Skip to main content

Epidemiology of Secondary Hypertension in Children


Secondary hypertension is more common in children compared with adults who predominantly have primary hypertension. Young age, severe hypertension, family history, and signs and symptoms of syndromes associated with hypertension are suggestive of an underlying secondary cause for elevated BP. Secondary hypertension is associated with more severe elevation in BP and, hence, early and prompt diagnosis with treatment addressing the underlying cause is needed for such patients. Renal conditions are the commonest cause of secondary hypertension in children and include chronic kidney injury, acute nephritic syndromes, renal artery stenosis, and renal scarring. Hypertension is also seen in association with Williams syndrome, neurofibromatosis, and others in association with renal vessel abnormalities. Iatrogenic steroid use for various conditions is one of the most common causes for hypertension in children. Other endocrine conditions associated with hypertension include catecholamine producing tumors (pheochromocytoma), corticoid hormone disorders (Cushing’s syndrome and disease, hyperaldosteronisn, congenital adrenal hyperplasia), and hyperthyroidism. Genetic forms of hypertension are rare but should be suspected in patients with early onset of elevated BP, young family members with hypertension and associated electrolyte abnormalities of alkalosis and hypokalemia.

This is a preview of subscription content, access via your institution.


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

  1. Roger VL, Go AS, Lloyd-Jones DM. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–220.

  2. Matson-Koffman D, Chattopadhyay S. Hypertension evidence-statement: screening and treatment. In: Campbell KP, Lanza A, Dixon R, et al., editors. Purchaser’s Guide to clinical preventive services: moving science into coverage. Washington, DC: National Business Group on Health; 2006.

    Google Scholar 

  3. High Blood Pressure Fact Sheet. National Center for Health Statistics: Hyattsville, MD; 2011.

  4. McNiece KL, Poffenbarger TS, Turner JL. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr. 2007;150:640–4.

  5. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298:874–9.

    CAS  PubMed  Article  Google Scholar 

  6. Redwine KM, Acosta AA, Poffenbarger T. Development of hypertension in adolescents with pre-hypertension. J Pediatr. 2012;160:98–103.

  7. Redwine KM, Falkner B. Progression of prehypertension to hypertension in adolescents. Curr Hypertens Rep. 2012;14:619–25.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  8. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl 4th Report):555–76. Expert recommendations on the management of hypertension in children.

  9. Kapur GK, Mattoo TK. Primary hypertension. In: Flynn JT, Ingelfinger JR, Portman RJ, editors. Pediatric hypertension. New York: Humana; 2013. p. 295–308.

    Chapter  Google Scholar 

  10. Wyszynska T, Cichocka E,Wieteska-Klimczak A. A single pediatric center experience with 1025 children with hypertension. Acta Paediatr. 1992;81:244–6.

  11. Arar MY, Hogg RJ, Arant BS. Etiology of sustained hypertension in children in the southwestern United States. Pediatr Nephrol. 1994;8:186–9.

  12. Gomes RS, Quirino IG, Pereira RM. Primary versus secondary hypertension in children followed up at an outpatient tertiary unit. Pediatr Nephrol. 2011;26:441–7.

  13. Viera AJ, Neutze DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician. 2010;82:1471–8.

    PubMed  Google Scholar 

  14. Flynn JT, Zhang Y, Solar-Yohay S. Clinical and demographic characteristics of children with hypertension. Hypertension. 2012;60:1047–54. A multicenter prospective randomized trial describing the demographics of children with hypertension.

  15. Flynn JT, Alderman MH. Characteristics of children with primary hypertension seen at a referral center. Pediatr Nephrol. 2005;20:961–6.

    PubMed  Article  Google Scholar 

  16. Kapur G, Ahmed M, Pan C. Secondary hypertension in overweight and stage 1 hypertensive children: a Midwest Pediatric Nephrology Consortium report. J Clin Hypertens. 2010;12:34–9. A large multicenter retrospective study of prevalence of secondary hypertension in overweight children with stage 1 hypertension and need for work-up of secondary hypertension. It concluded that work-up for secondary hypertension was not needed in every overweight child with stage 1 hypertension.

  17. Baracco R, Kapur G, Mattoo T. Prediction of primary vs secondary hypertension in children. J Clin Hypertens. 2012;14:316–21. A single center retrospective study aimed at identifying the risk factors for primary vs secondary hypertension. This study identified the increased risk of secondary hypertension in children aged 5–12 years old with hypertension and abnormal US findings.

  18. Vidi SR, Meyers KEC. Secondary forms of hypertension in children and adolescents. In: Flynn JT, Ingelfinger JR, Portman RJ, editors. Pediatric hypertension. New York: Springer Science+Business Media; 2013. p. 309–22. A book chapter with overview of secondary hypertension in children. It offers a likelihood table to predict need for work-up for secondary hypertension in an asymptomatic hypertensive child.

    Chapter  Google Scholar 

  19. Nguyen JV, Robbins JM, Houck KL. Severe obesity and high blood pressure among children, Philadelphia Health Centers, 2010. J Prim Care Community Health. 2014;5:152–5.

  20. Dorresteijn JA, Visseren FL, Spiering W. Mechanisms linking obesity to hypertension. Obes Rev. 2012;13:17–26.

    CAS  PubMed  Article  Google Scholar 

  21. Wang ZV, Scherer PE. Adiponectin, cardiovascular function, and hypertension. Hypertension. 2008;51:8–14.

    CAS  PubMed  Article  Google Scholar 

  22. Myers MG, Cowley MA, Munzberg H. Mechanisms of leptin action and leptin resistance. Annu Rev Physiol. 2008;70:537–56.

    CAS  PubMed  Article  Google Scholar 

  23. Colussi G, Catena C, Lapenna R. Insulin resistance and hyperinsulinemia are related to plasma aldosterone levels in hypertensive patients. Diabetes Care. 2007;30:2349–54.

  24. Kapur G, Baracco R. Evaluation of hypertension in children. Curr Hypertens Rep. 2013;15:433–43. Review article on the evaluation of hypertension in children. It gives a good overview on the evaluation of hypertension and suggests when to investigate for secondary hypertension.

    CAS  PubMed  Article  Google Scholar 

  25. Samuel JP, Swinford RD, Protman RJ. In: Flynn JT, Ingelfinger JR, Portman RJ, editors. Evaluation of the hypertensive pediatric patient in pediatric hypertension. New York: Humana; 2013. p. 491–504.

    Chapter  Google Scholar 

  26. Schaefer F, van de Walle J, Zurowska A. Efficacy, safety and pharmacokinetics of candesartan cilexetil in hypertensive children from 1 to less than 6 years of age. J Hypertens. 2010;28:1083–90.

  27. Giordano U, Matteucci MC, Calzolari A. Ambulatory blood pressure monitoring in children with aortic coarctation and kidney transplantation. J Pediatr. 2000;136:520–3.

  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;88:163–6.

    PubMed Central  PubMed  Article  Google Scholar 

  29. Flynn JT. Differentiation between primary and secondary hypertension in children using ambulatory blood pressure monitoring. Pediatrics. 2002;110(1 Pt 1):89–93.

    PubMed  Article  Google Scholar 

  30. Ksiazek A, Klosowska J, Sygulla K. Arterial hypertension and progression of chronic kidney disease in children during 10-year ambulatory observation. Clin Exp Hypertens. 2013;35:424–9.

  31. Mitsnefes M, Ho PL, McEnery PT. Hypertension and progression of chronic renal insufficiency in children: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). J Am Soc Nephrol. 2003;14:2618–22.

    PubMed  Article  Google Scholar 

  32. Flynn JT, Mitsnefes M, Pierce C. Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study. Hypertension. 2008;52:631–7.

  33. Wong H, Mylrea K, Feber J. Prevalence of complications in children with chronic kidney disease according to KDOQI. Kidney Int. 2006;70:585–90.

  34. Martz KS, Stablein DM. Renal transplantation dialysis chronic renal insufficiency. In: NAPRTCS; 2008.

  35. Wuhl E, Trivelli A, Picca, S. Strict blood-pressure control and progression of renal failure in children. N Engl J Med. 2009;361:1639–50. ESCAPE trial is a large randomized controlled trial on the role of strict BP control on progression of chronic renal failure. It showed the positive benefit of strict blood pressure control.

  36. Quirino IG, Diniz JS, Bouzada MC. Clinical course of 822 children with prenatally detected nephropathies. Clin J Am Soc Nephrol. 2012;7:444–51. A large retrospective study of children with CAKUT. It describes the natural history of CAKUT in children.

  37. Ahmed M, Eggleston D, Kapur G. Dimercaptosuccinic acid (DMSA) renal scan in the evaluation of hypertension in children. Pediatr Nephrol. 2008;23:435–8.

  38. Simoese Silva AC, Silva JM, Diniz JS. Risk of hypertension in primary vesicoureteral reflux. Pediatr Nephrol. 2007;22:459–62.

  39. Stokland E, Hellstrom M, Jakobsson B. Imaging of renal scarring. Acta Paediatr. 1999;88(Suppl):13–21.

  40. Marks SD, Tullus K. Update on imaging for suspected renovascular hypertension in children and adolescents. Curr Hypertens Rep. 2012;14:591–5.

    CAS  PubMed  Article  Google Scholar 

  41. Tullus K, Brennan E, Hamilton G. Renovascular hypertension in children. Lancet. 2008;371:1453–63. Recommendations on work-up in hypertensive children to identify renovascular cause.

  42. Geavlete O, Calin C, Croitoru M. Fibromuscular dysplasia—a rare cause of renovascular hypertension. Case study and overview of the literature data. J Med Life. 2012;5:5.

  43. Kimura H, Sato O, Deguchi JO. Surgical treatment and long-term outcome of renovascular hypertension in children and adolescents. Eur J Vasc Endovasc Surg. 2010;39:731–7.

  44. Brewer ED. Evaluation of hypertension in childhood diseases. In: Avner ED, Harmon WE, Niaudet P, et al., editors. Pediatric nephrology. Berlin: Springer; 2009. p. 1519–40.

    Google Scholar 

  45. Swartz MF, Morrow D, Atallah-Yunes N. Hypertensive changes within the aortic arch of infants and children with isolated coarctation. Ann Thorac Surg. 2013;96:190–5.

  46. Gillett C, Wong A, Wilson DG. Under recognition of elevated blood pressure readings in children after early repair of coarctation of the aorta. Pediatr Cardiol. 2011;32:202–5.

  47. Bocelli A, Favilli S, Pollini I. Prevalence and long-term predictors of left ventricular hypertrophy, late hypertension, and hypertensive response to exercise after successful aortic coarctation repair. Pediatr Cardiol. 2013;34:620–9.

  48. Tummolo A, Marks SD, Stadermann M. Mid-aortic syndrome: long-term outcome of 36 children. Pediatr Nephrol. 2009;24:2225–32.

  49. ten Dam K, van der Palen RL, Tanke RB. Clinical recognition of mid-aortic syndrome in children. Eur J Pediatr. 2013;172:413–6.

  50. Florczak E, Kadziela J, Michalowska I. [Mid-aortic syndrome in 18 year-old woman with arterial hypertension and bilateral renal artery stenosis]. Kardiol Pol. 2013;71:63–5.

  51. Poovazhagi V, Pauline L, Balakrishnan N. Hypertensive intracranial bleed due to mid aortic syndrome. Indian J Pediatr. 2014;81:285–7.

  52. McCarthy K, Bondy CA. Turner syndrome in childhood and adolescence. Expert Rev Endocrinol Metab. 2008;3:771–5.

    PubMed Central  PubMed  Article  Google Scholar 

  53. Akyurek N, Atabek ME, Eklioglu BS. Ambulatory blood pressure and subclinical cardiovascular disease in children with turner syndrome. Pediatr Cardiol. 2014;35:57–62.

  54. Vakili K, Fullington NM, Turner CG. Aorto-mesenteric and renal allograft transplant: a novel treatment for midaortic syndrome. Am J Transplant. 2013;13:1088–92.

  55. Kataoka K, Ozawa A, Inage A. Transcatheter repair of native coarctation in children with Turner syndrome: 3 case reports and literature review. Congenit Heart Dis. 2006;1:315–20.

  56. Nathwani NC, Unwin R, Brook CG. The influence of renal and cardiovascular abnormalities on blood pressure in Turner syndrome. Clin Endocrinol. 2000;52:371–7.

  57. Sybert VP. Cardiovascular malformations and complications in Turner syndrome. Pediatrics. 1998;101:E11.

    CAS  PubMed  Article  Google Scholar 

  58. Bolar K, Hoffman AR, Maneatis T. Long-term safety of recombinant human growth hormone in turner syndrome. J Clin Endocrinol Metab. 2008;93:344–51.

  59. Rose C, Wessel A, Pankau R. Anomalies of the abdominal aorta in Williams-Beuren syndrome—another cause of arterial hypertension. Eur J Pediatr. 2001;160:655–8.

  60. Broder K, Reinhardt E, Ahern J. Elevated ambulatory blood pressure in 20 subjects with Williams syndrome. Am J Med Genet. 1999;83:356–60.

  61. Salerno AE, Marsenic O, Meyers KE. Vascular involvement in tuberous sclerosis. Pediatr Nephrol. 2010;25:1555–61.

  62. Momtaz HE. Tuberous sclerosis with hypertension and abdominal pain in a child. Iran J Kidney Dis. 2010;4:253–5.

    PubMed  Google Scholar 

  63. Birca A, Mercier C, Major P. Rapamycin as an alternative to surgical treatment of subependymal giant cell astrocytomas in a patient with tuberous sclerosis complex. J Neurosurg Pediatr. 2010;6:381–4.

    PubMed  Article  Google Scholar 

  64. Kaas B, Huisman TA, Tekes A. Spectrum and prevalence of vasculopathy in pediatric neurofibromatosis type 1. J Child Neurol. 2013;28:561–9.

  65. Pham TH, Moir C, Thompson GB. Pheochromocytoma and paraganglioma in children: a review of medical and surgical management at a tertiary care center. Pediatrics. 2006;118:1109–17.

  66. Hack HA. The perioperative management of children with phaeochromocytoma. Paediatr Anaesth. 2000;10:463–76.

    CAS  PubMed  Article  Google Scholar 

  67. Mazza A, Armigliato M, Marzola MC. Anti-hypertensive treatment in pheochromocytoma and paraganglioma: current management and therapeutic features. Endocrine. 2014;45:469–78.

  68. Joynt KE, Moslehi JJ, Baughman KL. Paragangliomas: etiology, presentation, and management. Cardiol Rev. 2009;17:159–64.

    PubMed  Article  Google Scholar 

  69. Haberkern CM, Coles PG, Morray JP. Intraoperative hypertension during surgical excision of neuroblastoma. Case report and review of 20 years’ experience. Anesth Analg. 1992;75:854–8.

  70. Fishbein L, Orlowski R, Cohen D. Pheochromocytoma/Paraganglioma: review of perioperative management of blood pressure and update on genetic mutations associated with pheochromocytoma. J Clin Hypertens. 2013;15:428–34.

    CAS  Article  Google Scholar 

  71. Osman Y, Hussein N, Sarhan O. Surgical analysis of pediatric and adolescent sporadic pheochromocytoma: single center experience. Int Urol Nephrol. 2011;43:1019–24.

  72. Allan B, Davis J, Perez E. Malignant neuroendocrine tumors: incidence and outcomes in pediatric patients. Eur J Pediatr Surg. 2013;23:394–9.

  73. Yalcin B, Kremer LC, Caron HN. High-dose chemotherapy and autologous haematopoietic stem cell rescue for children with high-risk neuroblastoma. Cochrane Database Syst Rev. 2013;8, CD006301.

  74. Pretorius M, Rasmussen GE, Holcomb GW. Hemodynamic and catecholamine responses to a laparoscopic adrenalectomy for pheochromocytoma in a pediatric patient. Anesth Analg. 1998;87:1268–70.

    CAS  PubMed  Google Scholar 

  75. Stratakis CA. Cushing syndrome in pediatrics. Endocrinol Metab Clin North Am. 2012;41:793–803.

    PubMed Central  PubMed  Article  Google Scholar 

  76. Stowasser M. Update in primary aldosteronism. J Clin Endocrinol Metab. 2009;94:3623–30.

    CAS  PubMed  Article  Google Scholar 

  77. Onder A, Kremer LC, Caron HN. A pediatric Conn syndrome case. J Pediatr Endocrinol Metab. 2012;25:203–6.

  78. Rodriguez MA, Alkhoury F, Malvezzi L. Conn syndrome and Crohn disease in a pediatric case: an interesting parallel. J Pediatr Endocrinol Metab. 2013;26:155–9.

  79. Finkielstain GP, Kim MS, Sinaii N. Clinical characteristics of a cohort of 244 patients with congenital adrenal hyperplasia. J Clin Endocrinol Metab. 2012;97:4429–38.

  80. Subbarayan A, Dattani MT, Peters CJ. Cardiovascular risk factors in children and adolescents with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Clin Endocrinol. 2014;80:471–7.

  81. Ryodi E, Salmi J, Jaatinen P. Cardiovascular morbidity and mortality in surgically treated hyperthyroidism - a nation-wide cohort study with a long-term follow-up. Clin Endocrinol. 2013. doi:10.1111/cen.12359.

  82. White PC. Endocrine hypertension. In: Flynn JT, Ingelfinger JR, Portman RJ, editors. Pediatric hypertension. New York: Humana; 2013. p. 379–94. A good review of endocrine causes of hypertension in children.

    Chapter  Google Scholar 

  83. Mulatero P, Verhovez A, Morello F. Diagnosis and treatment of low-renin hypertension. Clin Endocrinol. 2007;67:324–34.

  84. Ingelfinger JR. Monogenic and polygenic contributions to Hypertension. In: Flynn JT, Ingelfinger JR, Portman RJ, editors. Pediatric hypertension. New York: Humana; 2013. p. 83–102.

    Chapter  Google Scholar 

  85. Bogdanovic R, Kuburovic V, Stajic N. Liddle’s syndrome in a Serbian family and literature review of underlying mutations. Eur J Pediatr. 2012;171:471–8.

  86. Assadi FK, Kimura RE, Subramanian U. Liddle’s syndrome in a newborn infant. Pediatr Nephrol. 2002;17:609–11.

  87. Vania A, Tucciarone L, Mazzeo D. Liddle’s syndrome: a 14-year follow-up of the youngest diagnosed case. Pediatr Nephrol. 1997;11:7–11.

  88. Tapolyai M, Uysal A, Dossabhoy NR. High prevalence of Liddle’s syndrome phenotype among hypertensive US Veterans in Northwest Louisiana. J Clin Hypertens. 2010;12:856–60.

  89. Sinha R, Salphale I, Agarwal I. A case of Liddle’s Syndrome. Indian J Pediatr. 2013;80:878–80.

    PubMed  Article  Google Scholar 

  90. Mendes AI, Mascarenhas M R, Matos S. A WNK4 gene variant relates to osteoporosis and not to hypertension in the Portuguese population. Mol Genet Metab. 2011;102:465–9.

  91. Tsuji S, Yamashita M, Unishi G. A young child with pseudohypoaldosteronism type II by a mutation of Cullin 3. BMC Nephrol. 2013;14:166.

  92. Puura A, Schultz R. Gordon syndrome and succinylcholine. J Inherit Metab Dis. 2005;28:1157–8.

    CAS  PubMed  Article  Google Scholar 

  93. Achard JM, Disse-Nicodeme S, Fiquet-Kempf B. Phenotypic and genetic heterogeneity of familial hyperkalaemic hypertension (Gordon syndrome). Clin Exp Pharmacol Physiol. 2001;28:1048–52.

  94. Al-Harbi T, Al-Shaikh A. Apparent mineralocorticoid excess syndrome: report of one family with 3 affected children. J Pediatr Endocrinol Metab. 2012;25:1083–8.

    CAS  PubMed  Article  Google Scholar 

  95. Aglony M, Martinez-Aguayo A, Carvajal CA. Frequency of familial hyperaldosteronism type 1 in a hypertensive pediatric population: clinical and biochemical presentation. Hypertension. 2011;57:1117–21.

  96. Toka O, Maass PG, Aydin A. Childhood hypertension in autosomal-dominant hypertension with brachydactyly. Hypertension. 2010;56:988–94.

  97. Jordan J, Toka HR, Heusser K. Severely impaired baroreflex-buffering in patients with monogenic hypertension and neurovascular contact. Circulation. 2000;102:2611–8.

  98. Grinsell MM, Norwood VF. At the bottom of the differential diagnosis list: unusual causes of pediatric hypertension. Pediatr Nephrol. 2009;24:2137–46.

    PubMed Central  PubMed  Article  Google Scholar 

  99. Berliner BC, Shenker IR, Weinstock MS. Hypercalcemia associated with hypertension due to prolonged immobilization. (An unusual complication of extensive burns). Pediatrics. 1972;49:92–6.

    CAS  PubMed  Google Scholar 

  100. Heij HA, Ekkelkamp S, dVos A. Hypertension associated with skeletal traction in children. Eur J Pediatr. 1992;151:543–5.

    CAS  PubMed  Article  Google Scholar 

  101. Lurbe E, Cifkova R, Cruickshank JK. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009;27:1719–42.

  102. Flynn JT. Evaluation and management of hypertension in childhood. Prog Pediatr Cardiol. 2001;12:177–88.

    PubMed  Article  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Gaurav Kapur received a grant from Genzyme. Maurico Romero Olivera and Prabesh Bajracharya declare that they have 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 the author.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Gaurav Kapur.

Additional information

This article is part of the Topical Collection on Obesity + Diet

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bajracharya, P., Olivera, M.R. & Kapur, G. Epidemiology of Secondary Hypertension in Children. Curr Cardiovasc Risk Rep 8, 388 (2014).

Download citation

  • Published:

  • DOI:


  • Secondary hypertension
  • Etiology
  • Children