Skip to main content

Advertisement

SpringerLink
Log in

Updated Guideline May Improve the Recognition and Diagnosis of Hypertension in Children and Adolescents; Review of the 2017 AAP Blood Pressure Clinical Practice Guideline

  • Pediatric Hypertension (B Falkner, Section Editor)
  • Published:
Current Hypertension Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Hypertension in children and adolescents is under-recognized and under-diagnosed in clinical practice. The 2017 AAP Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents provides updated recommendations that may improve hypertension identification and management.

Recent Findings

The AAP blood pressure guideline recommends annual screening for hypertension in children at preventive care visits and targeted routine screening in high-risk populations. A simplified blood pressure screening table is provided for easier recognition of blood pressures that may require attention. Normative blood pressure tables have been revised to include only data from normal-weight children as more representative of a healthy population. Classification of blood pressure in adolescents has been simplified to threshold values consistent with adult guidelines.

Summary

The updated AAP blood pressure guideline has clarified and simplified recommendations for hypertension screening, diagnosis, and management based on a systematic review of current best evidence.

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. •• Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al., for the Subcommittee on Screening and Management of High Blood Pressure in Children. 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 recent blood pressure guideline sponsored by the AAP is the most up-to-date comprehensive evidence-based guideline for the diagnosis, investigation, and treatment of hypertension in children and adolescents.

  2. • 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 has been the standard of care until the updated guideline by the AAP was published.

    Google Scholar 

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

    Article  PubMed  Google Scholar 

  4. • 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. This systematic review and meta-analysis confirms the association of ambulatory blood pressure with end organ damage.

    Article  CAS  PubMed  Google Scholar 

  5. 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 

  6. 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  PubMed  Google Scholar 

  7. 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.

    CAS  PubMed  PubMed Central  Google Scholar 

  8. Tirosh A, Afek A, Rudich A, Percik R, Gordon B, Ayalon N, et al. Progression of normotensive adolescents to hypertensive adults: a study of 26980 teenagers. Hypertension. 2010;56(2):203–9.

    Article  CAS  PubMed  Google Scholar 

  9. • 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. These important results from the Fels Longitudinal Study show that elevated blood pressure readings during childhood increase the risk of adulthood hypertension and metabolic syndrome.

    Article  PubMed  Google Scholar 

  10. 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  PubMed  Google Scholar 

  11. 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  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  13. • Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874–9. This large cohort study demonstrates the high rates of hypertension under-recognition with 74% of children with hypertension being undiagnosed.

    Article  CAS  PubMed  Google Scholar 

  14. 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  PubMed  Google Scholar 

  15. 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  PubMed  Google Scholar 

  16. Daley MF, Sinaiko AR, Reifler LM, Tavel HM, Glanz JM, Margolis KL, et al. Patterns of care and persistence after incident elevated blood pressure. Pediatrics. 2013;132(2):e349–55.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 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  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  19. Brady TM, Solomon BS, Neu AM, Siberry GK, Parekh RS. Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics. 2010;125(6):e1286–93.

    Article  PubMed  Google Scholar 

  20. Aatola H, Magnussen CG, Koivistoinen T, Hutri-Kahonen N, Juonala M, Viikari J, et al. Simplified definitions of elevated pediatric blood pressure and high adult arterial stiffness. Pediatrics. 2013;132:e70–6.

    Article  PubMed  Google Scholar 

  21. Friedemann C, Heneghan C, Mahtani K, Thompson M, Perera R, Ward AM. Cardiovascular disease risk in healthy children and its association with body mass index: systematic review and meta-analysis. BMJ. 2012;345:e4759.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Falkner B, Gidding SS, Ramirez-Garnica G, Wiltrout SA, West D, Rappaport EB. The relationship of body mass index and blood pressure in primary care pediatric patients. J Pediatr. 2006;148(2):195–200. https://doi.org/10.1016/j.jpeds.2005.10.030.

    Article  PubMed  Google Scholar 

  23. • 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):1–9. https://doi.org/10.1542/peds.2015-1662. This study demonstrates the incremental risk in children of developing hypertension over time associated with level of obesity.

    Article  Google Scholar 

  24. 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 

  25. 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  PubMed  Google Scholar 

  26. Flynn JT, Mitsnefes M, Pierce C, Cole SR, Parekh RS, Furth SL, et al. Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study. Hypertension. 2008;52(4):631–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Shroff R, Weaver DJ, Mitsnefes MM. Cardiovascular complications in children with chronic kidney disease. Nat Rev Nephrol. 2011;7:642–9.

    Article  CAS  PubMed  Google Scholar 

  28. O’Sullivan JJ, Derrick G, Darnell R. Prevalence of hypertension in children after early repair of coarctation of the aorta: a cohort study using casual and 24 hour blood pressure measurement. Heart. 2002;88(2):163–6.

    Article  PubMed  PubMed Central  Google Scholar 

  29. • 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. This comprehensive AHA statement outlines current evidence for cardiovascular risks in children with diabetes mellitus.

    Article  PubMed  Google Scholar 

  30. Keijzer-Veen MG, Finken MJ, Nauta J, Dekker FW, Hille ET, Frolich M, et al. Is blood pressure increased 19 years after intrauterine growth restriction and preterm birth? A prospective follow-up study in the Netherlands. Pediatrics. 2005;116:725–31.

    Article  PubMed  Google Scholar 

  31. Zamecznik A, Niewiadomska-Jarosik K, Wosiak A, Zamojska MJ, Stanczyk J. Intra-uterine growth restriction as a risk factor for hypertension in children six to 10 years old. Cardiovasc J Afr. 2014;25:73–7. https://doi.org/10.5830/CVJA-2014-009.

    Article  PubMed  PubMed Central  Google Scholar 

  32. • 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. This article describes the development of the blood pressure percentile standards for normal-weight children.

    Article  CAS  PubMed  Google Scholar 

  33. Rosner B, Cook N, Daniels S, Falkner B. Childhood blood pressure trends and risk factors for high blood pressure: the NHANES experience 1988–2008. Hypertension. 2013;62(2):247–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Xi B, Zong X, Kelishadi R, Hong YM, Khadilkar A, Steffen LM, et al. Establishing international blood pressure references among nonoverweight children and adolescents aged 6 to 17 years. Circulation. 2016;133:398–408.

    Article  PubMed  Google Scholar 

  35. Stabouli W, Kotsis V, Rizos Z, Toumanidis S, Karagianni C, Constantopoulos A, et al. Left ventricular mass in normotensive, prehypertensive and hypertensive children and adolescents. Pediatr Nephrol. 2009;24(8):1545–51.

    Article  PubMed  Google Scholar 

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

    Article  Google Scholar 

  37. Whelton PK, Carey RM, Aranow WS, et al. ACC/AHA/APPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and managament of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017;In press.

  38. • The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–16. This landmark trial of a lower blood pressure treatment target in adults demonstrating better outcomes with intensive treatment is changing the way in which blood pressure is managed in many adult patients.

    Article  PubMed Central  Google Scholar 

  39. Egan BM, Li J, Wagner S. Systolic Blood Pressure Intervention Trial (SPRINT) and target systolic blood pressure in future hypertension guidelines. Hypertension. 2016;68:318–23.

    Article  CAS  PubMed  Google Scholar 

  40. • 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. This cohort study showed that clinic blood pressure does not predict hypertension by ABPM and evaluated the economic impact of incorporation of ABPM in hypertension referrals.

    Article  PubMed  PubMed Central  Google Scholar 

  41. 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  PubMed  Google Scholar 

  42. Stergiou GS, Alamara CV, Salgami EV, Vaindirlis IN, Dacou-Voutetakis C, Mountokalakis TD. Reproducibility of home and ambulatory blood pressure in children and adolescents. Blood Press Monit. 2005;10:143–7.

    Article  PubMed  Google Scholar 

  43. Swartz SJ, Srivaths PR, Croix B, Feig DI. Cost-effectiveness of ambulatory blood pressure monitoring in the initial evaluation of hypertension in children. Pediatrics. 2008;122(6):1177–81.

    Article  PubMed  Google Scholar 

  44. Gimpel C, Wühl E, Arbeiter K, Drozdz D, Trivelli A, Charbit M, et al. Superior consistency of ambulatory blood pressure monitoring in children: implications for clinical trials. J Hypertens. 2009;27(8):1568–74.

    Article  CAS  PubMed  Google Scholar 

  45. Li Z, Snieder H, Harshfield GA, Treiber FA, Wang X. A 15-year longitudinal study on ambulatory blood pressure tracking from childhood to early adulthood. Hypertens Res. 2009;32:404–10.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Brady TM, Fivush B, Flynn JT, Parekh R. Ability of blood pressure to predict left ventricular hypertrophy in children with primary hypertension. J Pediatr. 2008;152:73–8.

    Article  PubMed  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.

  48. 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  PubMed  Google Scholar 

  49. Seeman T, Gilík J. Long-term control of ambulatory hypertension in children: improving with time but still not achieving new blood pressure goals. Am J Hypertens. 2013;26(7):939–45.

    Article  CAS  PubMed  Google Scholar 

  50. Seeman T, Simková E, Kreisinger J, Vondrak K, Dusek J, Gilik J, et al. Improved control of hypertension in children after renal transplantation: results of a two-yr interventional trial. Pediatr Transplant. 2007;11(5):491–7.

    Article  CAS  PubMed  Google Scholar 

  51. Di Salvo G, Castaldi B, Baldini L, Gala S, del Faizo F, D’Andrea A, et al. Masked hypertension in young patients after successful aortic coarctation repair: impact on left ventricular geometry and function. J Hum Hypertens. 2011;25(12):739–45.

    Article  PubMed  Google Scholar 

  52. Samuels J, Ng D, Flynn JT, Mitsnefes M, Poffenbarger T, for the Chronic Kidney Disease in Children Study Group, et al. Ambulatory blood pressure patterns in children with chronic kidney disease. Hypertension. 2012;60(1):43–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Tainio J, Qvist E, Miettinen J, Holtta R, Pakarinen M, Jahnukainen T, et al. Blood pressure profiles 5 to 10 years after transplant in pediatric solid organ recipients. J Clin Hypertens (Greenwich). 2015;17(2):154–61.

    Article  Google Scholar 

  54. • Lurbe E, Redon J, Kesani A, Pascual JM, Tacons J, Alvarez V, et al. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med. 2002;347(11):797–805. This important prospective study demonstrated that nocturnal blood pressure changes precede the development of albuminuria in young people with type 1 diabetes.

    Article  CAS  PubMed  Google Scholar 

  55. Leung LC, Ng DK, Lau MW, Chan CH, Kwok KL, Chow PU, et al. Twenty-four-hour ambulatory BP in snoring children with obstructive sleep apnea syndrome. Chest. 2006;130(4):1009–17.

    Article  PubMed  Google Scholar 

  56. • Flynn JT, Daniels SR, Hayman LL, Maahs DM, BW MC, Mitsnefes M, et al., for the American Heart Association Atherosclerosis, Hypertension and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63(5):1116–35. This AHA statement includes the most up to date recommendations and evidence for use of ABPM in pediatric hypertension.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. 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):667–75.

    Article  Google Scholar 

  58. 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 

  59. Heymann AD, Hoch I, Valinsky L, Shalev V, Silber H, Kokia E. Mandatory computer field for blood pressure measurement improves screening. Fam Pract. 2005;22(2):168–9.

    Article  CAS  PubMed  Google Scholar 

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

    Article  Google Scholar 

  61. Kapur G, Ahmed M, Pan C, Mitsnefes M, Chiang M, Mattoo TK. Secondary hypertension in overweight and stage 1 hypertensive children: a Midwest Pediatric Nephrology Consortium report. J Clin Hypertens (Greenwich). 2010;12(1):34–9.

    Article  Google Scholar 

  62. Dionne JM, Harris KC, Benoit G, Feber J, Poirier L, Cloutier L, et al., for the Hypertension Canada Guideline Committee. Hypertension Canada’s 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension. Can J Cardiol. 2017(33):577–85.

  63. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. 2016 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  PubMed  Google Scholar 

  64. 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(5):e988–93.

    Article  PubMed  Google Scholar 

  65. Woroniecki RP, Flynn JT. How are hypertensive children evaluated and managed? A survey of North American pediatric nephrologists. Pediatr Nephrol. 2005;20(6):791–7.

    Article  PubMed  Google Scholar 

  66. • 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. This report from the Fels Longitudinal Study shows that in males, the risk for hypertension in young adulthood is incrementally related to childhood blood pressure above the 90th percentile.

    Article  PubMed  PubMed Central  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

The author declares no conflicts of interest relevant to this manuscript.

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 Pediatric Hypertension

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dionne, J.M. Updated Guideline May Improve the Recognition and Diagnosis of Hypertension in Children and Adolescents; Review of the 2017 AAP Blood Pressure Clinical Practice Guideline. Curr Hypertens Rep 19, 84 (2017). https://doi.org/10.1007/s11906-017-0780-8

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11906-017-0780-8

Keywords

Search

Navigation