The rate of hypertension among children continues to rise. Evidence shows a correlation between elevated BP in childhood and persistent hypertension in adulthood.1 Pediatric hypertension is associated with increased left ventricular mass and atherosclerosis in youth, both of which are known to predict cardiovascular events in adulthood.2,3 A significant association has been reported between high BP in adolescence and stroke mortality later in life.4 The same study demonstrated that pediatric hypertension doubles the risk of future end-stage renal disease.4 Hypertension in children is largely unrecognized and poorly controlled.1,5 Identifying pediatric patients with hypertension and successfully treating them was shown to mitigate long-term cardiovascular outcomes.6
In 2017, the American Academy of Pediatrics (AAP) published a new clinical practice guideline for the diagnosis, evaluation, and treatment of high BP in children and adolescents.1 This new guideline builds on accumulating evidence and provides guidance for managing hypertension in children with the aims of increasing hypertension recognition and reducing hypertension-related complications. This article provides a review of the 2017 AAP guideline and discusses practice implications for NPs working with pediatric patients and their families.
The reported prevalence of pediatric hypertension is approximately 4%, although the true prevalence may be underestimated.7,8 The rate of hypertension is higher among Hispanic and non-Hispanic Black children compared with non-Hispanic White children.1 Children with a family history of hypertension are at higher risk of developing the condition.1,9 Low birth weight and prematurity increase the likelihood of high BP in childhood.10
Consistent observational data show the increasing prevalence of pediatric hypertension. The growing rate of hypertension parallels the rising prevalence of childhood obesity.11 In a recent study that included 101,606 participants from three healthcare systems in the US, children with obesity (BMI between the 85th and 94th percentiles) ages 3 to 17 years old had a twofold increased risk of hypertension relative to children with normal weight, whereas those with severe obesity (BMI of the 99th percentile or higher) had a more than fourfold increased risk.12 It has been proposed that insulin resistance and increased levels of insulin, which are present with increased body fat, stimulate renal sympathetic response that raises BP.6
Primary hypertension (idiopathic, with unknown underlying cause) was previously thought to be a diagnosis of exclusion in the pediatric population.9 More recent evidence suggests increasing rates of primary hypertension corresponding with the obesity epidemic.9 Primary hypertension is the most common type of hypertension in older children. Secondary hypertension (with an identifiable underlying cause) remains the most frequent etiology of high BP in infants and young children.6 Hypertension from secondary causes was reported in 57% of 275 children with hypertension in a tertiary clinic.13 The median age of a child with secondary hypertension was 9 years.13
Kidney disorders are the most common etiologies of secondary hypertension. Renal parenchymal conditions and structural abnormalities (such as glomerular, tubular, and interstitial abnormalities) account for 34% to 79% of secondary hypertension cases, while renovascular disorders (such as renal artery stenosis) are found in 12% to 13% of patients.1 Both renal parenchymal and renovascular disorders lead to activation of the renin-angiotensin-aldosterone system resulting in arterial vasoconstriction and volume expansion.6 (See Common causes of secondary hypertension in children.)
Definition of pediatric hypertension
The clinical practice guideline includes a number of important modifications to the BP classification that were endorsed by the American Heart Association.1 The guideline provides definitions of hypertension for two different age groups.
For children age 13 years and older, BP thresholds meeting the definition of hypertension replicate that for adults:
- Normal BP: <120/<80 mm Hg
- Elevated BP (previously referred to as prehypertension): systolic BP between 120 and 129 with a diastolic BP <80 mm Hg
- Stage 1 hypertension: BP between 130/80 and 139/89 mm Hg
- Stage 2 hypertension: BP ≥140/90 mm Hg.1
In children ages 1 to 13 years, BP levels defining hypertension are determined based on gender, age, and height in normal-weight children:1
- Normal BP: both systolic BP and diastolic BP <90th percentile
- Elevated BP (previously referred to as prehypertension): systolic BP and/or diastolic BP ≥90th percentile but <95th percentile or 120/80 mm Hg to < 95th percentile (whichever is lower)
- Stage 1 hypertension: systolic BP and/or diastolic BP ≥95th percentile to <95th percentile + 12 mm Hg or 130/80 to 139/89 mm Hg (whichever is lower)
- Stage 2 hypertension: systolic BP and/or diastolic BP ≥95th percentile + 12 mm Hg or ≥ 140/90 mmHg (whichever is lower).1
In contrast with adults, where cutoffs of BP reflect a degree of risk of poor cardiovascular outcomes, such as myocardial infarction or stroke, the definition of hypertension in children is based on the distribution of BP in healthy children with normal weight due to the rarity of these poor cardiovascular outcomes in the pediatric population and lack of data.1 Normative BP tables have been updated and published within the clinical practice guideline.
Screening and diagnosis
The March 2020 update of the Bright Futures/American Academy of Pediatrics Recommendations for Preventative Pediatric Health Care noted that BP screening should occur per the clinical practice guideline at the annual well-child care visit for all children age 3 years and older.1,14 Children age 3 years and older should be screened at every healthcare encounter only if they have at least one of the risk factors for hypertension (such as obesity, renal disease, diabetes) or if they take medications that may persistently elevate BP (steroids, central nervous system stimulants, hormonal contraceptives).1 Children younger than age 3 years should also have their BP measured at each visit if they have conditions such as a history of prematurity, low birth weight, congenital heart disease, or urologic malformations.1 Patients with BP that exceeds screening thresholds will require further evaluation, starting with repeat BP measurements.1 The simplified BP table with screening thresholds useful for screening of pediatric patients is provided in the clinical practice guideline.1
Accurately obtaining BP readings is essential to the diagnosis of hypertension in children.1 For optimal BP measurement, the child should be seated with feet flat on floor and the right arm positioned at the level of the heart and supported. Infants can be placed supine for more accurate BP measurements.1 The BP should be taken when the patient is calm for at least 5 minutes.1 It is crucial to use the correct BP cuff size, with the inflatable bladder length covering 80% to 100% of the upper arm circumference and with the width of at least 40% of the arm circumference.1 Too small or too large a cuff can distort BP readings. Per the clinical practice guideline, if the initial BP is elevated, two additional measurements should be taken, and the average of the two last readings should be recorded because the first measurement is always higher than the subsequent ones.1
Between and within healthcare encounters, BP in children is highly variable. Children who are anxious or crying may exhibit an isolated elevated BP known as white coat hypertension, that may not reflect true BP values.1,6 White coat hypertension is noted in half of children with elevated in-office BP.15 While long-term cardiovascular outcomes of white coat hypertension in children are largely unknown, several pediatric studies have demonstrated that ruling out white coat hypertension may reduce healthcare cost by avoiding unnecessary tests and treatments.15 The clinical practice guideline recommends that a hypertension diagnosis should be made when repeat BP values on three separate visits are in the 95th percentile or higher for children younger than age 13 years, or when BP is 130/80 mm Hg or higher for adolescents ages 13 years and older.1
Automated oscillometric devices are commonly used in clinical practice because of the ease of their use. Such devices measure mean arterial pressure and calculate systolic and diastolic BP based on algorithms that may differ among machines.5,6 It is acceptable to use these devices especially in young children for BP screening if they are validated in pediatric patients.6 However, readings taken by oscillometric machines are commonly higher compared with values obtained by auscultation; therefore, auscultatory readings should be used to confirm the diagnosis of hypertension.1,5,6
The updated guidelines place a strong emphasis on confirming elevated clinic BP readings with out-of-office measurements using 24-hour ambulatory BP monitoring (ABPM).1 ABPM records BP at set intervals (commonly every 30 minutes) during regular daily activities and sleep and is more accurate than office-based readings. It is a useful method for detecting white coat hypertension and eliminating the need for additional diagnostic tests.1,6 If available, ABPM should be routinely used for the diagnosis of hypertension in children. Home and school BP measurements are not sufficiently accurate to establish the diagnosis of hypertension, but can be used for treatment monitoring.1
Evaluation of children diagnosed with hypertension
When the diagnosis of hypertension is established, the initial evaluation should be focused on determining the etiology of high BP (primary or secondary hypertension) and identification of other comorbidities that can increase overall cardiovascular risk.1 A complete history (perinatal, medical, family, nutritional, psychosocial, physical activity, and medications) should be obtained. Particular attention should be paid to the history of low birth weight and prematurity as these conditions are associated with a reduced number of nephrons and an increased risk of hypertension.1,6 A history of recurrent urinary tract infection (especially acute pyelonephritis) is linked to renal scarring, leading to renal parenchymal damage and elevated BP in children.6 Hematuria, rash, and arthralgia may suggest acute glomerulonephritis.6 Endocrine hypertension should be considered if there is a history of ambiguous genitalia, hypokalemia, periodic headaches, and flushing.1,6 The patient's medication record needs to be reconciled and specific attention should be paid to prescription and over-the-counter medications, herbal supplements, and recreational substances that may increase BP (such as nonsteroidal anti-inflammatory drugs, combined oral contraceptives, stimulants, steroids, decongestants, amphetamines, cocaine, and alcohol).1,6
A careful physical examination should be performed with an emphasis on auscultation for an abdominal bruit (seeking evidence of renal artery stenosis), diminished or delayed femoral pulses and a lower systolic BP in the lower extremities compared with upper extremities (coarctation of the aorta), and skin lesions (vasculitis).1,6 The child's height, weight, and BMI should be determined, as poor growth may suggest an underlying serious pathology.1
Initial lab tests should include urinalysis and chemistry panel including blood urea nitrogen and creatinine to screen for renal abnormalities. Potassium level (particularly hypokalemia) is important for detection of pathologies associated with hyperaldosteronism. Renal ultrasound may be warranted for patients younger than 6 years of age or any child with abnormal renal function to assess for discrepancies in renal size and structural abnormalities.1 Additional testing should include a lipid panel for all patients, and hemoglobin A1C and liver profile in children with overweight or obesity to detect metabolic disturbances that may increase cardiovascular risk.1
The clinical practice guideline recommends obtaining echocardiography to assess for cardiac target organ damage (left ventricular hypertrophy [LVH]) when pharmacologic therapy is being considered.1 LVH is common in hypertensive children and associated with cardiovascular morbidities in adults, independent of BP levels.1 Limited pediatric data suggest that successful antihypertensive treatment reduces LVH.1 Further evaluation to determine secondary etiologies of hypertension, such as thyroid disease and sleep apnea, should be performed only if suggestive clinical features are present.1,16 Children with suspected secondary hypertension should be referred to an appropriate specialist for further diagnostic workup and treatment.
Management of pediatric hypertension
As recommended by the clinical practice guideline, the overall target of hypertension treatment is to reduce BP to less than the 90th percentile in children ages 13 years and younger or less than 130/80 mm Hg in adolescents.1 BP reduction in children decreases LVH and atherosclerosis that may translate into a decline in cardiovascular complications later in life.2
Nonpharmacologic treatment. Nonpharmacologic therapies that support healthy nutrition, physical activity, and healthy weight should be recommended to all children with elevated BP and hypertension. The long-term beneficial effect of nonpharmacologic approaches was shown in a prospective study of 798 children that were followed for 20 years.17 Hypertension resolution was seen in 44% of participants who were engaged in healthy lifestyles.17
Dietary modifications, such as a reduction in salt intake; limited sugar intake; and an increased intake of fresh fruits, vegetables, whole grains, fish, poultry, nuts, lean red meats, and low-fat dairy products (Dietary Approaches to Stop Hypertension [DASH] diet), remain the cornerstone of treatment for children with hypertension.1,6 Children with hypertension and overweight or obesity should be referred to a pediatric dietitian, who may provide customized education and recommendations to improve overall nutrition and body weight. Referral to a pediatric obesity center or intensive weight-loss program may be warranted.11
Regular physical activity is effective in lowering BP in children. The CDC endorses at least 60 minutes of moderate-to-vigorous physical activity daily for all children ages 6 to 17 years.18 Children with hypertension should be encouraged, supported, and provided with opportunities to engage in physical activity.1,18 Participation in competitive sports and intense physical training may present a challenge. Although there are no data on association between sudden death in athletes and hypertension, it is recommended that children with stage 2 hypertension, even without evidence of LVH, be restricted from high-static sports such as wrestling or weight lifting until their BP is well controlled.1
Tobacco smoking and other forms of nicotine inhalation in all children, including those with hypertension, should be discouraged. Though cigarette smoking can increase BP due to the vasoconstrictive effect of nicotine, this rise in BP is only transient.19 Smoking should be avoided not because it causes persistent hypertension but because it increases the risk of cardiovascular and pulmonary diseases. Numerous studies in adults have demonstrated a clear link between excessive alcohol consumption and development of hypertension.20 Despite uncertainties regarding this association in children, it is widely acknowledged that excess of alcohol contributes to poor health. Alcohol consumption should be avoided in all children and adolescents, including those with hypertension.
The clinical practice guideline recommends that children with hypertension who are treated nonpharmacologically should be followed up with every 3 to 6 months, so adherence to lifestyle modifications can be reinforced with education and support, and the need for pharmacologic therapies can be reevaluated.1 Ongoing patient and family education and support remain essential.
Pharmacologic treatment. The decision to initiate antihypertensive medications should be based on the severity of hypertension and the presence of cardiovascular comorbidities. The treatment is indicated for children who have failed nonpharmacologic treatment, particularly those who have LVH or stage 2 hypertension.1 These children are at higher risk and are likely to benefit from antihypertensive medications.
The number of antihypertensive drugs in children that have been evaluated for safety and efficacy has increased after regulatory agencies both in the US and Europe legislatively incentivized pediatric trials.6 As a result, efficacy and safety data for children are now available for drugs that have been recently introduced to the market.6 However, older, commonly prescribed antihypertensive medications were not reevaluated for safety and efficacy in children and as such, information on dosing, adverse reactions, and efficacy is extrapolated from adult studies.6
Available data demonstrate that major classes of antihypertensive medications are efficacious (compared with placebo), and well tolerated by children.1,21 Because there is little data comparing antihypertensive drugs in children, the choice of agents should be based on the presence of comorbid conditions, practitioner's experience, and patient's preferences.1,22 (See Pharmacologic therapies for hypertension in children.) The clinical practice guideline provides recommendations on initial medication doses.1
For children without particular compelling indications, pharmacologic therapy can be initiated with one of the following classes: thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or dihydropyridine calcium channel blockers (CCBs).1 Beta-blockers are not recommended as initial therapy because they are less effective than other antihypertensive drugs.1 In addition, beta-blockers can cause bronchoconstriction in children with asthma. ACE inhibitors and ARBs have been found highly teratogenic and are contraindicated in pregnancy. Sexually active females should be treated with alternative medication classes.
In children with chronic kidney disease and diabetic nephropathy, ACE inhibitors and ARBs are preferred medication classes.1 Based on convincing data from adult trials, ACE inhibitors and ARBs decrease albuminuria and slow progression of renal insufficiency. However, ACE inhibitors and ARBs may decrease a patient's glomerular filtration rate, so careful monitoring for a Closely monitor potential rise in creatinine and potassium is needed. Children with chronic kidney disease should be managed by a pediatric nephrologist or a cardiologist.
The updated guidelines recommend that patients treated with pharmacologic agents should be reassessed every 4 to 6 weeks for dose adjustments until goal BP is reached, then every 3 to 4 months after.1 Consider a second or third medication from a different medication class if target BP is not achieved on monotherapy.1 Secondary hypertension and poorly controlled primary hypertension requiring multiple medications warrants referral to a specialist.
Monitor children on antihypertensive medications closely for adverse reactions of prescribed medications, particularly electrolyte imbalances. Repeat echocardiography to evaluate progression or regression of LVH should be obtained for children with stage 2 hypertension and those with abnormal left ventricular function.1 Frequent echocardiography in the absence of LVH is discouraged.1
Patient engagement and care collaboration
Achieving adequate BP control requires adherence to medications and lifestyle modifications. Medication nonadherence is cited as the number-one cause of poorly controlled hypertension in adults and children.6 It is important to include children in the decision-making process regarding hypertension management. It is also essential for patients to understand that hypertension is usually asymptomatic but may still inflict significant end-organ damage. If children lack a clear understanding of the effect of hypertension on their bodies, they may not fully engage in self-care behaviors.1 Thus, patient education delivered in an easily understood way should be an important component of the treatment plan. Shared decision-making that involves children and their parents is a crucial strategy to achieve BP control. Parents of younger children will carry the burden of daily hypertension care pertaining to medications, food choices, and activities.1 Parents of older children are instrumental in providing healthy options and encouraging adherence to medications and lifestyle modifications.1 A family-based approach can be particularly important in hypertension treatment.1 Families can help by adjusting daily routines, for example, changing to low-fat family meals or instituting daily family walks. Strong interdisciplinary partnership with dietitians, pharmacists, medical assistants, and other healthcare professionals is important to improve hypertension management in children.1
Implications and conclusion
The 2017 clinical practice guideline provides updates and strategies regarding the diagnosis and management of pediatric hypertension. NP understanding and adherence to evidence-based clinical practice guidelines is vital to appropriately assessing and treating high BP in pediatric patients. Population level policies to reduce tobacco and alcohol use by adolescents and young adults are key to addressing pediatric hypertension along with more local advocacy to improve dietary choices and physical activity opportunities in schools and communities. Research to determine true prevalence of pediatric hypertension, benefits of lifestyle modifications, and long-term safety and efficacy of antihypertensive therapy is needed.8 Strategic partnership between industry, academia, and government are key to moving this field forward.8 Ongoing education along with systemwide strategies to improve timely uptake of evidence-informed clinical practice guidelines should be prioritized.
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