Hypertension

Tammy M. Brady
Pediatrics in Review 2012;33;541
DOI: 10.1542/pir.33-12-541

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 Article cardiovascular disorders

Hypertension
Tammy M. Brady, MD,
Educational Gap
MHS
Pediatric hypertension is on the rise, now affecting almost 5% of all children. Clinicians
should be following the latest guidelines on management of pediatric hypertension, in-
Author Disclosure cluding recommendations to measure blood pressure at every visit in all children age 3
Dr Brady has disclosed years and older and some at-risk children younger than age 3 years, as well as to employ
no financial pharmacologic therapy for some children.
relationships relevant
to this article. This
Objectives After completing this article, readers should be able to:
commentary does
contain a discussion of 1. Define hypertension in children, and be familiar with the approach to the diagnosis of
an unapproved/ hypertension.
investigative use of 2. Recognize important signs and symptoms associated with hypertension and its
a commercial product/ sequelae, and formulate an appropriate differential when presented with
device. a hypertensive child or adolescent.
3. Initiate an appropriate evaluation, and know when to refer to subspecialty care.
4. Prescribe both nonpharmacologic and pharmacologic antihypertensive therapy to
hypertensive children, and be familiar with the various classes of antihypertensive
medications available.

Case Study
Jennifer is a 12-year-old girl who plays field hockey and is in your office for a sports physical.
She reports feeling well, denies any complaints, and has no significant past medical history.
She is not taking any medications. Family history is reviewed and is significant only for
grandparents on both sides of the family having hypertension (HTN) and a paternal grand-
father who had a myocardial infarction at age 60 years and is still living. She is a straight A
student and lives at home with her parents and 2 brothers, who are healthy. Review of sys-
tems is significant for achieving menarche several months earlier.
Physical examination shows both her height and weight to be at the 50th percentile. Blood
pressure (BP) was 136/82 mm Hg initially in triage; repeat is 132/78 mm Hg by the same au-
tomated oscillometric device 5 minutes later. She is a healthy-appearing young girl who is com-
fortable and in no apparent distress. The rest of her physical examination is well within normal
limits. You repeat her BP by manual auscultation and obtain a measurement of 128/77 mm Hg.

Introduction
Although once affecting only 1% of all children, pediatric HTN is on the rise, now affecting
almost 5% of all children. One possible explanation for this striking increase in prevalence over
the past several decades is the concurrent rise in pediatric obesity, which currently affects 17%
of US children and adolescents. BP increases with increasing BMI, which explains the stag-
gering 30% of obese children who are hypertensive. This significant increase makes it much
more likely that clinicians will find themselves caring for hypertensive children, heightening
the need for proper recognition, evaluation, and treatment in the primary care setting.

Definition
Pediatric HTN is defined as the sustained elevation of either the systolic or diastolic BP at or
above the 95th percentile of BP for a child’s age, gender, and height percentile. Essential to
this definition is the presence of sustained BP elevation, which is why all elevated BP

Division of Pediatric Nephrology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD.

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cardiovascular disorders hypertension

measurements should be confirmed by repeated measure- current coronary artery aneurysms), kidney or heart
ments conducted by manual auscultation, with the aver- transplantation, chronic inflammatory diseases, human
age of all measurements used to determine the category immunodeficiency virus infection, and nephrotic syn-
of HTN. The severity of the elevation will dictate how drome, because they are at increased cardiovascular risk.
many measurements are needed before diagnosis and eval- In addition to regular BP measurement, these children
uation. (1) In 2004, Pediatrics published updated gender, should have additional cardiovascular risk factor assess-
age, and height percentile-specific 50th, 90th, 95th, and ment conducted at health care encounters.
99th percentile systolic and diastolic BPs for children aged Any child with a BP measurement at or above the 90th
1 to 17 years. (2) These normative values were compiled percentile (or ‡120/80 mm Hg if this figure is >90th per-
from more than 60,000 healthy children in the United centile for age) should have his or her BP remeasured at that
States, based on their first auscultatory BP measurement visit. The average of three measurements obtained by man-
obtained during screening, and should be used to classify ual auscultation should be recorded, and the child should be
children into one of the following BP categories: “staged” as defined above. This staging and the presence or
absence of symptoms will dictate plans for future follow-up:
1. Normal BP: Both systolic and diastolic BPs are less
than the 90th percentile or less than 120/80 mm Hg,
An Average Blood Pressure in the
whichever is lower.
Prehypertensive Range
2. Prehypertension: Systolic or diastolic BP is between the
These children should be considered prehypertensive and
90th percentile and the 95th percentile, or between 120/
should be followed closely because of their increased risk
80 mm Hg and the 95th percentile, if 120/80 mm Hg
of developing sustained HTN. They should be counseled
happens to be higher than the reported 90th percen-
on weight management, if indicated, and should be given
tile for the individual child based on his or her age,
activity and the Cardiovascular Health Integrated Life-
gender, and height percentile.
style Diet-1 recommendations (see “Treatment” sec-
3. Stage I HTN: Systolic or diastolic BP between the
tion below). (1) Prehypertensive children should have a
95th percentile and the 99th percentile þ 5 mm Hg.
follow-up appointment in 6 months to reassess BP.
4. Stage II HTN: Systolic or diastolic BP above the 99th
percentile þ 5 mm Hg.
An Average Blood Pressure in the Range of
The Figure provides a graph of the 95th percentile of Stage I Hypertension
blood pressure for boys and girls of different ages and If the child is asymptomatic, have him or her return for
heights. repeat BP measurements on two additional occasions,
Adolescents and young adults age 18 to 21 years 1 to 2 weeks apart. If stage I HTN is confirmed by aver-
should be classified as follows (1): aging all BP measurements obtained, perform evaluation
within 1 month. If the child is symptomatic, more imme-
1. Prehypertension: Systolic or diastolic BP ‡120/80
diate referral to a pediatric HTN specialist for initiation of
and £139/89 mm Hg
evaluation and treatment is indicated.
2. Stage I HTN: Systolic or diastolic BP ‡140/90 and
£159/99 mm Hg
An Average Blood Pressure in the Range of
3. Stage II HTN: Systolic or diastolic BP ‡160/100 mm Hg
Stage II Hypertension
If the child is asymptomatic, he or she should undergo
evaluation and treatment within 1 week. If symptomatic,
When to Screen for Hypertension the child should be referred immediately to the emer-
All children age 3 years and older should have their BP gency department or an inpatient facility for care.
measured during each physician visit, whether the visit Pediatric HTN is largely asymptomatic; however, chil-
is for health supervision care, urgent care, or emergency dren may present initially in hypertensive crisis with se-
care, at a minimum of once yearly. In addition, children verely elevated BP and symptoms ranging from nausea
younger than age 3 years should also have their BP mea- and vomiting to ataxia, mental status changes, seizures,
sured at each visit if they have a comorbid condition that and coma, or with symptoms related to the underlying
places them at increased risk for HTN (Table 1). cause of their HTN. In addition, some children may ex-
Particular attention should be given to children who perience anxiety during evaluations, which may cause el-
have conditions such as diabetes mellitus, chronic kidney evated BPs that are in the hypertensive range; yet, when
disease, a history of Kawasaki disease (with or without monitored in their home environment, the children have

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 cardiovascular disorders hypertension

Children who manifest white coat

HTN also should be considered at
increased risk for the development
of sustained HTN and therefore should
be followed every 6 months. (3–5)

Proper Blood Pressure

Measurement
To identify and diagnose a child with
HTN, one must use proper technique
when measuring BP. Proper tech-
nique begins with applying the cor-
rect size cuff to a child’s bare arm
and ensuring that his or her arm, feet,
and back are supported, with the cu-
bital fossa positioned at heart level. To
determine the correct cuff size, mea-
sure the cuff bladder (felt inside the
outer packaging) to the child’s arm.
The right size cuff will have a bladder
width that is at least 40% of the child’s
midarm circumference and a bladder
length that encircles 80% to 100% of
the midarm circumference. When in
doubt, choose a larger cuff because
a cuff that is too-small may result in
artificially elevated BP.
After the child has been resting
for 5 minutes:
1. Locate the child’s radial pulse,
quickly inflate the sphygmoma-
nometer to 60 mm Hg, then
slowly continue to inflate in in-
crements of 10 mm Hg until
the pulse disappears.
2. Note the peak inflation level,
which is the value at which the
pulse disappears þ 30 mm Hg.
3. Deflate the cuff, and after 30 sec-
onds inflate the sphygmomanom-
eter to the peak inflation level.
4. Deflate by 2 to 3 mm Hg/second
Figure 1. Blood pressure (BP) at the 95th percentile for boys and girls compared to height to a level that is 10 mm Hg lower
at the 5th, 50th, and 95th percentiles. Numbers in the brackets are BP (mm Hg) at 95th than the last Korotkoff sound (K5).
percentiles for height at age 1, 5, 10, 14, and 17 years.
a. Systolic BP ¼ onset of Korotk-
off sounds (K1).
BP measurements in the normal range. This phenome- b. Diastolic BP ¼ disappearance of Korotkoff sounds
non of “white coat” HTN can be diagnosed with a (K5).
24-hour ambulatory BP monitor that obtains many BP All BP elevations (systolic or diastolic BP ‡90th per-
measurements taken in a child’s home environment. centile or ‡120/80 mm Hg) should be confirmed by this

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cardiovascular disorders hypertension

Comorbid Conditions
Table 1.
a complete review of systems to help narrow the differen-
tial diagnosis (Table 3 below), particular attention should
Requiring a BP Measurement in be paid to the past medical history (including birth history),
Children Younger Than Age 3 current medications, family history, and social history.
When obtaining the past medical history, it is impor-
Years tant to inquire about any previous diagnosis or treatment
History of prematurity Solid organ transplant
of HTN. Any recent discontinuation of antihypertensive
History of low Malignancy or bone medications, such as b-blockers and a-adrenergic agonists,
birthweight/NICU stay marrow transplant can cause severe rebound HTN if discontinued abruptly.
Congenital heart disease Taking medications known It is important also to determine if the child has any of the
Recurrent urinary tract to increase blood following comorbid conditions or syndromes associated
infection, hematuria, pressure
with HTN:
proteinuria Presence of systemic
Known renal disease or illness associated with
genitourinary hypertension
Comorbid Conditions:
abnormalities Evidence of increased Diabetes mellitus
Family history of intracranial pressure
Thyroid disease
congenital kidney
disease Cushing syndrome
Systemic lupus erythematosus
Table adapted from The fourth report on the diagnosis, evaluation, Other rheumatologic disorder
and treatment of high blood pressure in children and adolescents.
Pediatrics. 2004;114:555–576.
Syndromes:
Williams syndrome (associated with supravalvular aor-
tic stenosis, midaortic syndrome, renal artery stenosis,
technique, rather than by an automated device. Auto-
renal anomalies)
mated, or oscillometric, devices, while useful as screen-
Turner syndrome (associated with coarctation of the
ing tools, can provide inaccurate BP measurements
aorta, renal anomalies, idiopathic HTN)
because they do not measure BP directly, but instead Tuberous sclerosis (associated with coarctation of the
estimate the systolic and diastolic BP based on the point aorta, renal artery stenosis, brain tumors)
of maximal oscillation (the mean intra-arterial pressure) Neurofibromatosis (associated with essential and reno-
during cuff deflation. The algorithms used to determine
vascular HTN)
these values vary from device to device, leading to non-
Polycystic kidney disease, both autosomal recessive and
uniformity of measurement across devices. Devices that
autosomal dominant variants
automatically inflate to 30 mm Hg above the previous
reading can influence each subsequent BP reading.
These limitations, and the fact that the normative val- A previous history of urinary tract infections or unex-
ues that make up the reference tables were obtained via plained fevers may suggest chronic pyelonephritis and renal
auscultation, form the basis for the recommendation cortical scars or reflux nephropathy. A recent or relatively
that all BP elevations must be confirmed by manual remote streptococcal infection of the pharynx or skin, or ex-
auscultation. posure to enterohemorrhagic Escherichia coli, may indicate
a resolving or resolved postinfectious glomerulonephritis
or hemolytic uremic syndrome, respectively. Henoch-
Initial Evaluation Schönlein purpura can be associated with persistent renal
All children diagnosed as having HTN should undergo manifestations, including HTN, even after initial complete
an evaluation to investigate for secondary causes of resolution of symptoms. Previous hospitalizations may re-
HTN. Although primary HTN is on the rise, and is veal information on systemic illnesses, exposure to nephro-
the most common cause of HTN among adolescents, toxic medications, or evidence of renal injury. Recent
secondary HTN is common enough to warrant investiga- injuries should be assessed, because renal or neurologic
tion, particularly in younger children and those with stage trauma can lead to HTN as well as associated pain.
II HTN at presentation (Table 2). Because prematurity and low birthweight are associ-
The initial evaluation should start with a focused his- ated with decreased nephron endowment and HTN,
tory and physical examination. In addition to obtaining and umbilical catheter placement can lead to renal artery

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 cardiovascular disorders hypertension

Differential Diagnosis of
Table 2.
• Corticosteroids
• Decongestants/cold preparations
Hypertension Among Children, • Nonsteroidal anti-inflammatory medications
by Age • Herbal medications/supplements
• Oral contraceptive pills
Age Primary or Most Common • Antihypertensive medications (recent discontinuation
Range Secondary Secondary Causes of these medications)
Birth to Secondary Cardiac • b-Adrenergic agonists/theophylline
1y (99%) Coarctation of aorta • Erythropoietin
Patent ductus • Cyclosporine/tacrolimus
arteriosus • Attention deficit disorder medications
Renal
Renovascular defect
Renal parenchymal The family history can be helpful in determining the
disease cause of HTN, particularly for children who have mono-
Pulmonary genic forms of HTN (such as Liddle syndrome, Gordon
Bronchopulmonary syndrome, and apparent mineralocorticoid excess) and renal
dysplasia
Neurologic disease, and can help also with risk stratification. As de-
Intraventricular scribed in the recent Expert Panel on Integrated Guidelines
hemorrhage for Cardiovascular Health and Risk Reduction in Children
Pain and Adolescents, (1) a positive family history of coronary
Neoplasia heart disease in a male relative (father, grandfather, sibling,
Wilms tumor
Neuroblastoma or uncle) younger than 55 years or in a female relative
Endocrine (mother, grandmother, sibling, or aunt) younger than 65
Congenital adrenal years is an independent risk factor for having cardiovascular
hyperplasia disease. This risk is inversely related to the age at the time of
Hyperaldosteronism event. Children who have this family history should be con-
Hyperthyroidism
Age 1– Secondary Renal sidered at increased cardiovascular risk.
12 y (70%–85%) Renal parenchymal Social history should focus on the following: sexual
Primary disease activity (pregnancy, pre-eclampsia); diet (consumption
(15%–30%) Renovascular defect of caffeine, licorice, sodium, nutritional supplements);
Cardiac smoking/drinking/illicit drug history (nicotine,
Coarctation of aorta
Urologic cocaine, amphetamines, anabolic steroids, phencyclidine,
Reflux nephropathy methylenedioxymethamphetamine [“ecstasy”]); level of
Endocrine physical activity (obesity); sleep history (snoring, daytime
Congenital adrenal somnolence, difficulty awakening, which may be sugges-
hyperplasia tive of obstructive sleep apnea); and psychosocial history
Hyperaldosteronism
Hyperthyroidism (stress, anxiety).
Neoplasia After eliciting a detailed history, the evaluation should
Wilms tumor then progress to a detailed physical examination, paying
Neuroblastoma particularly close attention to findings suggestive of un-
Miscellaneous derlying causes (Table 4).
Age 12– Primary Same causes as for
18 y (85%–95%) 1–12 y After the history and physical examination, all children
Secondary should undergo a laboratory and imaging evaluation, the
(5%–15%) details of which are listed in Table 5. If the results of this
initial evaluation are negative in an older child who has
stage I HTN, particularly if the average BP is close to
stenosis and renal vein thrombosis, a detailed birth his- the 95th percentile, the child can be given a diagnosis
tory also should be obtained. of primary HTN. Younger children and those with
A thorough review of both prescribed and over-the- more markedly elevated BP (stage II HTN) should un-
counter medications may reveal the following possible dergo further testing if the initial evaluation is unreveal-
causes for elevated BP: ing to exclude secondary causes for HTN (Table 6).

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cardiovascular disorders hypertension

Symptoms Suggesting Underlying Causes of Pediatric

Table 3.

Hypertension
Organ System Possible Symptoms Potential Diagnoses
Cardiovascular Chest pain Coarctation of the aorta
Shortness of breath Patent ductus arteriosus
Palpitations Midaortic syndrome
Claudication
Endocrine Weight loss or gain Thyroid disease
Sweating Pheochromocytoma
Flushing Congenital adrenal hyperplasia
Fever Cushing syndrome
Palpitations Primary aldosteronism
Muscle cramps Primary hyperparathyroidism
Weakness Hypercalcemia
Constipation Diabetes mellitus
Fatigue
Gynecologic Last menstrual period Pregnancy
Pre-eclampsia
Neurologic Headache Increased intracranial pressure
Vision changes Guillain-Barré syndrome
Vomiting
Developmental delay
Seizures
Renal Dysuria Renal parenchymal disease
Hematuria Glomerulonephritis
Foamy urine (suggestive of proteinuria) Genitourinary anomalies
Frequency Chronic pyelonephritis
Urgency Reflux nephropathy
Flank pain Polycystic kidney disease
Enuresis Wilms tumor
Edema Kidney stones
Fatigue
Hearing loss
Rheumatologic Rash Systemic lupus erythematosus
Joint or muscle pain Collagen vascular disease
Fever
Weight change
After eliciting a detailed history, the evaluation should then progress to a detailed physical examination, paying particularly close attention to findings
suggestive of underlying causes (Table 4).

Treatment 3. Decrease sedentary activities such as television watch-

Once a child is diagnosed as having HTN and has un- ing and playing video and computer games to less than
dergone an evaluation, antihypertensive therapy should 2 hours per day
be initiated. This therapy should include guidance on 4. Institute several dietary changes according to the Car-
lifestyle modification and nonpharmacologic therapy. diovascular Health Integrated Lifestyle diet and Die-
All children should be counseled on the following tary Approaches to Stop HTN eating plan (1) such as:
heart-healthy lifestyle: a. Increase intake of fresh vegetables, fruits, and low-
1. Weight loss if overweight fat dairy foods
2. For children age 5 years or older: participate in at b. Reduce carbohydrate, fat, and processed sugar intake
least 1 hour of moderate-to-vigorous exercise (eg, i. For 4- to 18-year-olds: aim for 10% to 30% of to-
jogging, baseball) every day of the week, and vigor- tal calories to come from protein, 45% to 65%
ous activity (eg, running, singles tennis, soccer) on 3 from carbohydrate, 25% to 30% from fat
days per week. c. Limit or avoid sugar-sweetened beverages

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 cardiovascular disorders hypertension

Table 4. Physical Examination Findings Suggesting Causes of Hypertension

Findings Possible Causes
Anthropometrics
Weight, height, and Growth failure Chronic renal disease, endocrine disease, other
appropriate percentiles chronic diseases
Obesity Primary hypertension, Cushing syndrome
(also associated with short stature)
Vital signs
Blood pressure (4 limb) and Lower blood pressures in lower Coarctation of the aorta
heart rate extremities compared with
upper extremities
Tachycardia Hyperthyroidism, pheochromocytoma,
neuroblastoma, primary hypertension
General examination
Volume status, overall appearance Fluid overload or edema Renal or heart failure
Moon facies Cushing syndrome, steroid use
Elfin facies William syndrome
Webbed neck, wide-spaced Turner syndrome
nipples, short stature
Pallor, flushing, diaphoresis Pheochromocytoma
Head, eyes, ears, nose, throat Papilledema Increased intracranial pressure,
including funduscopic hypertensive emergency, hypertensive
examination retinopathy
Retinal hemorrhage, exudates Hypertensive emergency, hypertensive retinopathy
Cotton wool spots, arteriovenous Hypertensive retinopathy
nicking
Contusions, lacerations, palpable Head trauma
skull defect, hemotympanum
Exophthalmos, thyromegaly Hyperthyroidism
Adenotonsillar hypertrophy Obstructive sleep apnea
Cardiovascular Heart murmur, diminished Coarctation of the aorta, patent ductus arteriosus
femoral pulses
Friction rub Systemic lupus erythematosus, collagen vascular
disease
Pulmonary Accessory muscle use, crackles, Heart failure, asthma, bronchopulmonary
wheeze dysplasia
Abdominal Hepatomegaly Heart failure
Bruit Renal artery stenosis, arteriovenous fistula
Mass Wilms tumor, neuroblastoma, pheochromocytoma
Palpable kidneys Polycystic kidney disease, urologic disease, mass
Extremities Joint swelling Systemic lupus erythematosus
Neurologic Altered mental status Hypertensive encephalopathy
Mood Anxiety, white coat hypertension
Weakness Monogenic forms of hypertension,
hyperaldosteronism
Skin Café-au-lait spots, axillary Neurofibromatosis
freckling, neurofibromas
Ash leaf patches, angiofibromas, Tuberous sclerosis
adenoma sebaceum
Malar rash Systemic lupus erythematosus
Palpable purpura Henoch-Schönlein purpura, vasculitis

Data from the Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555–576.

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cardiovascular disorders hypertension

d. Encourage foods with high dietary fiber content the time of diagnosis, while implementing the same life-
(age þ 5 ¼ number of grams per day) style interventions. The pharmacologic agent chosen
should be targeted to the underlying diagnosis, with at-
5. Salt restriction
tention being paid to existing comorbidities.
a. Initially recommend “no added salt,” with the ulti- Unless contraindicated, initial therapy with either a cal-
mate goal of achieving the current recommendation cium channel blocker or an angiotensin-converting en-
of 1.2 g/day total for 4- to 8-year-olds and 1.5 g/ zyme inhibitor could be considered, because these
day total for children age 9 years and older(2) medications are well-tolerated, have a minimal adverse ef-
fect profile, and can be dosed once daily. b-Blockers, an-
6. Smoking cessation, if applicable
giotensin receptor blockers, and diuretics also are
Children who have not experienced normalization of acceptable first-line agents for the treatment of HTN in
their BP with the above interventions after 6 months children. The lowest dose should be started, titrating to
should be started on antihypertensive medications. In ad- effect until the maximum recommended dose is achieved
dition, children who present initially with secondary or until the patient experiences adverse effects. At this
HTN, symptomatic HTN, left ventricular hypertrophy, point, if the BP is not controlled, an additional agent from
or hypertensive retinopathy, or who have diabetes melli- another class should be added to the regimen in the same
tus, should be started on antihypertensive medications at manner. Table 7 lists the major classes of antihypertensive

Initial Laboratory and Imaging Evaluation for All Children Who

Table 5.

Have Confirmed Hypertension

Laboratory or Imaging Test Result Possible Cause
Urinalysis with microscopy, urine Hematuria, proteinuria, pyuria, bacteria Occult renal disease, chronic urinary
culture tract infections
Blood urea nitrogen and creatinine Elevated values Acute kidney injury, chronic kidney
levels disease
Electrolytes, serum calcium levels Hyper- or hyponatremia, hyper- or Endocrine or genetic forms of
hypokalemia, hypercalcemia hypertension
Complete blood count Anemia Kidney disease, rheumatologic disease,
chronic disease
Fasting lipid levels Elevated total cholesterol, low-density Evaluating for co-morbidity
lipoprotein, triglycerides, low high-
density lipoprotein
Fasting glucose level Hyperglycemia Diabetes mellitus, corticosteroid use
Plasma renin activity Low or absent plasma renin activity Endocrine or genetic forms of
hypertension
Urine pregnancy test (all Positive test Pregnancy, pre-eclampsia
postmenarchal females)
Renal and bladder ultrasonography Mass Wilms tumor, neuroblastoma,
pheochromocytoma
Vascular malformation Arteriovenous malformation
Bilaterally small kidneys Chronic kidney disease
Discrepant kidney sizes (‡1.5 cm) Past perfusional insults, renal scar, renal
artery stenosis, renal hypoplasia,
renal vein thrombosis
Bilaterally large kidneys with or without cysts Cystic kidney disease
Hydronephrosis, thickened bladder Obstructive uropathy, vesicoureteral
reflux, obstructive kidney stone
Renal tubers Tuberous sclerosis
Congenital anomalies Horseshoe kidney, pelvic kidney
Echocardiography Cardiac abnormalities Coarctation of the aorta, congenital
anomalies, heart dysfunction,
pericardial effusion
Left ventricular hypertrophy End-organ damage

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 cardiovascular disorders hypertension

Table 6. Additional Tests to Determine Secondary Causes of Hypertension

Test Purpose
Urine toxicology screen Rule out illicit drug use
Plasma and urine steroid levels Rule out steroid-mediated hypertension
Plasma metanephrines Rule out pheochromocytoma
Polysomnography Rule out obstructive sleep apnea
24-hour ambulatory blood pressure monitoring Rule out white coat hypertension
Renal arteriogram with venous renin sampling Rule out renal artery stenosis

agents with several medications from each class. (Table 7 is systolic and diastolic BPs below either the 90th percentile
available in the online version of this article; visit http:// or 120/80 mm Hg, whichever is lower.
pedsinreview.aappublications.org/content/33/12/541/
suppl/DC1 to see Table 7.) Prognosis
Table 8 lists recommendations for prescribing classes Children who have HTN should be followed closely to
of antihypertensive agents for certain medical conditions. evaluate the effectiveness of prescribed antihypertensive
The goal of antihypertensive therapy is achievement of therapy, and to reinforce medication adherence and
normotension, defined as persistent systolic and diastolic heart-healthy behaviors. If available, BP measurements
BPs below the 95th percentile. In children at increased obtained by a school nurse can be useful in titrating
cardiovascular risk (those with chronic kidney disease, di- medication dosages between clinic appointments and
abetes mellitus, post-heart or kidney transplantation, his- in monitoring therapy. Hypertensive children also
tory of Kawasaki disease, chronic inflammatory disease, should be screened intermittently for the development
human immunodeficiency virus infection, or nephrotic of end-organ damage in the form of left ventricular hyper-
syndrome) or end-organ damage (left ventricular hyper- trophy, hypertensive retinopathy, and microalbuminuria.
trophy or hypertensive retinopathy), the antihypertensive Children who have left ventricular hypertrophy at diag-
goal is lower. These children should be treated to achieve nosis should have a repeat echocardiography completed

Medical Conditions that Warrant Specific Antihypertensive

Table 8.

Drug Classes
Diabetes
Consider: ACE inhibitors, angiotensin receptor blockers (offer renoprotection and can decrease proteinuria)
Avoid: b-blockers (can mask signs/symptoms of hypoglycemia)
Migraine headaches
Consider: b-blockers, calcium channel blockers (may offer symptomatic improvement for migraine headaches while
controlling blood pressure)
Asthma
Avoid: b-blockers because contraindicated for asthma (can cause bronchospasm)
Kidney disease and/or proteinuria
Consider: ACE inhibitors, angiotensin receptor blockers (offer renoprotection and can decrease proteinuria)
Athlete
Avoid: b-blockers, diuretics (may negatively affect athletic performance)
Sexually active female
Avoid: ACE inhibitors, angiotensin receptor blockers (teratogenic; recommend birth control methods)
Obesity
Consider: ACE inhibitors, angiotensin receptor blockers (may have beneficial effects on comorbidities such as diabetes and
dyslipidemia)
Avoid: b-blockers, diuretics
b-Blockers can lead to weight gain, increased triglycerides, and decreased high-density lipoprotein cholesterol concentrations. Diuretics can worsen insulin
resistance and dyslipidemia. They also can increase sympathetic system nervous system and renin activity, both of which are thought to be increased in obesity-
related hypertension. ACE¼angiotensin-converting enzyme.

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cardiovascular disorders hypertension

6 to 12 months after starting antihypertensive medications

to ensure that their left ventricular mass has decreased with • Pediatric hypertension (HTN) is defined as an average
therapy. Children without evidence of left ventricular hy- of systolic or diastolic blood pressure
pertrophy at diagnosis also should undergo follow-up (BP) measurements at or above the 95th percentile
of BP for the child’s age, gender, and height
echocardiography, because left ventricular hypertrophy percentile.
can develop relatively quickly, can be seen in children • All children age 3 years and older who present for care
who have presumably good BP control, and cannot be pre- (health supervision care, urgent care, emergency care)
dicted by the severity of a child’s BP elevation. Although should have their BP measured during each visit. In
often clinically silent in childhood, these forms of end- addition, some at-risk children younger than age 3
years also should have their BP measured at each
organ damage are associated with significant morbidity provider visit.
and mortality in adulthood. The presence of any one of • All children who have confirmed HTN should
these entities signifies increased cardiovascular risk and the undergo an evaluation to rule out secondary causes.
need for intensified antihypertensive treatment to reverse The age of the child and the severity of the BP
these findings and prevent worsening cardiovascular disease. elevation will dictate how extensive this evaluation
should be.
Some children will require long-term antihypertensive • Once a child is diagnosed as having HTN and has
therapy into adulthood to maintain normotension. How- undergone an evaluation, antihypertensive therapy
ever, successful implementation of lifestyle modifications should be initiated, which includes lifestyle
has been shown to be effective in lowering BP in both chil- modification for all children and pharmacologic
dren and adults, and can allow some children to avoid or therapy for some children.
discontinue pharmacologic treatment. Children who have
primary, obesity-related HTN, in particular, may be able
avoid or discontinue antihypertensive medications with life-
style modifications. Obese children have been shown to ex-
perience significant BP reductions with salt restriction, and References
weight loss is particularly effective at lowering BP. 1. National Heart, Lung, and Blood Institute, National Institutes
Children who have secondary HTN may experience of Health (NHLBINIH). Expert Panel on Integrated Guidelines
normalization of BP as their underlying disease process for Cardiovascular Health and Risk Reduction in Children and
resolves, allowing them to discontinue medical therapy. Adolescents: Summary Report. Pediatrics. 2011;128(suppl 5):
S213–S256
However, when a chronic underlying condition has led
2. National High Blood Pressure Education Program Working
to a child’s HTN, complete normalization of BP is less Group on High Blood Pressure in Children and Adolescents. The
likely and management may require long-term antihyper- fourth report on the diagnosis, evaluation, and treatment of high
tensive therapy and monitoring. blood pressure in children and adolescents. Pediatrics. 2004;114(2
suppl 4th report):555–576
3. Kavey RE, Kveselis DA, Atallah N, Smith FC. White coat
hypertension in childhood: evidence for end-organ effect. J Pediatr.
Summary 2007;150(5):491–497
4. Bidlingmeyer I, Burnier M, Bidlingmeyer M, Waeber B,
Based on the National High Blood Pressure Education Brunner HR. Isolated office hypertension: a prehypertensive state?
Program Working Group on Children and Adolescents J Hypertens. 1996;14(3):327–332
consensus, which was developed from the synthesis of all 5. Lande MB, Meagher CC, Fisher SG, Belani P, Wang H, Rashid
available scientific evidence (2): M. Left ventricular mass index in children with white coat
hypertension. J Pediatr. 2008;153(1):50–54

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 cardiovascular disorders hypertension

PIR Quiz
This quiz is available online at http://www.pedsinreview.aappublications.org. NOTE: Since January 2012, learners can take Pediatrics in Review
quizzes and claim credit online only. No paper answer form will be printed in the journal.

Pediatrics in Review QuizNew Minimum Performance Level Requirements

Per the 2010 revision of the American Medical Association (AMA) Physician’s Recognition Award (PRA) and credit system, a minimum performance
level must be established on enduring material and journal-based CME activities that are certified for AMA PRA Category 1 CreditTM. In order to
successfully complete 2012 Pediatrics in Review articles for AMA PRA Category 1 CreditTM, learners must demonstrate a minimum performance level
of 60% or higher on this assessment, which measures achievement of the educational purpose and/or objectives of this activity.
Starting with the 2012 issues of Pediatrics in Review, AMA PRA Category 1 CreditTM may be claimed only if 60% or more of the questions are
answered correctly. If you score less than 60% on the assessment, you will be given additional opportunities to answer questions until an overall
60% or greater score is achieved.

1. A 4-year-old girl has had blood pressure measurements taken by manual blood pressure cuff with the use of
the proper technique of 142/85, 138/81, and 135/80 mm Hg during three different measurements at the
beginning, middle, and end of an office visit, with rest between each measurement. She is healthy with no
significant past medical history, and she takes no medications. She has no family history of hypertension. The
findings of her physical examination are within normal limits with height and weight at the 75th percentile.
You are most likely to take which of the following steps next:
A. Compare blood pressure measurements in her upper and lower extremities.
B. Reassure her mother that because her blood pressure is lower at the end of the visit, no further evaluation is
needed.
C. Recommend a follow-up visit in 1 week to recheck her blood pressure.
D. Refer her for genetic evaluation for underlying genetic syndrome.
E. Refer her to the emergency department for urgent blood pressure management.

2. A 10-year-old girl has had elevated blood pressure noted on several measurements during several clinic visits
in the past year. She is healthy with no significant past medical history, and she takes no medications. She has
no family history of hypertension. The findings of her physical examination are unremarkable; her height is at
the 3rd percentile and her weight at the 25th percentile. On examination today, her blood pressure in her right
arm is 140/85 mm Hg, and her blood pressure in her right leg is 108/68 mm Hg. She is most likely to have the
following underlying syndrome or condition:
A. Cushing syndrome.
B. Neurofibromatosis.
C. Tuberous sclerosis.
D. Turner syndrome.
E. Williams syndrome.

3. A 9-month-old boy has had elevated blood pressure noted during each of his health care maintenance
evaluations. He was born at 30 weeks’ gestation and was discharged from the NICU at age 2 months. He
breastfeeds and eats pureed fruits and vegetables. He has no family history of hypertension. His growth
parameters are at the 25th percentile, corrected for prematurity. On examination today, his blood pressure in
his right arm is 95/75 mm Hg, and his blood pressure in his right leg is 100/76 mm Hg. Further history is most
likely to reveal the following:
A. Coarctation of the aorta.
B. Elevated maternal caffeine intake.
C. History of neonatal seizures.
D. History of umbilical catheter placement.
E. Hyperthyroidism.

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cardiovascular disorders hypertension

4. You see a 15-year-old obese boy who has persistent hypertension after 6 months of lifestyle modification. His
40-year-old father takes medication for hypertension. His past medical history is significant for asthma. The
findings of his physical examination are normal except for his obesity. You are most likely to recommend
initiating treatment with the following:
A. Furosemide.
B. Hydrochlorothiazide.
C. Labetalol.
D. Lisinopril.
E. Propranolol.

5. A 15-year-old girl was born at 34 weeks’ gestation. She was cared for in the NICU for 3 weeks for feeding
issues, but had no respiratory or cardiovascular concerns. She has been healthy since infancy. Her 40-year-old
father takes medication for hypertension. Her blood pressure was 132/85 mm Hg 2 weeks ago, and, during this
follow-up examination, her blood pressure is 135/80, 131/82, and 132/83 mm Hg on three measurements. Her
height is at the 50th percentile, and her weight is at the 90th percentile. On physical examination, she has two
1.5-cm café-au-lait spots and a grade II/VI heart murmur at the left upper sternal border. The findings of the
remainder of her examination are normal. The most likely cause of the findings on examination is
A. Coarctation of the aorta.
B. Neurofibromatosis.
C. Obesity.
D. Primary hypertension.
E. Renovascular disease related to prematurity.

HealthyChildren.org Parent Resources From the AAP

The reader is likely to find material to share with parents that is relevant to this article by visiting this link:
http://www.healthychildren.org/English/health-issues/conditions/heart/pages/High-Blood-Pressure-in-Children.aspx

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 Hypertension
Tammy M. Brady
Pediatrics in Review 2012;33;541
DOI: 10.1542/pir.33-12-541

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/33/12/541
References This article cites 5 articles, 1 of which you can access for free at:

http://pedsinreview.aappublications.org/content/33/12/541#BIB
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