CME
Pediatric Hypertension
A review of proper screening, diagnosis, evaluation, and treatment
N
icholas, a 10-year-old boy with a history of
inter mit tent a sthma and at tention def icit
hyperactivity disorder, is seeing you for the first
time for a well child visit. He has no complaints and
his mom has no specific questions or concerns. On
CME
EDUCATIONAL OBJECTIVES
• Identify children and adolescents for whom
hypertension screening is appropriate
• Implement an initial workup for pediatric
hypertension
• Develop treatment plans for children with
essential or secondary hypertension
46 www.contemporarypediatrics.com Vol. 25, No. 11
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review of symptoms, Nicholas reports that he has some
chest pain when he has an asthma exacerbation. Current
medications include methylphenidate once daily and an
albuterol metered-dose inhaler as needed. His family history
reveals hypertension (HTN) in his father and paternal
grandfather, and diabetes mellitus in his paternal grandfather.
His mother and 12-year-old sister are healthy with no chronic
medical problems. On physical exam, his anthropometrics
and vital signs are as follows:
Height: 140 cm (50%)
Weight: 45 kg (95%)
Body mass index (BMI): 23 (>95%)
Temperature 37 °C
Heart rate: 85 bpm
Blood pressure (BP): 124/82 mm Hg by automated cuff
Physical exam is normal
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TAMMY BRADY, MD, GEORGE K. SIBERRY, MD, MPH, AND BARRY SOLOMON, MD, MPH
You reference the BP tables published in the Fourth
Report by the National High Blood Pressure Education
Program Working Group on High Blood Pressure in Children
and Adolescents,1 and discover that the BP norms for
a child of this age, gender, and height percentile are as
follows:
50%: 102/61
90%: 116/76
95%: 120/80
99%: 127/88
This clinical scenario of a child found to have an
elevated initial blood pressure is not uncommon. Pediatric
hypertension, previously reported to affect only 0.3% to
1.2% of children in the 1970s and 1980s, 2,3 now affects
up to 5% of all children.4 One possible explanation for
this increase may be the current growing population
of obese children. 5 The prevalence of hypertension in
children increases with increasing BMI percentile,4 placing
obese children at three-times higher risk of becoming
hypertensive when compared to non-obese children.5
Regardless of the cause for this increase, a child with
hypertension can be a dilemma for many primary care
providers. It is essential for providers to understand when
to screen for hypertension, how to conduct an initial
work-up, how to manage these patients, and when to
refer them to a subspecialist.
ILLUSTRATION:JOEL AND SHARON HARRIS/ARTICUL ATE GRAPHICS:
Accreditation
cme2 is accredited by the ACCME to provide continuing
medical education for physicians.
Credit Designation
cme2 designates this educational activity for a maximum
of 1.0 AMA PRA Category 1 Credit™. Physicians should
only claim credit commensurate with the extent of their
participation in the activity.
Target audience: Pediatricians and primary care physicians
To earn CME credit for this activity
Participants should study the article and log on to www.
contemporarypediatrics.com, and click on the “Earn CME
Credit” button on the left-hand side. Participants must
pass a post-test and complete an online evaluation of the
CME activity. After passing the post-test and completing the
online evaluation, a CME certificate will be e-mailed to them.
The release date for this activity is November 1, 2008. The
expiration date is November 1, 2009.
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HYPERTENSION
Which children should get their blood
pressure checked?
Current recommendations state that all children 3 years of
age and older should have their blood pressure measured
at all health care encounters, including both well child
care and acute care or sick visits. Certain children younger
than 3 with comorbid conditions should also have their BP
measured at each visit. This population includes children
under 3 with1:
• History of prematurity
• History of low birth weight or neonatal intensive
care unit (NICU) stay
• Presence of congenital heart disease, kidney disease,
or genitourinary abnormality
• Family history of congenital kidney disease
• Recurrent urinary tract infection (UTI), hematuria,
proteinuria
• Transplant of solid organ or bone marrow
• Malignancy
• Taking medications known to increase blood
pressure (steroids, decongestants, nonsteroidal
anti-inflammatory drugs [NSAIDs], beta-adrenergic
agonists)
• Presence of systemic illness associated with hypertension
(neurofibromatosis, tuberous sclerosis)
• Evidence of increased intracranial pressure >>p.48
Disclosures The authors have nothing to disclose with regard to
Editors Toby Hindin, Jeannette Mallozzi, Jeff Ryan, and affiliations with, or financial interest in, any organization
John Merriman disclose that they do not have any financial that may have an interest in any part of this article.
relationships with any manufacturer in this area of medicine.
Resolution of conflict of interest
Manuscript reviewers disclose that they do not have any cme 2 has implemented a process to resolve conflicts
financial relationships with any manufacturer in this area of interest for each continuing medical education
of medicine. activity, to help ensure content validity, independence,
DR. BRADY is an assistant professor of pediatric fair balance, and that the content is aligned with the
nephrology at Johns Hopkins University School of interest of the public. Conflicts, if any, are resolved
Medicine. through a peer review process.
DR. SIBERRY is an assistant professor of pediatrics Unapproved/off-label use discussion
in the divisions of general pediatric and adolescent
Faculty may discuss information about pharmaceutical
medicine and pediatric infectious diseases at Johns agents, devices, or diagnostic products that are outside
Hopkins Hospital.
of FDA-approved labeling. This information is intended
DR. SOLOMON is an assistant professor of pediatrics solely for CME and is not intended to promote off-label
in the division of general pediatrics and adolescent use of these medications. If you have questions, contact
medicine at Johns Hopkins Hospital, and medical the medical affairs department of the manufacturer for
director of the Harriet Lane Clinic at the Johns the most recent prescribing information. Faculty are
Hopkins School of Medicine. required to disclose any off-label discussion.
NOVEMBER 2008 CONTEMPORARY PEDIATRICS 47
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 CME
How should blood pressure be
measured in children?
The proper technique for BP measurement via manual
auscultation is as follows1:
1. Ensure that the child has been resting for a minimum
of five minutes prior to measurement. The child should
be sitting with back supported, both feet on the floor and
right cubital fossa supported at heart level.
2. Choose the appropriate cuff size:
• The cuff width should cover ~70% of the distance
between the acromion (bony extremity of the
shoulder girdle) and the olecranon (tip of the elbow).
(Figure 1)
• The cuff bladder length should be 80 to 100% of the
arm circumference, and the width should be at least
40% of the arm circumference at the midpoint of the
acromion-olecranon distance.
Figure 1 Choose the appropriate size cuff
The importance of choosing the proper cuff size
should not be underestimated. Cuff sizes differ among
manufacturers (ie, all “child size” cuffs are not made
with the same dimensions), and choosing the wrong
cuff size can lead to either obtaining a falsely elevated
or underestimated BP reading (seen with a cuff that is
too small or too large, respectively).
3. Apply the cuff to the child’s bare arm.
4. Locate the radial pulse, inflate the sphygmomanometer
to 60 mm Hg and then slowly inflate in increments
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of 10 mm Hg until the pulse disappears. The value at
which the pulse disappears plus 30 mm Hg is peak
inflation.
5. Deflate; wait 30 seconds.
6. Place the stethoscope over the brachial artery pulse (2
cm above the cubital fossa).
7. Inflate to the peak inflation level and then deflate at
2 to 3 mm Hg/second to a level 10 mm Hg lower than
the level of last Korotkoff’s sound (K5).
8. Systolic blood pressure (SBP) is onset of two or more
consecutive tapping sounds (K1). Diastolic blood
pressure (DBP) is disappearance of Korotkoff’s sounds
(K5); a bell can be used to best hear softer Korotkoff’s
sounds.
• If sounds can be heard down to 0 mm Hg, repeat
using less pressure.
• If still present, use K4 as DBP (muffling of sounds).
But what about automated (oscillometric) measure-
ments? While t here is a place for automated BP
measurements in a busy pediatric practice, the preferred
method is by manual auscultation. There are several reasons
for this preference.
One reason is that the normative blood pressure
tables used in the diagnosis of hypertension are based
on auscultatory—not oscillometric—BP values. Another
factor is that oscillometric machines (ie, “Dynamap”)
do not directly measure BP. Rather these machines
estimate the SBP and DBP based on the point of maximal
oscillation (mean intra-arterial pressure) during deflation
using algorithms that vary from one device to another.6
Additionally, oscillometric machines accommodate to the
previous reading by automatically inflating to 30 mm Hg
above the expected (ie, previous) SBP reading. IMAGE:JOEL AND SHARON HARRIS/ARTICUL ATE GRAPHICS
In order to optimally use these machines, providers should
discard the first reading, repeat the BP two more times one
minute apart, and then use the average of these two readings.
If a child’s BP is elevated based on this method (an elevated
BP is defined as a systolic or diastolic BP measurement
greater than or equal to the 90th percentile for that child’s
age, gender, and height percentile or a SBP of 120 mm Hg
and/or DBP of 80 mm Hg at any age), a BP should then be
measured by manual auscultation. If the BP continues to be
elevated as defined above, the BP should be repeated twice
manually at the same office visit, and an average SBP and DBP
should be used.
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 HYPERTENSION

Table 1
Because of the inherent limitations to automated BP Initial work-up for pediatric hypertension
readings, public blood pressure machines should be used (in order of prevalence)9,10
with caution when including them in your evaluation and
Age range:
/or management of pediatric hypertension. Automated cuffs
need to be calibrated at regular intervals, and there is often
First year of life Secondary (99%)
no readily available record of scheduled maintenance of
• Coarctation of the aorta
these public machines. Also, there is often only one cuff • Renovascular*
size available, leading to false BP readings as described • Renal parenchymal disease
above.7,8 • Miscellaneous causes
†

• Neoplasia (4%)
Back to your patient • Endocrine (1%)

You repeat Nicholas’ BP by manual auscultation and obtain

a reading of 126/84 mm Hg; one minute later it’s 116/84 mm
1 to 12 years Secondary (70% to 85%)
Hg, giving him an average BP of 121/84. Again, referencing
• Renal parenchymal disease
the Fourth Report BP tables, you discover that Nicholas’
• Coarctation of the aorta
manual BP is between 120/80 and 132/93 (the 95th percentile • Reflux nephropathy
and 99th percentile plus 5 mm Hg for his age, gender and • Renovascular
height percentile). As he is asymptomatic (no complaints • Endocrine
of nausea, vomiting, epistaxis, blurry vision, or diplopia), • Neoplasia
you have him come back weekly on two more occasions. • Miscellaneous

Manual BPs at these visits confirm he has sustained BPs Primary (Essential) (15% to 30%)
greater than or equal to the 95th percentile, and less than
the 99th percentile plus 5 mm Hg. You diagnose him with
12 to 18 years Primary (Essential) (85% to 95%)
Stage 1 Hypertension and initiate a work-up as outlined
Secondary (5% to 15%)
by the Fourth Report*: • Same causes as 1- to

12-year-olds

SBP or DBP When to recheck *Renal artery/vein thrombosis, renal artery stenosis.
percentile blood pressure? †Bronchopulmonary dysplasia (BPD), patent ductus arteriosus
(PDA), intraventricular hemorrhage (IVH).
Normal <90th Next health care visit
Initial work-up for pediatric hypertension
Prehypertension 90th to <95th Six months A diagnostic work-up should be conducted to rule out
or
= 120/80 and secondary causes of hypertension for any child with a
<90th percentile confirmed diagnosis of prehypertension with comorbid
conditions (ie, African-American race, obesity, kidney
Stage 1 95th to One to two weeks or disease, insulin resistance or diabetes mellitus, history
hypertension [99th + 5 mm Hg] sooner if symptomatic;
of umbilical lines or recurrent urinary tract infections,
if it continues to be
elevated on two or more family history of HTN).
occasions, refer within While primary (or “essential”) HTN is on the rise
one month
in children, it should still be considered a diagnosis of
exclusion. Secondary hypertension is more common in
Stage 2 >99th + 5 mm Hg Evaluate or refer within
hypertension one week, or immediately children than in adults, and is more likely the younger the
if symptomatic child and the higher the blood pressure at presentation.1,11
Similarly, the likely etiologies will vary by age of the child
*Adapted from the Fourth Report1 (Table 1). >>p.50

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 CME

Table 2
evaluation should include:
Important history and physical elements for
• Basic metabolic panel (electrolytes, blood urea nitrogen
hypertension evaluation
[BUN], creatinine), urinalysis and urine culture to
History exclude renal disease and chronic pyelonephritis
• Complete blood count to exclude anemia, which would
• Symptoms suggestive of endocrine etiology (ie, weight loss, be consistent with chronic renal disease
sweating, flushing, fever, palpitations, muscle cramps, weakness, or • Fasting lipids and glucose to identify lipid and/or
constipation) metabolic abnormalities
• History of prematurity, neonatal course, UAC/UVC lines • Thyroid function tests to exclude thyroid disease
• History of UTIs • Renal ultrasound with Doppler examination of the
• Symptoms of obstructive sleep apnea (ie, difficulty falling asleep, renal vasculature to ensure the patient has two kidneys
multiple nighttime awakenings, snoring, daytime somnolence) of appropriate size, without cysts or other structural/
• Medications
– Steroids
congenital anomalies, and to evaluate flow in both
– Decongestants/cold preparations organs
– Oral contraceptive pills • Echocardiogram to exclude cardiac etiology and evaluate
– NSAIDs
– Stimulant medications (eg, dexedrine, methylphenidate)
for evidence of left ventricular hypertrophy indicating
– Beta-adrenergic agonists (eg, theophylline) end-organ damage from long-standing hypertension
– Erythropoietin • Retinal exam to evaluate for the presence of retinal
– Cyclosporine/tacrolimus
– Tricyclic antidepressants
vascular changes; hypertensive retinopathy is another
– Recent abrupt discontinuation of antihypertensives form of end-organ damage
• Nutritional supplements Additional evaluation for some children will include:
• Family history of HTN, early cardiovascular (CV) or cerebrovascular • Drug screen for children or adolescents with a history
events, end-stage renal disease (ESRD) suggestive of using illicit drugs or substances that might
• Diet (caffeine, salt intake) cause hypertension
• Smoking/drinking/illicit drugs (eg, tobacco, ethanol, amphetamines, • Polysomnography for children with a history of
cocaine, phencyclidine, MDMA [ecstasy])
loud snoring or daytime somnolence, suggestive of
• Physical activity
obstructive sleep apnea (see Obstructive sleep apnea
and hypertension on page 74)
Physical exam
Further evaluation for children under age 10 with Stage
1 HTN, or any child with Stage 2 HTN (generally done
• Four extremity pulses and BPs
by a specialist) is outlined as follows:
• Moon facies, truncal obesity, buffalo hump
• Ambulatory blood pressure monitoring to identify
• Retinopathy
children with white coat hypertension, and/or get more
• Enlarged tonsils
• Thyromegaly information on blood pressure pattern and average
• Skin lesions (café au lait spots, neurofibromas, adenoma sebaceum, daily blood pressure
striae, hirsutism, butterfly rash, palpable purpura) • Plasma renin to identify low renin states, which would
• Evidence of BPD, congestive heart failure suggest mineralocorticoid disease
• Abdominal mass, abdominal bruits • Renovascular imaging to identify renovascular disease
• Edema (ie, renal artery stenosis). Some examples of imaging
• Pregnancy include an magnetic resonance angiography, 3D
computed tomography, angiography (gold standard;
can simultaneously diagnose and treat renal artery
When evaluating a child with HTN, one should start with stenosis)
a focused history and physical (Tables 2 and 3). • Plasma and urine steroid levels to identify steroid
For all children with diagnosed hypertension, the initial mediated hypertension

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 HYPERTENSION

Table 3

Physical examination findings suggestive of definable hypertension

Findings* Possible etiology

Vital signs • Tachycardia • Hyperthyroidism, pheochromocytoma, neuroblastoma, primary hypertension
• Decreased lower extermity pulses; • Coarctation of the aorta
drop in BP from upper to lower
extremities
Eyes • Retinal changes • Severe hypertension, most likely to be associated with secondary hypertension

Ear, nose, and throat • Adenotonsillar hypertrophy • Suggests association with sleep disordered breathing (sleep apnea), snoring
Height/weight • Growth retardation • Chronic renal failure
• Obesity (high BMI) • Primary hypertension
• Truncal obesity • Cushing syndrome, insulin resistance syndrome
Head and neck • Moon facies • Cushing syndrome
• Elfin facies • Williams syndrome
• Webbed neck • Turner syndrome
• Thyromegaly • Hyperthyroidism
Skin • Pallor, flushing, diaphoresis • Pheochromocytoma
• Acne, hirsutism, striae • Cushing syndrome, anabolic steroid abuse
• Café-au-lait spots • Neurofibromatosis
• Adenoma sebaceum • Tuberous sclerosis
• Malar rash • Systemic lupus erythematosus
• Acanthrosis nigricans • Type 2 diabetes
Chest • Widly spaced nipples • Turner syndrome
• Heart murmur • Coarctation of the aorta
• Friction rub • Systemic lupus erythematosus (pericarditis), collagen vascular disease,
end-stage renal disease with uremia
Abdomen • Apical heave • LVH/chronic hypertension
• Mass • Wilms tumor, neuroblastoma, pheochromocytoma
• Epigastric/flank bruit • Renal artery stenosis
• Palpable kidneys • Polysystic kidney disease, hydronephrosis, multicystic dysplastic kidney, mass
(see above)
Genitalia • Ambiguous/virilization • Adrenal hyperplasia
Extremities • Joint swelling • Systemic lupus erythematosus, collagen vascular disease
• Muscle weakness • Hyperaldosteronism, Liddle syndrome
Adapted from Flynn JT: Prog Pediatr Cardiol 2001;12:177
*Findings listed are examples of physical findings and do not represent all possible physical findings.

• Plasma a nd uri ne catechola mi nes to ident if y
catecholamine-mediated hypertension (ie, pheo-
chromocytoma)
Your patient’s evaluation
Nicholas’ initial work-up is negative: he has normal electrolytes,
renal function, hemoglobin, thyroid function and lipid profile.
Renal ultrasound reveals two normal-sized kidneys with normal
arterial and venous flow. Echocardiogram demonstrates normal
left ventricular mass, and his ophthalmology evaluation ruled
out hypertensive retinopathy. You diagnose him with primary
hypertension and recommend lifestyle modifications as he
continues to be asymptomatic, and does not have evidence of
end-organ damage. >>p.52

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 CME

Primary hypertension their SBP and DBP have also been shown to increase with
Once a comprehensive work-up looking for secondary increasing BMI.15
causes of hypertension has been completed and found Obesity and hypertension both separately and together put
to be negative, a diagnosis of primary (or “essential”) children at increased cardiovascular risk.16 Obese children
hypertension can be made. This diagnosis, while still are more likely to have clustering of cardiovascular risk
considered to be a diagnosis of exclusion, is more frequently factors in addition to hypertension, such as hyperlipidemia,
found in post-pubertal and African American children, and insulin resistance, type 2 diabetes mellitus and left
in children with BP on the lower end of the hypertensive ventricular hypertrophy.5 Autopsy studies of children reveal
spectrum (ie, just above the 95th percentile). It is also more that even early in life there is evidence of coronary artery
frequently found in children with a positive family history pathology, associated with BMI, dyslipidemia, and systolic
of HTN, and in those who are overweight or obese.12 and diastolic BP.17
The role of obesity in this diagnosis should not be
overlooked. The number of children with primary
hypertension is on the rise concomitant with the rise in
childhood obesity.4,5,13,14 Several studies have demonstrated
the increased risk of hypertension that exists among obese
children. For example, for each one unit increase in BMI
z-score, children 8 to 17 years of age have been shown to
have twice the risk of having a BP greater than the 95th
percentile.13 Even children as young as 2 to 5 years of age
are not immune to these effects of obesity and overweight;

The link between OSA and

hypertension
The mechanism by which obstructive sleep apnea (OSA) leads to hypertension is still
not well understood. One study has found a linear relationship between the severity
of OSA symptoms, and the incidence of newly diagnosed HTN, independent of body
mass, age, gender, or baseline BP and cigarette and alcohol consumption.1
It is likely that the hypoxemia and hypercapnea experienced by individuals with
OSA leads to an increase in sympathetic nervous system activity, which then leads to
an increase in peripheral vascular resistance. Hypoxia has been shown to increase
IMAGE: GET T Y IMAGES/MEDIOIMAGES/PHOTODISC

levels of endothelin-1, a known potent and long-acting vasoconstrictor, as well as

other circulating vasoconstrictors.
Because appropriate treatment of OSA has been shown to decrease daytime and
nighttime mean systolic and diastolic blood pressures by up to 10 mm Hg, 2 screening
for OSA should be included in a clinician’s work-up of a child with hypertension.
Reference
1. Peppard PE, Young T, Palta M, et al: Prospective study of the association between sleep-disordered breathing and hypertension. N Engl
J Med 2000;342:1378
2. Becker HF, Jerrentrup A, Ploch T, et al: Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with
obstructive sleep apnea. Circulation 2003;107:68

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Table 4
obese children. It has been shown that weight loss by itself
Non-pharmacologic interventions1 can decrease blood pressure, 23 and other associated CV
risk factors should also be expected to regress or improve
• Aerobic exercise: 30 to 45 minutes “most days” of the week with weight loss.24 Additionally, increased physical activity
• Limit sedentary activities to less than two hours per day and fitness has been shown to be associated with lower
• Weight reduction if overweight childhood BP and a reduced risk of HTN 16 to 50 years
• Increased intake of fresh vegetables, fruits, and low-fat dairy (the later.25 Obese children are also more likely to be salt sensitive,
Dietary Approaches to Stop Hypertension (DASH) Study eating and thus more likely to respond to dietary restriction of
plan)18 sodium, and improved intake of potassium. The insulin
• Salt restriction* resistance often seen in obese children leads to salt and
• Adequate intake of potassium and calcium (both shown to have
water retention, 26 and preliminary studies have indicated
antihypertensive effects)19
that adipocytes may secrete factors leading to increased
• Cessation of smoking
serum aldosterone, which then leads to increased renal
*Can start with recommending “no added salt” with ultimate goal of sodium reabsorption.27-29
achieving the current recommendation of 1.2 grams/day total for 4- Often implementing these changes for all family
to 8-year-olds and 1.5 grams/day for children 9 years and older.1
members is necessary before any appreciable benefit can
be achieved.
Additionally, obesity and hypertension in childhood places
these children at higher risk for obesity and hypertension How should I treat?
as adults, 20 with increased risk for CV morbidity and There are multiple medications available to treat hypertension
mortality. 21 Blood pressure tracking from childhood to in children, for which pediatric dosing is now available
adulthood is much more likely to occur with increasing (Table 5). The particular agent
BMI. 22 Because of this BP tracking from childhood to chosen shou ld be a i med at Point
adulthood, lifestyle changes should be emphasized for all treating the underlying etiology, Taken
hypertensive children, but should also particularly be aimed with particular attention being
at obese children with primary hypertension. paid to co-morbid conditions Weight loss by
such as diabetes, asthma, and
Management of pediatric hypertension itself can
migraines.
Who gets treated? Af ter a f u l l eva luation to decrease blood
Once a child is diagnosed with HTN and is appropriately determine etiology is completed pressure, and
staged and evaluated, treatment should be initiated and (and any interventions are under-
aimed at the underlying etiology. Children with pre- taken to treat the underlying other associated
hypertension or asymptomatic, Stage 1 Primary HTN who disease process), initial antihyper- CV risk factors
do not have evidence of end-organ damage or diabetes, tensive therapy for a child who
should also
should be “prescribed” lifestyle modifications (Table 4) continues to be hypertensive
and be re-evaluated in six months. Children with persistent should include either a calcium be expected
hypertension after six months—despite attempts at lifestyle channel blocker (CCB) or an to regress or
modification—should be started on an anti-hypertensive angiotensin converting enzyme
medication. Similarly, any child with symptomatic HTN, (ACE) inhibitor, unless there is a improve with
Stage 2 HTN, secondary HTN, diabetes or evidence of end- compelling reason to use an agent weight loss.
organ damage should be started on an anti-hypertensive from another class. Both CCBs and
medication. ACE inhibitors are generally well tolerated with a minimal
Even after deciding to treat with an anti-hypertensive, side effect profile, and can be dosed once daily.
nonpharmacologic lifestyle interventions should continue to Obese children with primary hy pertension may
be emphasized at each visit, particularly in overweight or particularly benefit from ACE inhibitors or angiotensin-

NOVEMBER 2008 CONTEMPORARY PEDIATRICS 53

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Table 5
Pharmacologic interventions for pediatric hypertension
Drug Examples Major side effects Comments
class
Diuretics • Hydrochlorothiazide • Hypokalemia, hypercholesterolemia, • Would avoid in children active in sports because of risk of
• Metalozone hyperglycemia dehydration and/or electrolyte disturbances
• Furosemide Rare side effects: • Electrolytes should be monitored one week after initiation and
• Torasemide • Blood dyscrasias, photosensitivity, periodically thereafter
pancreatitis • Most useful as adjunctive therapy (particularly with calcium
channel blocker, direct vasodilators)
Potassium- • Spironolactone • Hyperkalemia • Would avoid in children active in sports because of risk of
sparing • Amiloride • Gynecomastia dehydration and/or electrolyte disturbances
diuretics • Electrolytes should be monitored one week after initiation and
periodically thereafter
Beta- • Atenolol Serious side effects: • Preferred for hypertensive children who suffer from migraine
blockers • Timolol • Bronchospasm, congestive heart headaches
• Pindolol failure, masking of insulin-induced • Non-cardioselective agents are contraindicated in asthma and in
• Bisoprolol hypoglycemia, depression children with heart failure; avoid in diabetics
Propranolol Less serious: • May decrease athletic performance
Available in pediatric labeling:* • Poor peripheral circulation, insomnia, • Maximum dose may be limited by heart rate
• Metoprolol fatigue, decreased exercise tolerance,
hypertriglyceridemia
Calcium • Verapamil, diltiazem • Conduction defects, decreased • Generally well tolerated
channel • Dihydropyridines contractility, gingival hyperplasia, • Consider for children active in sports
blockers (Felodipine, Isradipine, flushing, headache, peripheral edema
(CCBs) Nicardipine, Nifedipine)
Available in pediatric labeling:*
• Amlodipine

Angiotensin- • Captopril • Cough, rash, loss of taste, • Contraindicated in pregnancy and in children with hyperkalemia
converting • Ramipril hyperkalemia and/or bilateral renal artery stenosis (can cause flash pulmonary
enzyme Available in pediatric labeling:* Rare side effects: edema)*
inhibitors† • Benazepril* • Leukopenia, anemia, angioedema • Preferred medication for hypertensive diabetics or hypertensive
• Enalapril* patients with microalbuminuria or proteinuria
• Fosinopril • Should consider for obese children with primary hypertension
• Lisinopril* • Need to monitor for hyperkalemia and renal failure one week after
starting, with each dose increase, and periodically (every six to
12 mos after that)
Angiotensin Available in pediatric labeling:* • Hyperkalemia, cough (less frequent • Contraindicated in pregnancy*
receptor • Losartan* than with ACE inhibitors), angioedema • Preferred medication for hypertensive diabetics or hypertensive
blockers† • Valsartan* patients with microalbuminuria, proteinuria
• Irbesartan (label states was • Need to monitor for hyperkalemia and renal failure one week after
ineffective in children) starting, with each dose increase and periodically (every six to 12
mos after that)
Alpha- • Labetalol • Postural hypotension, Beta-blocking • Preferred medication for hypertensive children who suffer from
and • Carvedilol side effects migraine headaches
beta- • Contraindicated in asthma and in children with heart failure; avoid
blockers in diabetics
• May decrease athletic performance
• Maximum dose may be limited by heart rate
Direct • Hydralazine • Headaches, tachycardia, lupus- • Hydralazine: Long-term use not effective secondary to tolerance,
vasodilators • Minoxidil like syndrome (hydralazine), fluid edema
retention, hirsutism (minoxidil) • Minoxidil reserved for refractory cases in conjunction with other
medications (particularly diuretics)
Central • Methyldopa • Hepatic and “auto-immune” disorders • Abrupt discontinuation can lead to severe rebound HTN
alpha • Clonidine (methyldopa), sedation, dry mouth,
antagonists “withdrawal” (clonidine)
*These agents have pediatric labeling that includes instructions for extemporaneous suspension preparation.30
†
The choice of ACE inhibitor or ARB can be based on the formulation available (only certain members of each class can be compounded into a suspension),
and on tolerability (newer formulations of ACE inhibitor reportedly have less cough and angioedema associated with them; some patients are hyperkalemic
with one class and not the other).

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 HYPERTENSION

effects that limit reaching the maximium recommended

dose, an additional medication is initiated in the same
manner.
The goal for both non-pharmacologic and pharmacologic
therapy is to achieve BPs less than the 95th percentile
for most children, or less than the 90th percentile for
children with chronic kidney disease, diabetes, or evidence
of end-organ damage. This should be done in a manner
to maximize BP response while minimizing side effects
and maximizing probability of patient compliance. Side
effects can be minimized by prescribing the least amount of
drug necessary to effectively reduce BP. Higher degrees of
medication compliance can be achieved by being mindful of
medication side effects,
patient lifestyle, and Point
comorbid conditions. Taken
receptor blockers (ARBs) therapy as the likely mechanism Once therapy is in-
for HTN in this group is increased sodium retention and itiated, close moni- ACE inhibitors and
sympathetic nervous system (SNS) activation. Moreover, toring for desired effect,
ARBs can lead to
these agents may have beneficial effects on diabetes presence of side effects
and dyslipidemia. Because diuretics can worsen insulin and compliance is vitally hyperkalemia and
resistance and dyslipidemia, as well as increase SNS and important. There are renal failure in certain
renin activity, they should be avoided in obese children no specific, published
with hypertension. Also, beta blockers should be avoided guidelines regarding individuals. Therefore,
in this group as they can lead to weight gain, increased frequency of monitoring lab tests should be
triglycerides, and decreased high-density lipoprotein a nd fol low-up a f ter
undertaken one to two
cholesterol concentrations.31,32 initiation of therapy,
A word of caution: ACE inhibitors and ARBs can lead but in the beginning it weeks after starting
to hyperkalemia and renal failure in certain individuals. would be reasonable to either one of these
Therefore, lab tests should be undertaken one to two weeks measure a child’s blood
medications to look
after starting either one of these medications to look for pressure at least weekly
evidence of these conditions. Additionally, flash pulmonary and arrange for follow- for evidence of these
edema can occur if bilateral renal artery stenosis is present, up every three months.
conditions.
so it would be wise to delay prescribing an ACE inhibitor or Weekly BP monitoring
IMAGE: GET T Y IMAGES/PHOTODISC/KEITH BROFSK Y

ARB until after obtaining a renal ultrasound with Doppler
examination of the renal vessels. Lastly, as ACE inhibitors
and ARBs can also be highly teratogenic, contraception
should be discussed with females of childbearing age when
considering these classes of medications.
Once a medication is chosen, the lowest dose should
be started, with the dose increased in a step-wise fashion
to achieve normotension and regression of end-organ
damage, if present. Once the patient reaches the maximum
recommended dose of a medication, or experiences side
can occur in a clinic
setting (via a nursing visit), a school setting (where the
school nurse measures manual BPs and faxes the readings
to the physician), or in a home setting either with a
properly calibrated, automated cuff or by manual measure-
ment done by a properly trained family member. As previously
mentioned, public BP cuffs are not appropriate for this monitoring
as they are likely to be inaccurate.
Once the child has achieved target BP’s on a medication
regimen, clinic follow-up can be spaced to every six months.
>>p.56

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 CME
When to refer?
Depending on provider comfort level, the diagnosis, initial
work-up and treatment can be provided in the primary care
setting, or can be handled by a specialist with expertise in
pediatric hypertension. Ongoing collaboration and frequent
communication between specialists and primary care
providers is essential for successful patient management.
Once presented with refractory hypertension or with a
child very likely to have secondary hypertension, referral
to a specialist should be made for further work-up and
treatment. ◽
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