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.
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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
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