptoms and signs of underlying condition
    • Table 7. Differential of etiologies of secondary causes of hypertension.CTA, computed tomography angiography; MRA, magnetic resonance angiography; URI, upper respiratory infection; US, ultrasonography.
      ConditionDescriptionDifferentiated by
      Renal
      Postinfectious glomerulonephritisHematuria and edema several weeks following infection, often streptococcal18Hematuria

      Recent infection
      Henoch-Schönlein purpuraPurpuric rash, abdominal pain and joint pain usually developing weeks following URI19Purpuric lesions
      PyelonephritisKidney infection with flank pain, feverUrine with white cells, growth on culture
      Hemolytic uremic syndromeHemolytic anemia, thrombocytopenia, renal thrombi following a bloody diarrheal illness20Hemolytic anemia, thrombocytopenia

      Renal injury
      Wilms tumor21Malignant tumor of kidney in childrenBiopsy of mass
      Polycystic kidney disease22Genetic disease with multiple renal cystsBilateral kidney cysts on US
      Vascular
      Renal artery stenosis23Narrowing of renal artery associated with fibromuscular dysplasia, Williams syndrome, and neurofibromatosisImaging, usually CTA, MRA, or angiography
      Aortic coarctation24Congenital narrowing with diminished femoral pulses, murmurEchocardiography
      Vasculitis25Group of disorders resulting from inflammation of blood vessel wall including Takayasu, polyarteritis nodosa, KawasakiSpecific criteria for each disease often with rash, inflammatory markers
      Umbilical artery catheterization26Thrombus to renal artery, postulated embolization to kidney causing increase in renin secretionHistory of umbilical artery catheterization and neonatal hypertension
      Endocrine
      Congenital adrenal hyperplasia27Group of inherited recessive disorders that results in insufficient cortisol and aldosteroneNeonatal screening

      Elevated ACTH
      Hyperthyroidism28Excess thyroid hormone resulting in elevated heart rate/BP, proptosis, weight loss, fatigueDecreased TSH, elevated T3, T4

      Goiter
      Pheochromocytoma29Tumors that release catecholamines resulting in tachycardia/hypertension, flushingPlasma free and urinary metanephrines

      CT/MRI of abdomen/pelvis
      Cushing syndrome30Moon facies, truncal obesity, abdominal striae, hirsutismMidnight cortisol

      Low-dose dexamethasone suppression test
      NeuroblastomaAbdominal mass with tachycardia, hypertensionBiopsy
      Primary aldosteronism31Adrenal disorder characterized by hypertension, hypokalemia, and metabolic alkalosisHypokalemia, metabolic alkalosis

      Elevated aldosterone

      Decreased renin
      Drugs/medications
      CorticosteroidsUsed in inflammatory conditions including asthma, rheumatologic diseaseHistory

      Improvement in BPs following cessation
      Sympathomimetics29Tachycardia, hypertension from drugs such as decongestants, amphetamines, cocaineHistory and drug testing
      Oral contraceptives
      Genetic
      Liddle syndrome10Early-onset hypertension

      Autosomal dominant

      Hypokalemia, metabolic alkalosis
      Genetic testing
      Gordon syndrome32Inherited

      Hyperkalemia, metabolic acidosis
      Genetic testing
      Williams syndromeElfin facies with hypercalcemiaGenetic testing

    Treatment

    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 90th 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 90th 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 50th 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 95th 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.
      CategoryMechanismIndicationContraindicationAdverse effectsExamples
      First line therapies
      CCBs

      DHP subclass
      Vasodilation of peripheral arteries by relaxation of vascular smooth musclePrimary or secondary hypertensionHypersensitivity to CCBFlushing

      Dizziness

      Peripheral edema
      Amlodipine

      Isradipine

      Extended-release nifedipine
      ARBsBlocks 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 inhibitorsInhibits conversion of angiotensin I to angiotensin II, preventing vasoconstrictionCKD

      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
      ThiazidesInduces sodium and fluid lossEdema

      Osteoporosis

      Calcium nephrolithiasis
      AnuricDizziness

      Hypokalemia

      Severe: arrhythmias, cholestatic jaundice, pancreatitis
      Chlorthalidone

      Indapamide

      Hydrochlorothiazide
      Second line therapies
      β-BlockersDecreased renin

      Decreased cardiac output
      Use in patients whose hypertension does not respond to 2 or more first line agentsAsthmaticsDizziness

      Severe: chest pain, shortness of breath
      Atenolol

      Metoprolol

      Bisoprolol
      VasodilatorsRelaxes arteriolar smooth muscleUse in refractory hypertensionPericardial effusionPalpitations

      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 95th 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

    Special Considerations

    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)

    Follow-Up

    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 and Prevention

    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

    Author Affiliations

    Kimberly Reidy, MD
    Associate Professor and Chief
    Department of Pediatrics
    Division of Pediatric Nephrology
    Children’s Hospital at Montefiore/Albert Einstein College of Medicine

    Mohammed Amin, MD
    Fellow
    Department of Pediatrics
    Division of Pediatric Nephrology
    Children’s Hospital at Montefiore/Albert Einstein College of Medicine

    Flynn JT et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.28827377https://doi.org/10.1542/peds.2017-1904Thomas J et al. Pediatric hypertension: review of the definition, diagnosis, and initial management. Int J Pediatr Adolesc Med. 2022;9:1-6.35573063https://doi.org/10.1016/j.ijpam.2020.09.005Chen L et al. Racial differences of pediatric hypertension in relation to birth weight and body size in the United States. PLoS One. 2015;10(7):e0132606.26176843https://doi.org/10.1371/journal.pone.0132606Cheung EL et al. Race and obesity in adolescent hypertension. Pediatrics. 2017;139(5):e20161433.28557717https://doi.org/10.1542/peds.2016-1433Goulding M et al. Differences in blood pressure levels among children by sociodemographic status. Prev Chronic Dis. 2021;18:210058.34529555https://doi.org/10.5888/pcd18.210058Theodore RF et al. Childhood to early-midlife systolic blood pressure trajectories: early-life predictors, effect modifiers, and adult cardiovascular outcomes. Hypertension. 2015;66(6):1108–1115.26558818https://doi.org/10.1161/HYPERTENSIONAHA.115.05831Parker ED et al. Change in weight status and development of hypertension. Pediatrics. 2016;137(3):2015-1662.26908707https://doi.org/10.1542/peds.2015-1662Litwin M et al. Origins of primary hypertension in children. Hypertension AHA. 2020;76(5):1400-1409.32981361https://doi.org/10.1161/HYPERTENSIONAHA.120.14586Metoki H et al. Combination of genetic and environmental factors for childhood hypertension: a simple indicatory of family history remains useful. Hypertension Research. 2023;46:1061-1063.36697874https://doi.org/10.1038/s41440-022-01165-yEnslow BT et al. Liddle's syndrome mechanisms, diagnosis and management. Integr Blood Press Control. 2019;12:13-22.31564964https://doi.org/10.2147/IBPC.S188869Chen J et al. Physical activity and eating behaviors patterns associated with high blood pressure among Chinese children and adolescents. BMC Public Health. 2023;23(1):1516.37558994https://doi.org/10.1186/s12889-023-16331-1Chuang HH et al. Hypertension in children with obstructive sleep apnea syndrome-age, weight status, and disease severity. Int J Environ Res Public Health. 2021;18(18):9602.34574528https://doi.org/10.3390/ijerph18189602Crump C et al. Risk of hypertension into adulthood in persons born prematurely: a national cohort study. Eur Heart J. 2020;41(16):1542-1550.31872206https://doi.org/10.1093/eurheartj/ehz904Yang Y et al. Sodium intake and hypertension risk in children. Pediatrics. 2012;130(4):611-619.Aeberli I et al. Diet determines features of the metabolic syndrome in 6- to 14-year-old children. Int J Vitam Nutr Res. 2009;79(1):14-23.19838999https://doi.org/10.1024/0300-9831.79.1.14Virdis R et al. Hypertension in children with neurofibromatosis. J Hum Hypertens. 1994;8 (5):395-397.8064789Flynn 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-e124.35603599https://doi.org/10.1161/HYP.0000000000000215Balasubramanian R et al. Post-infectious glomerulonephritis. Paediatr Int Child Health. 2017;37:4:240-247,28891413https://doi.org/10.1080/20469047.2017.1369642Reamy BV et al. Henoch-Schonlein purpura (IgA vasculitis): rapid evidence review. Am Fam Physician. 2020;102(4):229-233.32803924Viteri B et al. Hemolytic uremic syndrome. Pediatr Rev. 2020;41(4):213-215.32238553https://doi.org/10.1542/pir.2018-0346Szychot E et al. Wilms’ tumor: biology, diagnosis and treatment. Tranl Pediatr. 2014;3(1):12-24.26835318https://doi.org/10.3978/j.issn.2224-4336.2014.01.09Cadnapaphornchai MA. Autosomal dominant polycystic kidney disease in children. Curr Opin Pediatr. 2015; 27(2):193-200.25635587https://doi.org/10.1097/MOP.0000000000000195Patel PA et al. Renovascular hypertension in children. CVIR Endovasc. 2021;4(1):10.33411105https://doi.org/10.1186/s42155-020-00176-5Dijkema E et al. Diagnosis, imaging and clinical management of aortic coarctation. Heart. 2017;103(15):1148-1155.28377475https://doi.org/10.1136/heartjnl-2017-311173Weiss PF. Pediatric vasculitis. Pediatr Clin North Am. 2012;59(2):407-423.22560577https://doi.org/10.1016/j.pcl.2012.03.013Flynn JT. Neonatal hypertension: diagnosis and management. Pediatr Nephrol. 2000;14:332-341.10775081https://doi.org/10.1007/s004670050771Claahsen-van der Grinten HL. Congenital adrenal hyperplasia--current insights in pathophysiology, diagnostics, and management. Endocr Rev. 2022;43(1):91-159.Srinivasan S et al. Hyperthyroidism in children. Pediatr Rev. 2015;36(6):239-248.26034254https://doi.org/10.1542/pir.36-6-239Bholah R et al. Review of pediatric pheochromocytoma and paraganglioma. Front Pediatr. 2017;5:155.28752085https://doi.org/10.3389/fped.2017.00155Guemes M et al. Management of Cushing syndrome in children and adolescents: experience of a single tertiary centre. Er J Ped. 2016;175:967-976.27169546https://doi.org/10.1007/s00431-016-2727-5Young WF. Diagnosis and treatment of primary aldosteronism: practical clinical perspectives. J Int Med. 2018;285(2):125-148.30255616https://doi.org/10.1111/joim.12831Mabillard H et al. The molecular genetics of Gordon syndrome. Genes (Basel). 2019;10(12):986.31795491https://doi.org/10.3390/genes10120986Raina R et al. Hypertensive crisis in pediatric patients: an overview. Front Pediatr. 2020;8:588911.33194923https://doi.org/10.3389/fped.2020.588911Torrance B et al. Overweight, physical activity and high blood pressure in children: a review of the literature. Vasc Health Risk Manag. 2007;3(1):139-149.17583184Puri M et al. Management of hypertension in children and adolescents with the metabolic syndrome. J Cardiometab Syndr. 2006 Summer;1(4):259-68.17679805https://doi.org/10.1111/j.1559-4564.2006.05801.xDaniels SR et al. Nonpharmacologic treatment of pediatric hypertension. In: Flynn J et al, eds. Pediatric Hypertension. Springer; 2018.https://doi.org/10.1007/978-3-319-31107-4_35Guo J et al. Long-term outcomes of angioplasty for pediatric renovascular hypertension: a single-center experience. Vascular. 2023;31(1):122-130.34846234.45https://doi.org/10.1177/17085381211059664Macumber I et al. Does treatment-resistant hypertension exist in children? A review of the evidence. Pediatr Nephrol. 2020;35(6):969-976.31147776https://doi.org/10.1007/s00467-019-04268-wDeJong F et al. Systematic review and meta-analysis of preterm birth and later systolic blood pressure. Hypertension. 2012;59:226-234.22158643https://doi.org/10.1161/HYPERTENSIONAHA.111.181784Grillo MA et al. Prematurity and low birth weight in neonates as a risk factor for obesity, hypertension, and chronic kidney disease in pediatric and adult age. Front Med (Lausanne). 2022;8:769734.35186967https://doi.org/10.3389/fmed.2021.769734Goulas I et al. Prevalence of masked hypertension and its association with left ventricular hypertrophy in children and young adults with chronic kidney disease: a systematic review and meta-analysis. J Hypertension. 2023;41(5):699-707.36883474https://doi.org/10.1097/HJH.0000000000003402Babu M et al. Masked hypertension in CKD: increased prevalence and risk for cardiovascular and renal events. Curr Cardiol Rep. 2019;21(7):58.31111326https://doi.org/10.1007/s11886-019-1154-4Shatat IF et al. Masked hypertension is prevalent in children with sickle cell disease: a Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol. 2013;28(1):115-120.22886281https://doi.org/10.1007/s00467-012-2275-9Kupferman JC et al. Blood pressure in children with sickle cell disease is higher than in the general pediatric population. BMC Pediatr. 2022;22:549.36109730https://doi.org/10.1186/s12887-022-03584-9Suvila K et al. Age of hypertension onset: overview of research and how to apply in practice. Curr Hypertens Rep. 2020;22(9):68.32852608https://doi.org/10.1007/s11906-020-01071-zJacobs DR et al. Childhood cardiovascular risk factors and adult cardiovascular events. N Engl J Med. 2022;386(20):1877-1888.35373933https://doi.org/10.1056/NEJMoa2109191
    Small Elsevier Logo

    Cookies are used by this site. To decline or learn more, visit our cookie notice.


    Copyright © 2024 Elsevier, its licensors, and contributors. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

    Small Elsevier Logo
    RELX Group