Management of High Blood Pressure

in Children and Adolescents:

Recommendations of the
European Society of Hypertension

Empar Lurbe – Chairperson; Renata Cifkova; J Kennedy

Cruickshank; Michael J Dillon; Isabel Ferreira; Cecilia Invitti;
Tatiana Kuznetsova; Stephane Laurent – Ex officio; Giuseppe
Mancia – Ex officio; Francisco Morales-Olivas; Wolfgang
Rascher; Josep Redon; Franz Schaefer; Tomas Seeman; George
Stergiou; Elke Wühl; Alberto Zanchetti
 Hypertension in Children and Adolescents:
Recommendations of the ESH
1. Introduction and purpose 9. Screening of secondary
forms
2. Definition and classification
10. Long-term follow-up
3. Diagnostic evaluation
11. Future research
4. Preventive measures
12. Implementation of
5. Evidence for therapeutic guidelines
management
13. Bibliography
6. Therapeutic strategies
Figures
7. Therapeutic approaches
under special conditions Tables
8. Treatment of associated risk Boxes
factors
 Introduction and Purpose

Introduction and Purpose (I)

 There is growing evidence that children and adolescents with

mild BP elevation are much more common than was thought in
the past
 Longitudinal studies have demonstrated that BP abnormalities
in those age ranges do not infrequently translate into adult
hypertension
 Hypertension in children and adolescents has gained ground in
CV medicine thanks to the progress made in several areas of
pathophysiological and clinical research
 Introduction and Purpose

Introduction and Purpose (II)

 The remoteness of cardiovascular events from the BP values of

many years before makes the relationship between those BP
values and the events difficult to establish
 Large intervention studies are lacking, and therefore cannot
provide hints about cutoffs for evidence-based
recommendations
 Many of the classifications and recommendations in children
are based on statistical considerations and are the result of
assumptions or extrapolations from evidence obtained in
adults
 Introduction and Purpose

Characteristics of blood pressure

 Blood pressure increases during growth and maturation

 Adolescence is a fast growth period during which body mass
and BP change rapidly
 Reference BP values over the last few decades have been
referred to as ones specific for sex, age and/or height
 Definition and classification

Definition and classification

SBP and/or DBP Percentile

Normal <90th

High-normal ● ≥ 90th to <95th

● ≥ 120/80 even if below 90th
percentile in adolescents
Stage 1 hypertension 95th percentile to the 99th
percentile plus 5 mmHg
Stage 2 hypertension >99th percentile plus 5 mmHg
 Definition and classification

Diagnostic algorithm of hypertension

SBP and/or DBP

<P90th >P90th

NORMOTENSION Repeated
measurements

<P90th P90-95th ≥P95th

NORMOTENSION FOLLOW-UP HYPERTENSION

Evaluation for
Repeated
etiology and
measurements
organ damage
Figure 1
 Diagnostic evaluation

Blood pressure measurement

 The recommended method is auscultatory

 Use K1 for systolic BP and K5 for diastolic BP
 If the oscillometric method is used, the monitor needs to be
validated for this age group
 If hypertension is detected by the oscillometric method, it needs
to be confirmed using the auscultatory method
 Use the appropriate cuff size according to arm width
 Children above 3 years of age who are seen in a medical setting
should have their BP measured
 In younger children, BP should be measured under special
circumstances that increase the risk for hypertension

Box 1
 Diagnostic evaluation

Indications for 24-hour ABPM

● During the process of diagnosis

– Confirm hypertension before starting antihypertensive drug
treatment
– Type 1 diabetes
– Chronic kidney disease
– Renal, liver or heart transplant
● During antihypertensive drug treatment
– Evaluation of refractory hypertension
– Assessment of BP control in children with organ damage
– Symptoms of hypotension
● Clinical trials
● Other clinical conditions
– Autonomic dysfunction
– Suspicion of catecholamine-secreting tumours
Box 2
 Diagnostic evaluation

Evaluation of organ damage

● Organ damage is common and LV hypertrophy is the most

prominent type
● Echocardiography should be performed. Left Ventricular
Hypertrophy is an indication to initiate or intensify
antihypertensive therapy
● Microalbuminuria is recommended for routine clinical use
● Carotid intima-media thickness, arterial stiffness, retinal and
CNS assessment are not recommended for routine clinical use
 Screening for secondary forms

Evaluation for Secondary Hypertension

● Very young children with Stage 1 or Stage 2 hypertension

● Children or adolescents with Stage 2 hypertension

Age-distribution of hypertension etiologies

< 1 month >1 month to <6 years > 10 years

Renal arterial thrombosis Renal parenchymal disease Essential Hypertension
Congenital renal disease Coarctation of the aorta Renal Parenchymal Disease
Renovascular disease Exogenous Hypertension (drugs)
Umbilical canalization
Bronchopulmonary dysplasia Endocrine Disorders
Coarctation of the aorta
> 6 years to 10 years Mendelian Genetic Disorders
Renal parenchymal disease
Renovascular disease
Essential hypertension
 Preventive measures
Life style recommendations to reduce high
BP values
GOAL
● Maintain or achieve BMI <85th
GENERAL RECOMMENDATIONS
● Moderate to vigorous physical aerobic activity 40 minutes, 3-5 days/week and
avoid more than 2 hours daily of sedentary activities
● Avoid intake of excess sugar, excess soft drinks, saturated fat and salt and
recommend fruits, vegetables and grain products
● Implement the behavioural changes (physical activity and diet) tailored to
individual and family characteristics
● Involve the parents/family as partners in the behavioural change process
● Provide educational support and materials
● Establish realistic goals
● Develop a health-promoting reward system
● Competitive sports participation should be limited only in the presence of
uncontrolled stage 2 hypertension
Box 6
 Evidence for therapeutic management

When to initiate antihypertensive treatment

Life threatening
High-normal BP Hypertension
hypertension

One or more of the following conditions:

Symptomatic
Secondary
Organ damage
Diabetes

NO YES

Nonpharmacological Pharmacological
treatment treatment

Figure 3
 Evidence for therapeutic management

Blood pressure targets

In general
● BP <90th age, sex and height specific percentile
Chronic kidney disease
● BP <75th percentile in children without proteinuria
and <50th percentile in cases of proteinuria
● 24-hour ABP strongly recommended.
● Goals: <75th percentile in children without proteinuria and
<50th percentile in cases of proteinuria
 Therapeutic strategies

How to initiate antihypertensive treatment

Particular conditions All hypertensives
Stage 2
Chronic kidney disease Monotherapy
Secondary (low dose
4-8 w)

No response

Monotherapy
(full dose)
No response Switch
Side effects drug
No response
Combination
therapy
 Therapeutic strategies
Antihypertensive agents with efficacy and
safety studies in children and adolescents

Class Efficacy studies

Diuretics Clorthalidone, HCZT

b-blockers Atenolol, Metoprolol, Propanolol

CCB Amlodipine, Felodipne, Isradipine

ACEi Captopril, Enalapril, Fosinopril, Lisinopril, Quinapril, Ramipril

ARB Candesartan, Irbesartan, Losartan, Valsartan

 Long-term follow-up

Long-term follow-up

● Initial frequent follow up visits to monitor

 BP control, organ damage
 Side effects of treatment
 Other reversible risk factors
● Once BP stable and in target range, frequency of visits can be
reduced
● Home monitoring of BP or 24 hour ABPM can facilitate follow up
assessments
● Dependent on the underlying cause of hypertension, further
investigative procedures may be indicated to monitor success of
surgical intervention or medical treatment
 Future research

Future research

 Develop accurate non-mercury sphygmomanometer for auscultatory

BP measurement and oscillometric BP
 Reference values for office, home and ambulatory BP based on a
European pediatric population
 Increase knowledge in the use of out-of-office BP measurements
 Collect information about early organ damage to refine risk
stratification and use the information to set intermediate objectives
during treatment

Box 10
 Future research

Future research

 Conduct controlled studies with antihypertensive drugs in order to

improve knowledge about specific benefits and disadvantages of BP
lowering agents and establish adequate doses
 Conduct large, long term randomized therapeutic trials using onset of
organ damage to obtain information about when to initiate
antihypertensive drug treatment and about BP goals

Box 10
 Implementation guidelines

Implementation of Guidelines

 Joint efforts should be started so as to promptly implement the

guidelines
 Synergistic actions at various levels (learned societies, expert
committees, GPs, pediatricians, nurses and other healthcare
providers, school, parents and policy makers) should be
encouraged to participate
 The role of learned Societies, particularly ESH, is crucial for
spreading the guidelines and the acceptance by National
Hypertension Societies and Leagues
 Active support of research is necessary in order to gain knowledge
helpful to future developments in the field, so studies that are
recommended should be promptly initiated
 Hypertension in Children and Adolescents: Recommendations
of the European Society of Hypertension

Renata Cifkova, Prague Giuseppe Mancia, Milan - Ex officio

J Kennedy Cruickshank, Manchester Francisco Morales-Olivas, Valencia
Michael J Dillon, London Wolfgang Rascher, Erlangen
Isabel Ferreira, Maastricht Josep Redon, Valencia
Cecilia Invitti, Milan Franz Schaefer, Heidelberg
Tatiana Kuznetsova, Leuven Tomas Seeman, Prague
Stephane Laurent, Paris - Ex officio George Stergiou, Athens
Empar Lurbe, Valencia – Chair Elke Wühl, Heidelberg
Alberto Zanchetti, Milan