High Blood Pressure in Children and Adolescents
Am Fam Physician. 2018 Oct 15;98(8):486-494.
Patient information: See related handout on high blood pressure in children.
Author disclosure: No relevant financial affiliations.
High blood pressure in children and adolescents is a growing health problem that is often overlooked. Children should be screened for elevated blood pressure annually beginning at three years of age or at every visit if risk factors are present. In children younger than 13 years, elevated blood pressure is defined as blood pressure in the 90th percentile or higher for age, height, and sex, and hypertension is defined as blood pressure in the 95th percentile or higher. In adolescents 13 years and older, elevated blood pressure is defined as blood pressure of 120 to 129 mm Hg systolic and less than 80 mm Hg diastolic, and hypertension is defined as blood pressure of 130/80 mm Hg or higher. Ambulatory blood pressure monitoring should be performed to confirm hypertension in children and adolescents. Primary hypertension is now the most common cause of hypertension in children and adolescents. A history and physical examination and targeted screening tests should be done to evaluate for underlying medical disorders, and children and adolescents with hypertension should be screened for comorbid cardiovascular diseases, including diabetes mellitus and hyperlipidemia. Hypertension in children is initially treated with lifestyle changes such as weight loss if overweight or obese, a healthy diet, and regular exercise. Children with symptomatic hypertension (e.g., headaches, cognitive changes), stage 2 hypertension without a modifiable factor such as obesity, evidence of left ventricular hypertrophy on echocardiography, any stage of hypertension associated with chronic kidney disease or diabetes, or persistent hypertension despite a trial of lifestyle modifications require antihypertensive medications and should be evaluated for cardiovascular damage with echocardiography. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics are effective, safe, and well-tolerated in children.
High blood pressure in children and adolescents is a growing health problem, along with the worldwide epidemics of obesity and physical inactivity. The combined prevalence of elevated blood pressure and hypertension in children is around 6%, or 3% for each.1,2 The combined prevalence increases by nearly five times, to around 30%, in adolescents who are obese.2 High blood pressure in childhood is correlated with higher blood pressure and risk of cardiovascular disease (CVD) in adulthood, and this relationship strengthens with age.3 Primary hypertension in children is associated with other risk factors for CVD, including hyperlipidemia and insulin resistance.4 Children also experience target organ damage from hypertension, including left ventricular hypertrophy and pathologic vascular changes (i.e., carotid intima-media thickness).5,6
WHAT IS NEW ON THIS TOPIC
Normal and elevated blood pressures for children one to 12 years of age are based on the normative distribution of blood pressures in healthy children of normal weight and should be interpreted on the basis of sex, age, and height. For adolescents 13 years and older, elevated blood pressure is now defined by the absolute value of 120 to 129 mm Hg systolic and < 80 mm Hg diastolic, and hypertension as ≥ 130/80 mm Hg.
Primary hypertension, rather than secondary hypertension, now accounts for most cases of childhood hypertension.
When available, ambulatory blood pressure monitoring is recommended to help clarify the diagnosis in children who have had elevated blood pressure readings for one year or more, or earlier if it is necessary to confirm the diagnosis of hypertension.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
Children should have blood pressure measured annually beginning at three years of age. Measurement should occur at every health care encounter in children who are obese; who have known kidney disease, aortic arch obstruction, coarctation, or diabetes mellitus; or who are taking a medication known to increase blood pressure.
When available, ambulatory blood pressure monitoring should be used to confirm hypertension in children and adolescents.
All children and adolescents with hypertension should be screened for hyperlipidemia and underlying renal disease via urinalysis and electrolyte, blood urea nitrogen, and creatinine testing.
Children younger than six years with hypertension, and children and adolescents with abnormal renal function or urinalysis results should undergo renal ultrasonography.
Obese children and adolescents with hypertension should be evaluated for diabetes mellitus and fatty liver.
All children with elevated blood pressure or hypertension should make therapeutic lifestyle changes (e.g., lose weight if overweight or obese; get regular physical activity; eat a healthy diet low in salt; avoid smoking and alcohol intake; reduce
Referencesshow all references
1. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874–879....
2. McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr. 2007;150(6):640–644.
3. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117(25):3171–3180.
4. Martino F, Puddu PE, Pannarale G, et al. Hypertension in children and adolescents attending a lipid clinic. Eur J Pediatr. 2013;172(12):1573–1579.
5. Brady TM, Fivush B, Flynn JT, Parekh R. Ability of blood pressure to predict left ventricular hypertrophy in children with primary hypertension. J Pediatr. 2008;152(1):73–78.
6. Urbina EM, Khoury PR, McCoy C, Daniels SR, Kimball TR, Dolan LM. Cardiac and vascular consequences of pre-hypertension in youth. J Clin Hypertens (Greenwich). 2011;13(5):332–342.
7. Riley M, Dobson M, Sen A, Green L. Recognizing elevated BP in children and adolescents: how are we doing? J Fam Pract. 2013;62(6):294–299.
8. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published correction appears in Pediatrics. 2017;140(6):e20173035]. Pediatrics. 2017;140(3):e20171904.
9. Hauk L. Screening and management of high BP in children and adolescents: an updated guideline from the AAP [Practice Guideline]. Am Fam Physician. 2018;97(8):543–544.
10. Khoury M, Khoury PR, Dolan LM, Kimball TR, Urbina EM. Clinical Implications of the Revised AAP Pediatric Hypertension Guidelines. Published ahead of print July 5, 2018. Pediatrics. http://pediatrics.aappublications.org/content/early/2018/07/03/peds.2018-0245. Accessed July 25, 2018.
11. Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016;34(10):1887–1920.
12. Vogt BA. Hypertension in children and adolescents: definition, pathophysiology, risk factors and long-term sequelae. Current Therap Res. 2001;62(4):283–297.
13. Kapur G, Ahmed M, Pan C, Mitsnefes M, Chiang M, Mattoo TK. Secondary hypertension in overweight and stage 1 hypertensive children: a Midwest Pediatric Nephrology Consortium report. J Clin Hypertens (Greenwich). 2010;12(1):34–39.
14. Falkner B, Gidding SS, Ramirez-Garnica G, Wiltrout SA, West D, Rappaport EB. The relationship of body mass index and blood pressure in primary care pediatric patients. J Pediatr. 2006;148(2):195–200.
15. Archbold KH, Vasquez MM, Goodwin JL, Quan SF. Effects of sleep patterns and obesity on increases in blood pressure in a 5-year period: report from the Tucson Children's Assessment of Sleep Apnea Study. J Pediatr. 2012;161(1):26–30.
16. Flynn JT, Mitsnefes M, Pierce C, et al. Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study. Hypertension. 2008;52(4):631–637.
17. Brady TM, Fivush B, Parekh RS, Flynn JT. Racial differences among children with primary hypertension. Pediatrics. 2010;126(5):931–937.
18. Lawlor DA, Najman JM, Sterne J, Williams GM, Ebrahim S, Davey Smith G. Associations of parental, birth, and early life characteristics with systolic blood pressure at 5 years of age: findings from the Mater-University study of pregnancy and its outcomes. Circulation. 2004;110(16):2417–2423.
19. Martin RM, Ness AR, Gunnell D, Emmett P, Davey Smith G. Does breast-feeding in infancy lower blood pressure in childhood? The Avon Longitudinal Study of Parents and Children (ALSPAC). Circulation. 2004;109(10):1259–1266.
20. Moyer VA. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(9):613–619.
21. American Academy of Family Physicians. Clinical preventive service recommendation. Hypertension, children and adolescents. https://www.aafp.org/patient-care/clinical-recommendations/all/hypertension.html. Accessed February 12, 2018.
22. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111(5):697–716.
23. Luma GB, Spiotta RT. Hypertension in children and adolescents. Am Fam Physician. 2006;73(9):1558–1568.
24. Flynn JT, Pierce CB, Miller ER III, et al.; Chronic Kidney Disease in Children Study Group. Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr. 2012;160(3):434–440.e1.
25. Negroni-Balasquide X, Bell CS, Samuel J, Samuels JA. Is one measurement enough to evaluate blood pressure among adolescents? A blood pressure screening experience in more than 9000 children with a subset comparison of auscultatory to mercury measurements. J Am Soc Hypertens. 2016;10(2):95–100.
26. Salice P, Ardissino G, Zanchetti A, et al. Age-dependent differences in office (OBP) vs ambulatory blood pressure monitoring (ABPM) in hypertensive children and adolescents: 8C.03. J Hypertens. 2010;28(1):e423–e424.
27. Stein DJ, Scott K, Haro Abad JM, et al. Early childhood adversity and later hypertension: data from the World Mental Health Survey. Ann Clin Psychiatry. 2010;22(1):19–28.
28. Wiesen J, Adkins M, Fortune S, et al. Evaluation of pediatric patients with mild-to-moderate hypertension: yield of diagnostic testing. Pediatrics. 2008;122(5):e988–e993.
29. Farpour-Lambert NJ, Aggoun Y, Marchand LM, Martin XE, Herrmann FR, Beghetti M. Physical activity reduces systemic blood pressure and improves early markers of atherosclerosis in pre-pubertal obese children. J Am Coll Cardiol. 2009;54(25):2396–2406.
30. Yang Q, Zhang Z, Kuklina EV, et al. Sodium intake and blood pressure among US children and adolescents. Pediatrics. 2012;130(4):611–619.
31. Damasceno MM, de Araújo MF, de Freitas RW, de Almeida PC, Zanetti ML. The association between blood pressure in adolescents and the consumption of fruits, vegetables and fruit juice—an exploratory study. J Clin Nurs. 2011;20(11–12):1553–1560.
32. Sieverdes JC, Mueller M, Gregoski MJ, et al. Effects of Hatha yoga on blood pressure, salivary α-amylase, and cortisol function among normotensive and prehypertensive youth. J Altern Complement Med. 2014;20(4):241–250.
33. Yun M, Li S, Sun D, et al. Tobacco smoking strengthens the association of elevated blood pressure with arterial stiffness: the Bogalusa Heart Study. J Hypertens. 2015;33(2):266–274.
34. Jerez SJ, Coviello A. Alcohol drinking and blood pressure among adolescents. Alcohol. 1998;16(1):1–5.
35. McCambridge TM, Benjamin HJ, Brenner JS, et al.; Council on Sports Medicine and Fitness. Athletic participation by children and adolescents who have systemic hypertension. Pediatrics. 2010;125(6):1287–1294.
36. Li JS, Baker-Smith CM, Smith PB, et al. Racial differences in blood pressure response to angiotensin-converting enzyme inhibitors in children: a meta-analysis [published correction appears in Clin Pharmacol Ther. 2008;84(5):636]. Clin Pharmacol Ther. 2008;84(3):315–319.
37. Riley M, Bluhm B. High blood pressure in children and adolescents. Am Fam Physician. 2012;85(7):693–700.
Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions