Skip to main content

Advertisement

SpringerLink
Log in

Hypertension Diagnosis and Management in Children and Adolescents: Important Updates

  • Renal (D Noone, Section Editor)
  • Published:
Current Pediatrics Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This review aims to examine new literature and clinical practice guidelines on the diagnosis and management of hypertension in children along with the potential impact on clinical practice of the new recommendations.

Recent Findings

Hypertension is underrecognized and underdiagnosed in clinical practice. Tools for improving diagnosis may include prompts in electronic medical records, use of a blood pressure screening table, and standardized blood pressure thresholds for adolescents. The recent AAP clinical practice guideline on the management of hypertension in children developed new blood pressure tables with lower norms that may increase the percentage of children diagnosed with elevated blood pressure and hypertension. In this high cardiovascular-risk population, therapeutic lifestyle modifications remain a fundamental management strategy.

Summary

There is more evidence demonstrating the importance of identification and management of elevated blood pressure in childhood. New tools and strategies may improve recognition and treatment of hypertension as the number of children at risk increases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. • National High Blood Pressure Education Program. Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl):555–76 This guideline was the main reference for blood pressure management for more than 10 years.

    Google Scholar 

  2. •• Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, for the Subcommittee on Screening and Management of High Blood Pressure in Children et al., Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017:140(3):e20171904. https://doi.org/10.1542/peds.2017-1904. This clinical practice guideline by the AAP includes the most current recommendations and blood pressure norms and classification for children and adolescents.

    Article  Google Scholar 

  3. • Harris KC, Benoit G, Dionne J, Feber J, Cloutier L, Zarnke KB, et al. Hypertension Canada’s 2016 Canadian Hypertension Education Program guidelines for blood pressure measurement, diagnosis, and assessment of risk of pediatric hypertension. Can J Cardiol. 2016;32:589–97 The first evidence-based recommendations for assessment of blood pressure in children developed by the established Hypertension Canada Guideline Committee.

    Article  Google Scholar 

  4. • Dionne JM, Harris KC, Benoit G, Feber J, Poirier L, Cloutier L, et al. Hypertension Canada’s 2017 guidelines for the diagnosis, assessment, prevention, and treatment of pediatric hypertension. Can J Cardiol. 2017;33:577–85 Complete recommendations from Hypertension Canada for blood pressure management in children and adolescents by primary care practitioners.

    Article  Google Scholar 

  5. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016;34(10):1887–920.

    Article  CAS  Google Scholar 

  6. Kollias A, Dafni M, Poulidakis E, Ntineri A, Stergiou G. Out-of-office blood pressure and target organ damage in children and adolescents: a systematic review and meta-analysis. J Hypertens. 2014;32:2315–31.

    Article  CAS  Google Scholar 

  7. Day TG, Park MH, Kinra S. The association between blood pressure and carotid intima-media thickness in children: a systematic review. Cardiol Young. 2017;27:1295–305.

    Article  Google Scholar 

  8. Urbina EM, Khoury PR, McCoy C, Daniels SR, Kimball TR, Dolan LM. Cardiac and vascular consequences of prehypertension in youth. J Clin Hypertens. 2011;13(5):332–42.

    Article  Google Scholar 

  9. Brady T, Fivush B, Parekh R, Flynn J. Racial differences among children with primary hypertension. Pediatrics. 2010;126:931–7.

    Article  Google Scholar 

  10. Berenson GS, Srinivasan SR, Bao W, Newmann WP III, Tracy RE, Wattigney WA, et al. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. N Engl J Med. 1998;338:1650–6.

    Article  CAS  Google Scholar 

  11. McMahan CA, Gidding SS, Fayad ZA, Zieske AW, Malcom GT, Tracy RE, et al. Risk scores predict atherosclerotic lesions in young people. Arch Intern Med. 2005;165:883–90.

    Article  Google Scholar 

  12. Conkar S, Yılmaz E, Hacıkara Ş, Bozabalı S, Mir S. Is daytime systolic load an important risk factor for target organ damage in pediatric hypertension? J Clin Hypertens (Greenwich). 2015;17(10):760–6.

    Article  Google Scholar 

  13. Daniels SR, Lipman MJ, Burke MJ, Loggie JMH. The prevalence of retinal vascular abnormalities in children and adolescents with essential hypertension. Am J Ophthalmol. 1991;111:205–8.

    Article  CAS  Google Scholar 

  14. Assadi F. Effect of microalbuminuria lowering on regression of left ventricular hypertrophy in children and adolescents with essential hypertension. Pediatr Cardiol. 2007;28:27–33.

    Article  Google Scholar 

  15. Seeman T, Dostalek L, Gilik J. Control of hypertension in treated children and its association with target organ damage. Am J Hypertens. 2012;25:389–95.

    Article  CAS  Google Scholar 

  16. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2224–60.

    Article  Google Scholar 

  17. • Sun SS, Grave GD, Siervogel RM, Pickoff AA, Arslanian SS, Daniels SR. Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics 2007:119(2):237–46. Important longitudinal study showing the link between childhood blood pressure and adulthood disease.

    Article  Google Scholar 

  18. Tirosh A, Afek A, Rudich A, Percik R, Gordon B, Ayalon N, Derazne E, Tzur D, Gershnabel D, Grossman E, Karasik A, Shamiss A, Shai I Progression of normotensive adolescents to hypertensive adults: a study of 26980 teenagers. Hypertension 2010:56(2):203–209.

    Article  CAS  Google Scholar 

  19. Carrico RJ, Sun SS, Sima AP, Rosner B. The predictive value of childhood blood pressure values for adult elevated blood pressure. Open J Pediatr. 2013;3(2):116–26.

    Article  Google Scholar 

  20. Theodore RF, Broadbent J, Nagin D, Ambler A, Hogan S, Ramrakha S, et al. Childhood to early-midlife systolic blood pressure trajectories: early-life predictors, effect modifiers, and adult cardiovascular outcomes. Hypertension. 2015;66(6):1108–15.

    Article  CAS  Google Scholar 

  21. • Parker ED, Sinaiko AR, Kharbanda EO, Margolis KL, Daley MF, Trower NK, et al. Change in weight status and development of hypertension. Pediatrics. 2016;137(3):e20151662 This study clearly establishes the risk of hypertension with obesity in children.

    Article  Google Scholar 

  22. Li HY, Wei JN, Ma WY, Sung FC, Lin MS, Chiang CC et al. Hypertension and hypercholesterolemia aggregate in nondiabetic children and adolescents with higher fasting plasma glucose levels. Pediatr Diabetes 2011:12:41–9.

    Article  CAS  Google Scholar 

  23. May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease risk factors among US adolescents, 1999-2008. Pediatrics. 2012;129:1035–41.

    Article  Google Scholar 

  24. Juonala M, Viikari JS, Kähönen M, Taittonen L, Laitinen T, Hutri-Kahonen N, et al. Life-time risk factors and progression of carotid atherosclerosis in young adults: the Cardiovascular Risk in Young Finns study. Eur Heart J. 2010;31:1745–51.

    Article  CAS  Google Scholar 

  25. Juhola J, Magnussen CG, Berenson GS, Venn A, Burns RL, Sabin MA, et al. Combined effects of child and adult elevated blood pressure on subclinical atherosclerosis: the International Childhood Cardiovascular Cohort Consortium. Circulation. 2013;128:217–24.

    Article  Google Scholar 

  26. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circulation. 2010;121(4):586–613.

    Article  Google Scholar 

  27. Stabouli S, Sideras L, Vareta G, Eustratiadou M, Printza N, Dotis J, et al. Hypertension screening during healthcare pediatric visits. J Hypertens. 2015;33(5):1064–8.

    Article  CAS  Google Scholar 

  28. Shapiro DJ, Hersh AL, Cabana MD, Sutherland SM, Patel AI. Hypertension screening during ambulatory pediatric visits in the United States, 2000–2009. Pediatrics. 2012;130(4):604–10.

    Article  Google Scholar 

  29. • Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874–9 Important study documenting the under-recognition of hypertension in children.

    Article  CAS  Google Scholar 

  30. Bijlsma MW, Blufpand HN, Kaspers GJ, BokenKamp A. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Pediatr. 2014;164(1):173–7.

    Article  Google Scholar 

  31. Kaelber DC, Pickett F. Simple table to identify children and adolescents needing further evaluation of blood pressure. Pediatrics. 2009;123(6):e972–4.

    Article  Google Scholar 

  32. Mourato FA, Filho JL, da Silva Mattos S. Comparison of different screening methods for blood pressure disorders in children and adolescents. J Pediatr 2015:91:278–283.

    Article  Google Scholar 

  33. • Brady TM, Neu AM, Miller ER III, Appel LJ, Siberry GK, Solomon BS. Real-time electronic medical record alerts increase high blood pressure recognition in children. Clin Pediatr (Phila) 2015:54(7):667–675. This study shows how to establish EMR prompts to improve diagnosis of blood pressure abnormalities in children.

    Article  Google Scholar 

  34. Samal L, Linder JA, Lipsitz SR, Hicks LS. Electronic health records, clinical decision support, and blood pressure control. Am J Manag Care. 2011;17(9):626–32.

    PubMed  Google Scholar 

  35. Twichell SA, Rea CJ, Melvin P, Capraro AJ, Mandel JC, Ferguson MA, et al. The effect of an electronic health record-based tool on abnormal pediatric blood pressure recognition. Congenital Heart Dis. 2017;12:484–90.

    Article  Google Scholar 

  36. Flynn JT, Pierce CB, Miller ER III, Charleston J, Samuels JA, Kupferman J, et al. Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr. 2012;160(3):434–40.

    Article  Google Scholar 

  37. Duncombe SL, Voss C, Harris KC. Oscillometric and auscultatory blood pressure measurement methods in children: a systematic review and meta-analysis. J Hypertens. 2017;35:213–24.

    Article  CAS  Google Scholar 

  38. Chiolero A, Cachat F, Burnier M, Paccaud F, Bovet P. Prevalence of hypertension in school children based on repeated measurements and association with overweight. J Hypertens. 2007;25(11):2209–17.

    Article  CAS  Google Scholar 

  39. McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr. 2007;150(6):640–4.

    Article  Google Scholar 

  40. Falkner B, Gidding SS, Portman R, Rosner B. Blood pressure variability and classification of prehypertension and hypertension in adolescence. Pediatrics. 2008;122(2):238–42.

    Article  Google Scholar 

  41. Veloudi P, Blizzard CL, Srikanth VK, Schultz MG, Sharman JE. Influence of blood pressure level and age on within-visit blood pressure variability in children and adolescents. Eur J Pediatr. 2018;177:205–10.

    Article  Google Scholar 

  42. de Oliveira LM, da Silva AO, Diniz PR, Farah BQ, Pirana AL, de Lima Neto AJ, et al. The number of visits and blood pressure measurements influence the prevalence of high blood pressure in adolescents. J Am Soc Hypertens. 2017;11:343–9.

    Article  Google Scholar 

  43. Koebnick C, Mohan Y, Li X, Porter AH, Daley MF, Luo G, et al. Failure to confirm high blood pressures in pediatric care-quantifying the risks of misclassification. J Clin Hypertens. 2018;20:174–82.

    Article  Google Scholar 

  44. Stergiou GS, Nasothimiou E, Giovas P, Kapoyiannis A, Vazeou A. Diagnosis of hypertension in children and adolescents based on home versus ambulatory blood pressure monitoring. J Hypertens. 2008;26(8):1556–62.

    Article  CAS  Google Scholar 

  45. Davis ML, Ferguson MA, Zachariah JP. Clinical predictors and impact of ambulatory blood pressure monitoring in pediatric hypertension referrals. J Am Soc Hypertens. 2014;8(9):660–7.

    Article  Google Scholar 

  46. Richey PA, DiSessa TG, Hastings MC, Somes GW, Alpert BS, Jones DP. Ambulatory blood pressure and increased left ventricular mass in children at risk for hypertension. J Pediatr. 2008;152:343–8.

    Article  Google Scholar 

  47. McNiece KL, Gupta-Malhotra M, Samuels J, Bell C, Garcia K, Poffenbarger T, et al. Left ventricular hypertrophy in hypertensive adolescents analysis of risk by 2004 National High Blood Pressure Education Program Working Group staging criteria. Hypertension. 2007;50:392–5.

    Article  CAS  Google Scholar 

  48. Rosner B, Cook N, Portman R, Daniels S, Falkner B. Determination of blood pressure percentiles in normal-weight children: some methodological issues. Am J Epidemiol. 2008;167(6):653–66.

    Article  CAS  Google Scholar 

  49. • Whelton PK, Carey RM, Aranow WS, Casey DE, Collins KJ, Himmelfarb CD, et al. ACC/AHA/APPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice guidelines. Hypertension. 2018;71(6):e13–e115 This guideline includes the most current evidence-based recommendations for blood pressure management in adults.

    CAS  PubMed  Google Scholar 

  50. Dionne JM. Updated guideline may improve recognition and diagnosis of hypertension in children and adolescents; review of the 2017 AAP blood pressure clinical practice guideline. Curr Hypertens Rep 2017:19:84.

  51. Sharma AK, Metzger DL, Rodd CJ. Prevalence and severity of high blood pressure among children based on the 2017 American Academy of Pediatrics guidelines. JAMA Pediatr. 2018;172:557–65.

    Article  Google Scholar 

  52. Jackson SL, Zhang Z, Wiltz JL, Loustalot F, Ritchey MD, Goodman AB, Yang Q Hypertension among youths – United States, 2001-2016. Mord Mortal Weekly Rep 2018:67:758–62.

  53. • Khoury M, Khoury PR, Dolan LM, Kimball TR, Urbina EM. Clinical implications of the revised AAP pediatric hypertension guidelines. Pediatrics. 2018;142(2):e20180245 This study analyzes the effect of the new AAP blood pressure classification including correlation with cardiovascular disease markers.

    Article  Google Scholar 

  54. Baracco R, Kapur G, Mattoo T, Jain A, Valentini R, Ahmed M, et al. Prediction of primary vs secondary hypertension in children. J Clin Hypertens (Greenwich). 2012;14(5):316–21.

    Article  Google Scholar 

  55. Gupta-Malhotra M, Banker A, Shete S, Tyson JE, Baratt MS, Hecht JT, et al. Essential hypertension vs. secondary hypertension among children. Am J Hypertens. 2015;28(1):73–80.

    Article  Google Scholar 

  56. Yoon EY, Cohn L, Freed G, Rocchini A, Kershaw D, Ascione F, et al. Use of antihypertensive medications and diagnostic tests among privately insured adolescents and young adults with primary versus secondary hypertension. J Adolesc Health. 2014;55:73–8.

    Article  Google Scholar 

  57. Wiesen J, Adkins M, Fortune S, Horowitz J, Pincus N, Frank R, et al. Evaluation of pediatric patients with mild-to-moderate hypertension: yield of diagnostic testing. Pediatrics. 2008;122:e998–3.

    Article  Google Scholar 

  58. Peres A, Martins JD, Parames F, Gil R, Matias C, Joao F, et al. Isolated aortic coarctation: experience in 100 consecutive patients. Rev Port Cardiol. 2010;29(01):23–35.

    PubMed  Google Scholar 

  59. Rosner B, Cook NR, Daniels S, Falkner B. Childhood blood pressure trends and risk factors for high blood pressure: the NHANES experience 1988-2008. Hypertension. 2013;62:247–54.

    Article  CAS  Google Scholar 

  60. Daniels SD, Meyer RA, Loggie JM. Determinants of cardiac involvement in children and adolescents with essential hypertension. Circulation. 1990;82(4):1243–8.

    Article  CAS  Google Scholar 

  61. He FJ, MacGregor GA. Importance of salt in determining blood pressure in children: meta-analysis of controlled trials. Hypertension. 2006;48:861–9.

    Article  CAS  Google Scholar 

  62. Saneei P, Hashemipour M, Kelishadi R, Rajaei S, Esmaillzadeh A. Effects of recommendations to follow the Dietary Approaches to Stop Hypertension (DASH) diet vs. usual dietary advice on childhood metabolic syndrome: a randomised cross-over clinical trial. Br J Nutr. 2013;110:2250–9.

    Article  CAS  Google Scholar 

  63. Garcia-Hermoso A, Saavedra JM, Escalante Y. Effects of exercise on resting blood pressure in obese children: a meta-analysis of randomized controlled trials. Obes Rev. 2013;14:919–28.

    Article  CAS  Google Scholar 

  64. Farpour-Lambert NJ, Aggoun Y, Marchand LM, Martin XE, Herrmann FR, Beghetti M. Physical activity reduces systemic blood pressure and improves early markers of atherosclerosis in pre-pubertal obese children. J Am Coll Cardiol. 2009;54:2396–406.

    Article  CAS  Google Scholar 

  65. Cai L, Wu Y, Wilson RF, Segal JB, Kim MT, Wang Y. Effect of childhood obesity prevention programs on blood pressure: a systematic review and meta-analysis. Circulation. 2014;129:1832–9.

    Article  Google Scholar 

  66. Simonetti GD, Rizzi M, Donadini R, Bianchetti MG. Effects of antihypertensive drugs on blood pressure and proteinuria in childhood. J Hypertens. 2007;25:2370–6.

    Article  CAS  Google Scholar 

  67. Nerenberg KA, Zarnke KB, Leung AA, Dasgupta K, Butalia S, McBrien K, et al. Hypertension Canada’s 2018 Guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol. 2018(34):506–25.

  68. Maahs DM, Daniels SR, de Ferranti SD, Dichek HL, Flynn J, Goldstein BI, et al. Cardiovascular disease risk factors in youth with diabetes mellitus: a scientific statement from the American Heart Association. Circulation. 2014;130(17):1532–58.

    Article  Google Scholar 

  69. • Council on Sports Medicine and Fitness. Athletic participation by children and adolescents who have systemic hypertension. Pediatrics 2010:125:1287–94. This policy statement from the AAP Council on Sports Medicine and Fitness includes an outstanding figure classifying sports based on cardiovascular demands.

    Article  Google Scholar 

  70. Boneparth A, Flynn JT. Evaluation and treatment of hypertension in general pediatric practice. Clin Pediatr. 2009;48:44–9.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pediatrics, Division of Nephrology, BC Children’s Hospital, University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada

    Janis M. Dionne

Authors
  1. Janis M. Dionne
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Janis M. Dionne.

Ethics declarations

Conflict of Interest

Janis M. Dionne declares no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Renal

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dionne, J.M. Hypertension Diagnosis and Management in Children and Adolescents: Important Updates. Curr Pediatr Rep 6, 269–277 (2018). https://doi.org/10.1007/s40124-018-0182-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40124-018-0182-7

Keywords

Search

Navigation