Report on the Diagnosis, Evaluation, and Treatment of

High Blood Pressure in Children and Adolescents

American Family Physician - Volume 71, Issue 5 (March 2005) - Copyright 2005
American Academy of Family Physicians - About This Journal
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Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

KAREN HELLEKSON PH.D.

The National High Blood Pressure Education Program Working Group on High Blood
Pressure in Children and Adolescents has issued its Fourth Report on the Diagnosis,
Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. The
full text, which appeared in the August 2, 2004, issue of Pediatrics, is available online
at http://pediatrics.aappublications.org/cgi/content/full/114/2/S2/555.

It is now apparent that primary hypertension is detectable in the young and is

common. The long-term health risks for children and adolescents who have
hypertension can be substantial; therefore, it is important that clinical measures be
taken to reduce these risks and optimize health outcomes.

Definition of Hypertension

The definition of hypertension in children and adolescents is based on the normative

distribution of blood pressure in healthy children. Table 1 (Table Not Available) lists
the classifications of hypertension in children and adolescents.

TABLE 1 -- Classification of Hypertension in Children and Adolescents, with

Measurement Frequency and Therapy Recommendations
(Not Available)

Children younger than three years should have their blood pressure measured by
auscultation when seen clinically; the physician should use a cuff appropriate to the
 size of the childs upper arm. Elevated blood pressure must be confirmed on repeated
visits before diagnosing hypertension. Children who are three years of age or younger
should have blood pressure measured only under certain conditions, including
prematurity or other neonatal conditions requiring intensive care; presence of
congenital heart disease, elevated intracranial pressure, recurrent urinary tract
infections, or systemic illnesses (such as neurofibromatosis) associated with
hypertension; transplant recipients; and presence of renal disease or urologic
malformations.

The physician should then look up the normal range of blood pressure on newly
revised and expanded tables based on gender, age, and height (available online). The
child is normotensive if blood pressure is less than the 90th percentile. If an
adolescents blood pressure is greater than 120/80 mm Hg, the patient is
prehypertensive, even if within the less than 90th percentile. If the blood pressure is in
the 95th percentile or more, blood pressure should be assessed at least two more times
before the child is diagnosed with hypertension.

Table 2 (Table Not Available) outlines the clinical evaluation of primary hypertension.

TABLE 2 -- Clinical Evaluation of

Confirmed Hypertension
(Not Available)

Primary Hypertension

Primary hypertension in childhood usually is characterized by mild or stage 1

hypertension and often is associated with a family history of hypertension or
cardiovascular disease. Frequently, children and adolescents with primary
hypertension are overweight. The strong association of high blood pressure with
obesity and the marked increase in the prevalence of childhood obesity indicate that
hypertension and prehypertension are becoming a significant health issue in the young.

Primary hypertension often clusters with other risk factors. Medical history, physical
examination, and laboratory evaluation should include a comprehensive assessment
for additional cardiovascular risk. These risk factors, in addition to high blood pressure
and being overweight, include low high-density lipoprotein cholesterol levels, elevated
triglyceride levels, and abnormal glucose tolerance. Fasting plasma insulin
concentration generally is elevated, but an elevated insulin concentration may be
reflective only of obesity. To identify other cardiovascular risk factors, a fasting lipid
panel and fasting glucose level should be obtained in children who are overweight and
have blood pressure between the 90th and 94th percentile and in all children with
blood pressure above the 95th percentile.
 Because of the associations with hypertension and the frequency of occurrence of
sleep disorders, particularly among overweight children, a history of sleeping patterns
should be obtained in a child with hypertension. One practical strategy for identifying
children with a sleep problem or sleep disorder is to obtain a brief sleep history, using
an instrument called BEARS, the components of which include Bedtime problems,
Excessive daytime sleepiness, Awakenings during the night, Regularity and duration
of sleep, and Snoring.

Secondary Hypertension

Secondary hypertension is more common in children than in adults. The possibility

that some underlying disorder may be the cause of the hypertension should be
considered in every child or adolescent who has elevated blood pressure. Very young
children, children with stage 2 hypertension, and children or adolescents with clinical
signs that suggest the presence of systemic conditions associated with hypertension
should be evaluated more extensively than those with stage 1 hypertension.

Medical history should elicit information to focus the subsequent evaluation and to
uncover definable causes of hypertension. Questions should be asked about previous
hospitalizations, trauma, urinary tract infections, and snoring and other sleep
problems. Questions should address family history of hypertension, diabetes, obesity,
sleep apnea, renal disease, and other cardiovascular diseases. Many drugs can increase
blood pressure, so physicians should ask directly about the use of over-the-counter and
prescription medication, illicit drugs, and nutritional supplements (particularly those
that aim to enhance athletic performance).

The physical examination should assess the childs height, weight, and body mass
index. Poor growth may indicate an underlying chronic illness. When hypertension is
confirmed, blood pressure should be measured in both arms and in a leg. Normally,
blood pressure is 10 to 20 mm Hg higher in the legs than in the arms. If the leg blood
pressure is lower than the arm blood pressure or if femoral pulses are weak or absent,
coarctation of the aorta may be present. Obesity alone is an insufficient explanation for
diminished femoral pulses in the presence of high blood pressure.

Target-Organ Abnormalities

Target-organ abnormalities are commonly associated with hypertension in children

and adolescents, with left ventricular hypertrophy (LVH) providing the most
prominent evidence of target-organ damage. The presence of LVH is an indication to
initiate or intensify antihypertensive therapy. LVH is assessed by echocardiography,
and the cut-point is 51 g/m, which is above the 99th percentile in children and
adolescents. Pediatric patients with established hypertension should have left
ventricular mass assessed (using a formula) at diagnosis and periodically thereafter.
Ascertainment of left ventricular mass index is helpful in clinical decision-making.
Lifestyle Changes to Lower Blood Pressure

Because hypertension has been linked to obesity, the first line of treatment should be
family-based diet and behavior modification. Children should: lose weight; eat more
vegetables, fruit, and low-fat dairy products; cut down on salt intake; and reduce their
intake of high-calorie food and drinks. Children also should reduce the amount of time
spent in sedentary activities, such as playing video games, to less than two hours a day,
and they should try to be physically active for 30 to 60 minutes a day. Consultation
with a nutritionist may be helpful. Weight control can make treatment with drugs
unnecessary, but if drug use is indicated, it should not be delayed.

Drugs to Treat Hypertension

In children, the long-term consequences of untreated hypertension are unknown, and

data are unavailable on the long-term effects of antihypertensive drugs on growth,
development, or mortality. A definite indication for initiating pharmacologic therapy
should therefore be ascertained before a drug is prescribed. The goal for
antihypertensive treatment in children should be reduction of blood pressure to less
than the 95th percentile. Indications for antihypertensive drug therapy in children
include secondary hypertension and insufficient response to lifestyle modifications.
Pharmacologic therapy should be started with a single drug. Acceptable drug classes
for use in children include angiotensin-converting enzyme (ACE) inhibitors,
angiotensin-receptor blockers, beta blockers, calcium channel blockers, and diuretics.
Hypertensive emergencies can be treated with intravenous antihypertensive drugs.

The child should be started on the lowest recommended dosage, which is increased
until the desired blood pressure is reached. Once the highest recommended dosage is
reached, or if the child experiences side effects, a second drug from a different class
should be added. Ongoing monitoring for target-organ damage should be performed. If
possible, in selected patients (such as obese patients who lose weight), the drug should
be stepped down and, if possible, withdrawn, although ongoing blood pressure
monitoring should be performed to determine a recurrence.

Use of the following drugs to treat hypertension in children is supported by research:

ACE inhibitors: benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril.

Angiotensin-receptor blockers: irbesartan, losartan.
Alpha and beta blocker: labetalol.
Beta blockers: atenolol, bisoprolol/hydrochlorothiazide (HCTZ), metoprolol,
propranolol.
Calcium-channel blockers: amlodipine, felodipine, isradipine, extended-release
nifedipine.
Central alpha-agonists: clonidine.
 Diuretics: HCTZ, chlorthalidone, furose-mide, spironolactone, triamterene,
amiloride.
Peripheral alpha antagonists: doxazosin, prazosin, terazosin.
Vasodilators: hydralazine, minoxidil.

For severe hypertension, the most useful drugs are esmolol, hydralazine, labetalol,
nicardipine, and sodium nitroprusside. Occasionally, useful drugs, mostly used in
urgent situations, are clonidine, enalaprilat, fenoldopam, isradipine, and minoxidil.
However, most of these must be administered intravenously.