Screenshot

Guidance for the Clinician in Rendering Pediatric Care
CLINICAL PRACTICE GUIDELINE
Clinical Practice Guideline for

Screening and Management
of High Blood Pressure in
Children and Adolescents
Joseph T. Flynn, MD, MS, FAAP,a David C. Kaelber, MD, PhD, MPH, FAAP, FACP, FACMI,b Carissa M. Baker-Smith, MD, MS,
MPH, FAAP, FAHA,c Douglas Blowey, MD,d Aaron E. Carroll, MD, MS, FAAP,e Stephen R. Daniels, MD, PhD, FAAP,f Sarah D.
de Ferranti, MD, MPH, FAAP,g Janis M. Dionne, MD, FRCPC,h Bonita Falkner, MD,i Susan K. Flinn, MA, j Samuel S. Gidding,
MD,k Celeste Goodwin,l Michael G. Leu, MD, MS, MHS, FAAP,m Makia E. Powers, MD, MPH, FAAP,n Corinna Rea, MD, MPH,
FAAP,o Joshua Samuels, MD, MPH, FAAP,p Madeline Simasek, MD, MSCP, FAAP,q Vidhu V. Thaker, MD, FAAP,r Elaine M.
Urbina, MD, MS, FAAP,s SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN
These pediatric hypertension guidelines are an update to the 2004 “Fourth abstract
Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure
in Children and Adolescents.” Significant changes in these guidelines
include (1) the replacement of the term “prehypertension” with the term
“elevated blood pressure,” (2) new normative pediatric blood pressure (BP) aDr. Robert O. Hickman Endowed Chair in Pediatric Nephrology,
Division of Nephrology, Department of Pediatrics, University of
tables based on normal-weight children, (3) a simplified screening table for Washington and Seattle Children's Hospital, Seattle, Washington;
bDepartments of Pediatrics, Internal Medicine, Population and
identifying BPs needing further evaluation, (4) a simplified BP classification Quantitative Health Sciences, Center for Clinical Informatics Research
in adolescents ≥13 years of age that aligns with the forthcoming American and Education, Case Western Reserve University and MetroHealth
System, Cleveland, Ohio; cDivision of Pediatric Cardiology, School of
Heart Association and American College of Cardiology adult BP guidelines, Medicine, University of Maryland, Baltimore, Maryland; dChildren’s
(5) a more limited recommendation to perform screening BP measurements Mercy Hospital, University of Missouri-Kansas City and Children’s
Mercy Integrated Care Solutions, Kansas City, Missouri; eDepartment
only at preventive care visits, (6) streamlined recommendations on the of Pediatrics, School of Medicine, Indiana University, Bloomington,
Indiana; fDepartment of Pediatrics, School of Medicine, University
initial evaluation and management of abnormal BPs, (7) an expanded role of Colorado-Denver and Pediatrician in Chief, Children’s Hospital
for ambulatory BP monitoring in the diagnosis and management of pediatric Colorado, Aurora, Colorado; gDirector, Preventive Cardiology Clinic,
Boston Children's Hospital, Department of Pediatrics, Harvard Medical
hypertension, and (8) revised recommendations on when to perform School, Boston, Massachusetts; hDivision of Nephrology, Department
of Pediatrics, University of British Columbia and British Columbia
echocardiography in the evaluation of newly diagnosed hypertensive Children’s Hospital, Vancouver, British Columbia, Canada; Departments
pediatric patients (generally only before medication initiation), along with a of iMedicine and Pediatrics, Sidney Kimmel Medical College, Thomas
Jefferson University, Philadelphia, Pennsylvania; jConsultant, American
revised definition of left ventricular hypertrophy. These guidelines include Academy of Pediatrics, Washington, District of Columbia; kCardiology
30 Key Action Statements and 27 additional recommendations derived Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for
Children, Wilmington, Delaware; lNational Pediatric Blood Pressure
from a comprehensive review of almost 15 000 published articles between Awareness Foundation, Prairieville, Louisiana; Departments of
mPediatrics and Biomedical Informatics and Medical Education,
January 2004 and July 2016. Each Key Action Statement includes level of University of Washington, University of Washington Medicine and
evidence, benefit-harm relationship, and strength of recommendation. This Information Technology Services, and Seattle Children's Hospital,
clinical practice guideline, endorsed by the American Heart Association, is

intended to foster a patient- and family-centered approach to care, reduce To cite: Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical
unnecessary and costly medical interventions, improve patient diagnoses Practice Guideline for Screening and Management of High
and outcomes, support implementation, and provide direction for future Blood Pressure in Children and Adolescents. Pediatrics.
2017;140(3):e20171904
research.
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on July 14, 2021

PEDIATRICS Volume 140, number 3, September 2017:e20171904 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Flynn et al 2017 ROUGH GALLEY PROOF

Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017
1. INTRODUCTION preparation process. Potential thickness (cIMT), flow-mediated
conflicts of interest were addressed dilation (FMD), left ventricular
1. Scope of the Clinical Practice and resolved by the AAP. A detailed hypertrophy (LVH), and other
Guideline list of subcommittee members markers of vascular dysfunction?
Interest in childhood hypertension and affiliations can be found in the
To address these key questions, a
(HTN) has increased since the 2004 Consortium section at the end of this
systematic search and review of
publication of the “Fourth Report article. A listing of subcommittee
literature was performed. The initial
on the Diagnosis, Evaluation, and members with conflicts of interest
search included articles published
Treatment of High Blood Pressure in will be included in the forthcoming
between the publication of the Fourth
Children and Adolescents” (Fourth technical report.
Report (January 2004) and August
Report).1 Recognizing ongoing The subcommittee epidemiologist 2015. The process used to conduct
evidence gaps and the need for an created a detailed content outline, the systematic review was consistent
updated, thorough review of the which was reviewed and approved with the recommendations of the
relevant literature, the American by the subcommittee. The outline Institute of Medicine for systematic
Academy of Pediatrics (AAP) and its contained a list of primary and reviews.2
Council on Quality Improvement and secondary topics generated to
Patient Safety developed this practice guide a thorough literature search For the topics not researched by
guideline to provide an update on and meet the goal of providing an using the PICOT format, separate
topics relevant to the diagnosis, up-to-date systemic review of the searches were conducted. Not all
evaluation, and management of literature pertaining to the diagnosis, topics (eg, economic aspects of
pediatric HTN. It is primarily directed management, and treatment pediatric HTN) were appropriate for
at clinicians caring for children and of pediatric HTN as well as the the PICOT format. A third and final
adolescents in the outpatient setting. prevalence of pediatric HTN and its search was conducted at the time the
This guideline is endorsed by the associated comorbidities. Key Action Statements (KASs) were
American Heart Association. generated to identify any additional
Of the topics covered in the outline, relevant articles published between
When it was not possible to ∼80% were researched by using August 2015 and July 2016. (See
identify sufficient evidence, a Patient, Intervention/Indicator, Table 1 for a complete list of KASs.)
recommendations are based on the Comparison, Outcome, and Time
consensus opinion of the expert (PICOT) format to address the A detailed description of the
members of the Screening and following key questions: methodology used to conduct the
Management of High Blood Pressure literature search and systematic
1. How should systemic HTN (eg,
in Children Clinical Practice Guideline review for this clinical practice
primary HTN, renovascular HTN,
Subcommittee (henceforth, “the guideline will be included in the
white coat hypertension [WCH],
subcommittee”). The subcommittee forthcoming technical report. In
and masked hypertension [MH])
intends to regularly update this brief, reference selection involved
in children be diagnosed, and
guideline as new evidence becomes a multistep process. First, 2
what is the optimal approach to
available. Implementation tools for subcommittee members reviewed
diagnosing HTN in children and
this guideline are available on the the titles and abstracts of references
adolescents?
AAP Web site (https://www.aap.org/ identified for each key question.
en-us/about-the-aap/Committees- 2. What is the recommended workup The epidemiologist provided a
Councils-Sections/coqips/Pages/ for pediatric HTN? How do we deciding vote when required. Next,
Implementation-Guide.aspx). best identify the underlying 2 subcommittee members and the
etiologies of secondary HTN in epidemiologist conducted full-text
1.1 Methodology children? reviews of the selected articles.
3. What is the optimal goal systolic Although many subcommittee
The subcommittee was co-chaired
blood pressure (SBP) and/or members have extensively published
by a pediatric nephrologist and a
diastolic blood pressure (DBP) for articles on topics covered in
general pediatrician and consisted
children and adolescents? this guideline, articles were not
of 17 members, including a parent
preferentially selected on the basis of
representative. All subcommittee 4. In children 0 to 18 years of age,
authorship.
members were asked to disclose how does treatment with lifestyle
relevant financial or proprietary versus antihypertensive agents Articles selected at this stage were
conflicts of interest for members or influence indirect measures of mapped back to the relevant main
their family members at the start cardiovascular disease (CVD) topic in the outline. Subcommittee
of and throughout the guideline risk, such as carotid intimamedia members were then assigned to

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

TABLE 1 Summary of KASs for Screening and Management of High BP in Children and Adolescents
KAS Evidence Quality, Strength
of Recommendation
1. BP should be measured annually in children and adolescents ≥3 y of age. C, moderate
2. BP should be checked in all children and adolescents ≥3 y of age at every health care encounter if they have obesity, are taking C, moderate
medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes.
3. Trained health care professionals in the office setting should make a diagnosis of HTN if a child or adolescent has auscultatory- C, moderate
confirmed BP readings ≥95th percentile at 3 different visits.
4. Organizations with EHRs used in an office setting should consider including flags for abnormal BP values, both when the values C, weak
are being entered and when they are being viewed.
5. Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a B, strong
device that has been validated in the pediatric age group. If elevated BP is suspected on the basis of oscillometric readings,
confirmatory measurements should be obtained by auscultation.
6. ABPM should be performed for confirmation of HTN in children and adolescents with office BP measurements in the elevated C, moderate
BP category for 1 year or more or with stage 1 HTN over 3 clinic visits.
7. Routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions (see Table B, moderate
12) to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk
for target organ damage.
8. ABPM should be performed by using a standardized approach (see Table 13) with monitors that have been validated in a C, moderate
pediatric population, and studies should be interpreted by using pediatric normative data.
9. Children and adolescents with suspected WCH should undergo ABPM. Diagnosis is based on the presence of mean SBP and DBP B, strong
<95th percentile and SBP and DBP load <25%.
10. Home BP monitoring should not be used to diagnose HTN, MH, or WCH but may be a useful adjunct to office and ambulatory BP C, moderate
measurement after HTN has been diagnosed.
11. Children and adolescents ≥6 y of age do not require an extensive evaluation for secondary causes of HTN if they have a C, moderate
positive family history of HTN, are overweight or obese, and/or do not have history or physical examination findings (Table 14)
suggestive of a secondary cause of HTN.
12. Children and adolescents who have undergone coarctation repair should undergo ABPM for the detection of HTN (including B, strong
MH).
13. In children and adolescents being evaluated for high BP, the provider should obtain a perinatal history, appropriate B, strong
nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination to
identify findings suggestive of secondary causes of HTN.
14. Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for LVH. B, strong
15-1. It is recommended that echocardiography be performed to assess for cardiac target organ damage (LV mass, geometry, C, moderate
and function) at the time of consideration of pharmacologic treatment of HTN.
15-2. LVH should be defined as LV mass >51 g/m2.7 (boys and girls) for children and adolescents older than age 8 y and defined
by LV mass >115 g/BSA for boys and LV mass >95 g/BSA for girls.
15-3. Repeat echocardiography may be performed to monitor improvement or progression of target organ damage at 6- to 12-
mo intervals. Indications to repeat echocardiography include persistent HTN despite treatment, concentric LV hypertrophy,
or reduced LV ejection fraction.
15-4. In patients without LV target organ injury at initial echocardiographic assessment, repeat echocardiography at yearly
intervals may be considered in those with stage 2 HTN, secondary HTN, or chronic stage 1 HTN incompletely treated
(noncompliance or drug resistance) to assess for the development of worsening LV target organ injury.
16. Doppler renal ultrasonography may be used as a noninvasive screening study for the evaluation of possible RAS in normal- C, moderate
wt children and adolescents ≥8 y of age who are suspected of having renovascular HTN and who will cooperate with the
procedure.
17. In children and adolescents suspected of having RAS, either CTA or MRA may be performed as noninvasive imaging studies. D, weak
Nuclear renography is less useful in pediatrics and should generally be avoided.
18. Routine testing for MA is not recommended for children and adolescents with primary HTN. C, moderate
19. In children and adolescents diagnosed with HTN, the treatment goal with nonpharmacologic and pharmacologic therapy C, moderate
should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥ 13 years old.
20. At the time of diagnosis of elevated BP or HTN in a child or adolescent, clinicians should provide advice on the DASH diet and C, weak
recommend moderate to vigorous physical activity at least 3 to 5 d per week (30–60 min per session) to help reduce BP.
21. In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy B, moderate
on echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor [eg, obesity]), clinicians should
initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic.
22. ABPM may be used to assess treatment effectiveness in children and adolescents with HTN, especially when clinic and/or B, moderate
home BP measurements indicate insufficient BP response to treatment.
23-1. Children and adolescents with CKD should be evaluated for HTN at each medical encounter. B, strong
23-2. Children or adolescents with both CKD and HTN should be treated to lower 24-hr MAP <50th percentile by ABPM.
23-3. Regardless of apparent control of BP with office measures, children and adolescents with CKD and a history of HTN
should have BP assessed by ABPM at least yearly to screen for MH.
24. Children and adolescents with CKD and HTN should be evaluated for proteinuria. B, strong
25. Children and adolescents with CKD, HTN, and proteinuria should be treated with an ACE inhibitor or ARB. B, strong

PEDIATRICS Volume 140, number 3, September 2017 3

TABLE 1 Continued
KAS Evidence Quality, Strength
of Recommendation
26. Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP ≥95th C, moderate
percentile or >130/80 mm Hg in adolescents ≥13 y of age.
27. In children and adolescents with acute severe HTN and life-threatening symptoms, immediate treatment with short-acting Expert opinion, D, weak
antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over
the first 8 h.
28. Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and C, moderate
cardiovascular risk have been assessed.
29. Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participation in C, moderate
competitive sports.
30. Adolescents with elevated BP or HTN (whether they are receiving antihypertensive treatment) should typically have their care X, strong
transitioned to an appropriate adult care provider by 22 y of age (recognizing that there may be individual cases in which this
upper age limit is exceeded, particularly in the case of youth with special health care needs). There should be a transfer of
information regarding HTN etiology and past manifestations and complications of the patient’s HTN.
writing teams that evaluated the since 1988, indicate that there has Trajectory data on BP (including
evidence quality for selected topics been an increase in the prevalence repeat measurements from early
and generated appropriate KASs of childhood high BP, including childhood into midadulthood)
in accordance with an AAP grading both HTN and elevated BP.4,5 High confirm the association of elevated
matrix (see Fig 1 and the detailed BP is consistently greater in boys BP in adolescence with HTN in early
discussion in the forthcoming (15%–19%) than in girls (7%–12%). adulthood11 and that normal BP in
technical report).3 Special working The prevalence of high BP is higher childhood is associated with a lack of
groups were created to address 2 among Hispanic and non-Hispanic HTN in midadulthood.11
specific topics for which evidence African American children compared
was lacking and expert opinion with non-Hispanic white children, 2.2 Awareness, Treatment, and
was required to generate KASs, with higher rates among adolescents Control of HTN in Children
“Definition of HTN” and “Definition than among younger children.6
Of the 32.6% of US adults who
of LVH.” References for any topics not
However, in a clinical setting and have HTN, almost half (17.2%) are
covered by the key questions were
with repeated BP measurements, not aware they have HTN; even
selected on the basis of additional
the prevalence of confirmed HTN is among those who are aware of
literature searches and reviewed by
lower in part because of inherent BP their condition, only approximately
the epidemiologist and subcommittee
variability as well as an adjustment half (54.1%) have controlled BP.12
members assigned to the topic. When
to the experience of having BP Unfortunately, there are no large
applicable, searches were conducted
measured (also known as the studies in which researchers have
by using the PICOT format .
accommodation effect). Therefore, systematically studied BP awareness
In addition to the 30 KASs listed the actual prevalence of clinical or control in youth, although an
above, this guideline also contains HTN in children and adolescents analysis of prescribing patterns
27 additional recommendations is ∼3.5%.7,8 The prevalence of from a nationwide prescription drug
that are based on the consensus persistently elevated BP (formerly provider found an increase in the
expert opinion of the subcommittee termed “prehypertension,” including number of prescriptions written
members. These recommendations, BP values from the 90th to 94th for high BP in youth from 2004 to
along with their locations in the percentiles or between 120/80 and 2007.13
document, are listed in Table 2. 130/80 mm Hg in adolescents) is also
The SEARCH for Diabetes in Youth
∼2.2% to 3.5%, with higher rates
study found that only 7.4% of
among children and adolescents who
2. EPIDEMIOLOGY AND CLINICAL youth with type 1 diabetes mellitus
have overweight and obesity.7,9
SIGNIFICANCE (T1DM) and 31.9% of youth with
Data on BP tracking from childhood type 2 diabetes mellitus (T2DM)
2.1 Prevalence of HTN in Children to adulthood demonstrate that demonstrated knowledge of their
Information on the prevalence higher BP in childhood correlates BP status.14 Even after becoming
of high blood pressure (BP) in with higher BP in adulthood aware of the diagnosis, only 57.1%
children is largely derived from data and the onset of HTN in young of patients with T1DM and 40.6% of
from the NHANES and typically is adulthood. The strength of the patients with T2DM achieved good
based on a single BP measurement tracking relationship is stronger in BP control.14 The HEALTHY Primary
session. These surveys, conducted older children and adolescents.10 Prevention Trial of Risk Factors for


TABLE 2 Additional Consensus Opinion Recommendations and Text Locations Type 2 Diabetes in Middle-School
Recommendation CPG Youth, which examined a school-
Section(s) based intervention designed to
1. Follow the revised classification scheme in Table 3 for childhood BP levels, including 3.1 reduce cardiovascular (CV) risk
the use of the term “elevated BP,” the new definition of stage 2 HTN, and the use of among middle school students, found
similar BP levels as adults for adolescents ≥13 y of age. the prevalence of stage 1 or 2 HTN to
2. Use simplified BP tables (Table 4) to screen for BP values that may require further 3.2a be ∼9.5%.15 There was no significant
evaluation by a clinician.
3. Use reference data on neonatal BP from ref 80 to identify elevated BP values in 3.3 reduction in HTN in the control
neonates up to 44 wk postmenstrual age and BP curves from the 1987 Second Task group after the intervention; the
Force report to identify elevated BP values in infants 1–12 mo of age. intervention group saw a reduction
4. Use the standardized technique for measuring BP by auscultation described in Table 4.1 in the prevalence of HTN of ∼1%,
7 and Fig 2 (including appropriate cuff size, extremity, and patient positioning) to
leaving 8.5% with BP still above the
obtain accurate BP values.
5. If the initial BP at an office visit is elevated, as described in Fig 3, obtain 2 4.1 ideal range.
additional BP measurements at the same visit and average them; use the averaged
Researchers in a number of
auscultatory BP measurement to determine the patient’s BP category.
6. Oscillometric devices are used to measure BP in infants and toddlers until they are 4.1a small, single-center studies have
able to cooperate with auscultatory BP. Follow the same rules for BP measurement evaluated BP control in children
technique and cuff size as for older children. and adolescents with HTN. One
7. Measure BP at every health care encounter in children <3 y of age if they have an 4.2 study found that lifestyle change
underlying condition listed in Table 9 that increases their risk for HTN.
and medications produced adequate
8. After a patient’s BP has been categorized, follow Table 11 for when to obtain repeat 4.3
BP readings, institute lifestyle changes, or proceed to a workup for HTN. BP control in 46 of 65 youth (70%)
9. When an oscillometric BP reading is elevated, obtain repeat readings, discard the 4.5 with HTN.16 Another study in which
first reading, and average subsequent readings to approximate auscultatory BP. researchers used ambulatory blood
10. Wrist and forearm BP measurements should not be used in children and 4.6 pressure monitoring (ABPM) to
adolescents for the diagnosis or management of HTN.
assess BP control among a group
11. Use ABPM to evaluate high-risk patients (those with obesity, CKD, or repaired aortic 4.7a, 4.8
coarctation) for potential MH. of 38 children (of whom 84% had
12. Routine use of BP readings obtained in the school setting is not recommended for 4.10 chronic kidney disease [CKD]) found
diagnosis of HTN in children and adolescents. that only 13 children (34%) achieved
13. Use the history and physical examination to identify possible underlying causes of 5.2–5.4, 5.7, adequate BP control even among
HTN, such as heart disease, kidney disease, renovascular disease, endocrine HTN 9.2
those who received more than 1
(Table 15), drug-induced HTN (Table 8), and OSAS-associated HTN (Table 18).
14. Suspect monogenic HTN in patients with a family history of early-onset HTN, 5.8 drug.17 A similar study found that
hypokalemia, suppressed plasma renin, or an elevated ARR. additional drugs did increase rates
15. Obtain laboratory studies listed in Table 10 to evaluate for underlying secondary 6.4 of BP control in children with CKD,
causes of HTN when indicated. however.18
16. Routine use of vascular imaging, such as carotid intimal-media measurements or 6.7
PWV measurements, is not recommended in the evaluation of HTN in children and
adolescents.
2.3 Prevalence of HTN Among
17. Suspect renovascular HTN in selected children and adolescents with stage 2 HTN, 6.8a Children With Various Chronic
significant diastolic HTN, discrepant kidney sizes on ultrasound, hypokalemia on Conditions
screening laboratories, or an epigastric and/or upper abdominal bruit on physical
examination.
It is well recognized that HTN rates
18. Routine measurement of serum UA is not recommended for children and 6.9 are higher in children with certain
adolescents with elevated BP. chronic conditions, including children
19. Offer intensive weight-loss programs to hypertensive children and adolescents with 7.2c with obesity, sleep-disordered
obesity; consider using MI as an adjunct to the treatment of obesity. breathing (SDB), CKD, and those born
20. Follow-up children and adolescents treated with antihypertensive medications 7.3c
every 4–6 wk until BP is controlled, then extend the interval. Follow-up every 3–6 mo
preterm. These are described below.
is appropriate for patients treated with lifestyle modification only.
21. Evaluate and treat children and adolescents with apparent treatment-resistant HTN 7.4 2.3a Children With Obesity
in a similar manner to that recommended for adults with resistant HTN.
HTN prevalence ranges from 3.8%
22. Treat hypertensive children and adolescents with dyslipidemia according to 9.1
current, existing pediatric lipid guidelines. to 24.8% in youth with overweight
23. Use ABPM to evaluate for potential HTN in children and adolescents with known or 9.2 and obesity. Rates of HTN increase
suspected OSAS. in a graded fashion with increasing
24. Racial, ethnic, and sex differences need not be considered in the evaluation and 10 adiposity.19–24 Similar relationships
management of children and adolescents with HTN.
are seen between HTN and increasing
25. Use ABPM to evaluate BP in pediatric heart- and kidney-transplant recipients. 11.3
waist circumference.4,25,26 Systematic
reviews of 63 studies on BMI27 and
61 studies on various measures


TABLE 2 Continued latter in pediatric patients is lacking.
Recommendation CPG Among children and adolescents
Section(s) with CKD, ∼50% are known to be
26. Reasonable strategies for HTN prevention include the maintenance of a normal 13.2 hypertensive.46–48 In children and
BMI, consuming a DASH-type diet, avoidance of excessive sodium consumption, and
regular vigorous physical activity.
adolescents with end-stage renal
27. Provide education about HTN to patients and their parents to improve patient 15.2, 15.3 disease (either those on dialysis
involvement in their care and better achieve therapeutic goals. or after transplant), ∼48% to 79%
Based on the expert opinion of the subcommittee members (level of evidence = D; strength of recommendations = weak). are hypertensive, with 20% to 70%
CPG, clinical practice guideline. having uncontrolled HTN.49–53
Almost 20% of pediatric HTN may be
of abdominal adiposity28 have hard to demonstrate definitively, attributable to CKD.54
shown associations between these the Strong Heart Study did show
conditions and HTN. Obesity is also that American Indian adolescents 2.3d Children With History of
associated with a lack of circadian with multiple cardiometabolic risk Prematurity
variability of BP,29,30 with up to 50% factors had a higher prevalence of Abnormal birth history—including
of children who have obesity not LVH (43.2% vs 11.7%), left atrial preterm birth and low birth weight—
experiencing the expected nocturnal dilation (63.1% vs 21.9%; P < .001), has been identified as a risk factor for
BP dip.31–33 and reduced LV systolic and diastolic HTN and other CVD in adults55; only
Studies have shown that childhood function compared with those low birth weight has been associated
obesity is also related to the without multiple cardiometabolic with elevated BP in the pediatric age
development of future HTN.22 risk factors.39 Notably, both obesity range.56 One retrospective cohort
Elevated BMI as early as infancy and HTN were drivers of these CV study showed a prevalence of HTN
is associated with higher future abnormalities, with obesity being of 7.3% among 3 year olds who
BP.34 This risk appears to increase a stronger determinant of cardiac were born preterm.57 Researchers
with obesity severity; there is a abnormalities than HTN (odds ratio, in another retrospective case series
fourfold increase in BP among those 4.17 vs 1.03). noted a high prevalence of HTN
with severe obesity (BMI >99th in older children with a history of
2.3b Children With SDB preterm birth.58 It also appears that
percentile) versus a twofold increase
in those with obesity (BMI 95th–98th SDB occurs on a spectrum that preterm birth may result in abnormal
percentiles) compared with normal- includes (1) primary snoring, circadian BP patterns in childhood.59
weight children and adolescents.35 (2) sleep fragmentation, and (3) These data are intriguing but limited.
obstructive sleep apnea syndrome Further study is needed to determine
Collectively, the results of these (OSAS). Researchers in numerous how often preterm birth results in
cross-sectional and longitudinal studies have identified an association childhood HTN.
studies firmly establish an increasing between SDB and HTN in the
prevalence of HTN with increasing pediatric population.40–42 Studies 2.4 Importance of Diagnosing HTN in
BMI percentile. The study results suggest that children who sleep Children and Adolescents
also underscore the importance of 7 hours or less per night are at Numerous studies have shown that
monitoring BP in all children with increased risk for HTN.43 Small elevated BP in childhood increases
overweight and/or obesity at every studies of youth with sleep disorders the risk for adult HTN and metabolic
clinical encounter. have found the prevalence of high BP syndrome.10,60–62 Youth with higher
Obesity in children with HTN may to range between 3.6% and 14%.40,41 BP levels in childhood are also more
be accompanied by additional The more severe the OSAS, the more likely to have persistent HTN as
cardiometabolic risk factors (eg, likely a child is to have HTN.44,45 adults.60,63 One recent study found
dyslipidemia and disordered glucose Even inadequate duration of sleep that adolescents with elevated
metabolism)36,37 that may have their and poor-quality sleep have been BP progressed to HTN at a rate
own effects on BP or may represent associated with elevated BP.43 of 7% per year, and elevated BMI
comorbid conditions arising from the predicted sustained BP elevations.64
same adverse lifestyle behaviors.25,38
2.3c Children With CKD In addition, young patients with HTN
Some argue that the presence of There are well-established are likely to experience accelerated
multiple risk factors, including pathophysiologic links between vascular aging. Both autopsy65 and
obesity and HTN, leads to far greater childhood HTN and CKD. Certain imaging studies66 have demonstrated
increases in CV risk than is explained forms of CKD can lead to HTN, and BP-related CV damage in youth.
by the individual risk factors alone. untreated HTN can lead to CKD in These intermediate markers of CVD
Although this phenomenon has been adults, although evidence for the (eg, increased LV mass,67 cIMT,68 and


pulse wave velocity [PWV]69) are TABLE 3 Updated Definitions of BP Categories and Stages
known to predict CV events in adults, For Children Aged 1–13 y For Children Aged ≥13 y
making it crucial to diagnose and Normal BP: <90th percentile Normal BP: <120/<80 mm Hg
treat HTN early. Elevated BP: ≥90th percentile to <95th percentile or 120/80 Elevated BP: 120/<80 to 129/<80 mm Hg
mm Hg to <95th percentile (whichever is lower)
Eighty million US adults (1 in 3) have
Stage 1 HTN: ≥95th percentile to <95th percentile + 12 mmHg, Stage 1 HTN: 130/80 to 139/89 mm Hg
HTN, which is a major contributor or 130/80 to 139/89 mm Hg (whichever is lower)
to CVD.12 Key contributors to CV Stage 2 HTN: ≥95th percentile + 12 mm Hg, or ≥140/90 mm Hg Stage 2 HTN: ≥140/90 mm Hg
health have been identified by the (whichever is lower)
American Heart Association (AHA)
as “Life’s Simple 7,” including 4
disorder. Early detection of HTN lower. HTN was defined as average
ideal health behaviors (not smoking,
is vital given the greater relative clinic measured SBP and/or DBP
normal BMI, physical activity at goal
prevalence of secondary causes of ≥95th percentile (on the basis of
levels, and a healthy diet) and 3 ideal
HTN in children compared with age, sex, and height percentiles)
health factors (untreated, normal
adults. and was further classified as stage 1
total cholesterol; normal fasting
or stage 2 HTN.
blood glucose; and normal untreated
BP, defined in childhood as ≤90th There are still no data to identify
3. DEFINITION OF HTN
percentile or <120/80 mm Hg). a specific level of BP in childhood
Notably, elevated BP is the least 3.1 Definition of HTN (1–18 Years of that leads to adverse CV outcomes
common abnormal health factor in Age) in adulthood. Therefore, the
children and adolescents70; 89% of subcommittee decided to
Given the lack of outcome data,
youth (ages 12–19 years) are in the maintain a statistical definition
the current definition of HTN in
ideal BP category.6 for childhood HTN. The staging
children and adolescents is based
criteria have been revised for
Given the prevalence of known key on the normative distribution of
stage 1 and stage 2 HTN for ease
contributors in youth (ie, tobacco BP in healthy children.1 Because
of implementation compared with
exposure, obesity, inactivity, and it is a major determinant of BP in
the Fourth Report. For children
nonideal diet12,71), adult CVD likely growing children, height has been
≥13 years of age, this staging
has its origins in childhood. One- incorporated into the normative
scheme will seamlessly interface
third of US adolescents report data since the publication of the
with the 2017 AHA and American
having tried a cigarette in the past 1996 Working Group Report.1 BP
College of Cardiology (ACC) adult
30 days.72 Almost half (40%–48%) levels should be interpreted on
HTN guideline.* Additionally, the
of teenagers have elevated BMI, the basis of sex, age, and height to
term “prehypertension” has been
and the rates of severe obesity avoid misclassification of children
replaced by the term “elevated
(BMI >99th percentile) continue who are either extremely tall or
blood pressure,” to be consistent
to climb, particularly in girls and extremely short. It should be noted
with the AHA and ACC guideline
adolescents.73–75 Physical activity that the normative data were
and convey the importance of
measured by accelerometry shows collected by using an auscultatory
lifestyle measures to prevent the
less than half of school-aged boys technique,1 which may provide
development of HTN (see Table 3).
and only one-third of school-aged different values than measurement
girls meet the goal for ideal physical obtained by using oscillometric 3.2 New BP Tables
activity levels.72 More than 80% devices or from ABPM.
New normative BP tables based on
of youth 12 to 19 years of age In the Fourth Report, “normal blood normal-weight children are included
have a poor diet (as defined by pressure” was defined as SBP and with these guidelines (see Tables 4
AHA metrics for ideal CV health); DBP values <90th percentile (on and 5). Similar to the tables in the
only ∼10% eat adequate fruits the basis of age, sex, and height
and vegetables, and only ∼15% percentiles). For the preadolescent,
consume <1500 mg per day of “prehypertension” was defined as
sodium, both of which are key SBP and/or DBP ≥90th percentile *Whelton PK, Carey RM, Aranow WS, et al. ACC/
dietary determinants of HTN.76 and <95th percentile (on the basis AHA/APPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/
Finally, measuring BP at routine of age, sex, and height tables). For PCNA Guideline for the prevention, detection,
well-child visits enables the early adolescents, “prehypertension” evaluation and managament of high blood
pressure in adults: A report of the American
detection of primary HTN as well as was defined as BP ≥120/80 mm Hg
College of Cardiology/American Heart Association
the detection of asymptomatic HTN to <95th percentile, or ≥90th and Task Force on Clinical Practice Guidelines.
secondary to another underlying <95th percentile, whichever was Hypertension. 2017, In press.


Fourth Report,1 they include SBP and understand that the scheme in Table In an attempt to develop a more
DBP values arranged by age, sex, and 3 was chosen to align with the new standardized approach to the HTN
height (and height percentile). These adult guideline and facilitate the definition in preterm and term
values are based on auscultatory management of older adolescents neonates, Dionne et al79 compiled
measurements obtained from with high BP. The percentile- available data on neonatal BP and
∼50 000 children and adolescents. A based values in Tables 4 and 5 are generated a summary table of BP
new feature in these tables is that the provided to aid researchers and values, including values for the 95th
BP values are categorized according others interested in a more precise and 99th percentiles for infants from
to the scheme presented in Table 3 classification of BP. 26 to 44 weeks’ postmenstrual age.
as normal (50th percentile), elevated The authors proposed that by using
BP (>90th percentile), stage 1 HTN 3.2a. Simplified BP Table these values, a similar approach to
(≥95th percentile), and stage 2 HTN This guideline includes a new, that used to identify older children
(≥95th percentile + 12 mm Hg). simplified table for initial BP with elevated BP can be followed in
Additionally, actual heights in screening (see Table 6) based on neonates, even in those who are born
centimeters and inches are provided. the 90th percentile BP for age and preterm.
sex for children at the 5th percentile
Unlike the tables in the Fourth At present, no alternative data have
of height, which gives the values in
Report,1 the BP values in these been developed, and no outcome data
the table a negative predictive value
tables do not include children and are available on the consequences of
of >99%.78 This simplified table is
adolescents with overweight and high BP in this population; thus, it is
designed as a screening tool only
obesity (ie, those with a BMI ≥85th reasonable to use these compiled BP
for the identification of children
percentile); therefore, they represent values in the assessment of elevated
and adolescents who need further
normative BP values for normal- BP in newborn infants. Of note, the
evaluation of their BP starting with
weight youth. The decision to create 1987 “Report of the Second Task
repeat BP measurements. It should
these new tables was based on Force on Blood Pressure Control
not be used to diagnose elevated
evidence of the strong association in Children” published curves
BP or HTN by itself. To diagnose
of both overweight and obesity with of normative BP values in older
elevated BP or HTN, it is important
elevated BP and HTN. Including infants up to 1 year of age.81 These
to locate the actual cutoffs in the
patients with overweight and normative values should continue
complete BP tables because the SBP
obesity in normative BP tables was to be used given the lack of more
and DBP cutoffs may be as much as 9
thought to create bias. The practical contemporary data for this age group.
mm Hg higher depending on a child’s
effect of this change is that the BP
age and length or height. A typical-
values in Tables 4 and 5 are several
use case for this simplified table is
millimeters of mercury lower than 4. MEASUREMENT OF BP
for nursing staff to quickly identify
in the similar tables in the Fourth
BP that may need further evaluation
Report.1 These tables are based on 4.1 BP Measurement Technique
by a clinician. For adolescents ≥13
the same population data excluding
years of age, a threshold of 120/80 BP in childhood may vary
participants with overweight and
mm Hg is used in the simplified considerably between visits and
obesity, and the same methods used
table regardless of sex to align with even during the same visit. There
in the Fourth Report.1 The methods
adult guidelines for the detection of are many potential etiologies for
and results have been published
elevated BP. isolated elevated BP in children and
elsewhere.77 For researchers and
adolescents, including such factors as
others interested in the equations 3.3 Definition of HTN in the Neonate anxiety and recent caffeine intake.82
used to calculate the tables’ BP and Infant (0–1 Year of Age) BP generally decreases with repeated
values, detailed methodology and
Although a reasonably strict measurements during a single visit,83
the Statistical Analysis System (SAS)
definition of HTN has been developed although the variability may
code can be found at: http://sites.
for older children, it is more difficult not be large enough to affect BP
google.com/a/channing.harvard.
to define HTN in neonates given the classification.84 BP measurements
edu/bernardrosner/pediatric-blood-
well-known changes in BP that occur can also vary across visits64,85; one
press/childhood-blood-pressure.
during the first few weeks of life.79 study in adolescents found that only
There are slight differences between These BP changes can be significant 56% of the sample had the same
the actual percentile-based values in preterm infants, in whom BP HTN stage on 3 different occasions.8
in these tables and the cut-points in depends on a variety of factors, Therefore, it is important to obtain
Table 3, particularly for teenagers including postmenstrual age, birth multiple measurements over time
≥13 years of age. Clinicians should weight, and maternal conditions.80 before diagnosing HTN.


Flynn et al
TABLE 4 BP Levels for Boys by Age and Height Percentile
Age (y) BP Percentile SBP (mm Hg) DBP (mm Hg)
Height Percentile or Measured Height Height Percentile or Measured Height
5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95%
1 Height (in) 30.4 30.8 31.6 32.4 33.3 34.1 34.6 30.4 30.8 31.6 32.4 33.3 34.1 34.6
Height (cm) 77.2 78.3 80.2 82.4 84.6 86.7 87.9 77.2 78.3 80.2 82.4 84.6 86.7 87.9
50th 85 85 86 86 87 88 88 40 40 40 41 41 42 42
90th 98 99 99 100 100 101 101 52 52 53 53 54 54 54
95th 102 102 103 103 104 105 105 54 54 55 55 56 57 57
95th + 12 mm Hg 114 114 115 115 116 117 117 66 66 67 67 68 69 69
Clinical Practice Guideline for Screening

2 Height (in) 33.9 34.4 35.3 36.3 37.3 38.2 38.8 33.9 34.4 35.3 36.3 37.3 38.2 38.8
Height (cm) 86.1 87.4 89.6 92.1 94.7 97.1 98.5 86.1 87.4 89.6 92.1 94.7 97.1 98.5
50th 87 87 88 89 89 90 91 43 43 44 44 45 46 46
90th 100 100 101 102 103 103 104 55 55 56 56 57 58 58
PEDIATRICS Volume 140, number 3, September 2017

95th 104 105 105 106 107 107 108 57 58 58 59 60 61 61
95th + 12 mm Hg 116 117 117 118 119 119 120 69 70 70 71 72 73 73
2017
3 Height (in) 36.4 37 37.9 39 40.1 41.1 41.7 36.4 37 37.9 39 40.1 41.1 41.7
Height (cm) 92.5 93.9 96.3 99 101.8 104.3 105.8 92.5 93.9 96.3 99 101.8 104.3 105.8
50th 88 89 89 90 91 92 92 45 46 46 47 48 49 49
90th 101 102 102 103 104 105 105 58 58 59 59 60 61 61
95th 106 106 107 107 108 109 109 60 61 61 62 63 64 64
95th + 12 mm Hg 118 118 119 119 120 121 121 72 73 73 74 75 76 76
4 Height (in) 38.8 39.4 40.5 41.7 42.9 43.9 44.5 38.8 39.4 40.5 41.7 42.9 43.9 44.5
Height (cm) 98.5 100.2 102.9 105.9 108.9 111.5 113.2 98.5 100.2 102.9 105.9 108.9 111.5 113.2
50th 90 90 91 92 93 94 94 48 49 49 50 51 52 52
90th 102 103 104 105 105 106 107 60 61 62 62 63 64 64
95th 107 107 108 108 109 110 110 63 64 65 66 67 67 68
95th + 12 mm Hg 119 119 120 120 121 122 122 75 76 77 78 79 79 80
5 Height (in) 41.1 41.8 43.0 44.3 45.5 46.7 47.4 41.1 41.8 43.0 44.3 45.5 46.7 47.4
Height (cm) 104.4 106.2 109.1 112.4 115.7 118.6 120.3 104.4 106.2 109.1 112.4 115.7 118.6 120.3
https://doi.org/10.1542/peds.2017-1904
50th 91 92 93 94 95 96 96 51 51 52 53 54 55 55
90th 103 104 105 106 107 108 108 63 64 65 65 66 67 67
95th 107 108 109 109 110 111 112 66 67 68 69 70 70 71
95th + 12 mm Hg 119 120 121 121 122 123 124 78 79 80 81 82 82 83
6 Height (in) 43.4 44.2 45.4 46.8 48.2 49.4 50.2 43.4 44.2 45.4 46.8 48.2 49.4 50.2
Height (cm) 110.3 112.2 115.3 118.9 122.4 125.6 127.5 110.3 112.2 115.3 118.9 122.4 125.6 127.5
50th 93 93 94 95 96 97 98 54 54 55 56 57 57 58
90th 105 105 106 107 109 110 110 66 66 67 68 68 69 69

95th 108 109 110 111 112 113 114 69 70 70 71 72 72 73
September 2017
95th + 12 mm Hg 120 121 122 123 124 125 126 81 82 82 83 84 84 85
7 Height (in) 45.7 46.5 47.8 49.3 50.8 52.1 52.9 45.7 46.5 47.8 49.3 50.8 52.1 52.9
Height (cm) 116.1 118 121.4 125.1 128.9 132.4 134.5 116.1 118 121.4 125.1 128.9 132.4 134.5
ROUGH GALLEY PROOF

50th 94 94 95 97 98 98 99 56 56 57 58 58 59 59
90th 106 107 108 109 110 111 111 68 68 69 70 70 71 71
95th 110 110 111 112 114 115 116 71 71 72 73 73 74 74
95th + 12 mm Hg 122 122 123 124 126 127 128 83 83 84 85 85 86 86
9
Flynn et al
10
TABLE 4 Continued
5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95%
8 Height (in) 47.8 48.6 50 51.6 53.2 54.6 55.5 47.8 48.6 50 51.6 53.2 54.6 55.5
Height (cm) 121.4 123.5 127 131 135.1 138.8 141 121.4 123.5 127 131 135.1 138.8 141
50th 95 96 97 98 99 99 100 57 57 58 59 59 60 60
90th 107 108 109 110 111 112 112 69 70 70 71 72 72 73
95th 111 112 112 114 115 116 117 72 73 73 74 75 75 75
95th + 12 mm Hg 123 124 124 126 127 128 129 84 85 85 86 87 87 87
9 Height (in) 49.6 50.5 52 53.7 55.4 56.9 57.9 49.6 50.5 52 53.7 55.4 56.9 57.9

Height (cm) 126 128.3 132.1 136.3 140.7 144.7 147.1 126 128.3 132.1 136.3 140.7 144.7 147.1
50th 96 97 98 99 100 101 101 57 58 59 60 61 62 62
90th 107 108 109 110 112 113 114 70 71 72 73 74 74 74
95th 112 112 113 115 116 118 119 74 74 75 76 76 77 77
95th + 12 mm Hg 124 124 125 127 128 130 131 86 86 87 88 88 89 89
2017
10 Height (in) 51.3 52.2 53.8 55.6 57.4 59.1 60.1 51.3 52.2 53.8 55.6 57.4 59.1 60.1
Height (cm) 130.2 132.7 136.7 141.3 145.9 150.1 152.7 130.2 132.7 136.7 141.3 145.9 150.1 152.7
50th 97 98 99 100 101 102 103 59 60 61 62 63 63 64
90th 108 109 111 112 113 115 116 72 73 74 74 75 75 76
95th 112 113 114 116 118 120 121 76 76 77 77 78 78 78
95th + 12 mm Hg 124 125 126 128 130 132 133 88 88 89 89 90 90 90
11 Height (in) 53 54 55.7 57.6 59.6 61.3 62.4 53 54 55.7 57.6 59.6 61.3 62.4
Height (cm) 134.7 137.3 141.5 146.4 151.3 155.8 158.6 134.7 137.3 141.5 146.4 151.3 155.8 158.6
50th 99 99 101 102 103 104 106 61 61 62 63 63 63 63
90th 110 111 112 114 116 117 118 74 74 75 75 75 76 76
95th 114 114 116 118 120 123 124 77 78 78 78 78 78 78
95th + 12 mm Hg 126 126 128 130 132 135 136 89 90 90 90 90 90 90
12 Height (in) 55.2 56.3 58.1 60.1 62.2 64 65.2 55.2 56.3 58.1 60.1 62.2 64 65.2
Height (cm) 140.3 143 147.5 152.7 157.9 162.6 165.5 140.3 143 147.5 152.7 157.9 162.6 165.5
50th 101 101 102 104 106 108 109 61 62 62 62 62 63 63
90th 113 114 115 117 119 121 122 75 75 75 75 75 76 76
95th 116 117 118 121 124 126 128 78 78 78 78 78 79 79
95th + 12 mm Hg 128 129 130 133 136 138 140 90 90 90 90 90 91 91
13 Height (in) 57.9 59.1 61 63.1 65.2 67.1 68.3 57.9 59.1 61 63.1 65.2 67.1 68.3
Height (cm) 147 150 154.9 160.3 165.7 170.5 173.4 147 150 154.9 160.3 165.7 170.5 173.4
50th 103 104 105 108 110 111 112 61 60 61 62 63 64 65
90th 115 116 118 121 124 126 126 74 74 74 75 76 77 77
95th 119 120 122 125 128 130 131 78 78 78 78 80 81 81

95th + 12 mm Hg 131 132 134 137 140 142 143 90 90 90 90 92 93 93
September 2017
14 Height (in) 60.6 61.8 63.8 65.9 68.0 69.8 70.9 60.6 61.8 63.8 65.9 68.0 69.8 70.9
Height (cm) 153.8 156.9 162 167.5 172.7 177.4 180.1 153.8 156.9 162 167.5 172.7 177.4 180.1
50th 105 106 109 111 112 113 113 60 60 62 64 65 66 67
ROUGH GALLEY PROOF

90th 119 120 123 126 127 128 129 74 74 75 77 78 79 80
95th 123 125 127 130 132 133 134 77 78 79 81 82 83 84
95th + 12 mm Hg 135 137 139 142 144 145 146 89 90 91 93 94 95 96
FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al
TABLE 4 Continued
5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95%
15 Height (in) 62.6 63.8 65.7 67.8 69.8 71.5 72.5 62.6 63.8 65.7 67.8 69.8 71.5 72.5
Height (cm) 159 162 166.9 172.2 177.2 181.6 184.2 159 162 166.9 172.2 177.2 181.6 184.2
50th 108 110 112 113 114 114 114 61 62 64 65 66 67 68
90th 123 124 126 128 129 130 130 75 76 78 79 80 81 81
95th 127 129 131 132 134 135 135 78 79 81 83 84 85 85
95th + 12 mm Hg 139 141 143 144 146 147 147 90 91 93 95 96 97 97
16 Height (in) 63.8 64.9 66.8 68.8 70.7 72.4 73.4 63.8 64.9 66.8 68.8 70.7 72.4 73.4

Height (cm) 162.1 165 169.6 174.6 179.5 183.8 186.4 162.1 165 169.6 174.6 179.5 183.8 186.4
50th 111 112 114 115 115 116 116 63 64 66 67 68 69 69
90th 126 127 128 129 131 131 132 77 78 79 80 81 82 82

95th 130 131 133 134 135 136 137 80 81 83 84 85 86 86
95th + 12 mm Hg 142 143 145 146 147 148 149 92 93 95 96 97 98 98
2017
17 Height (in) 64.5 65.5 67.3 69.2 71.1 72.8 73.8 64.5 65.5 67.3 69.2 71.1 72.8 73.8
Height (cm) 163.8 166.5 170.9 175.8 180.7 184.9 187.5 163.8 166.5 170.9 175.8 180.7 184.9 187.5
50th 114 115 116 117 117 118 118 65 66 67 68 69 70 70
90th 128 129 130 131 132 133 134 78 79 80 81 82 82 83
95th 132 133 134 135 137 138 138 81 82 84 85 86 86 87
95th + 12 mm Hg 144 145 146 147 149 150 150 93 94 96 97 98 98 99
Use percentile values to stage BP readings according to the scheme in Table 3 (elevated BP: ≥90th percentile; stage 1 HTN: ≥95th percentile; and stage 2 HTN: ≥95th percentile + 12 mm Hg). The 50th, 90th, and 95th percentiles were derived by using
quantile regression on the basis of normal-weight children (BMI <85th percentile).77
September 2017
ROUGH GALLEY PROOF
11
Flynn et al
12
TABLE 5 BP Levels for Girls by Age and Height Percentile
5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95%
1 Height (in) 29.7 30.2 30.9 31.8 32.7 33.4 33.9 29.7 30.2 30.9 31.8 32.7 33.4 33.9
Height (cm) 75.4 76.6 78.6 80.8 83 84.9 86.1 75.4 76.6 78.6 80.8 83 84.9 86.1
50th 84 85 86 86 87 88 88 41 42 42 43 44 45 46
90th 98 99 99 100 101 102 102 54 55 56 56 57 58 58
95th 101 102 102 103 104 105 105 59 59 60 60 61 62 62
95th + 12 mm Hg 113 114 114 115 116 117 117 71 71 72 72 73 74 74

2 Height (in) 33.4 34 34.9 35.9 36.9 37.8 38.4 33.4 34 34.9 35.9 36.9 37.8 38.4
Height (cm) 84.9 86.3 88.6 91.1 93.7 96 97.4 84.9 86.3 88.6 91.1 93.7 96 97.4
50th 87 87 88 89 90 91 91 45 46 47 48 49 50 51
90th 101 101 102 103 104 105 106 58 58 59 60 61 62 62
95th 104 105 106 106 107 108 109 62 63 63 64 65 66 66
95th + 12 mm Hg 116 117 118 118 119 120 121 74 75 75 76 77 78 78
2017
3 Height (in) 35.8 36.4 37.3 38.4 39.6 40.6 41.2 35.8 36.4 37.3 38.4 39.6 40.6 41.2
Height (cm) 91 92.4 94.9 97.6 100.5 103.1 104.6 91 92.4 94.9 97.6 100.5 103.1 104.6
50th 88 89 89 90 91 92 93 48 48 49 50 51 53 53
90th 102 103 104 104 105 106 107 60 61 61 62 63 64 65
95th 106 106 107 108 109 110 110 64 65 65 66 67 68 69
95th + 12 mm Hg 118 118 119 120 121 122 122 76 77 77 78 79 80 81
4 Height (in) 38.3 38.9 39.9 41.1 42.4 43.5 44.2 38.3 38.9 39.9 41.1 42.4 43.5 44.2
Height (cm) 97.2 98.8 101.4 104.5 107.6 110.5 112.2 97.2 98.8 101.4 104.5 107.6 110.5 112.2
50th 89 90 91 92 93 94 94 50 51 51 53 54 55 55
90th 103 104 105 106 107 108 108 62 63 64 65 66 67 67
95th 107 108 109 109 110 111 112 66 67 68 69 70 70 71
95th + 12 mm Hg 119 120 121 121 122 123 124 78 79 80 81 82 82 83
5 Height (in) 40.8 41.5 42.6 43.9 45.2 46.5 47.3 40.8 41.5 42.6 43.9 45.2 46.5 47.3
Height (cm) 103.6 105.3 108.2 111.5 114.9 118.1 120 103.6 105.3 108.2 111.5 114.9 118.1 120
50th 90 91 92 93 94 95 96 52 52 53 55 56 57 57
90th 104 105 106 107 108 109 110 64 65 66 67 68 69 70
95th 108 109 109 110 111 112 113 68 69 70 71 72 73 73
95th + 12 mm Hg 120 121 121 122 123 124 125 80 81 82 83 84 85 85
6 Height (in) 43.3 44 45.2 46.6 48.1 49.4 50.3 43.3 44 45.2 46.6 48.1 49.4 50.3
Height (cm) 110 111.8 114.9 118.4 122.1 125.6 127.7 110 111.8 114.9 118.4 122.1 125.6 127.7
50th 92 92 93 94 96 97 97 54 54 55 56 57 58 59
90th 105 106 107 108 109 110 111 67 67 68 69 70 71 71

95th 109 109 110 111 112 113 114 70 71 72 72 73 74 74
September 2017
95th + 12 mm Hg 121 121 122 123 124 125 126 82 83 84 84 85 86 86
7 Height (in) 45.6 46.4 47.7 49.2 50.7 52.1 53 45.6 46.4 47.7 49.2 50.7 52.1 53
Height (cm) 115.9 117.8 121.1 124.9 128.8 132.5 134.7 115.9 117.8 121.1 124.9 128.8 132.5 134.7
ROUGH GALLEY PROOF

50th 92 93 94 95 97 98 99 55 55 56 57 58 59 60
90th 106 106 107 109 110 111 112 68 68 69 70 71 72 72
95th 109 110 111 112 113 114 115 72 72 73 73 74 74 75
95th + 12 mm Hg 121 122 123 124 125 126 127 84 84 85 85 86 86 87

Flynn et al
TABLE 5 Continued
5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95%
8 Height (in) 47.6 48.4 49.8 51.4 53 54.5 55.5 47.6 48.4 49.8 51.4 53 54.5 55.5
Height (cm) 121 123 126.5 130.6 134.7 138.5 140.9 121 123 126.5 130.6 134.7 138.5 140.9
50th 93 94 95 97 98 99 100 56 56 57 59 60 61 61
90th 107 107 108 110 111 112 113 69 70 71 72 72 73 73
95th 110 111 112 113 115 116 117 72 73 74 74 75 75 75
95th + 12 mm Hg 122 123 124 125 127 128 129 84 85 86 86 87 87 87
9 Height (in) 49.3 50.2 51.7 53.4 55.1 56.7 57.7 49.3 50.2 51.7 53.4 55.1 56.7 57.7

Height (cm) 125.3 127.6 131.3 135.6 140.1 144.1 146.6 125.3 127.6 131.3 135.6 140.1 144.1 146.6
50th 95 95 97 98 99 100 101 57 58 59 60 60 61 61
90th 108 108 109 111 112 113 114 71 71 72 73 73 73 73

95th 112 112 113 114 116 117 118 74 74 75 75 75 75 75
95th + 12 mm Hg 124 124 125 126 128 129 130 86 86 87 87 87 87 87
2017
10 Height (in) 51.1 52 53.7 55.5 57.4 59.1 60.2 51.1 52 53.7 55.5 57.4 59.1 60.2
Height (cm) 129.7 132.2 136.3 141 145.8 150.2 152.8 129.7 132.2 136.3 141 145.8 150.2 152.8
50th 96 97 98 99 101 102 103 58 59 59 60 61 61 62
90th 109 110 111 112 113 115 116 72 73 73 73 73 73 73
95th 113 114 114 116 117 119 120 75 75 76 76 76 76 76
95th + 12 mm Hg 125 126 126 128 129 131 132 87 87 88 88 88 88 88
11 Height (in) 53.4 54.5 56.2 58.2 60.2 61.9 63 53.4 54.5 56.2 58.2 60.2 61.9 63
Height (cm) 135.6 138.3 142.8 147.8 152.8 157.3 160 135.6 138.3 142.8 147.8 152.8 157.3 160
50th 98 99 101 102 104 105 106 60 60 60 61 62 63 64
90th 111 112 113 114 116 118 120 74 74 74 74 74 75 75
95th 115 116 117 118 120 123 124 76 77 77 77 77 77 77
95th + 12 mm Hg 127 128 129 130 132 135 136 88 89 89 89 89 89 89
12 Height (in) 56.2 57.3 59 60.9 62.8 64.5 65.5 56.2 57.3 59 60.9 62.8 64.5 65.5
Height (cm) 142.8 145.5 149.9 154.8 159.6 163.8 166.4 142.8 145.5 149.9 154.8 159.6 163.8 166.4
50th 102 102 104 105 107 108 108 61 61 61 62 64 65 65
90th 114 115 116 118 120 122 122 75 75 75 75 76 76 76
95th 118 119 120 122 124 125 126 78 78 78 78 79 79 79
95th + 12 mm Hg 130 131 132 134 136 137 138 90 90 90 90 91 91 91
13 Height (in) 58.3 59.3 60.9 62.7 64.5 66.1 67 58.3 59.3 60.9 62.7 64.5 66.1 67
Height (cm) 148.1 150.6 154.7 159.2 163.7 167.8 170.2 148.1 150.6 154.7 159.2 163.7 167.8 170.2
50th 104 105 106 107 108 108 109 62 62 63 64 65 65 66
90th 116 117 119 121 122 123 123 75 75 75 76 76 76 76
95th 121 122 123 124 126 126 127 79 79 79 79 80 80 81

95th + 12 mm Hg 133 134 135 136 138 138 139 91 91 91 91 92 92 93
September 2017
14 Height (in) 59.3 60.2 61.8 63.5 65.2 66.8 67.7 59.3 60.2 61.8 63.5 65.2 66.8 67.7
Height (cm) 150.6 153 156.9 161.3 165.7 169.7 172.1 150.6 153 156.9 161.3 165.7 169.7 172.1
50th 105 106 107 108 109 109 109 63 63 64 65 66 66 66
ROUGH GALLEY PROOF

90th 118 118 120 122 123 123 123 76 76 76 76 77 77 77
95th 123 123 124 125 126 127 127 80 80 80 80 81 81 82
95th + 12 mm Hg 135 135 136 137 138 139 139 92 92 92 92 93 93 94
13
The initial BP measurement may
Use percentile values to stage BP readings according to the scheme in Table 3 (elevated BP: ≥90th percentile; stage 1 HTN: ≥95th percentile; and stage 2 HTN: ≥95th percentile + 12 mm Hg). The 50th, 90th, and 95th percentiles were derived by using
be oscillometric (on a calibrated
68.4
173.7
68.3
173.4
68.1
95%
94
67
78
82
67
78
82
94
78
82
94
173
67
machine that has been validated for

use in the pediatric population) or
auscultatory (by using a mercury or
67.4
171.3
67.3
171.1
67.2
170.6
90%
94
66
78
82
67
78
82
94
67
78
82
94
aneroid sphygmomanometer86,87).
(Validation status for oscillometric
Height Percentile or Measured Height
BP devices, including whether they

65.9
167.4
65.8
167.1
65.6
166.7
75%
66
78
82
94
78
82
94
82
94
66
66
77
are validated in the pediatric age

group, can be checked at www.
DBP (mm Hg)
dableducational.org.) BP should be
64.2
163.0
64.1
162.8
63.9
162.3
50%
measured in the right arm by using

81
93
81
93
66
77
93
66
77
65
77
81
standard measurement practices

unless the child has atypical aortic
62.5
158.7
62.4
158.4
62.2
157.9
25%
arch anatomy, such as right aortic

77
80
92
80
92
65
80
92
65
76
64
76
arch and aortic coarctation or left

aortic arch with aberrant right
60.9
154.7
60.8
154.5
60.6
subclavian artery (see Table 7).

10%
64
76
80
92
80
92
64
76
80
92
154
64
76
Other important aspects of proper

BP measurement are illustrated in
an AAP video available at http://
60.0
152.4
59.9
152.1
59.7
151.7
5%
64
76
80
92
64
76
80
92
64
76
80
92
youtu.be/JLzkNBpqwi0. Care
should be taken that providers
follow an accurate and consistent
68.4
173.7
68.3
173.4
68.1
95%
128
140
140
111
125
140
110
124
128
173
109
124
128
measurement technique.88,89
An appropriately sized cuff should be
67.4
171.3
67.3
171.1
67.2
170.6
used for accurate BP measurement.83

90%
128
140
128
140
110
125
139
110
124
109
123
127
Researchers in 3 studies in the United

Kingdom and 1 in Brazil documented
Height Percentile or Measured Height
the lack of availability of an

65.9
167.4
65.8
167.1
65.6
166.7
75%
128
140
139
110
124
139
109
124
127
109
123
127
appropriately sized cuff in both the

inpatient and outpatient settings.91–94
SBP (mm Hg)
Pediatric offices should have access

64.2
163.0
64.1
162.8
63.9
162.3
50%
139
139
110
124
127
109
123
127
108
122
126
138
to a wide range of cuff sizes, including

a thigh cuff for use in children and
adolescents with severe obesity. For
62.5
158.7
62.4
158.4
62.2
157.9
25%
quantile regression on the basis of normal-weight children (BMI <85th percentile).77

109
123
126
138
108
122
125
137
107
121
125
137
children in whom the appropriate

cuff size is difficult to determine, the
midarm circumference (measured as
60.9
154.7
60.8
154.5
60.6
10%
125
137
125
137
108
121
136
107
120
154
106
119
124
the midpoint between the acromion

of the scapula and olecranon of the
elbow, with the shoulder in a neutral
60.0
152.4
59.9
152.1
59.7
151.7
5%
position and the elbow flexed to

124
136
107
120
125
137
124
136
106
119
105
118
90°86,95,96) should be obtained for an

accurate determination of the correct
95th + 12 mm Hg
95th + 12 mm Hg
95th + 12 mm Hg
cuff size (see Fig 2 and Table 7).95

BP Percentile
Height (cm)
Height (cm)
Height (cm)
Height (in)
Height (in)
Height (in)
50th
90th
95th
50th
90th
95th
50th
90th
95th
If the initial BP is elevated (≥90th

percentile), providers should
perform 2 additional oscillometric
TABLE 5 Continued
or auscultatory BP measurements
at the same visit and average them.
If using auscultation, this averaged
Age (y)
measurement is used to determine

17
16
15
the child’s BP category (ie, normal,


TABLE 6 Screening BP Values Requiring
Further Evaluation
Age, y BP, mm Hg
Boys Girls
Systolic DBP Systolic DBP
1 98 52 98 54
2 100 55 101 58
3 101 58 102 60
4 102 60 103 62
5 103 63 104 64
6 105 66 105 67
7 106 68 106 68
8 107 69 107 69
9 107 70 108 71
10 108 72 109 72
11 110 74 111 74
12 113 75 114 75
≥13 120 80 120 80
elevated BP, stage 1 HTN, or stage 2

HTN). If the averaged oscillometric
reading is ≥90th percentile, 2
auscultatory measurements should
FIGURE 1
be taken and averaged to define the AAP grading matrix.
BP category (see Fig 3).
4.1a Measurement of BP in the Neonate and toddlers). Normative values for Offices that will be obtaining BP
Multiple methods are available neonatal and infant BP have generally measurements in neonates need to
for the measurement of BP in been determined in the right upper have a variety of cuff sizes available.
hospitalized neonates, including arm with the infant supine, and a In addition, the oscillometric device
direct intra-arterial measurements similar approach should be followed used should be validated in neonates
using indwelling catheters as well in the outpatient setting. and programmed to have an initial
as indirect measurements using inflation value appropriate for
the oscillometric technique. In the As with older children, proper infants (generally ≤120 mm Hg).
office, however, the oscillometric cuff size is important in obtaining Auscultation becomes technically
technique typically is used at least accurate BP readings in neonates. feasible once the infant’s upper arm
until the infant is able to cooperate The cuff bladder length should is large enough for the smallest cuff
with manual BP determination encircle 80% to 100% of the arm available for auscultatory devices.
(which also depends on the ability circumference; a cuff bladder with a Measurements are best taken when
of the individual measuring the BP width-to-arm circumference ratio of the infant is in a calm state; multiple
to obtain auscultatory BP in infants 0.45 to 0.55 is recommended.79,97,98 readings may be needed if the first
TABLE 7 Best BP Measurement Practices

1. The child should be seated in a quiet room for 3–5 min before measurement, with the back supported and feet uncrossed on the floor.
2. BP should be measured in the right arm for consistency, for comparison with standard tables, and to avoid a falsely low reading from the left arm in the
case of coarctation of the aorta. The arm should be at heart level,90 supported, and uncovered above the cuff. The patient and observer should not speak
while the measurement is being taken.
3. The correct cuff size should be used. The bladder length should be 80%–100% of the circumference of the arm, and the width should be at least 40%.
4. For an auscultatory BP, the bell of the stethoscope should be placed over the brachial artery in the antecubital fossa, and the lower end of the cuff should be
2–3 cm above the antecubital fossa. The cuff should be inflated to 20–30 mm Hg above the point at which the radial pulse disappears. Overinflation should
be avoided. The cuff should be deflated at a rate of 2–3 mm Hg per second. The first (phase I Korotkoff) and last (phase V Korotkoff) audible sounds should
be taken as SBP and DBP. If the Korotkoff sounds are heard to 0 mm Hg, the point at which the sound is muffled (phase IV Korotkoff) should be taken as the
DBP, or the measurement repeated with less pressure applied over the brachial artery. The measurement should be read to the nearest 2 mm Hg.
5. To measure BP in the legs, the patient should be in the prone position, if possible. An appropriately sized cuff should be placed midthigh and the stethoscope
placed over the popliteal artery. The SBP in the legs is usually 10%–20% higher than the brachial artery pressure.
Adapted from Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement
in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research.
Circulation. 2005;111(5):697–716.


to increase BP (see Table 8 and the
“Secondary Causes: Medication-
related” section of this guideline).112,113
Children younger than 3 years should
have BP measurements taken at
well-child care visits if they are at
increased risk for developing HTN
(see Table 9).1
Key Action Statement 1

BP should be measured annually
in children and adolescents ≥3
years of age (grade C, moderate
recommendation).

BP should be checked in all children
and adolescents ≥3 years of age at
every health care encounter if they
have obesity, are taking medications
known to increase BP, have renal
disease, a history of aortic arch
obstruction or coarctation, or
diabetes (see Table 9) (grade C,
moderate recommendation).
4.3 Patient Management on the

Basis of Office BP
4.3a Normal BP
If BP is normal or normalizes after
repeat readings (ie, BP <90th
percentile), then no additional action
is needed. Practitioners should
measure the BP at the next routine
well-child care visit.
FIGURE 2
Determination of proper BP cuff size.95 A, Marking spine extending from acromion process. B, Correct 4.3b Elevated BP
tape placement for upper arm length. C, Incorrect tape placement for upper arm length. D, Marking 1. If the BP reading is at the
upper arm length midpoint.
elevated BP level (Table 3),
lifestyle interventions should be
reading is elevated, similar to the the ambulatory setting beginning recommended (ie, healthy diet,
technique recommended for older at 3 years of age should remain sleep, and physical activity); the
children.99,100 unchanged.1 For otherwise healthy measurement should be repeated
children, however, BP need only in 6 months by auscultation.
4.2 BP Measurement Frequency be measured annually rather than Nutrition and/or weight
during every health care encounter. management referral should be
It remains unclear what age
is optimal to begin routine BP Some children should have BP considered as appropriate;
measurement in children, although measured at every health encounter, 2. If BP remains at the elevated BP
available data suggest that prevention specifically those with obesity (BMI level after 6 months, upper and
and intervention efforts should ≥95 percentile),5,27,107–109 renal lower extremity BP should be
begin at a young age.10,60,101–106 disease,46 diabetes,110,111 aortic arch checked (right arm, left arm, and
The subcommittee believes that the obstruction or coarctation, or those 1 leg), lifestyle counseling should
recommendation to measure BP in who are taking medications known be repeated, and BP should be


Key Action Statement 1. BP should be measured annually in children and the patient is asymptomatic,
adolescents ≥3 years of age (grade C, moderate recommendation). provide lifestyle counseling and
Aggregate Evidence Quality Grade C recheck the BP in 1 to 2 weeks by
Benefits Early detection of asymptomatic HTN; prevention of short- and long- auscultation;
term HTN-related morbidity
Risks, harm, cost Overtesting, misclassification, unnecessary treatment, discomfort 2. If the BP reading is still at the
from BP measurement procedure, time involved in measuring BP stage 1 level, upper and lower
Benefit–harm assessment Benefit of annual BP measurement exceeds potential harm extremity BP should be checked
Intentional vagueness None
Role of patient preferences Increased visit time, discomfort of cuff
(right arm, left arm, and 1 leg),
Exclusions None and BP should be rechecked in 3
Strength Moderate recommendation months by auscultation. Nutrition
Key references 10,60,102,103 and/or weight management
referral should be considered as
Key Action Statement 2. BP should be checked in all children and adolescents appropriate; and
≥3 years of age at every health care encounter if they have obesity, are taking
medications known to increase BP, have renal disease, a history of aortic 3. If BP continues to be at the stage
arch obstruction or coarctation, or diabetes (see Table 9) (grade C, moderate 1 HTN level after 3 visits, ABPM
recommendation).
should be ordered (if available),
Aggregate Evidence Quality Grade C diagnostic evaluation should be
Benefits Early detection of HTN and prevention of CV morbidity in predisposed
conducted, and treatment should
children and adolescents
Risks, harm, cost Time for and difficulty of conducting measurements be initiated. Subspecialty referral
Benefit–harm assessment Benefits exceed harm should be considered (see Table
Intentional vagueness Frequency of evaluation 11).
Role of patient preferences Increased visit time, discomfort of cuff
Exclusions Children and adolescents who are not at increased risk for HTN 4.3d Stage 2 HTN
Strength Moderate recommendation
Key references 27,46,107,110–112 1. If the BP reading is at the stage 2
HTN level (Table 3), upper and
rechecked in 6 months (ie, at (see Table 10 for a list of screening lower extremity BP should be
the next well-child care visit) by tests and the populations in checked (right arm, left arm, and
auscultation; which they should be performed). 1 leg), lifestyle recommendations
Consider subspecialty referral (ie, given, and the BP measurement
3. If BP continues at the elevated BP
cardiology or nephrology) (see should be repeated within 1 week.
level after 12 months (eg, after
Table 11); and Alternatively, the patient could
3 auscultatory measurements),
be referred to subspecialty care
ABPM should be ordered (if 4. If BP normalizes at any point,
within 1 week;
available), and diagnostic return to annual BP screening at
evaluation should be conducted well-child care visits. 2. If the BP reading is still at the
stage 2 HTN level when repeated,
then diagnostic evaluation,
4.3c Stage 1 HTN
TABLE 8 Common Pharmacologic Agents including ABPM, should be
Associated With Elevated BP in 1. If the BP reading is at the stage conducted and treatment should
Children 1 HTN level (Table 3) and be initiated, or the patient should
Over-the-counter Decongestants
drugs Caffeine
Nonsteroidal anti-
TABLE 9 Conditions Under Which Children Younger Than 3 Years Should Have BP Measured
inflammatory drugs History of prematurity <32 week’s gestation or small for gestational age, very low birth weight, other
Alternative therapies, neonatal complications requiring intensive care, umbilical artery line
herbal and nutritional Congenital heart disease (repaired or unrepaired)
supplements Recurrent urinary tract infections, hematuria, or proteinuria
Prescription Stimulants for attention- Known renal disease or urologic malformations
drugs deficit/hyperactivity Family history of congenital renal disease
disorder Solid-organ transplant
Hormonal contraception Malignancy or bone marrow transplant
Steroids Treatment with drugs known to raise BP
Tricyclic antidepressants Other systemic illnesses associated with HTN (neurofibromatosis, tuberous sclerosis, sickle cell
Illicit drugs Amphetamines disease,114 etc)
Cocaine Evidence of elevated intracranial pressure
Adapted from the Fourth Report.1 Adapted from Table 3 in the Fourth Report.1


Key Action Statement 3. Trained health care professionals in the office setting decision support in conjunction with
should make a diagnosis of HTN if a child or adolescent has auscultatory- an EHR in adult populations has also
confirmed BP readings ≥95th percentile on 3 different visits (grade C, moderate been associated with improved BP
recommendation). screening, recognition, medication
Aggregate Evidence Quality Grade C prescribing, and control; pediatric
Benefits Early detection of HTN; prevention of CV morbidity in predisposed data are limited, however.122–125
children and adolescents; identification of secondary causes of HTN Some studies failed to show
Risks, harm, cost Overtesting, misclassification, unnecessary treatment, discomfort from improvement in BP screening or
BP measurement, time involved in taking BP
control,122,126 but given the inherent
Benefit–harm assessment Benefits of repeated BP measurement exceeds potential harm
Intentional vagueness None complexity in the interpretation
Role of patient preferences Families may have varying levels of concern about elevated BP readings of pediatric BP measurements,
and may request evaluation on a different time line EHRs should be designed to flag
Exclusions None abnormal values both at the time of
measurement and on entry into the
Key references 8,84,85
EHR.
be referred to subspecialty care One analysis using nationally Key Action Statement 4
within 1 week (see Table 11); and representative survey data found
that providers measured BP at only Organizations with EHRs used in
3. If the BP reading is at the stage an office setting should consider
67% of preventive visits for children
2 HTN level and the patient is including flags for abnormal BP
3 to 18 years of age. Older children
symptomatic, or the BP is >30 values both when the values are
and children with overweight or
mm Hg above the 95th percentile being entered and when they
obesity were more likely to be
(or >180/120 mm Hg in an are being viewed (grade C, weak
screened.117 In a large cohort study
adolescent), refer to an immediate recommendation).
of 14 187 children, 507 patients met
source of care, such as an
the criteria for HTN, but only 131
emergency department (ED).
(26%) had the diagnosis documented 4.5 Oscillometric Versus
Key Action Statement 3 in their electronic health records Auscultatory (Manual) BP
(EHRs). Elevated BP was only Measurement
Trained health care professionals
recognized in 11% of cases.7 Although pediatric normative BP
in the office setting should make
a diagnosis of HTN if a child or data are based on auscultatory
It is likely that the low rates of
adolescent has auscultatory- measurements, oscillometric BP
screening and diagnosis of pediatric
confirmed BP readings ≥95th devices have become commonplace
HTN are related, at least in part, to
percentile on 3 different visits (grade in health care settings.127 Ease of
the need to use detailed reference
C, moderate recommendation). use, a lack of digit preference, and
tables incorporating age, sex, and
automation are all perceived benefits
height to classify BP levels.118
4.4 Use of Electronic Health Records of using oscillometric devices. Unlike
Studies have shown that using
auscultatory measurement, however,
Studies have demonstrated that health information technology
oscillometric devices measure
primary care providers frequently can increase adherence to clinical
the oscillations transmitted from
fail to measure BP and often guidelines and improve practitioner
disrupted arterial flow by using the
underdiagnose HTN.85,115,116 performance.119–121 In fact, applying
cuff as a transducer to determine
mean arterial pressure (MAP). Rather
than directly measuring any pressure
Key Action Statement 4. Organizations with EHRs used in an office setting should
that correlates to SBP or DBP, the
consider including flags for abnormal BP values both when the values are being
device uses a proprietary algorithm
entered and when they are being viewed (grade C, weak recommendation).
to calculate these values from the
Aggregate Evidence Quality Grade C
directly measured MAP.127 Because
Benefits Improved rate of screening and recognition of elevated BP
Risks, harm, cost Cost of EHR development, alert fatigue the algorithms vary for different
Benefit–harm assessment Benefit of EHR flagging of elevated BP outweighs harm from brands of oscillometric devices, there
development cost and potential for alert fatigue is no standard oscillometric BP.128
Role of patient preferences None Researchers in several studies
Exclusions None have evaluated the accuracy of
Strength Weak recommendation (because of a lack of pediatric data) oscillometric devices127,129–134
Key references 7,117,120,125
and compared auscultatory and


FIGURE 3
Modified BP measurement algorithm.
TABLE 10 Screening Tests and Relevant Populations

oscillometric readings’ ability to
Patient Population Screening Tests
predict target organ damage.135
These studies demonstrated that All patients Urinalysis
Chemistry panel, including electrolytes, blood urea nitrogen, and
oscillometric devices systematically
creatinine
overestimate SBP and DBP Lipid profile (fasting or nonfasting to include high-density lipoproteina
compared with values obtained and total cholesterol)
by auscultation.129,133 BP status Renal ultrasonography in those <6 y of age or those with abnormal
potentially can be misclassified urinalysis or renal function
In the obese (BMI >95th Hemoglobin A1c (accepted screen for diabetes)
because of the different values
percentile) child or Aspartate transaminase and alanine transaminase (screen for fatty
obtained by these 2 methods, which adolescent, in addition to liver)
may be magnified in the office the above Fasting lipid panel (screen for dyslipidemia)
setting.86,88,129 Target organ damage Optional tests to be obtained Fasting serum glucose for those at high risk for diabetes mellitus
(such as increased LV mass and on the basis of history, Thyroid-stimulating hormone
physical examination, and Drug screen
elevated PWV) was best predicted by
initial studies Sleep study (if loud snoring, daytime sleepiness, or reported history of
BPs obtained by auscultation.135 apnea)
Complete blood count, especially in those with growth delay or
A major issue with oscillometric abnormal renal function
devices is that there appears to Adapted from Wiesen J, Adkins M, Fortune S, et al. Evaluation of pediatric patients with mild-to-moderate hypertension:
be great within-visit variation yield of diagnostic testing. Pediatrics. 2008;122(5). Available at: www.pediatrics.org/cgi/content/full/122/5/e988.
with inaccurately high readings
obtained on initial measurement.136 repeat measures averaged to Key Action Statement 5
An elevated initial oscillometric approximate values obtained by Oscillometric devices may be
reading should be ignored and auscultation. used for BP screening in children


TABLE 11 Patient Evaluation and Management According to BP Level ventricular mass index (LVMI) than
BP Category BP Screening Lifestyle Check ABPMa Diagnostic Initiate Consider systolic office BP.138,139
(See Table Schedule Counseling Upper Evaluationb Treatmentc Subspecialty
3) (Weight and and Referral
Although many wrist devices have
Nutrition) Lower been validated in adults,140–142 some
Extremity studies have shown greater variation
BP and decreased accuracy in the
Normal Annual X — — — — — resulting measurements.143–146 These
Elevated BP Initial X — — — — — negative outcomes may possibly
measurement result from differences in the number
Second X X — — — —
of measurements taken,139 the
measurement:
repeat in 6 mo position of the wrist in relation to
Third X — X X — X the heart,147 flexion or extension of
measurement: the wrist during measurement,148
repeat in 6 mo or differences in pulse pressure.149
Stage 1 HTN Initial X — — — — —
measurement
Technologies are being developed to
Second X X — — — — help standardize wrist position.150,151
measurement:
repeat in 1–2 Few studies using wrist monitors
wk have been conducted in children.
Third X — X X X X One study in adolescents compared
measurement:
repeat in 3 mo
a wrist digital monitor with a
Stage 2 HTNd Initial X X — — — — mercury sphygmomanometer and
measurement found high agreement between
Second X — X X X X systolic measurements but
measurement: lower agreement for diastolic
repeat, refer
to specialty
measurements, which was clinically
care within relevant.152 Researchers in 2
1 wk small studies conducted in PICUs
X, recommended intervention; —, not applicable. compared wrist monitors with
a ABPM is done to confirm HTN before initiating a diagnostic evaluation.
indwelling arterial lines and found
b See Table 15 for recommended studies.
c Treatment may be initiated by a primary care provider or subspecialist.
good agreement between the 2
d If the patient is symptomatic or BP is >30 mm Hg above the 95th percentile (or >180/120 mm Hg in an adolescent), send measurement modalities.153,154 No
to an ED. large comparative studies or formal
validation studies of wrist monitors
and adolescents. When doing so, BP measurements, equivalence have been conducted in children,
providers should use a device that to readings obtained by mercury however. Because of limited data, the
has been validated in the pediatric sphygmomanometers or ABPM, use of wrist and forearm monitors is
age group. If elevated BP is suspected and better correlation with left not recommended in the diagnosis or
on the basis of oscillometric readings,
confirmatory measurements should Key Action Statement 5. Oscillometric devices may be used for BP screening in
be obtained by auscultation (grade B, children and adolescents. When doing so, providers should use a device that has
strong recommendation). been validated in the pediatric age group. If elevated BP is suspected on the basis
of oscillometric readings, confirmatory measurements should be obtained by
auscultation (grade B, strong recommendation).
4.6 Forearm and/or Wrist BP
Measurement Aggregate Evidence Quality Grade B
Benefits Use of auscultatory readings prevents potential misclassification of
Wrist monitors have several potential patients as hypertensive because of inaccuracy of oscillometric
advantages when compared with arm devices
devices. They are smaller; they can Risks, harm, cost Auscultation requires more training and experience and has flaws such
be placed more easily; and, because as digit preference
Benefit–harm assessment Benefit exceeds harm
wrist diameter is less affected by Intentional vagueness None
BMI, they do not need to be modified Role of patient preferences Patients may prefer the convenience of oscillometric monitors
for patients with obesity.83,137 Exclusions None
Several studies in adults have found Strength Strong recommendation
excellent reproducibility of wrist Key references 86,88,128–136


TABLE 12 High-Risk Conditions for Which ABPM May Be Useful
Condition Rationale
Secondary HTN Severe ambulatory HTN or nocturnal HTN indicates higher likelihood of secondary
HTN161,167
CKD or structural renal abnormalities Evaluate for MH or nocturnal HTN,168–172 better control delays progression of renal
disease173
T1DM and T2DM Evaluate for abnormal ABPM patterns,174,175 better BP control delays the development
of MA176–178
Solid-organ transplant Evaluate for MH or nocturnal HTN, better control BP179–188
Obesity Evaluate for WCH and MH23,189–192
OSAS Evaluate for nondipping and accentuated morning BP surge43,46,193,194
Aortic coarctation (repaired) Evaluate for sustained HTN and MH58,112,113
Genetic syndromes associated with HTN (neurofibromatosis, Turner HTN associated with increased arterial stiffness may only be manifest with activity
syndrome, Williams syndrome, coarctation of the aorta) during ABPM58,195
Treated hypertensive patients Confirm 24-h BP control155
Patient born prematurely Evaluate for nondipping196
Research, clinical trials To reduce sample size197
TABLE 13 Recommended Procedures for the Application of ABPM

Procedure Recommendation
Device Should be validated by the Association for the Advancement of Medical Instrumentation or the British Hypertension Society for use in
children
May be oscillometric or auscultatory
Application Trained personnel should apply the monitor
Correct cuff size should be selected
Right and left arm and a lower extremity BP should be obtained to rule out coarctation of the aorta
Use nondominant arm unless there is large difference in size between the left arm and right arm, then apply to the arm with the higher
BP
Take readings every 15–20 min during the day and every 20–30 min at night
Compare (calibrate) the device to resting BP measured by the same technique (oscillometric or auscultatory)
Record time of medications, activity, and sleep
Assessment A physician who is familiar with pediatric ABPM should interpret the results
Interpret only recordings of adequate quality. Minimum of 1 reading per hour, 40–50 for a full day, 65%–75% of all possible recordings
Edit outliers by inspecting for biologic plausibility, edit out calibration measures
Calculate mean BP, BP load (% of readings above threshold), and dipping (% decline in BP from wake to sleep)
Interpret with pediatric ABPM normal data by sex and height
Use AHA staging schema155
Consider interpretation of 24-h, daytime, and nighttime MAP, especially in patients with CKD173,198
Adapted from Flynn JT, Daniels SR, Hayman LL, et al; 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):1116–1135.
management of HTN in children and pediatric providers have access to BP,158,159 is more predictive of
adolescents at this time. ABPM, there are still gaps in access future BP,160 and can assist in the
and knowledge regarding the optimal detection of secondary HTN.161
4.7 ABPM application of ABPM to the evaluation Furthermore, increased LVMI and
of children’s BP.155,157 For example, LVH correlate more strongly with
An ambulatory BP monitor consists
there are currently no reference data ABPM parameters than casual
of a BP cuff attached to a box slightly
for children whose height is <120 cm. BP.162–166 In addition, ABPM is more
larger than a cell phone, which
Because no outcome data exist reproducible than casual or home BP
records BP periodically (usually
linking ABPM data from childhood measurements.159 For these reasons,
every 20–30 minutes) throughout
to hard CV events in adulthood, the routine application of ABPM is
the day and night; these data are
recommendations either rely largely recommended, when available, as
later downloaded to a computer for
on surrogate outcome markers or are indicated below (see also Tables
analysis.155
extrapolated from adult studies. 12 and 13). Obtaining ABPM may
ABPM has been recommended by require referral to a specialist.
the US Preventive Services Task However, sufficient data exist
Force for the confirmation of HTN in to demonstrate that ABPM is Key Action Statement 6
adults before starting treatment.156 more accurate for the diagnosis ABPM should be performed for the
Although a growing number of of HTN than clinic-measured confirmation of HTN in children


and adolescents with office BP that compared with those with with established HTN.209 Most (but
measurements in the elevated BP normal 24-hour BP, these patients not all) studies suggest that WCH
category for 1 year or more or with have significant risk for end organ is not associated with increased
stage 1 HTN over 3 clinic visits (grade hypertensive damage.200,203 Patients LV mass.200,207,210 Although the
C, moderate recommendation). who are at risk of MH include distinction between WCH and true
For technical reasons, ABPM may patients with obesity and secondary HTN is important, abnormal BP
need to be limited to children ≥5 forms of HTN, such as CKD or response to exercise and increased
years of age who can tolerate the repaired aortic coarctation. MH is LVM has been found to occur in
procedure and those for whom particularly prevalent in patients children with WCH.207 Furthermore,
reference data are available. with CKD48 and is associated with the identification of WCH may reduce
target organ damage.203 Children costs by reducing the number of
Key Action Statement 7 with CKD should be periodically additional tests performed and
evaluated using ABPM for MH as decreasing the number of children
The routine performance of ABPM
part of routine CKD who are exposed to antihypertensive
should be strongly considered
management.201,204–206 medications.208 Children and
in children and adolescents with
adolescents with WCH should
high-risk conditions (see Table
have screening BP measured at
12) to assess HTN severity and 4.7b White Coat Hypertension
regular well-child care visits with
determine if abnormal circadian BP
WCH is defined as BP ≥95th consideration of a repeat ABPM in 1
patterns are present, which may
percentile in the office or clinical to 2 years.
indicate increased risk for target
setting but <95th percentile outside
organ damage (grade B, moderate Key Action Statement 9
of the office or clinical setting.
recommendation).
WCH is diagnosed by ABPM when Children and adolescents with
Key Action Statement 8 the mean SBP and DBP are <95th suspected WCH should undergo
percentile and SBP and DBP load ABPM. Diagnosis is based on the
ABPM should be performed by using
are <25%; load is defined as the presence of mean SBP and DBP
a standardized approach (see Table
percentage of valid ambulatory BP <95th percentile and SBP and
13) with monitors that have been
measurements above a set threshold DBP load <25% (grade B, strong
validated in a pediatric population,
value (eg, 95th percentile) for recommendation).
and studies should be interpreted by
age, sex, and height.155,156,206 It is
using pediatric normative data (grade
estimated that up to half of children
C, moderate recommendation). 4.8 Measurement in Children With
who are evaluated for elevated office
BP have WCH.207,208 Obesity
4.7a Masked Hypertension
Accurate BP measurement can be
MH occurs when patients have In adults, compared with
challenging in individuals with
normal office BP but elevated BP on normotension, WCH is associated
obesity. 23,211,212 Elevated BMI
ABPM, and it has been found in 5.8% with only a slightly increased risk
in children and adolescents is
of unselected children studied by of adverse outcomes but at a much
associated with an increase in the
ABPM.199 There is growing evidence lower risk compared with those
midarm circumference,96 requiring
the use of a larger cuff to obtain
Key Action Statement 6. ABPM should be performed for the confirmation of HTN accurate BP measurements.83 During
in children and adolescents with office BP measurements in the elevated BP NHANES 2007–2010, among children
category for 1 year or more or with stage 1 HTN over 3 clinic visits (grade C,
9 to 11 years of age with obesity,
one-third of boys and one-quarter of
Aggregate Evidence Quality Grade C girls required an adult BP cuff, and
Benefits Avoids unnecessarily exposing youth with WCH to extensive diagnostic
testing or medication
a fraction required a large adult cuff
Risks, harm, cost Risk of discomfort to patient. Some insurance plans may not reimburse or an adult thigh cuff for an accurate
for the test measurement of BP.213 Researchers
Benefit–harm assessment The risk of ABPM is lower than the risk of unnecessary treatment. The in studies of adults have also noted
use of ABPM has also been shown to be more cost-effective than other
the influence of the conical upper
approaches to diagnosing HTN
Intentional vagueness None arm shape on BP measurements in
Role of patient preferences Some patients may prefer repeat office or home measurements to ABPM people with obesity.214,215 ABPM is a
Exclusions None valuable tool in the diagnosis of HTN
Strength Moderate recommendation in children with obesity because of
the discrepancies between casual and


Key Action Statement 7. The routine performance of ABPM should be strongly in children.222,225–227 Home BP
considered in children and adolescents with high-risk conditions (see Table 12) measurements show no consistent
to assess HTN severity and determine if abnormal circadian BP patterns are pattern when compared with office
present, which may indicate increased risk for target organ damage (grade B, measurements.228–230
There are several practical
Aggregate Evidence Quality Grade B
Benefits Improved 24-h control of BP improves outcomes. Recognition of MH or concerns with the use of home BP
nocturnal HTN might lead to therapeutic changes that will limit end measurement, however. The only
organ damage normative data available are from
Risks, harm, cost Risk of discomfort to patient. Some insurance plans may not the relatively small Arsakeion
reimburse for the test. The risk of diagnosing and labeling a patient
School study.231 In addition, only a
as having MH or nocturnal HTN might lead to increased anxiety and
cost of evaluation few automated devices have been
Benefit–harm assessment The risk of ABPM is much lower than the risk of inadequate treatment validated for use in the pediatric
Intentional vagueness Frequency at which normal or abnormal ABPM should be repeated is population, and available cuff sizes
not known for them are limited. Furthermore,
Role of patient preferences Some patients may prefer repeat office or home measurements to
there is no consensus regarding how
ABPM
Exclusions None many home measurements across
Strength Moderate recommendation what period of time are needed to
Key references 47,155,199–202 evaluate BP.

Key Action Statement 8. ABPM should be performed by using a standardized Home BP monitoring should not be
approach (see Table 13) with monitors that have been validated in a pediatric used to diagnose HTN, MH, or WCH
population, and studies should be interpreted by using pediatric normative data but may be a useful adjunct to office
(grade C, moderate recommendation). and ambulatory BP measurement
Aggregate Evidence Quality Grade C after HTN has been diagnosed (grade
Benefits Validated monitors applied and interpreted correctly will provide the C, moderate recommendation).
most accurate results
Risks, harm, cost Risk of discomfort to patient. Some insurance plans may not reimburse
for the test. Monitors validated in the pediatric population and 4.10 School Measurement and
expertise in reading pediatric ABPM may not be universally available the Role of School-Based Health
Benefit–harm assessment There is substantial evidence showing incorrect application or Professionals
interpretation reduces the accuracy of results
Intentional vagueness None There is limited evidence to support
Role of patient preferences Some patients may prefer repeat office or home measurements to ABPM school-based measurement of
Exclusions None children’s BP.8,232 Observational
Key references 155
studies demonstrate that school
measurements can be reliable233
and that longitudinal follow-up is
ambulatory BP23,33 and the higher Numerous studies have shown feasible.8,232,234 Available data do not
prevalence of MH.26,29,155,216,217 that it is feasible for families to distinguish between the efficacy of
conduct repeated measurements at school-based screening programs in
4.9. At-Home Measurement home.221–223 Home BP measurements which measurements are obtained
Home measurement (or self- appear to be more reproducible than by trained clinical personnel (not a
monitoring) of BP has advantages those conducted in the office, likely school nurse) versus measurements
over both office and ambulatory because of the familiarity of the home obtained by the school nurse.
monitoring, including convenience environment and greater comfort Because of insufficient evidence
and the ability to obtain repeated with repeated measurements.159,223,224 and a lack of established protocols,
measurements over time.83,218 Inaccuracies occur when the routine use of school-based
Furthermore, automated devices with measurements obtained at home are measurements to diagnose HTN
memory capacity are straightforward either excluded or inappropriately cannot be recommended. However,
to use and avoid potential problems, recorded.219 Inconsistencies in school-based BP measurement can be
such as observer bias, inaccurate home, office, and ambulatory a useful tool to identify children who
reporting, and terminal digit BP measurements seem to be require formal evaluation as well as
preference (ie, overreporting of influenced by both age and HTN a helpful adjunct in the monitoring of
certain digits, like 0, as the terminal status, with ABPM tending to be diagnosed HTN. Note: School-based
digit in recording BP).219,220 higher than home BP measurements health clinics are considered part of


Key Action Statement 9. Children and adolescents with suspected WCH should evaluation for secondary causes of
undergo ABPM. Diagnosis is based on the presence of mean SBP and DBP <95th HTN if they have a positive family
percentile and SBP and DBP load <25% (grade B, strong recommendation). history of HTN, are overweight or
Aggregate Evidence Quality Grade B (Evidence Level A in Adults) obese, and/or do not have history
Benefits Improved diagnosis of WCH and the benefit of fewer additional or physical examination findings
laboratory tests and/or treatment of primary HTN. Costs might be (Table 14) suggestive of a secondary
reduced if the treatment of those misdiagnosed as hypertensive is
prevented
cause of HTN (grade C, moderate
Risks, harm, cost Additional costs; costs may not be covered by insurance companies. recommendation).
The ambulatory BP monitor is uncomfortable for some patients
Benefit–harm assessment Benefit exceeds risk
5.2 Secondary Causes: Renal and/or
Role of patient preferences Important; some patients may not want to undergo ABPM. Benefits
Renovascular
of the procedure should be reviewed with families to assist in Renal disease and renovascular
decision-making
disease are among the most common
Exclusions None
Strength Strong recommendation secondary causes of HTN in children.
Key references 206 Renal parenchymal disease and
renal structural abnormalities
Key Action Statement 10. Home BP monitoring should not be used to diagnose accounted for 34% to 79% of
HTN, MH, or WCH but may be a useful adjunct to office and ambulatory patients with secondary HTN in 3
BP measurement after HTN has been diagnosed (grade C, moderate retrospective, single-center case
recommendation). series, and renovascular disease was
Aggregate Evidence Quality Grade C present in 12% to 13%.101,240,241
Benefits Convenient, cost-effective, widely available, can be used over time The literature suggests that renal
Risks, harm, cost Risk of inaccurate diagnosis. Unclear what norms or schedule should disease is a more common cause
be used. Few validated devices in children, and cuff sizes are limited of HTN in younger children.239
Benefit–harm assessment Benefits outweigh harm when used as an adjunctive measurement
Renal disorders (including vascular
technique
Intentional vagueness None problems) accounted for 63% to 74%
Role of patient preferences Patients may find home BP more convenient and accessible than office of children <6 years of age who were
or ambulatory BP enrolled in 3 recent clinical trials
Exclusions None of angiotensin receptor blockers
(ARBs).239,242–244 No increased
Key references 159,221–225,227,230
frequency was seen in younger
patients in a recent single-center case
series, however.101 It is appropriate
systems of pediatric primary care, more common than secondary HTN to have a high index of suspicion
and these comments would not apply among American youth.238 for renal and renovascular disease
to them. in hypertensive pediatric patients,
General characteristics of children
particularly in those <6 years of age.
with primary HTN include older
5. PRIMARY AND SECONDARY CAUSES age (≥6 years),239,240 positive
family history (in a parent and/or 5.3 Secondary Causes: Cardiac,
OF HTN Including Aortic Coarctation
grandparent) of HTN,236,237,240 and
5.1 Primary HTN overweight and/or obesity.16,236,237,239 Coarctation of the aorta is a congenital
Severity of BP elevation has not abnormality of the aortic arch
Primary HTN is now the predominant differed significantly between characterized by discrete narrowing
diagnosis for hypertensive children children with primary and secondary of the aortic arch, generally at the
and adolescents seen in referral HTN in some studies,235,237 but level of the aortic isthmus. It is usually
centers in the United States,235,236 DBP elevation appears to be more associated with HTN and right arm
although single-center studies from predictive of secondary HTN,239,240 BP that is 20 mm Hg (or more)
outside the United States still find whereas systolic HTN appears to be greater than the lower extremity BP.
primary HTN to be uncommon.237 more predictive of primary Repair in infants is often surgical;
Although prospective, multicenter HTN.236,239 adolescents may be treated with
studies are generally lacking, at least angioplasty or stenting. Long-segment
one large study in which researchers
Key Action Statement 11 narrowing of the abdominal aorta
used insurance claims data confirmed Children and adolescents ≥6 years can also cause HTN and should be
that primary HTN is significantly of age do not require an extensive considered in children with refractory


Key Action Statement 11. Children and adolescents ≥6 years of age do not require surgical cure or achieve a dramatic
an extensive evaluation for secondary causes of HTN if they have a positive family response with pharmacologic
history of HTN, are overweight or obese, and/or do not have history or physical therapy.248 Known endocrine causes
examination findings (Table 14) suggestive of a secondary cause of HTN (grade C, with associated molecular defects
moderate recommendation). (when known) are summarized in
Aggregate Evidence Quality Grade C Table 15.
Benefits Avoidance of unnecessary diagnostic evaluation
Risks, harm, cost Potential to miss some children with secondary HTN
5.5 Secondary Causes:
Benefit–harm assessment Benefit equals harm
Intentional vagueness Not applicable
Environmental Exposures
Role of patient preferences Some families may want further testing performed Several environmental exposures
Exclusions Hypertensive children <6 y of age
have been associated with higher
Key references 16,129,235–240 childhood BP, although most studies
are limited to small case series. Among
the most prominent are lead, cadmium,
HTN and a gradient between the more useful than casual BP.58,245–247 mercury, and phthalates.
upper and lower extremities in Screening is recommended as a part
which the upper extremity SBP of usual care on an annual basis Lead: Long-term exposure to lead
exceeds the lower extremity SBP by beginning, at most, 12 years after in adults has been associated with
20 mm Hg.245 Of note, children with coarctation repair. Earlier screening higher BP in population studies295,296
abdominal aortic obstruction may may be considered on the basis of and in studies of industrial workers
have neurofibromatosis, Williams risk factors and clinician discretion. with high lead exposure,297 although
syndrome, Alagille syndrome, or findings have not been consistent.298
Takayasu arteritis. Key Action Statement 12 At least 1 cross-sectional study of
122 children demonstrated that
Patients with coarctation can remain Children and adolescents who have
children with higher blood lead
hypertensive or develop HTN even undergone coarctation repair should
concentrations had higher BP;
after early and successful repair, undergo ABPM for the detection of
lower socioeconomic status was
with reported prevalence varying HTN (including MH) (grade B, strong
also seen in this group, which may
from 17% to 77%.112 HTN can be recommendation).
have confounded the BP results.299
a manifestation of recoarctation. Furthermore, in a randomized study
5.4 Secondary Causes: Endocrine
Recoarctation in repaired patients of lead-exposed children, those who
HTN
should be assessed for by using 4 received chelation with succimer did
extremity BP measurements and HTN resulting from hormonal
not have lower BP than in those who
echocardiography. HTN can also excess accounts for a relatively
received a placebo.300
occur without recoarctation.246 The small proportion of children with
prevalence of HTN increases over time secondary HTN. Although rare (with Cadmium: Environmental cadmium
after successful coarctation repair.112 a prevalence ranging from 0.05% exposure has been linked to higher
to 6% in children101,237,239,240), an BP levels and the development
Routine office BP measurement alone
accurate diagnosis of endocrine HTN of HTN in adults, particularly
is often insufficient for diagnosing
provides the clinician with a unique among women.296,301–303 Although
HTN after coarctation repair.113,246
treatment opportunity to render a cross-sectional studies have
Children who have undergone
coarctation repair may have normal
in-office BP but high BP out of the Key Action Statement 12. Children and adolescents who have undergone
office, which is consistent with coarctation repair should undergo ABPM for the detection of HTN (including MH)
MH.58,112 Of children with a history (grade B, strong recommendation).
of aortic coarctation, ∼45% have MH Aggregate Evidence Quality Grade B (Aggregate Level of Evidence Equals B, Given 3 Studies
at ∼1 to 14 years after coarctation With Similar Findings)
Benefits Early detection of HTN
repair.58,113 Children with a history Risks, harm, cost Additional costs related to the placement of ABPM
of repaired aortic coarctation and Benefit–harm assessment Benefits exceed harms
normal in-office BP are at risk for Intentional vagueness Frequency of measurement. Because the development of HTN after
LVH,58 HTN, and MH.58,112 coarctation repair is influenced by many factors, the ideal onset
of screening for HTN (including MH) is unknown
ABPM has emerged as the gold Role of patient preferences None
standard for diagnosing HTN among Exclusions Individuals with a history of residual aortic arch obstruction
individuals who have undergone Strength Strong recommendation
coarctation repair, and it is likely


TABLE 14 Examples of Physical Examination Findings and History Suggestive of Secondary HTN or confirmed potential nephrotoxicity
Related to End Organ Damage Secondary to HTN of cadmium in children,304 no
Body System Finding, History Possible Etiology definite effect on BP has been
Vital signs Tachycardia Hyperthyroidism demonstrated.304,305
PCC
Neuroblastoma
Mercury: Mercury is a known
Decreased lower extremity pulses; drop Coarctation of the aorta nephrotoxin, particularly in its
in BP from upper to lower extremities elemental form.306,307 Severe
Eyes Proptosis Hyperthyroidism mercury intoxication has been
Retinal changesa Severe HTN, more likely to be associated linked to acute HTN in children
with secondary HTN
Ear, nose, throat Adenotonsillar hypertrophy SDB
in several case reports; patients’
History of snoring Sleep apnea symptoms may resemble
Height, weight Growth retardation Chronic renal failure those seen in patients with
Obesity (high BMI) Cushing syndrome pheochromocytoma (PCC).308–310
Truncal obesity Insulin resistance syndrome
Head, neck Elfin facies Williams syndrome Phthalates: Antenatal and
Moon facies Cushing syndrome childhood exposure to phthalates
Thyromegaly, goiter Hyperthyroidism
has recently been associated
Webbed neck Turner syndrome
Skin Pallor, flushing, diaphoresis PCC with higher childhood BP311–313
Acne, hirsutism, striae Cushing syndrome but not with the development of
Anabolic steroid abuse overt HTN. Specific metabolites of
Café-au-lait spots Neurofibromatosis these ubiquitous chemicals may
Adenoma sebaceum Tuberous sclerosis
have differential effects on BP,313
Malar rash Systemic lupus
Acanthosis nigricans T2DM indicating that much more detailed
Hematologic Pallor Renal disease study is needed to completely
Sickle cell anemia understand the effect of such
Chest, cardiac Chest pain Heart disease exposure.
Palpitations
Exertional dyspnea
Widely spaced nipples Turner syndrome 5.6 Secondary Causes:
Heart murmur Coarctation of the aorta Neurofibromatosis
Friction rub Systemic lupus (pericarditis)
Collagen vascular disease
Neurofibromatosis type 1 (NF-1)
Apical heavea LVH (also known as Von Recklinghausen
Abdomen Abdominal mass Wilms tumor disease) is a rare autosomal
Neuroblastoma dominant disorder characterized by
PCC distinct clinical examination findings.
Epigastric, flank bruit RAS
Palpable kidneys Polycystic kidney disease
These include the following: cafe-
Hydronephrosis au-lait macules, neurofibromas,
Multicystic dysplastic kidney Lisch nodules of the iris, axillary
Genitourinary Ambiguous or virilized genitalia Congenital adrenal hyperplasia freckling, optic nerve gliomas, and
Urinary tract infection Renal disease distinctive bone lesions. Patients
Vesicoureteral reflux
Hematuria, edema, fatigue
with NF-1 have several unique and
Abdominal trauma potential secondary causes of HTN,
Extremities Joint swelling Systemic lupus most commonly renal artery stenosis
Collagen vascular disease (RAS); coarctation of the aorta,
Muscle weakness Hyperaldosteronism
middle aortic syndrome, and PCC are
Liddle syndrome
Neurologic, Hypokalemia, headache, dizziness, Reninoma also well described.314–319
metabolic polyuria, nocturia
Additionally, an increased incidence
Muscle weakness, hypokalemia Monogenic HTN (Liddle syndrome, GRA,
AME) of idiopathic HTN has been
AME, apparent mineralocorticoid excess; GRA, glucocorticoid-remediable aldosteronism. Adapted from Flynn JT. Evaluation
documented in patients with NF-1,
and management of hypertension in childhood. Prog Pediatr Cardiol. 2001;12(2):177–188; National High Blood Pressure as high as 6.1% in a recent pediatric
Education Program Working Group on Hypertension Control in Children and Adolescents. The fourth report on the case series, which is a much greater
diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2):555–576.
a Findings that may be indicative of end organ damage related to HTN. incidence than in the general
population.320 PCC has also been
well described in patients with NF-1,
although exact incidences are difficult


Flynn et al
TABLE 15 Endocrine Causes of HTN
Name of Disorder Genetic Mutation Mode of Inheritance Clinical Feature(s) Biochemical Mechanism and Notes Ref No(s).
Catecholamine excess
PCC, paraganglioma VHL (49%) De novo, AD HTN Diagnostic test: fractionated plasmaa and/or urine 248–254
metanephrines and normetanephrines
SDHB (15%) Palpitations, headache, sweating
SDHD (10%) Abdominal mass
RET Incidental radiographic finding
Family screening
Mineralocorticoid excess
Specific etiologies addressed below Screening test: ARR: PAC, PRA preferably obtained between 8:00 and 10:00 AM 255,256

Consider if:
Early onset HTN
Potassium level abnormalities

Family history of primary aldosteronism
Resistant HTN
Congenital adrenal hyperplasia
2017
11β–hydroxylase deficiency CYP11B1 (loss of function) AR HTN Elevated levels of DOC, 11-deoxycortisol, 257–259
androstenedione, testosterone, and DHEAS
Hypokalemia Higher prevalence in Moroccan Jews
Acne, hirsutism, and virilization in
girls
Pseudoprecocious puberty in boys
11% of congenital adrenal
hyperplasia
17-α hydroxylase deficiency CYP17 (loss of function) AR HTN and hypokalemia Elevated DOC and corticosterone 260–262
Low aldosterone and renin Decreased androstenedione, testosterone and DHEAS
Undervirilized boys, sexual infantilism Prominent in Dutch Mennonites
in girls
<1% of congenital adrenal
hyperplasia
Familial hyperaldosteronism
Type 1 Hybrid CYP11B1 and CYP11B2 AD Young subjects with PA Excessive, ACTH-regulated aldosterone production 263,264
(11β-hydroxylase– Family history of young strokes Prescription with low-dose dexamethasone
aldosterone synthase, gain May add low-dose spironolactone, calcium channel
of function) blocker, or potassium supplementation
Type 2 Unknown, possibly 7p22 AD (prevalence varies PA in the patient with an affected Excessive autonomous aldosterone production 265–267
from 1.2% to 6%) first-degree relative
Unresponsive to dexamethasone

May have adrenal adenoma or
September 2017
bilateral adrenal hyperplasia
Type 3 KCNJ5 G-protein potassium AD Early onset severe HTN in the first Mutation leads to loss of potassium+ sensitivity 268–270
channel (loss of function) family described causing sodium+ influx that activates Ca++
ROUGH GALLEY PROOF

Milder phenotypes also seen channels, leading to aldosterone synthesis
Type 4 CACNA1D coding for calcium AD PA and HTN age <10 y Increased Ca++ channel sensitivity causing increased 271,272
channel (gain of function) Variable developmental abnormalities aldosterone synthesis
Other genetic causes
27
Flynn et al
28
TABLE 15 Continued
Name of Disorder Genetic Mutation Mode of Inheritance Clinical Feature(s) Biochemical Mechanism and Notes Ref No(s).
Carney complex PRKAR1A AD Skin pigmentation Rare familial cause 273,274
Pituitary and other tumors
McCune Albright syndrome GNAS, α-subunit Somatic Cutaneous pigmentation Tumors in the breast, thyroid, pituitary gland, or 275,276
Fibrous dysplasia testicles may be present
Primary glucocorticoid NR3C1 (loss of function AD HTN Loss of function of glucocorticoid receptor 277–279
resistance (Chrousos glucocorticoid receptor) Ambiguous genitalia
syndrome) Precocious puberty
Androgen excess, menstrual
abnormalities or infertility in

women
Apparent mineralocorticoid HSD11B2 (loss of function) AR HTN Reduced or absent activity of 11 β-HSD2: cortisol 280,281
excess gains access to MR
Hypokalemia Mimicked by licorice toxicity
Low birth weight
Failure to thrive
2017
Polyuria, polydipsia
Liddle syndrome SCNN1B β-subunit–SCNN1G Severe HTN Constitutive activation of the epithelial sodium 282,283
γ-subunit (activating Hypokalemia channel causing salt retention and volume
mutation) Metabolic alkalosis expansion
Muscle weakness
Geller syndrome MCR (mineralocorticoid-d AD Onset of HTN <20 y Constitutive activation of MR 284
receptor, activating Exacerbated by pregnancy Also activated by progesterone
mutation)
Pseudohypo-aldosteronism WNK1,4; KLHL3; CUL3; SPAK AD Short stature Increased activity of sodium chloride cotransporter 285–287
type 2 (Gordon syndrome) (activating mutation) Hyperkalemic and hyperchloremic causing salt retention and volume expansion
metabolic acidosis
Borderline HTN
Glucocorticoid excess
Cushing syndrome, To be discovered — HTN Likely attributable to increased DOC, sensitivity to 288–290
adrenocortical Other signs of Cushing syndrome vasoconstriction, cardiac output, activation of RAS
carcinoma, iatrogenic
excess
Other endocrine abnormalities
Hyperthyroidism To be discovered — Tachycardia Mechanism increased cardiac output, stroke volume, 291,292
and decreased peripheral resistance
HTN Initial prescription with β blockers
Tremors
Other signs of hyperthyroidism

Hyperparathyroidism — — Hypercalcemia Mechanism unknown, may not remit after treatment 293,294
September 2017
Other signs of hyperparathyroidism of hyperparathyroidism
ACTH, adrenocorticotropic hormone; AD, autosomal dominant; AR, autosomal recessive; DHEAS, dehydroepiandrosterone sulfate; DOC, deoxycortisol; MR, magnetic resonance; PA, primary hyperaldosteronism; PAC, plasma aldosterone concentration;
ROUGH GALLEY PROOF

RAS, renin angiotensin system; —, not applicable.
a influenced by posture, specialized center preferred.

to determine, and patients may not HTN include stimulants (eg, cocaine is a critical component in the
have classic symptoms of PCC.321,322 and amphetamine derivatives) and evaluation of a patient with
anabolic steroids. suspected HTN. Evaluation focuses
Vascular causes of HTN and PCC on determining possible causes of
all require specific treatment 5.8 Monogenic HTN and/or comorbidities associated
and follow-up, so maintaining a with HTN. Evaluation, as is detailed
high index of suspicion for these Monogenic forms of HTN are
in the following sections, should
disorders is important in evaluating uncommon, although the exact
include appropriate patient history,
hypertensive children and incidence is unknown. In a study of
family history, physical examination,
adolescents with NF-1. select hypertensive children without
laboratory evaluation, and imaging.
a known etiology, genetic testing
5.7 Secondary Causes: Medication for familial hyperaldosteronism
6.2 History
Related type I (FH-I), or glucocorticoid-
remediable aldosteronism, confirmed The first step in the evaluation of the
Many over-the-counter drugs, responsible genetic mutations in 3% child or adolescent with elevated BP
prescription medications, alternative of the population.263 is to obtain a history. The various
therapies (ie, herbal and nutritional components of the history include the
supplements), dietary products, and Other monogenic forms of HTN in
perinatal history, past medical history,
recreational drugs can increase BP. children include Liddle syndrome,
nutritional history, activity history,
Common prescription medications pseudohypoaldosteronism type
and psychosocial history. Each is
associated with a rise in BP include II (Gordon syndrome), apparent
discussed in the following sections.
oral contraceptives,323–325 central mineralocorticoid excess, familial
nervous system stimulants,326 and glucocorticoid resistance, 6.2a Perinatal History
corticosteroids.1,327 When a child mineralocorticoid receptor activating
mutation, and congenital adrenal As discussed, perinatal factors such
has elevated BP measurements, the
hyperplasia (see “Secondary as maternal HTN and low birth
practitioner should inquire about the
Causes: Endocrine Causes of weight have been shown to influence
intake of pharmacologic agents (see
Hypertension”).328 All manifest as later BP, even in childhood.56,330
Table 8).
HTN with suppressed plasma renin Additionally, a high incidence of
Usually, the BP elevation is mild activity (PRA) and increased sodium preterm birth among hypertensive
and reversible on discontinuation absorption in the distal tubule. children has recently been reported
of the medication, but a significant Other features may include serum in 1 large case series.101 Thus, it
increase in BP can occasionally potassium abnormalities, metabolic is appropriate to obtain a history
occur with higher doses or as an acid-base disturbances, and abnormal of pertinent prenatal information,
idiosyncratic response. Over-the- plasma aldosterone concentrations, including maternal pregnancy
counter cold medications that contain although the clinical presentations complications; gestational age;
decongestants (eg, pseudoephedrine can be highly variable.263,328,329 In the birth weight; and, if pertinent,
and phenylpropanolamine) may study of FH-I, all affected children had complications occurring in the
cause a mild increase in BP with the suppressed PRA and an aldosterone neonatal nursery and/or ICU. It
recommended dosing, but severe HTN to renin ratio (ARR) (ng/dL and ng/ is also appropriate to document
has been observed as an idiosyncratic M1 per hour, respectively) of >10; the pertinent procedures, such as
response with appropriate dosing as authors suggest that an ARR >10 is an umbilical catheter placement.
well as with excessive doses. indication to perform genetic testing
in a hypertensive child.263 Monogenic
6.2b Nutritional History
Nonsteroidal anti-inflammatory
drugs may antagonize forms of HTN should be suspected High sodium intake has been linked
the BP-lowering effect of in hypertensive children with a to childhood HTN and increased LVMI
antihypertensive medications suppressed PRA or elevated ARR, and is the focus of several population
(specifically, angiotensin-converting especially if there is a family history of health campaigns.4,331 In NHANES
enzyme [ACE] inhibitors) but do not early-onset HTN. 2003–2008, among children 8 to
appear to have an impact on BP in 18 years of age (n = 6235), higher
those without HTN. The commonly sodium intake (as assessed by dietary
used supplement ephedra (ma 6. DIAGNOSTIC EVALUATION recall) was associated with a twofold
haung) likely contains some amount increase in the combined outcome
6.1 Patient Evaluation
of ephedrine and caffeine that can of elevated BP or HTN. The effect
cause an unpredictable rise in BP. As with any medical condition, was threefold among participants
Recreational drugs associated with appropriate diagnostic evaluation with obesity.332 Limited data suggest


the same effect is seen in younger 6.2e Family History physical examination findings. The
children.333 One study found that high physical examination in hypertensive
Taking and updating the family
intake of total fat and saturated fat, as children is frequently normal except
history is a quick and easy way
well as adiposity and central obesity, for the BP elevation.
to risk-stratify pediatric patients
were also predictors of SBP.334–336
with an increased risk for HTN. It
Nutrition history is an important
is important to update the family
part of the patient assessment history for HTN over the course of In children and adolescents being
because it may identify dietary the pediatric patient’s lifetime in the evaluated for high BP, the provider
contributors to HTN and detect practice (typically until 18–21 years should obtain a perinatal history,
areas in which lifestyle modification of age) because first- and second- appropriate nutritional history,
may be appropriate. The important degree relatives may develop HTN physical activity history, psychosocial
components to discuss include salt during this time. All too often, the history, and family history and
intake (including salt added in the diagnosis of HTN in the pediatric perform a physical examination
kitchen and at the table and sodium patient stimulates the collection of to identify findings suggestive of
hidden in processed and fast food), a detailed family history of HTN, secondary causes of HTN (grade B,
consumption of high-fat foods, and sometimes even years after the strong recommendation).
consumption of sugary beverages.337,338 pediatric patient has had elevated BP,
Infrequent consumption of fruits, instead of the other way around.352 6.4 Laboratory Evaluation
vegetables, and low-fat dairy
products should also be identified. 6.3 Physical Examination The purpose of the laboratory
A complete physical examination may evaluation is to identify underlying
6.2c Physical Activity History
provide clues to potential secondary secondary causes of HTN (eg, renal
A detailed history of physical causes of HTN and assess possible or endocrine disease) that would
activity and inactivity is an integral hypertensive end organ damage. The require specific treatment guided by a
part of the patient assessment, not child’s height, weight, calculated BMI, subspecialist. In general, such testing
only to understand contributors and percentiles for age should be includes a basic set of screening tests
to the development of HTN but determined at the start of the physical and additional, specific tests; the
also to direct lifestyle modification examination. Poor growth may latter are selected on the basis of clues
counseling as an important part of indicate an underlying chronic illness. obtained from the history and physical
management.339–344 examination and/or the results of the
At the second visit with confirmed initial screening tests.354 Table 10
6.2d Psychosocial History elevated BP or stage 1 HTN or the provides a list of screening tests and
first visit with confirmed stage 2 the populations in which they should
Providers should obtain a HTN, BP should be measured in both be performed.
psychosocial history in children arms and in a leg. Normally, BP is
and adolescents with suspected or 10 to 20 mm Hg higher in the legs 6.5 Electrocardiography
confirmed HTN. Adverse experiences than the arms. If the leg BP is lower
both prenatally345 and during Approximately one-half of
than the arm BP, or if femoral pulses
childhood (including maltreatment, adolescents with HTN have
are weak or absent, coarctation of
early onset depression, and anxiety) undergone electrocardiography
the aorta may be present. Obesity
are associated with adult-onset at least once as an assessment for
alone is an insufficient explanation
HTN.346,347 The identification of stress LVH.355 Unlike echocardiography,
for diminished femoral pulses in the
may suggest a diagnosis of WCH. electrocardiography takes little
presence of high BP.
The psychosocial history should time and is a relatively low-cost
include questions about feelings of The remainder of the physical test. Electrocardiography has high
depression and anxiety, bullying, examination should pursue clues specificity but poor sensitivity
and body perceptions. The latter is found in the history and should focus for identifying children and
particularly important for patients on body systems and findings that adolescents with LVH.356–358
with overweight or obesity because may indicate secondary HTN and/ The positive predictive value of
∼70% of these children report or end organ damage related to HTN. electrocardiography to identify LVH
having bullying and body perception Table 14 lists important physical is extremely low.359
concerns.348 Starting at 11 years of examination findings in hypertensive
age, the psychosocial history should children.353 These are examples of Key Action Statement 14
include questions about smoking,349,350 history and physical findings and do Clinicians should not perform
alcohol, and other drug use.351 not represent all possible history and electrocardiography in hypertensive


Key Action Statement 13. In children and adolescents being evaluated for high BP, The American Society of
the provider should obtain a perinatal history, appropriate nutritional history, Echocardiography recommendations
physical activity history, psychosocial history, and family history and perform a should be followed with regard to
physical examination to identify findings suggestive of secondary causes of HTN image acquisition and LV measurement
(grade B, strong recommendation). for calculating LV ejection fraction,
Aggregate Evidence Quality Grade B mass, and relative wall thickness.369,371
Benefits Identify personal risk factors for HTN LV ejection fraction may be
Risks, harm, cost None
Benefit–harm assessment Identification of personal risk factors is useful in
significantly decreased in severe or
the assessment of childhood HTN acute onset HTN with associated
Intentional vagueness None congestive heart failure.1 Rarely,
Role of patient preferences None LV ejection fraction may be mildly
Exclusions Children with normal BP depressed in chronic HTN.
Strength Strong recommendation
Key references 56,330 Because the heart increases in size
in relation to body size, indexing
children and adolescents being regression of LVH independently LV mass is required.361 Indexing LV
evaluated for LVH (grade B, strong predicts outcomes in adults.368 mass is particularly important in
recommendation). infants and younger children because
The best-studied measures of LV of their rapid growth.372,373 Physical
6.6 Imaging Evaluation, target organ injury are measures training increases LV mass in a
Echocardiography: Detection of of LV structure (LV mass and the healthful manner. Lean body mass
Target Organ Damage relationship of LV wall thickness is more strongly associated with
Echocardiography was identified or mass to LV cavity volume) and LV mass than fat mass.370 Because
in the Fourth Report as a tool systolic function (LV ejection body composition is not routinely
to measure left ventricular (LV) fraction). LV structure is usually measured clinically, surrogate
target organ injury related to HTN stratified into 4 groups on the formulae for indexing are required.
in children.1 The basis for this basis of LV mass (normal or It is unclear whether expected values
assessment is as follows: (1) the hypertrophied) and relative LV wall for LV mass should be derived from
relationship of LV mass to BP,361 thickness (normal or increased). reference populations of normal
(2) the independent and strong These 4 are as follows: (1) normal weight and normotensive children
relationship of LVH to adverse CVD geometry with normal LV mass or should include normotensive
outcomes in adults,362–364 and (3) and wall thickness, (2) concentric children who have overweight or
that a significant percentage of geometry with normal LV mass and obesity. The best method for indexing
children and adolescents with HTN increased LV wall thickness, (3) LV mass in children is an area of
demonstrate the degree of LVH eccentric LVH with increased LV active investigation.
associated with adverse outcomes mass and normal LV wall thickness,
in adults.365–367 Antihypertensive and (4) concentric LVH with both For this document, the following
treatment reduces LVH. increased LV mass and increased definitions for LV target organ
Observational data suggest that the relative wall thickness.369,370 injury have been chosen regarding
hypertrophy, relative wall thickness,
and ejection fraction. These definitions
Key Action Statement 14. Clinicians should not perform electrocardiography in are based on published guidelines
hypertensive children and adolescents being evaluated for LVH (grade B, strong from the American Society of
recommendation). Echocardiography and associations of
Aggregate Evidence Quality Grade B (Aggregate of Level of Evidence Equals B Because of thresholds for indexed LV mass with
Multiple Level of Evidence C References With Similar Findings)
adverse outcomes in adults362,363,369:
Benefits Electrocardiography is less expensive than echocardiography or
other imaging modalities for identifying LVH
Risks, harm, cost Electrocardiography has a low sensitivity for detecting LVH LVH is defined as LV mass >51 g/m2.7
Benefit–harm assessment The risk of concluding that a child with HTN does not have LVH on or LV mass >115 g per body
the basis of a normal electrocardiogram means that a diagnosis surface area (BSA) for boys and
of end organ injury is potentially missed
LV mass >95 g/BSA for girls. (Note
Role of patient preferences Patients and families may prefer electrocardiography because of that the values for LVH are well
cost and convenience, but the sensitivity of the test is poor above the 95th percentile for
Exclusions None distributions of LV mass in children
Strength Strong recommendation and adolescents.369 The clinical
Key references 1,355–360
significance of values between the


95th percentile of a population- TABLE 16 DASH Diet Recommendations
based distribution and these Food Servings per Day
thresholds is uncertain372); Fruits and vegetables 4–5
Low-fat milk products ≥2
An LV relative wall thickness >0.42 Whole grains 6
cm indicates concentric geometry. Fish, poultry, and lean red meats ≤2
LV wall thickness >1.4 cm is Legumes and nuts 1
abnormal373; and Oils and fats 2–3
Added sugar and sweets (including sweetened beverages) ≤1
Decreased LV ejection fraction is a Dietary sodium <2300 mg per d
value <53%. Adapted from Barnes TL, Crandell JL, Bell RA, Mayer-Davis EJ, Dabelea D, Liese AD. Change in DASH diet score and
cardiovascular risk factors in youth with type 1 and type 2 diabetes mellitus: the SEARCH for Diabetes in Youth study.
Nutr Diabetes. 2013;3:e91; US Department of Health and Human Services, US Department of Agriculture. Appendix 7.
There are a number of additional Nutritional goals for age-sex groups based on dietary reference intakes and dietary guidelines recommendations. In: 2015-
evidence gaps related to the 2020 Dietary Guidelines for Americans. Washington, DC: US Department of Health and Human Services, US Department of
echocardiographic assessment of Agriculture; 2015; and Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and
Adolescents; National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and
LV target organ injury. The value Risk Reduction in Children and Adolescents: Summary Report. Pediatrics. 2011;128 (suppl 5): S213–S256.
of LV mass assessment in risk
reclassification independent of 4. In patients without target organ injury (grade C,
conventional risk assessment has not LV target organ injury at moderate recommendation).
been established in adults.364 The initial echocardiographic
costs and benefits of incorporation 6.7 Vascular Structure and Function
assessment, repeat
of echocardiography into HTN echocardiography at yearly Emerging data demonstrate an
care has not been assessed. Quality intervals may be considered association of higher levels of BP
control regarding reproducibility of in those with stage 2 HTN, in youth with adverse changes in
measurements across laboratories may secondary HTN, or chronic measures of vascular structure and
be suboptimal.374 The most accurate stage 1 HTN incompletely function, including ultrasonography
method to measure LV mass (M-mode; treated (noncompliance or drug of the cIMT, PWV, a robust measure
two-dimensional; or, in the near resistance) to assess for the of central arterial stiffness66 that is
future, three-dimensional techniques) development of worsening LV related to hard CV events in adults
requires further research.
Key Action Statement 15 Key Action Statement 15. It is recommended that echocardiography be performed
to assess for cardiac target organ damage (LV mass, geometry, and function) at
1. It is recommended that the time of consideration of pharmacologic treatment of HTN;
echocardiography be performed LVH should be defined as LV mass >51 g/m2.7 (boys and girls) for children and
to assess for cardiac target organ adolescents older than 8 years and defined by LV mass >115 g/BSA for boys and
damage (LV mass, geometry, LV mass >95 g/BSA for girls;
and function) at the time of Repeat echocardiography may be performed to monitor improvement or
consideration of pharmacologic progression of target organ damage at 6- to 12-month intervals. Indications to
treatment of HTN; repeat echocardiography include persistent HTN despite treatment, concentric LV
2. LVH should be defined as LV mass hypertrophy, or reduced LV ejection fraction; and
>51 g/m2.7 (boys and girls) for In patients without LV target organ injury at initial echocardiographic
children and adolescents older assessment, repeat echocardiography at yearly intervals may be considered
than 8 years and defined by LV in those with stage 2 HTN, secondary HTN, or chronic stage 1 HTN incompletely
mass >115 g/BSA for boys and LV treated (noncompliance or drug resistance) to assess for the development of
mass >95 g/BSA for girls; worsening LV target organ injury (grade C, moderate recommendation).
3. Repeat echocardiography Benefits Severe LV target organ damage can only be identified
may be performed to monitor with LV imaging. May improve risk stratification
improvement or progression Risks, harm, cost Adds cost; improvement in outcomes from incorporating
of target organ damage at 6- to echocardiography into clinical care is not established
Benefit–harm assessment Benefits exceed harms
12-month intervals. Indications to Intentional vagueness None
repeat echocardiography include Role of patient preferences Patients may elect to not to have the study
persistent HTN despite treatment, Exclusions None
concentric LV hypertrophy, or Strength Moderate recommendation
Key references 361,363,364,367–369
reduced LV ejection fraction; and


(eg, stroke, myocardial infarction, vascular parameters. The routine of renal artery stenoses was 75%
etc),69 and FMD, which assesses measurement of vascular structure and 89%, respectively.389 Factors
endothelial function and describes the and function to stratify risk in that may affect the accuracy of
ability of the endothelium to release hypertensive youth cannot be Doppler ultrasonography include
nitric oxide in response to stress.375 recommended at this time. patient cooperation, the technician’s
experience, the age of the child,
Although there are multiple large 6.8 Imaging for Renovascular and the child’s BMI. Best results
studies of PWV in youth,376–381 they Disease are obtained in older (≥8 years),388
all suffer from notable limitations,
There are no evidence-based criteria nonobese (BMI ≤85th percentile),
primarily the lack of racial and
for the identification of children and cooperative children and adolescents
ethnic diversity and differences in
adolescents who may be more likely who are examined in a facility with
measurement devices and protocols.
to have RAS. Some experts will do a extensive pediatric vascular imaging
Researchers in the largest study of
more extensive evaluation for RAS experience. Doppler ultrasonography
PWV in youth to date (N = 6576)
in children and adolescents with should probably not be obtained
only evaluated 10 and 11 year olds
stage 2 HTN, those with significant in patients who do not meet these
and measured only carotid-radial
diastolic HTN (especially on ABPM), criteria or in facilities that lack
PWV across the arm; this measure
those with HTN and hypokalemia on appropriate pediatric experience.
has not been linked to CV events in
screening laboratories, and those with
adults.382 Researchers in one large
a notable size discrepancy between Key Action Statement 16
study of FMD performed in youth
the kidneys on standard ultrasound
(N = 5809) only included 10- to Doppler renal ultrasonography may
imaging. Bruits over the renal arteries
11-year-old children in England.382 be used as a noninvasive screening
are also suggestive of RAS but are not
The largest set of data for cIMT study for the evaluation of possible
always present. Consultation with a
included 1155 European youth RAS in normal-weight children and
subspecialist is recommended to help
who were 6 to 18 years of age.383 adolescents ≥8 years of age who are
decide which patients warrant further
No racial and ethnic breakdown suspected of having renovascular
investigation and to aid in the selection
was provided for this study. The HTN and who will cooperate with
of the appropriate imaging modality.
wide heterogeneity in the methods the procedure (grade C, moderate
for cIMT measurement hinders 6.8a Renal Ultrasonography recommendation).
the pooling of data. For instance,
The utility of Doppler renal
researchers in the aforementioned 6.8b Computed Tomographic
ultrasonography as a noninvasive
article only measured common Angiography, Magnetic Resonance
screening study for the identification
carotid,383 although the bulb and Angiography, and Renography
of RAS in children and adolescents
internal carotid are the sites of
has been examined in at least 2 Other noninvasive imaging studies
earliest atherosclerotic disease.384
recent case series; sensitivity has that have been assessed for their
Many studies have had significant been reported to be 64% to 90%, ability to identify RAS include
issues related to methodology. For with a specificity of 68% to 70%.387,388 computed tomographic angiography
example, carotid-femoral PWV is not In another study that included both (CTA), magnetic resonance
measured identically with different children and adults, sensitivity angiography (MRA), and nuclear
devices and is not equivalent to and specificity for the detection medicine studies. Each of these
other measures of PWV, such as
brachial-femoral PWV.385,386 No Key Action Statement 16. Doppler renal ultrasonography may be used as a
direct comparisons have been made noninvasive screening study for the evaluation of possible RAS in normal-
between carotid-femoral and brachial- weight children and adolescents ≥8 years of age who are suspected of having
renovascular HTN and who will cooperate with the procedure (grade C, moderate
ankle PWV, methods in which
recommendation).
brachial-ankle PWV provide values
considerably higher than carotid-
Benefits Avoidance of complications of invasive procedure (angiography) or
femoral PWV.378 The brachial-ankle radiation from traditional or computed tomography angiography
PWV measures stiffness along both a Risks, harm, cost Potential false-positive or false-negative results
central elastic artery (aorta) and the Benefit–harm assessment Potential for avoidance of an invasive procedure outweighs risk of
medium muscular arteries of the leg. false-negative or false-positive results
Therefore, insufficient normative Role of patient preferences None
data are available to define clinically Exclusions Children and adolescents without suspected renovascular HTN
actionable cut-points between Strength Moderate recommendation
Key references 387–390
normal and abnormal for these


Flynn et al
34
TABLE 17 Dosing Recommendations for the Initial Prescription of Antihypertensive Drugs for Outpatient Management of Chronic HTN
Drug Age Initial Dose Maximal Dose Dosing Interval Formulations
ACE inhibitors
Contraindications: pregnancy, angioedema
Common adverse effects: cough, headache, dizziness, asthenia
Severe adverse effects: hyperkalemia, acute kidney injury, angioedema, fetal toxicity
Benazepril ≥6 ya 0.2 mg/kg per d (up to 10 mg per d) 0.6 mg/kg per d (up to 40 mg Daily Tablet: 5, 10, 20, 40 mg (generic)
per d) Extemporaneous liquid: 2 mg/mL
Captopril Infants 0.05 mg/kg per dose 6 mg/kg per d Daily to 4 times a day Tablet: 12.5, 25, 50, 100 mg (generic)
Children 0.5 mg/kg per dose 6 mg/kg per d Three times a day Extemporaneous liquid: 1 mg/mL
Enalapril ≥1 moa 0.08 mg/kg per d (up to 5 mg per d) 0.6 mg/kg per d (up to 40 mg Daily to twice a day Tablet: 2.5, 5, 10, 20 mg (generic)

per d) Solution: 1 mg/mL
Fosinopril ≥6 y 0.1 mg/kg per d (up to 5 mg per d) 40 mg per d Daily Tablet: 10, 20, 40 mg (generic)
<50 kg
≥50 kga 5 mg per d 40 mg per d
Lisinopril ≥6 ya 0.07 mg/kg per d (up to 5 mg per d) 0.6 mg/kg per d (up to 40 mg Daily Tablet: 2.5, 5, 10, 20, 30, 40 mg (generic)
per d) Solution: 1 mg/mL
2017
Ramipril — 1.6 mg/m2 per d 6 mg/m2 per d Daily Capsule: 1.25, 2.5, 5 10 mg (generic)
Quinapril — 5 mg per d 80 mg per d Daily Tablet: 5, 10, 20, 40 mg (generic)
ARBs
Contraindications: pregnancy
Common adverse effects: headache, dizziness
Severe adverse effects: hyperkalemia, acute kidney injury, fetal toxicity
Candesartan 1–5 ya 0.02 mg/kg per d (up to 4 mg per d) 0.4 mg/kg per d (up to 16 mg Daily to twice a day Tablet: 4, 8, 16, 32 mg
per d)
≥6 ya Extemporaneous liquid: 1 mg/mL
<50 kg 4 mg per d 16 mg per d
≥50 kg 8 mg per d 32 mg per d
Irbesartan 6–12 y 75 mg per d 150 mg per d Daily Tablet: 75, 150, 300 mg (generic)
≥13 150 mg per d 300 mg per d
Losartan ≥6 ya 0.7 mg/kg (up to 50 mg) 1.4 mg/kg (up to 100 mg) Daily Tablet: 25, 50 100 (generic)
Extemporaneous liquid: 2.5 mg/mL
Olmesartan ≥6 ya — — Daily Tablet: 5, 20, 40 mg
<35 kg 10 mg 20 mg Extemporaneous liquid: 2 mg/mL
≥35 kg 20 mg 40 mg
Valsartan ≥6 ya 1.3 mg/kg (up to 40 mg) 2.7 mg/kg (up to 160 mg) Daily Tablet: 40, 80, 160, 320 mg (generic)
Extemporaneous liquid: 4 mg/mL
Thiazide diuretics
Contraindications: anuria

Common adverse effects: dizziness, hypokalemia
September 2017
Severe adverse effects: cardiac dysrhythmias, cholestatic jaundice, new onset diabetes mellitus, pancreatitis
Chlorthalidone Child 0.3 mg/kg 2 mg/k per d (50 mg) Daily Tablet: 25, 50, 100 mg (generic)
Chlorothiazide Childa 10 mg/kg per d 20 mg/kg per d (up to 375 mg Daily to twice a day Tablet: 250, 500 mg (generic)
ROUGH GALLEY PROOF

per d) Suspension: 250/5 mL
Hydrochlorothiazide Childa 1 mg/kg per d 2 mg/kg per d (up to 37.5 mg Daily to twice a day Tablet: 12.5, 25, 50 mg
per d)

has been compared with the gold
standard, renal arteriography. CTA
Tablet (extended-release): 30, 60, 90 mg

and MRA have generally been found
Tablet (extended release): 2.5,5,10 mg
to be acceptable as noninvasive
Extended-release tablet: 5, 10 mg
imaging modalities for the

Formulations
identification of hemodynamically
significant vascular stenosis. One
study that included both pediatric
Tablet: 2.5, 5,10 mg
Capsule: 2.5, 5 mg
and adult patients showed that the

(generic)
(generic)
sensitivity and specificity for the

detection of RAS was 94% and 93%
for CTA and 90% and 94% for MRA,
respectively.389
Unfortunately, studies of either
times a day; extended-
Capsule: twice daily to 3
release tablet: daily

Dosing Interval
technique that include only pediatric

Daily to twice a day
patients are limited at best for

CTA and are nonexistent for MRA.
Despite this, expert opinion holds
that either modality may be used for
Daily
Daily
noninvasive screening for suspected

RAS, but neither is a substitute
0.6 mg/kg (up to 10 mg per d)
0.6 mg/kg (up to 5 mg per d)
for angiography.390 CTA typically

3 mg/kg/d (up to 120 mg
involves significant radiation

Maximal Dose
exposure, and MRA generally

requires sedation or anesthesia in
young children, which are factors that
per d)
must be considered when deciding to

10 mg
10 mg
use one of these modalities.
Nuclear renography is based

on the principle that after the
administration of an agent
affecting the renin-angiotensin-
aldosterone system (RAAS), there
Initial Dose
will be reduced blood flow to a

kidney or kidney segment affected
0.2–0.5 mg/kg per d
by hemodynamically significant
0.05–0.1 mg/kg
RAS. Such reduced blood flow

Common adverse effects: flushing, peripheral edema, dizziness
can be detected by a comparison

0.1 mg/kg
of perfusion before and after

2.5 mg
2.5 mg
the administration of the RAAS

agent. Limited pediatric nuclear
renography studies exist that show
≥6 ya
1–5 y
Child
Child
≥6 y
Contraindications: hypersensitivity to CCBs
Age
variable sensitivity and specificity,

ranging from 48% to 85.7% and
Severe adverse effects: angioedema
73% to 92.3%, respectively.391–393

The utility of nuclear renography
may be less in children then adults
Calcium channel blockers
Nifedipine extended release
because children with RAS often

TABLE 17 Continued
have more complicated vascular

a FDA pediatric labeling.
abnormalities than adults.394 Given

—, not applicable.
these issues, nuclear renography

Amlodipine
Felodipine
Isradipine
has generally been abandoned as a

screening test for RAS in children and
Drug
adolescents.390


Key Action Statement 17 also shown that lowering UA can Seeman et al411 did not control for
decrease BP levels, and increased UA these potential confounders.
In children and adolescents
levels blunt the efficacy of lifestyle
suspected of having RAS, either Limited, single-center data suggest
modifications on BP control.400–404
CTA or MRA may be performed as a that a reduction in the degree of MA,
No large-scale, multicenter study has
noninvasive imaging study. Nuclear more than a reduction in BMI or
yet been conducted to confirm these
renography is less useful in pediatrics SBP, is associated with a decrease in
preliminary findings. Hence, there is
and should generally be avoided LVMI. In particular, researchers in
currently not sufficient evidence to
(grade D, weak recommendation). this single-center, nonrandomized,
support the routine measurement
prospective study of 64 hypertensive
6.9 Uric Acid of serum UA in the evaluation
children without kidney disease who
and management of children with
Cross-sectional data have suggested were 11 to 19 years of age evaluated
elevated BP.
a relationship between elevated the children at baseline and after
serum uric acid (UA) levels and HTN. 6.10 Microalbuminuria 12 months of combination ACE and
Two recent studies of adolescents hydrochlorothiazide (N = 59) or
included in NHANES 1999–2000 Microalbuminuria (MA), which ACE, hydrochlorothiazide, and ARB
and a small study conducted in Italy should be differentiated from therapy (N = 5). Results found that
found that elevated UA levels were proteinuria in CKD, has been shown lowering MA in children is associated
associated with higher BP.395–397 to be a marker of HTN-related kidney with a regression of LVH.413 Given
In the Italian study and in another injury and a predictor of CVD in the single-center design and lack
US study of youth with obesity and adults.405–408 MA has been shown to of a control group, however, the
HTN,397,398 elevated UA was also be effectively reduced via the use of applicability of these findings to the
associated with other markers of CV ARBs and ACE inhibitors in adults. general population of children with
risk. These findings suggest that the Lowering the degree of MA in adults primary HTN is unknown.
measurement of UA levels may best has been associated with decreased
CVD risk. Key Action Statement 18
be viewed as 1 component of CV risk
assessment, especially in those with In contrast, data to support a clear Routine testing for MA is not
obesity. relationship between HTN and MA recommended for children and
in pediatric patients with primary adolescents with primary HTN (grade
A causative role for elevated UA in HTN are limited.408–410 A single, C, moderate recommendation).
the development of childhood HTN retrospective study of children with
has not been definitively established, primary HTN and WCH found that
although recent studies suggest that 20% of the former had MA versus 7. TREATMENT
it may be on the causal pathway. 0% of the latter.411 MA appears to
7.1 Overall Goals
A longitudinal study in which be a nonspecific finding in children
researchers followed a group of that can occur in the absence of HTN; The overall goals for the treatment
children for an average of 12 years it can occur in children who have of HTN in children and adolescents,
demonstrated that childhood UA obesity, insulin resistance, diabetes, including both primary and
levels were associated with adult dyslipidemia, and even in those secondary HTN, include achieving a
BP levels even after controlling who have recently participated in BP level that not only reduces the risk
for baseline BP.399 A few small, vigorous physical activity.412 The for target organ damage in childhood
single-center clinical trials have previously mentioned study by but also reduces the risk for HTN and
related CVD in adulthood. Several
Key Action Statement 17. In children and adolescents suspected of having RAS, studies have shown that currently
either CTA or MRA may be performed as a noninvasive imaging study. Nuclear
available treatment options can
renography is less useful in pediatrics and should generally be avoided (grade D,
even reverse target organ damage in
weak recommendation).
hypertensive youth.105,414,415
Aggregate Evidence Quality Grade D
Benefits Avoidance of complications of an invasive procedure (angiography) The previous recommendations for
Risks, harm, cost Potential false-positive or false-negative results HTN treatment target in children
Benefit–harm assessment Potential for avoidance of an invasive procedure outweighs risk of
without CKD or diabetes were SBP
false-negative or false-positive results
Intentional vagueness None and DBP <95th percentile. Since that
Role of patient preferences None recommendation was made, evidence
Exclusions Children and adolescents without suspected RAS has emerged that markers of target
Strength Weak recommendation; pediatric data are limited organ damage, such as increased
Key references 389,390
LVMI, can be detected among some


Key Action Statement 18. Routine testing for MA is not recommended for children that the relationship between
and adolescents with primary HTN (grade C, moderate recommendation). diet, physical activity, and BP
Aggregate Evidence Quality Grade C in childhood is similar to that
Benefits Avoid improper detection of MA in children with HTN. Detection of MA observed in adults.
is strongly influenced by other factors, such as recent participation
in rigorous physical activity, obesity, insulin resistance and
7.2a Diet
diabetes. Hence, there is no clear benefit for testing for MA in the
absence of other known comorbidities The Dietary Approaches to Stop
Risks, harm, cost No known risks given a lack of clear association between MA and Hypertension (DASH) approach
primary HTN in children
and specific elements of that diet
Benefit–harm assessment Limited data to support any real benefit for screening children for MA
Intentional vagueness Screening of children with primary HTN versus screening of children have been the primary dietary
with single kidney or CKD and HTN strategy tested in the literature.
Role of patient preferences Unknown These elements include a diet that
Exclusions None is high in fruits, vegetables, low-
fat milk products, whole grains,
fish, poultry, nuts, and lean red
meats; it also includes a limited
children with BP >90th percentile Key Action Statement 19 intake of sugar and sweets along
(or >120/80 mm Hg) but <95th with lower sodium intake (see
percentile.66,416,417 Longitudinal Table 16). Cross-sectional studies
diagnosed with HTN, the treatment
studies on BP from childhood to demonstrate associations between
goal with nonpharmacologic and
adulthood that include indirect elements of the DASH diet and BP.
pharmacologic therapy should be a
measures of CV injury indicate that For example, population-based data
reduction in SBP and DBP to <90th
the risk for subsequent CVD in early from NHANES show correlations
percentile and <130/80 mm Hg in
adulthood increases as the BP level between dietary sodium and BP
adolescents ≥ 13 years old (grade C,
in adolescence exceeds 120/80 in childhood and elevated BP and
mm Hg.11,103,418 In addition, there is HTN, particularly in people with
some evidence that targeting a BP 7.2 Lifestyle and Nonpharmacologic excess weight.332
<90th percentile results in reductions Interventions
in LVMI and prevalence of LVH.104 A high intake of fruits, vegetables,
Therefore, an optimal BP level to be Lifestyle interventions are and legumes (ie, a plant-strong
achieved with treatment of childhood recommended to lower BP. There diet) is associated with lower
HTN is <90th percentile or <130/80 is good evidence from studies in BP.421 A lack of fruit consumption
mm Hg, whichever is lower. adults showing that nutritional in childhood has been linked
interventions lower BP,419 including to increases in cIMT in young
Treatment and management clinical trials demonstrating that adulthood in the Young Finns
options are discussed below, reducing dietary sodium results in study.422 Higher intake of low-fat
including lifestyle modifications and lower BP and CV mortality,338 dairy products has been associated
pharmacologic therapy to achieve and a diet high in olive oil with lower BP in childhood.423
optimal BP levels in children and polyphenols lowers BP.420 Studies
adolescents with HTN. of hypertensive youth suggest Longitudinal, observational, and
interventional data also support
Key Action Statement 19. In children and adolescents diagnosed with HTN, the relationships between diet and BP
treatment goal with nonpharmacologic and pharmacologic therapy should be a in youth. The National Heart Lung
reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents and Blood Institute’s Growth and
≥ 13 years old (grade C, moderate recommendation). Health Study, which followed 2185
Aggregate Evidence Quality Grade C girls over 10 years, demonstrated
Benefits Lower risk of childhood target organ damage, lower risk of that consuming ≥2 servings of
adulthood HTN and CVD dairy and ≥3 servings of fruits and
Risk, harm, cost Risk of drug adverse effects and polypharmacy vegetables daily was associated
Benefit–harm assessment Preponderance of benefit
with lower BP in childhood and a
Role of patient preferences Patient may have preference for nonpharmacologic or 36% lower risk of high BP by young
pharmacologic treatment adulthood.424 Similar associations
Exclusions None have been demonstrated in children
Strength Moderate recommendation and adolescents with diabetes.425
Key references 11,66,103,104,416–418
Moreover, an improvement in diet


led to lower BP in some studies of TABLE 18 OSAS Symptoms and Signs
adolescents with elevated BP,426 History of frequent snoring (≥3 nights per week)
youth with overweight,427 girls with Labored breathing during sleep
metabolic syndrome,428 and youth Gasps, snorting noises, observed episodes of apnea
Sleep enuresis (especially secondary enuresis)
with T2DM.429 However, consuming
Sleeping in a seated position or with the neck hyperextended
a healthier diet may increase Cyanosis
costs.430 Headaches on awakening
Daytime sleepiness
7.2b Physical Activity Attention-deficit/hyperactivity disorder
Learning problems
Observational data support a Physical examination
relationship between physical Underweight or overweight
activity and lower BP, although the Tonsillar hypertrophy
Adenoidal facies
data are scant.339 Interventional Micrognathia, retrognathia
data demonstrate increasing High-arched palate
physical activity leads to lower BP. Failure to thrive
A review of 9 studies of physical HTN
activity interventions in children and Adapted from Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of
adolescents with obesity suggested childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3). Available at: www.pediatrics.org/cgi/content/full/
130/3/e714.
that 40 minutes of moderate to
vigorous, aerobic physical activity at
week (30–60 minutes per session) combination with other behavioral
least 3 to 5 days per week improved
to help reduce BP (grade C, weak techniques to address overweight
SBP by an average of 6.6 mm Hg and
recommendation). and obesity in children.436 Studies
prevented vascular dysfunction.340
in hypertensive adults support the
A number of subsequent, additional 7.2c Weight Loss and Related CV Risk use of MI to improve adherence to
studies with small sample sizes Factors antihypertensive medications437 and
support a benefit of physical activity
As is true for children and decrease SBP.436 Although there are
on BP.341 A more recent analysis
adolescents with isolated HTN, no trials investigating the use of MI
of 12 randomized controlled trials
a DASH diet426,432 and vigorous in the care of hypertensive youth,
including 1266 subjects found
physical activity431 are recommended a number of studies have shown
reductions of 1% and 3% for resting
in pediatric patients with multiple that MI can be used successfully
SBP and DBP, respectively. These
obesity-related risk factors as part of to address or prevent childhood
results did not reach statistical
intensive weight-loss therapy.433,434 obesity by promoting physical
significance, however, and the
Motivational interviewing (MI) is a activity and dietary changes.438–441
authors suggested that longer
tool recommended for pediatricians’ However, other studies have been
studies with larger sample sizes
use by the AAP Expert Committee less promising.442,443 In addition to
are needed.344 Any type of exercise,
Statement on Obesity.435 MI may the standard lifestyle approaches,
whether it’s aerobic training,
be a useful counseling tool to use in intensive weight-loss therapy
resistance training, or combined
training, appears to be beneficial342
(see “HTN and the Athlete”). Key Action Statement 20. At the time of diagnosis of elevated BP or HTN in a child
Programs that combine diet and or adolescent, clinicians should provide advice on the DASH diet and recommend
physical activity can have a beneficial moderate to vigorous physical activity at least 3 to 5 days per week (30–60
effect on SBP, as is shown in minutes per session) to help reduce BP (grade C, weak recommendation).
several studies designed to prevent Aggregate Evidence Quality Grade C
childhood obesity and address Benefits Potential to reduce BP
Risk, harm, cost No or low potential for harm. Following a healthier diet may increase
cardiometabolic risk.431 costs to patients and families
Benefit–harm assessment Potential benefit outweighs lack of harm and minimal cost
Key Action Statement 20 Intentional vagueness None
Role of patient preferences Level of caregiver and patient concern may influence adoption of the
At the time of diagnosis of elevated
DASH diet and physical activity. Patients may also have preferences
BP or HTN in a child or adolescent, around the use of a medication. These factors may influence the
clinicians should provide advice efficacy of lifestyle change
on the DASH diet and recommend Exclusions None
moderate to vigorous physical Strength Weak recommendation
Key references 332,339–342,424–431
activity at least 3 to 5 days per


involving regular patient and/or initial drug. Because of the salt and despite their continued widespread
family contact and at least 1 hour water retention that occurs with use.238
of moderate to vigorous physical many antihypertensive medications,
activity on a daily basis should be a thiazide diuretic is often the
offered to children and adolescents preferred second agent. 7.3b Pharmacologic Treatment: Choice
with obesity and HTN.444 of Agent
Lifestyle modifications should be
7.2d Stress Reduction continued in children requiring
Pharmacologic treatment of HTN
pharmacologic therapy. An ongoing
Complimentary medicine in children and adolescents should
emphasis on a healthy, plant-strong
interventions have shown some be initiated with an ACE inhibitor,
diet rich in fruits and vegetables;
promise in studies in normotensive ARB,469 long-acting calcium channel
reduced sodium intake; and
children and adolescents and in blocker, or a thiazide diuretic.
increased exercise can improve the
those with elevated BP. Breathing- Because African American children
effectiveness of antihypertensive
awareness meditation, a component may not have as robust a response
medications. The use of a
of the Mindfulness-Based Stress to ACE inhibitors,470,471 a higher
combination product as initial
Reduction Program at the University initial dose for the ACE inhibitor
treatment has been studied only for
of Massachusetts Memorial Medical may be considered; alternatively,
bisoprolol and hydrochlorothiazide,449
Center,445 led to a reduction in therapy may be initiated with a
so the routine use of combination
daytime, nighttime, and 24-hour SBP thiazide diuretic or long-acting
products to initiate treatment in
(3–4 mm Hg) and DPB (1 mm Hg) calcium channel blocker. In view of
children cannot be recommended.
in normotensive African American the expanded adverse effect profile
Once BP control has been achieved,
adolescents and African American and lack of association in adults
a combination product can be
adolescents with elevated BP.446 with improved outcomes compared
considered as a means to improve
Another study of transcendental with other agents, β-blockers are not
adherence and reduce cost if the dose
meditation showed no significant BP recommended as initial treatment
and formulation are appropriate.
effect but did lead to a decrease in in children. ACE inhibitors and ARBs
LVM in African American adolescents 7.3a Pharmacologic Treatment and are contraindicated in pregnancy
with elevated BP.447 Scant data Pediatric Exclusivity Studies because these agents can cause injury
suggest yoga may also be helpful.448 and death to the developing fetus.
Studies completed in hypertensive Adolescents of childbearing potential
7.3 Pharmacologic Treatment children show that antihypertensive should be informed of the potential
drugs decrease BP with few adverse risks of these agents on the developing
Children who remain hypertensive
effects.173,202,242–244,450–467 There fetus; alternative medications (eg,
despite a trial of lifestyle
are few studies in children in which calcium channel blocker, β-blocker)
modifications or who have
researchers compare different can be considered when appropriate.
symptomatic HTN, stage 2 HTN
antihypertensive agents.453 These
without a clearly modifiable factor
studies do not show clinically
(eg, obesity), or any stage of HTN In children with HTN and CKD,
significant differences in the degree
associated with CKD or diabetes proteinuria, or diabetes mellitus,
of BP lowering between agents.
mellitus therapy should be initiated an ACE inhibitor or ARB is
There are no clinical trials in children
with a single medication at the low recommended as the initial
that have CV end points as outcomes.
end of the dosing range (see Table antihypertensive agent unless there
Long-term studies on the safety of
17). Depending on repeated BP is an absolute contraindication. Other
antihypertensive medications in
measurements, the dose of the initial antihypertensive medications (eg,
children and their impact on future
medication can be increased every α-blockers, β-blockers, combination α-
CVD are limited.455
2 to 4 weeks until BP is controlled and β-blockers, centrally acting agents,
(eg, <90th percentile), the maximal Because of legislative acts that potassium-sparing diuretics, and direct
dose is reached, or adverse effects provide incentives and mandates vasodilators) should be reserved for
occur. Although the dose can be for drug manufacturers to complete children who are not responsive to 2
titrated every 2 to 4 weeks using pediatric assessments,468 most of the or more of the preferred agents (see
home BP measurements, the patient newer antihypertensive medications “Treatment in CKD”).
should be seen every 4 to 6 weeks have undergone some degree of
until BP has normalized. If BP is efficacy and safety evaluation. Key Action Statement 21
not controlled with a single agent, Antihypertensive drugs without In hypertensive children and
a second agent can be added to the patent protection have not been, and adolescents who have failed lifestyle
regimen and titrated as with the are unlikely to be, studied in children modifications (particularly those


Flynn et al
40
TABLE 19 Oral and Intravenous Antihypertensive Medications for Acute Severe HTN
Useful for Severely Hypertensive Patients With Life-Threatening Symptoms
Drug Class Dose Route Comments
Esmolol β-adrenergic blocker 100–500 mcg/kg per min Intravenous infusion Short acting, constant infusion preferred. May cause
profound bradycardia
Hydralazine Direct vasodilator 0.1–0.2 mg/kg per dose up to 0.4 mg/kg Intravenous, intramuscular Causes tachycardia
per dose Give every 4 h when given intravenous bolus
Labetalol α- and β-adrenergic blocker Bolus: 0.20–1.0 mg/kg per dose up to 40 mg Intravenous bolus or infusion Asthma and overt heart failure are relative
per dose contraindications
Infusion: 0.25–3.0 mg/kg per h

Nicardipine Calcium channel blocker Bolus: 30 mcg/kg up to 2 mg per dose Intravenous bolus or infusion May cause reflex tachycardia. Increases cyclosporine and
Infusion: 0.5–4 mcg/kg per min tacrolimus levels
Sodium nitroprusside Direct vasodilator Starting: 0–3 mcg/kg per min Intravenous infusion Monitor cyanide levels with prolonged (>72 h) use or in
Maximum: 10 mcg/kg per min renal failure; or coadminister with sodium thiosulfate
Useful for Severely Hypertensive Patients With Less Significant Symptoms
2017
Clonidine Central α-agonist 2–5 mcg/kg per dose up to 10 mcg/kg per Oral Adverse effects include dry mouth and drowsiness
dose given every 6–8 h
Fenoldopam Dopamine receptor agonist 0.2–0.5 mcg/kg per min up to 0.8 mcg/kg Intravenous infusion Higher doses worsen tachycardia without further reducing
per min BP
Hydralazine Direct vasodilator 0.25 mg/kg per dose up to 25 mg per dose Oral Half-life varies with genetically determined acetylation
given every 6–8 h rates
Isradipine Calcium channel blocker 0.05–0.1 mg/kg per dose up to 5 mg per Oral Exaggerated decrease in BP can be seen in patients
dose given every 6–8 h receiving azole antifungal agents
Minoxidil Direct vasodilator 0.1–0.2 mg/kg per dose up to 10 mg per Oral Most potent oral vasodilator, long acting
dose given Q 8–12 h
Monitoring
reassessed.
September 2017
recommendation).
every 3 to 4 months.
In patients treated with
ROUGH GALLEY PROOF

ABPM and Assessment”).
with HTN requires ongoing
diuretic (grade B, moderate
7.3c Treatment: Follow-Up and
of BP control (see “At-Home

HTN, or stage 2 HTN without
who have LV hypertrophy on
a clearly modifiable factor [eg,
BP measurement is frequently
of a second or third agent until
can be reinforced and the need

ACE inhibitor, ARB, long-acting
used to get a better assessment
on the medication (for example,

If the decision has been made to
echocardiography, symptomatic
adverse effects of the prescribed

then follow-up visits can occur at
pharmacologic treatment with an
should be assessed for adherence

preceding section). After that, the
to prescribed therapy and for any

with CKD (see “Treatment: Use of
for initiation of medication can be
medication; such assessment may

is especially important in patients
Treatment of a child or adolescent
At each follow-up visit, the patient

obesity]), clinicians should initiate
to continually reinforce adherence

goal BP has been achieved (see the
monitoring because goal BP can be
Measurement”). Repeat ABPM may

with medication, the patient should
is on a diuretic). It is also important

proceed with lifestyle changes only,
has been made to initiate treatment
electrolyte monitoring if the patient

calcium channel blocker, or thiazide
longer intervals (every 3–6 months)

difficult to achieve.472 If the decision
so that adherence to lifestyle change
antihypertensive medications, home
also be used to assess BP control and
include laboratory testing depending

for dose adjustments and/or addition
be seen frequently (every 4–6 weeks)
frequency of visits can be extended to

Key Action Statement 21. In hypertensive children and adolescents who have despite treatment with 3 or more
failed lifestyle modifications (particularly those who have LV hypertrophy on antihypertensive agents of different
echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable classes. All of these drugs should be
factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an prescribed at maximally effective
ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic (grade doses, and at least 1 should be a
B, moderate recommendation). diuretic. Key to the identification
Aggregate Evidence Quality Grade B of patients with true resistant HTN
Benefits Potential prevention of progressive CVD; regression or avoidance of is correct office BP measurement,
target organ damage; resolution of hypertensive symptoms; improved confirmation of adherence to
cognition; avoidance of worsening HTN; potential avoidance of stroke,
current therapy, and confirmation of
heart failure, coronary artery disease, kidney failure
Risks, harm, cost Potential for hypotension, financial cost, chronic medication treatment, treatment resistance by ABPM.
adverse medication effects, impact on insurability (health and life) The treatment of patients with
Benefit–harm assessment Preponderance of benefits over harms
resistant HTN includes dietary
Role of patient preferences The choice of which antihypertensive medication to use should be sodium restriction, the elimination
made in close discussion with the patient and parent regarding risk, of substances known to elevate
benefits, and adverse effects BP, the identification of previously
Exclusions None undiagnosed secondary causes of
HTN, the optimization of current
therapy, and the addition of
additional agents as needed.475
Recent clinical trial data suggest that
to lifestyle changes because effective treatment, ABPM results indicated an aldosterone receptor antagonist
treatment will depend on the that treatment-goal BP was achieved (such as spironolactone) is the
combination of effects from both in only one-third of children with optimal additional agent in adults
medication and lifestyle measures. HTN.17 with resistant HTN; it helps address
Finally, known hypertensive target volume excess as well as untreated
organ damage (such as LVH) should Key Action Statement 22
hyperaldosteronism, which is
be reassessed according to the common in adult patients with true
ABPM may be used to assess
recommendations in “Imaging resistant HTN.476,477
treatment effectiveness in children
Evaluation, Echocardiography:
and adolescents with HTN, especially At present, there are no data on
Coarctation of the Aorta and
when clinic and/or home BP whether true treatment-resistant
Detection of Target Organ Damage.”
measurements indicate insufficient HTN exists in pediatric patients.
BP response to treatment (grade B, Evaluation and management
7.3d Treatment: Use of ABPM to Assess moderate recommendation). strategies similar to those proven
Treatment effective in adults with resistant HTN
7.4 Treatment-Resistant HTN would be reasonable in children
ABPM can be an objective method
to evaluate treatment effect during Resistant HTN in adults is defined and adolescents who present with
antihypertensive drug therapy. Data as persistently elevated BP apparent treatment resistance.
obtained in a multicenter, single-blind,
Key Action Statement 22. ABPM may be used to assess treatment effectiveness
crossover study in which hypertensive in children and adolescents with HTN, especially when clinic and/or home BP
children received a placebo or measurements indicate insufficient BP response to treatment (grade B, moderate
no treatment demonstrated no recommendation).
change in ABPM after receiving Aggregate Evidence Quality Grade B
the placebo.473 A report from a
Benefits ABPM results can guide adjustment in medication. ABPM can facilitate
single center found that among achieving treatment-goal BP levels
hypertensive children receiving Risks, harm, cost Inconvenience and patient annoyance in wearing an ABPM monitor.
antihypertensive drugs, BP data Cost of ABPM monitors
from ABPM resulted in medication Benefit–harm assessment Overall benefit
changes in 63% of patients.474
Role of patient preferences Patients may choose not to wear the ambulatory BP monitor
Another study of 38 hypertensive repeatedly, which may necessitate alternative approaches to
children used ABPM to evaluate the evaluate treatment efficacy
effectiveness of antihypertensive Exclusions Uncomplicated HTN with satisfactory BP control
therapy (nonpharmacologic and Strength Moderate recommendation
pharmacologic). After 1 year of


8. TREATMENT IN SPECIAL to intensive BP control (24-hour beneficial for preserving renal
POPULATIONS MAP <50th percentile by ABPM). function. Researchers in multiple
The study demonstrated fewer studies have evaluated the utility of
8.1 Treatment in Patients With CKD
composite CKD outcomes in children RAAS blockade therapy in patients
and Proteinuria
with the lower BP target.173 Recent with CKD and HTN.452,464,465,484–487
8.1a CKD adult data from the Systolic Blood These medications have been shown
Children and adolescents with Pressure Intervention Trial suggest to benefit both BP and proteinuria.
CKD often present with or develop lower BP targets may be beneficial
The benefit of such therapies may
HTN.478 HTN is a known risk factor in preventing other, adverse CV
not be sustained, however.173,488 The
for the progression of kidney disease outcomes as well.482
Effect of Strict Blood Pressure Control
in adults and children.173,479,480 and ACE-Inhibition on Progression
Evidence suggests that the treatment of Chronic Renal Failure in Pediatric
of HTN in children with CKD might 1. Children and adolescents with Patients study demonstrated an
slow the progression of or reverse CKD should be evaluated for HTN initial 50% reduction in proteinuria
end organ damage.173,415 When at each medical encounter; in children with CKD after treatment
evaluated by 24-hour ABPM, children with ramipril but with a rebound effect
and adolescents with CKD often 2. Children or adolescents with both
CKD and HTN should be treated after 36 months.450,464,488 This study
have poor BP control even if BP also showed that BP reduction with
measured in the clinic appears to be to lower 24-hour MAP to <50th
percentile by ABPM; and a ramipril-based antihypertensive
normal.48 MH is associated with end regimen improved renal outcomes.
organ damage, such as LVH.203,481 3. Regardless of apparent control of In children with HTN related to
Threshold values that define HTN are BP with office measures, children underlying CKD, the assessment of
not different in children with CKD, and adolescents with CKD and a proteinuria and institution of RAAS
although there is some evidence that history of HTN should have BP blockade therapy appears to have
lower treatment goals might improve assessed by ABPM at least yearly important prognostic implications.
outcomes. to screen for MH (grade B; strong
recommendation). Key Action Statement 24
In the European Effect of Strict Blood
Pressure Control and ACE-Inhibition Children and adolescents with
8.1b Proteinuria
on Progression of Chronic Renal CKD and HTN should be evaluated
Failure in Pediatric Patients study, Proteinuric renal disease is often for proteinuria (grade B, strong
researchers randomly assigned associated with HTN and a rapid recommendation).
children with CKD to standard decline in glomerular filtration.483
antihypertensive therapy (with Studies in both adults and children Key Action Statement 25
a treatment goal of 24-hour MAP have indicated that both BP control
Children and adolescents with CKD,
<90th percentile by ABPM) or and a reduction in proteinuria are
HTN, and proteinuria should be
treated with an ACE inhibitor or ARB
Key Action Statement 23. Children and adolescents with CKD should be evaluated (grade B, strong recommendation).
for HTN at each medical encounter;
Children or adolescents with both CKD and HTN should be treated to lower 24-hour 8.2. Treatment in Patients With
MAP to <50th percentile by ABPM; and Diabetes
Regardless of apparent control of BP with office measures, children and
Based on the Fourth Report criteria
adolescents with CKD and a history of HTN should have BP assessed by ABPM at
least yearly to screen for MH (grade B; strong recommendation). for the diagnosis of HTN,1 between
4% and 16% of children and
Aggregate Evidence Quality Grade B
Benefits Control of BP in children and adolescents with CKD has been shown adolescents with T1DM are found to
to decrease CKD progression and lead to resolution of LVH have HTN.14,489–491 In the SEARCH
Risks, harm, cost Cost of ABPM and BP control, both financial and nonfinancial study of 3691 youth between the
Benefit–harm assessment Benefits of BP control in patients with CKD outweigh treatment risks ages of 3 and 17 years, elevated BP
Intentional vagueness Threshold
was documented in 6% of children
Role of patient preferences Patients may not want to wear the ambulatory BP monitor
repeatedly, which should lead to detailed counseling regarding the with T1DM, with the highest
benefits of this procedure in CKD prevalence in Asian Pacific Islander
Exclusions None and American Indian children
Strength Strong recommendation followed by African American and
Key references 47,173,203,415,480–483
Hispanic children and those with


higher glycosylated hemoglobin A1c Association,499 the International may have OSAS and consequent
levels.14 An office-based study in Society for Pediatric and Adolescent HTN.507 The more severe the OSAS,
Australia found much higher rates Diabetes,500 AHA,110 and the National the more likely a child is to have
(16%) and a positive correlation Heart, Lung, and Blood Institute.501 elevated BP44,45 (see Table 18).
with BMI.490 BP >130/90 mm Hg Children with moderate to severe
has been associated with a more- Key Action Statement 26 OSAS are at increased risk for HTN.
than-fourfold increase in the relative Children and adolescents with T1DM However, it is not known whether
risk of coronary artery disease and or T2DM should be evaluated for OSAS treatment with continuous
mortality at 10-year follow-up of HTN at each medical encounter and positive airway pressure results
individuals with T1DM.492 treated if BP is ≥95th percentile in improved BP in all children.44
or >130/80 mm Hg in adolescents Furthermore, adenotonsillectomy
The prevalence of HTN is higher in
≥13 years of age (grade C, moderate may not result in BP improvement
youth with T2DM compared with
recommendation). in all children with OSAS. In
T1DM, ranging from 12% at baseline
(N = 699) in the Treatment Options particular, children who have obesity
for Type 2 Diabetes in Adolescents and OSAS may be less likely to
9. COMORBIDITIES experience a lowering of BP after an
and Youth study493 to 31% (N = 598)
in the Pediatric Diabetes Consortium 9.1 Comorbidities: Dyslipidemia adenotonsillectomy.508
Type 2 Diabetes Clinic Registry.494 Children and adolescents with Therefore, children with signs of
BP and arterial stiffness in cohort HTN are at increased risk for lipid OSAS (eg, daytime fatigue, snoring,
studies have correlated with BMI, disorders attributable to the “common hyperactivity, etc) should undergo
male sex, African American race, and soil” phenomenon,502 in which poor evaluation for elevated BP regardless
age of onset of diabetes.14,494,495 diet, inactivity, and obesity contribute of treatment status. Given that both
Unlike T1DM, HTN in T2DM is to both disorders. Some observational nighttime and daytime BP is affected
not correlated with glycosylated pediatric data confirm this by OSAS, the use of ABPM is the
hemoglobin A1c levels or glycemic association.503–506 Furthermore, both recommended method for assessing
failure, and it develops early in HTN and dyslipidemias are associated the BP of children with suspected
the course of the disease.496 It is with subclinical atherosclerosis206 OSAS.
also associated with rapid onset of and are risk factors for future
adverse cardiac changes111,497 and CVD.503 Screening is recommended
may not respond to diet changes.425 to identify those at increased risk for 9.3 Comorbidities: Cognitive
The concurrence of obesity and early atherosclerosis.503 Treatment Impairment
T2DM compounds the risks for target of lipid disorders identified in the
end organ damage.111,498 Data from studies conducted in
setting of HTN should follow existing
adults suggest that the central
Empirical evidence shows a poor pediatric lipid guidelines with lifestyle
nervous system is a target organ
awareness of HTN in youth with advice, including weight loss and
that can be affected by HTN.419
T1DM and T2DM.14 Additionally, pharmacotherapy, as necessary.503
Preliminary studies suggest that
only a fraction of children with HTN this is true in children as well.
and diabetes were found to be on 9.2 Comorbidities: OSAS
Hypertensive children score lower
pharmacologic therapy14,490,498,499 Children with snoring, daytime on tests of neurocognition and on
despite treatment recommendations sleepiness (in adolescents), or parental reports of executive function
from the American Diabetes hyperactivity (in younger children) compared with normotensive
controls.509,510 Adams et al511 found
Key Action Statement 24. Children and adolescents with CKD and HTN should be an increased prevalence of learning
evaluated for proteinuria (grade B, strong recommendation). disabilities in children with primary
Aggregate Evidence Quality Grade B HTN compared with normotensive
Benefits Detection of proteinuria among children with CKD and HTN may controls. The postulated mechanism
foster early detection and treatment of children at risk for more for these findings is impaired
advanced renal disease cerebrovascular reactivity.512–515 At
Risks, harm, cost Additional testing
the present time, these findings do not
Benefit–harm assessment Benefit of detection of a higher-risk group exceeds the risk of testing
Intentional vagueness Whether to screen children with HTN without CKD for proteinuria have specific clinical implications with
Role of patient preferences None respect to the diagnostic evaluation
Exclusions Children without CKD of childhood HTN, although they
Strength Strong recommendation underscore the importance of early
Key references 47,484
detection and treatment.


Key Action Statement 25. Children and adolescents with CKD, HTN, and proteinuria over the past decade by the
should be treated with an ACE inhibitor or ARB (grade B, strong recommendation). publication of several pediatric
Aggregate Evidence Quality Grade B clinical trials and case series of
Benefits ACE inhibitor and ARB therapy has been shown in the short-term to antihypertensive agents that can be
be effective in reducing urine proteinuria used to treat such patients.465,523–530
Risks, harm, cost Positive effect on urine protein concentrations after the receipt of
an ACE inhibitor may not be sustained over time
Although children and adolescents
Benefit–harm assessment Treatment with an ACE inhibitor or ARB may lower the rate of
progression of renal disease even if the effect is not sustained in can become symptomatic from HTN
the long-term at lesser degrees of BP elevation,
Intentional vagueness Whether to aggressively treat the BP so that it is <90th percentile in general, patients who present
Role of patient preferences Patients may have concerns about the choice of medication, which with acute severe HTN will have BP
should be addressed
elevation well above the stage 2 HTN
Exclusions Children without CKD
Strength Strong recommendation threshold. In a study of 55 children
Key references 173,464,465,485,487,488 presenting to a pediatric ED in
Taiwan with hypertensive crisis, 96%
Key Action Statement 26. Children and adolescents with T1DM or T2DM should had SBP greater than that of stage
be evaluated for HTN at each medical encounter and treated if BP is ≥95th 2 HTN, and 76% had DBP greater
percentile or >130/80 mm Hg in adolescents ≥13 years of age (grade C, moderate than that of stage 2 HTN.531 The
recommendation). major clinical issue in such children
Aggregate Evidence Quality Grade C is that this level of BP elevation
Benefits Early detection and treatment of HTN in children with T1DM and may produce acute target organ
T2DM may reduce future CV and kidney disease effects, including encephalopathy,
Risks, harm, cost Risk of drug adverse effects and polypharmacy acute kidney injury, and congestive
Benefit–harm assessment Preponderance of benefit
heart failure. Clinicians should be
concerned about the development of
these complications when a child’s
Role of patient preferences Family concerns about additional testing and/or medication may
BP increases 30 mm Hg or more
need to be addressed
above the 95th percentile.
Exclusions None
Although a few children with primary
Strength Weak to moderate recommendation
HTN may present with features
of acute severe HTN,532 the vast
majority will have an underlying
secondary cause of HTN.532,533
10. SEX, RACIAL, AND ETHNIC in response to ACE inhibitors in the Thus, for patients who present with
DIFFERENCES IN BP AND MEDICATION pediatric age group,471 the strength acute severe HTN, an evaluation for
CHOICE of available evidence is insufficient to secondary causes is appropriate and
BP differences between various ethnic recommend using racial, sex, or ethnic should be conducted expediently.
groups are well described in the adult factors to inform the evaluation or Additionally, target organ effects
population.216,516 Large, cross-sectional management of HTN in children. should be assessed with renal
studies have demonstrated that, per function, echocardiography, and
capita, minority ethnic groups have central nervous system imaging,
both a higher prevalence of HTN and 11. SPECIAL POPULATIONS AND among others.
more significant end organ damage SITUATIONS
and outcomes.517,518 Although a Given the potential for the
growing body of evidence indicates 11.1 Acute Severe HTN development of potentially life-
that racial and ethnic differences in BP threatening complications, expert
appear during adolescence,519–521 the There is a lack of robust evidence opinion holds that children and
cause of these differences and when to guide the evaluation and adolescents who present with acute
they develop in childhood are yet to management of children and severe HTN require immediate
be fully determined. The risk of HTN adolescents with acute presentations treatment with short-acting
correlates more with obesity status of severe HTN. Thus, much of what antihypertensive medications that
than with ethnicity or race, although is known is derived from studies may abort such sequelae.533,534
there may be some interaction.216 At conducted in adults, including Treatment may be initiated with
this time, although limited data suggest medication choice.522 The evidence oral agents if the patient is able
that there may be a racial difference base has been enhanced somewhat to tolerate oral therapy and if


life-threatening complications have
false-positive screening
not yet developed. Intravenous
ABPM results in fewer
diagnosed HTN has no

interpreted correctly
Assumptions Made
WCH estimated at 35%,
benefit for correctly

agents are indicated when oral
Assumes treatment
be arranged and
Assumes ABPM can
therapy is not possible because of
complications
the patient’s clinical status or when
results
a severe complication has developed
(such as congestive heart failure)
—
—
that warrants a more controlled BP
reduction. In such situations, the
Family opinion depends
BP should be reduced by no more

Preferred Option
on family’s values
than 25% of the planned reduction

over the first 8 hours, with the
remainder of the planned reduction
over the next 12 to 24 hours.533,534
The ultimate short-term BP goal in
—
B
C
C
such patients should generally be
Less desirable to have more visits; more desirable to have better accuracy
around the 95th percentile. Table

Patients referred to provider who
interpret ABPM for all patients
If HTN, treatment improves long-
All patients correctly diagnosed;
All patients correctly diagnosed

Additional work to arrange and
19 lists suggested doses for oral

Option C (ABPM Only)
$1880 for visits, ABPM, and
and intravenous antihypertensive

fewer complications
medications that may be used to treat

who are treated
laboratory tests
patients with acute severe HTN.

only used ABPM
term outcome
Assumes 100%

with acute severe HTN and life-
threatening symptoms, immediate
Auscultatory or oscillatory BP >90%
Increased mortality for not treating

Option B (Clinic BP Confirmed by
If HTN, treatment improves long-
treatment with short-acting

interpret confirmatory ABPM
Additional work to arrange or
antihypertensive medication should

$1330 for visits, ABPM, and
30% undiagnosed patients
be initiated, and BP should be

ABPM)
reduced by no more than 25% of the

undiagnosed HTN
laboratory tests
term outcome
planned reduction over the first 8

Assumes 100%
then ABPM
hours (grade expert opinion D, weak

recommendation).
11.2 HTN and the Athlete

of treatment of patients with WCH
$1860 for visits and laboratory tests
Auscultatory or oscillatory BP >95%
Increased mortality for not treating

undiagnosed HTN; inconvenience
60% undiagnosed patients; 35% of
Sports participation and increased

Option A (Clinic BP Alone)
those diagnosed with WCH
physical activity should be

Costs from complications, adverse events, nonoptimal treatment
encouraged in children with

HTN. In adults, physical fitness is
associated with lower all-cause
Assumes 100%
TABLE 20 Comparison of HTN Screening Strategies
mortality.536 Although meta-analyses

Baseline
Baseline
Baseline
and randomized controlled trials

consistently show lower BP after
exercise training in adults,535 the
results are less robust in children.340
Percent adherence to care (goal
estimated cost for 1 patient)

analyzed at single-patient level
Costs of nonoptimal treatment

nephrology referred patients;
Visit, diagnosis costs (annual
On the basis of this evidence, sports

Care delivery team effects
participation should improve BP

Likelihood of nonoptimal
Population: 170 cardiology,
Patient, family effects
over time. Additionally, there is

Clinical significance
evidence that exercise itself has a

Operational factors
beneficial effect on cardiac structure

treatment
Cost of options
of 80%)
in adolescents.537
Dimension
Benefits
—, none.
The athlete interested in

participating in competitive sports


and/or intense training presents It should be acknowledged that there transplants, the presence of native
a special circumstance. Existing are no data linking the presence kidneys, CKD, and transplant
guidelines present conflicting of HTN to sudden death related to glomerulopathy are additional risk
recommendations.1,538 Although sports participation in children, factors for HTN. HTN rates are higher
increased LV wall dimension may be although many cases of sudden death by 24-hour ABPM compared with
a consequence of athletic training,360 are of unknown etiology. That said, clinic BP measurements because these
recommendations from AHA and athletes identified as hypertensive populations commonly have MH and
ACC include the following: (1) limiting (eg, during preparticipation nocturnal HTN.179–183,542 Control
competitive athletic participation sports screening) should undergo of HTN in renal-transplant patients
among athletes with LVH beyond appropriate evaluation as outlined has been improved with the use of
that seen with athlete’s heart until above. For athletes with more severe annual ABPM.184,185 Therefore, ABPM
BP is normalized by appropriate HTN (stage 2 or greater), treatment should be used to identify and monitor
antihypertensive drug therapy, and should be initiated before sports nocturnal BP abnormalities and MH in
(2) restricting athletes with stage participation. pediatric kidney and heart-transplant
2 HTN (even among those without recipients. The use of home BP
evidence of target organ injury) from Key Action Statement 28 assessment may provide a comparable
participating in high-static sports Children and adolescents with HTN alternative to ABPM for BP assessment
(eg, weight lifting, boxing, and may participate in competitive after transplant as well.186
wrestling) until HTN is controlled sports once hypertensive target
The management of identified HTN
with either lifestyle modification or organ effects and risk have been
in the pediatric transplant patient
drug therapy.539 assessed (grade C, moderate
can be challenging. Rates of control
recommendation).
The AAP policy statement “Athletic of HTN in renal-transplant patients
Participation by Children and Key Action Statement 29 generally range from 33% to 55%.180,
Adolescents Who Have Systemic 187 In studies by Seeman et al,188
Children and adolescents with HTN
Hypertension” recommends that intensified antihypertensive
should receive treatment to lower
children with stage 2 HTN be treatment in pediatric renal-
BP below stage 2 thresholds before
restricted from high-static sports transplant recipients improved
participating in competitive sports
(classes IIIA to IIIC) in the absence nocturnal SBP and significantly
(grade C, weak recommendation).
of end organ damage, including LVH reduced proteinuria.543 Children
or concomitant heart disease, until in these studies who achieved
their BP is in the normal range after 11.3 HTN and the Posttransplant normotension had stable graft
lifestyle modification and/or drug Patient function, whereas those who
therapy.538 It is further recommended HTN is common in children after remained hypertensive at 2
that athletes be promptly referred solid-organ transplants, with years had a progression of renal
and evaluated by a qualified pediatric prevalence rates ranging from 50% disease.544
medical subspecialist within 1 week to 90%.179,180,540,541 Contributing
Antihypertensive medications have
if they are asymptomatic or factors include the use of steroids,
rarely been systematically studied
immediately if they are symptomatic. calcineurin inhibitors, and mTOR
in this population. There is limited
The subcommittee agrees with these (mammalian target of rapamycin)
evidence that ACE inhibitors and ARBs
recommendations. inhibitors. In patients with renal
may be superior to other agents in
achieving BP control and improving
Key Action Statement 27. In children and adolescents with acute severe long-term graft survival in renal-
HTN and life-threatening symptoms, immediate treatment with short-acting transplant patients.185,543,544 However,
antihypertensive medication should be initiated, and BP should be reduced by the combination of ACE inhibitors
no more than 25% of the planned reduction over the first 8 hours (grade expert and ARBs in renal-transplant
opinion D, weak recommendation). patients has been associated with
Aggregate Evidence Quality Expert Opinion, D acidosis and hyperkalemia and is not
Benefits Avoidance of complications caused by rapid BP reduction recommended.545
Risks, harm, cost Severe BP elevation may persist
Benefit–harm assessment Benefit outweighs harm
Intentional vagueness None 12. LIFETIME HTN TREATMENT AND
Role of patient preferences None
TRANSITION TO ADULTHOOD
Exclusions Patients without acute severe HTN and life-threatening symptoms
Strength Weak recommendation because of expert opinion For adolescents with HTN
requiring ongoing treatment, the


Key Action Statement 28. Children and adolescents with HTN may participate in demonstrated that the risk of HTN
competitive sports once hypertensive target organ effects and risk have been in early adulthood is dependent on
assessed (grade C, moderate recommendation). childhood BP, with greater numbers
Aggregate Evidence Quality Grade C of elevated BP measurements in
Benefits Aerobic exercise improves CVD risk factors in children and childhood conferring an increased
adolescents with HTN risk of adult HTN.
Risks, harm, cost Unknown, but theoretical risk related to a rise in BP with strenuous
exercise may exist
Benefit–harm assessment The benefits of exercise likely outweigh the potential risk in the vast Because the tracking of BP
majority of children and adolescents with HTN levels in children has also been
Intentional vagueness None well documented,10 it is not
Role of patient preferences Families may have different opinions about sports participation in surprising that analyses of the
children with HTN
National Childhood BP database
Exclusions None
Strength Moderate recommendation found 7% of adolescents with
Key references 341,360,538,540,541 elevated BP per year progressed to
true hypertensive BP levels.
Of note, initial BMI and change in
Key Action Statement 29. Children and adolescents with HTN should receive BMI were major determinants of
treatment to lower BP below stage 2 thresholds before participating in the development of HTN.22
competitive sports (grade C, weak recommendation). Therefore, in both children
Aggregate Evidence Quality Grade C and adults, efforts (discussed
Benefits Aerobic exercise improves CVD risk factors in children and below) should be made to
adolescents with HTN prevent progression to
Risks, harm, cost Unknown, but theoretical risk related to a rise in BP with
sustained HTN and to avoid the
strenuous exercise may exist
Benefit–harm assessment The benefits of exercise likely outweigh the potential risk in the development of hypertensive CV
vast majority of children and adolescents with HTN diseases.
Role of patient preferences None
Exclusions None
13.2 Strategies for Prevention
Strength Weak recommendation
Key references 341,360,538,540,541
One of the largest trials of
preventing progression to HTN
in adults, the Trial of Preventing
transition from pediatric care to of information regarding HTN Hypertension study, proved
an adult provider is essential.546 etiology and past manifestations and that 2 years of treatment with
HTN definition and treatment complications of the patient’s HTN candesartan reduced the number
recommendations in this guideline (grade X, strong recommendation). of subjects with elevated BP from
are generally consistent with the developing stage 1 HTN even
forthcoming adult HTN treatment after the drug was withdrawn.547
guideline, so diagnosis and treatment However, no similar study has
should not typically change with 13. PREVENTION OF HTN been conducted in youth; for
transition. this reason, prevention efforts
13.1 Importance of Preventing HTN
to date have focused on lifestyle
BP levels tend to increase with modification, especially dietary
time even after adult height is intervention,426 exercise,549 and
Adolescents with elevated BP or reached. The rate of progression treatment of obesity.550 The best
HTN (whether they are receiving to frank HTN in a study of more evidence for the potential of such
antihypertensive treatment) should than 12 000 Japanese adults (20–35 prevention strategies comes
typically have their care transitioned years of age at baseline, followed from epidemiologic evidence for
to an appropriate adult care provider for 9 years) was 36.5% and was risk factors for the development
by 22 years of age (recognizing greater with higher baseline BP of HTN or from studies focused
that there may be individual cases category.548 The rate of progression on the treatment of established
in which this upper age limit is may also be accelerated in African HTN. These risk factors include
exceeded, particularly in the case American individuals. Similarly, positive family history, obesity, a
of youth with special health care both the Bogalusa Heart63 and Fels high-sodium diet, the absence of a
needs). There should be a transfer Longitudinal60 studies have clearly DASH-type diet, larger amounts of


Key Action Statement 30. Adolescents with elevated BP or HTN (whether they The third challenge is for
are receiving antihypertensive treatment) should typically have their care clinic personnel to be aware
transitioned to an appropriate adult care provider by 22 years of age (recognizing of what to do with high BP
that there may be individual cases in which this upper age limit is exceeded, measurements when they occur.
particularly in the case of youth with special health care needs). There should Knowing when to counsel patients,
be a transfer of information regarding HTN etiology and past manifestations and order tests or laboratory work,
complications of the patient’s HTN (grade X, strong recommendation).
and reach out for help is essential.
Aggregate Evidence Quality Grade X Making this part of standard
Benefits Provides continuity of care for patients
Risks, harm, cost None
practice so every child follows
Benefit–harm assessment No risk the prescribed pathway may be
Intentional vagueness None challenging.
Role of patient preferences Patient can pick adult care provider
Exclusions None The final diagnosis of HTN
Strength Strong recommendation
also relies on a number of
Key references 547
sequential visits. Ensuring that
patients return for all of these
visits and are not lost to follow-up
sedentary time, and possibly other and avoidance of tobacco products may require new clinic processes
dietary factors.551–553 are also reasonable strategies to or mechanisms. Information
reduce CV risk. technology may help remind
Because family history is immutable, providers to schedule these visits
it is difficult to build a preventive These preventive strategies can and remind patients to attend
strategy around it. However, a be implemented as part of routine these visits; even with that
positive family history of HTN primary health care for children and assistance, however, completing all
should suggest the need for closer adolescents. the visits may be difficult for some
BP monitoring to detect HTN if it patients.
occurs.
Appropriate energy balance with 14. CHALLENGES IN THE In addition, family medicine
calories eaten balanced by calories IMPLEMENTATION OF PEDIATRIC HTN physicians and general
expended in physical activity is GUIDELINES pediatricians may face challenges
important. This is the best strategy in having normative pediatric
to maintain an appropriate BMI Many studies have shown that BP values available for use at all
percentile for age and sex and physicians fail to meet benchmarks times. Although adult BP cutoffs
to avoid the development of with respect to screening, especially are easy to memorize, pediatric
obesity.554 From a broader dietary universal screening for high BP in BP percentile cutoffs are greatly
perspective, a DASH-type diet (ie, children.7,115 Although the reasons dependent on age and height. The
high in fruits, vegetables, whole for this failure likely vary from BP tables in this guideline provide
grains, and low-fat dairy, with practice to practice, a number of cutoffs to use for the proper
decreased intake of foods high common challenges can be identified. diagnosis of HTN; their availability
in saturated fat or sugar) may be will simplify the recognition of
The first challenge is determining how abnormal BP values.
beneficial (see Table 16).423,427
to identify every child in a clinic who
Avoiding high-sodium foods may
merits a BP measurement. This could The AAP Education in Quality
prove helpful in preventing HTN,
be accomplished through flags in an Improvement for Pediatric Practice
particularly for individuals who are
EHR, documentation rules for specific module on HTN identification
more sensitive to dietary sodium
patients, and/or clinic protocols. and management556 and its
intake.555
The second challenge is establishing accompanying implementation
Adhering to recommendations a local clinic protocol for measuring guide557 should be of assistance to
for 60 minutes a day of moderate BP correctly on the basis of the practitioners who wish to improve
to vigorous physical activity can algorithms in this guideline. It their approach to identifying
be important to maintaining an is important to determine the and managing childhood HTN.
appropriate weight and may optimal approach on the basis of This module is currently being
be independently helpful to the available equipment, the skills updated to incorporate the new
maintaining a lower BP.344 The of clinic personnel, and the clinic’s recommendations in this
achievement of normal sleep habits throughput needs. guideline.


15. OTHER TOPICS screening strategies; these options choices lead to better decisions
are summarized in the following executed in self-care. For clear
15.1 Economic Impact of BP value-analysis framework (see judgments to be made, there needs
Management Table 20).560 It appears that the to be open communication between
Researchers in a small number of implementation of ABPM for all physicians and families, a provision
studies have examined the potential patients is not ensured. The next of appropriate education on optimal
economic impacts related to pediatric best option, screening clinic BP HTN management, and a strong
BP management.208,558,559 Wang et al558 with ABPM, is most likely to be partnership assembled within a
estimated both the effectiveness and implementable and has significant multidisciplinary health care team
cost-effectiveness of 3 screening clinical benefit given the high including physicians, advanced
strategies and interventions to prevalence of WCH. practice providers, dietitians,
normalize pediatric BP based on the nurses, and medical and clinical
literature and through a simulation Swartz et al208 conducted a assistants.
of children (n = 4 017 821). The 3 retrospective review of 267 It is important for physicians
screening strategies included the children with elevated clinic BP to be mindful that children and
following: (1) no screening; (2) measurements referred for ABPM. adolescents want, and need, to
selected screening and treatment, as Of the 126 patients who received be involved in their medical care.
well as “treating everyone” (ie, with ABPM, 46% had WCH, 49% had Pediatric HTN patients are likely
population-wide interventions, such stage 1 HTN, and 5% had stage 2 to feel excluded when clinicians
as targeted programs for overweight HTN. This is consistent with the or other providers speak to their
adolescents [eg, weight-loss concept that screening with clinic parents instead of including them in
programs, exercise programs, and BP alone results in high numbers the conversation. When patients are
salt-reduction programs]); and (3) of false-positive results for HTN. neither included in the discussion
nontargeted programs for exercise The diagnosis of HTN in this study nor encouraged to ask questions,
and salt reduction. resulted in an additional $3420 for their anxiety can increase, thus
evaluation (includes clinic visit, worsening their HTN. Keeping
The simulation suggested that these facility fee, laboratory testing, renal an open line of communication
various strategies could reduce ultrasound, and echocardiography) is important and is best done by
mortality, with a modest expected vs $1265 (includes clinic visit, using a team approach consisting
survival benefit of 0.5 to 8.6 days. facility fee, and ABPM). This of the patient, the family, health
The researchers also examined suggests that ABPM is cost- care support staff, and physicians.
quality-adjusted life-years (QALYs) effective because of the reduction With practical education on
and the cost per QALY. Only 1 of unnecessary testing in patients HTN management provided in
intervention, a nontargeted salt- with WCH. easily understandable terms, the
reduction campaign, had a negative patients will be more likely to
When examining these costs,
cost per QALY. This intervention apply the concepts presented to
the availability of ABPM, and the
and the other 2 described in that them. Education is important and
availability of practitioners who are
article support the concept that should be given in a way that is
skilled in pediatric interpretation,
population-wide interventions appropriate for young children
the most cost-effective and
may be the most cost-effective way and their families to understand.
implementable screening solution
to improve CV health. The article Education should consist of
is to measure clinic BP and confirm
has serious limitations, however, suitable medication dosing, a
elevated readings by ABPM.
including the fact that population- proper diet and level of activity,
wide interventions for exercise and the identification of symptoms,
the reduction of sodium intake have
15.2 Patient Perspective and
Pediatric HTN and appropriate BP monitoring
not, thus far, been effective. (including cuff size).
Children and adolescents are
The accurate determination of not just patients; they are
those who actually have HTN (as active participants in their 15.3 Parental Perspective and
Pediatric HTN
opposed to WCH) is fundamental to health management. If children
providing sound care to patients. and adolescents lack a clear Parents play a key role in the
Researchers in two studies understanding of what is happening management and care of their
examined the effects of using ABPM inside their bodies, they will not children’s health. Parents and
in the diagnosis of HTN.208,559 be able to make informed choices physicians should act as a cohesive
Davis et al559 compared 3 HTN in their daily activities. Better unit to foster the best results. It


is vital for physicians to provide Understanding the family and the types of clinical trials that
concise information in plain language patient’s perception of HTN and are needed to produce high-
and do so using a team approach. any underlying disease that may quality evidence. For example,
This will facilitate parents having a be contributing to it is important no large pediatric cohort has
clear understanding of the required to resolve any misconceptions ever been assembled to answer
tests, medications, follow-ups, and and encourage adherence to the the question of whether routine
outcomes. physician’s recommendations. To BP measurement in childhood is
attain therapeutic goals, proper useful to prevent adult CVD.566
education must be provided to the Given this, other types of evidence,
Patient Perspective, by Matthew family as a whole. This education such as from cross-sectional and
Goodwin should include proper medication observational cohort studies, must
dosages, recommended sodium be examined to guide practice.567
“I am not just a 13 year old, I am
intake, any dietary changes,
a teenager who has lived with
exercise expectations, and any From the standpoint of the primary
hypertension, renal disease, and
other behavioral changes. It is care provider, the most significant
midaortic syndrome since I was
equally important to stress to evidence gaps relate to whether
4 years old. I have experienced
the family the short- and long- diagnosing elevated BP and HTN in
surgeries, extended hospitalizations,
term effects of HTN if it is not children and adolescents truly has
daily medications, procedures,
properly managed. Parents with long-term health consequences,
tests, continued blood pressure
younger children will carry the whether antihypertensive
monitoring, lifestyle changes, and
ultimate burden of daily decisions medications should be used in a
dietary restrictions. Hypertension
as it applies to medications, food child or adolescent with elevated
is a part of my everyday life. It will
choices, and activity. Parents of BP, and what medications should be
always be a component of me. I had
older adolescents will partner with preferentially used. These evidence
to learn the effects of hypertension
the children to encourage the right gaps have been alluded to previously
at a young age. I knew what would
choices. Education as a family unit in this document.
happen to me if I ate too much
is important for everyone involved
salt or did not fully hydrate, thus I Other important evidence gaps
to understand the consequences.
became watchful. I did this so I could should be highlighted, including the
efficiently communicate with my following:
A family-based approach is important
physicians any changes I physically
for all pediatric diseases but plays a
felt or any symptoms that were new
particular role in conditions that are Is there a specific BP level in
or different regarding my illness.
substantially influenced by lifestyle childhood that predicts adverse
This has allowed me, my family, and
behaviors. This has been shown outcomes, and can a single number
my doctors to work effectively as
in several pediatric populations, (or numbers) be used to define
one unit. I am grateful for my doctors
including those with T2DM and HTN, as in adults?
listening to me as a person and not
obesity.561–565
as a kid.” Can and should ABPM ever replace
auscultation in the diagnosis of
childhood HTN?
Parents of children with 16. EVIDENCE GAPS AND PROPOSED Are the currently used, normative
hypertensive issues can encounter FUTURE DIRECTIONS standards for ABPM appropriate,
1 or more specialists in addition or are new normative data
to their pediatric clinician. This In general, the pediatric HTN needed?568
can prove to be overwhelming, literature is not as robust as the What is the best diagnostic
frightening, and may fill the parent adult HTN literature. The reasons evaluation to confidently exclude
with anxiety. Taking these things for this are many, but the 2 most secondary causes of HTN?
into account and creating unified important are as follows: (1)
partners, built with the physician the lower prevalence of HTN in Are other assessments of
and family, will encourage the childhood compared with adults, hypertensive target organ
family to be more involved in the and (2) the lack of adverse CV damage (such as urine MA or
patient’s health management. Plain events (myocardial infarction, vascular studies) better than
language in a team approach will stroke, and death) attributable echocardiography?
yield the most positive outcomes to HTN in young patients. These How confident can we be that a
for the patient. factors make it difficult to conduct child or teenager with elevated BP


will have HTN and/or CVD disease Susan K. Flinn, MA
as an adult? Bonita Falkner, MD ABBREVIATIONS
Samuel S. Gidding, MD
AAP: American Academy of
Some of these questions may Celeste Goodwin
Pediatrics
eventually be answered by research Michael G. Leu, MD, MS, MHS, FAAP
Makia E. Powers, MD, MPH, FAAP ABPM: ambulatory blood pressure
that is currently in progress, such as
Corinna Rea, MD, MPH, FAAP monitoring
further analysis of the International Joshua Samuels, MD, MPH, FAAP ACC: American College of
Childhood Cardiovascular Cohort Madeline Simasek, MD, MSCP, FAAP
Cardiology
Consortium569 and the promising Vidhu V. Thaker, MD, FAAP
ACE: angiotensin-converting
Adult Hypertension Onset in Youth Elaine M. Urbina, MD, MS, FAAP
enzyme
study, which seeks to better define the
AHA: American Heart Association
level of BP in childhood that predicts SUBCOMMITTEE ON SCREENING
ARB: angiotensin receptor blocker
the development of hypertensive AND MANAGEMENT OF HIGH BLOOD
ARR: aldosterone to renin ratio
target organ damage.570 Other PRESSURE IN CHILDREN (OVERSIGHT
BY THE COUNCIL ON QUALITY BP: blood pressure
studies will need to be performed
IMPROVEMENT AND PATIENT BSA: body surface area
in children and adolescents to fill
SAFETY)† cIMT: carotid intimamedia thickness
in the remaining gaps, including
CKD: chronic kidney disease
more rigorous validation studies of Joseph T. Flynn, MD, MS, FAAP, Co-chair, Section on
Nephrology CTA: computed tomographic
automated BP devices in the pediatric
David Kaelber, MD, MPH, PhD, FAAP, Co-chair, angiography
population, expanded trials of lifestyle Section on Medicine-Pediatrcs, Council on Clinical CV: cardiovascular
interventions, further comparative Information Technology
CVD: cardiovascular disease
trials of antihypertensive medications, Carissa M. Baker-Smith, MD, MS, MPH,
DASH: Dietary Approaches to Stop
and studies of the clinical applicability Epidemiologist and Methodologist
Aaron Carroll, MD, MS, FAAP, Partnership for Hypertension
of hypertensive target organ
Policy Implementation DBP: diastolic blood pressure
assessments. Stephen R. Daniels, MD, PhD, FAAP, Committee on ED: emergency department
Furthermore, and perhaps more Nutrition
EHR: electronic health record
Sarah D. de Ferranti, MD, MPH, FAAP, Committee
crucially, there needs to be prospective FMD: flow-mediated dilation
on Cardiology and Cardiac Surgery
assessment of the recommendations Michael G. Leu, MD, MS, MHS, FAAP, Council on HTN: hypertension
made in this document with regular Quality Improvement and Patient Safety LVH: left ventricular hypertrophy
updates based on new evidence as Makia Powers, MD, MPH, FAAP, Committee on LVMI: left ventricular mass index
it is generated (generally, per AAP Adolescence
MA: microalbuminuria
Corinna Rea, MD, MPH, FAAP, Section on Early
policy, these occur approximately MAP: mean arterial pressure
Career Physicians
every 5 years). With such ongoing Joshua Samuels, MD, MPH, FAAP, Section on MH: masked hypertension
reassessment and revision, it is hoped Nephrology MI: motivational interviewing
that this document and its future Madeline Simasek, MD, FAAP, Quality Improvement MRA: magnetic resonance angiography
revisions will come to be viewed as Innovation Networks
NF-1: neurofibromatosis type 1
Vidhu Thaker, MD, FAAP, Section on Obesity
an effective guide to practice and will OSAS: obstructive sleep apnea
improve the care of the young patients LIAISONS syndrome
who are entrusted to us. PCC: pheochromocytoma
Douglas Blowey, MD, American Society of
Pediatric Nephrology PICOT: Patient, Intervention/
Implementation tools for this
Janis Dionne, MD, FRCPC, Canadian Association of Indicator, Comparison,
guideline are available on the AAP Paediatric Nephrologists Outcome, and Time
Web site https://www.aap.org/ Bonita Falkner, MD, International Pediatric
PRA: plasma renin activity
en-us/professional-resources/ Hypertension Association
PWV: pulse wave velocity
quality-improvement/quality- Samuel Gidding, MD, American College of
Cardiology, American Heart Association QALY: quality-adjusted life-year
improvement-resources-and-tools/
Celeste Goodwin, National Pediatric Blood RAAS: renin-angiotensin-
Pages/hypertension.aspx. Pressure Awareness Foundation aldosterone system
Elaine Urbina, MD, FAAP, American Heart
AUTHORS RAS: renal artery stenosis
Association AHOY Committee
Joseph T. Flynn, MD, MS, FAAP SBP: systolic blood pressure
David C. Kaelber, MD, PhD, MPH, FAAP, FACP, FACMI MEDICAL WRITER SDB: sleep-disordered breathing
Carissa M. Baker-Smith, MD, MS, MPH, FAAP, FAHA T1DM: type 1 diabetes mellitus
Susan K. Flinn, MA
Douglas Blowey, MD T2DM: type 2 diabetes mellitus
Aaron E. Carroll, MD, MS, FAAP
STAFF UA: uric acid
Stephen R. Daniels, MD, PhD, FAAP
Sarah D. de Ferranti, MD, MPH, FAAP Kymika Okechukwu, MPA, Manager, Evidence- WCH: white coat hypertension
Janis M. Dionne, MD, FRCPC Based Practice Initiatives


Seattle, Washington; nDepartment of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia; oAssociate Director, General Academic Pediatric Fellowship, Staff Physician,
Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts; Departments of pPediatrics and Internal Medicine, McGovern
Medical School, University of Texas, Houston, Texas; qPediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of
Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; rDivision of Molecular
Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and sPreventive Cardiology, Cincinnati Children’s Hospital Medical Center, Department of
Pediatrics, University of Cincinnati, Cincinnati, Ohio
Drs Flynn and Kaelber served as the specialty and primary care chairs of the Subcommittee and had lead roles in developing the framework for the guidelines and coordinating
the overall guideline development; Dr Baker-Smith served as the epidemiologist and led the evidence review and synthesis; Ms. Flinn compiled the first draft of the manuscript and
coordinated manuscript revisions; All other authors were significantly involved in all aspects of the guideline creation including initial scoping, literature review and synthesis, draft
manuscript creation and manuscript review; and all authors approved the final manuscript as submitted.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American
Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted
any commercial involvement in the development of the content of this publication.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be
appropriate.
All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Endorsed by the American Heart Association.
DOI: https://doi.org/10.1542/peds.2017-1904
Address correspondence to Joseph T Flynn. Email: joseph.flynn@seattlechildrens.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated that they have no financial relationships relevant to this article to disclose.
FUNDING: The American Academy of Pediatrics provided funding to cover travel costs for subcommittee members to attend subcommittee meetings, to pay for the epidemiologist (Dr
Baker-Smith) and consultant (Susan Flynn), and to produce the revised normative blood pressure tables.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated that they have no potential conflicts of interest to disclose.
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Clinical Practice Guideline for Screening and Management of High Blood
Pressure in Children and Adolescents
Joseph T. Flynn, David C. Kaelber, Carissa M. Baker-Smith, Douglas Blowey, Aaron
E. Carroll, Stephen R. Daniels, Sarah D. de Ferranti, Janis M. Dionne, Bonita Falkner,
Susan K. Flinn, Samuel S. Gidding, Celeste Goodwin, Michael G. Leu, Makia E.
Powers, Corinna Rea, Joshua Samuels, Madeline Simasek, Vidhu V. Thaker, Elaine
M. Urbina and SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF
HIGH BLOOD PRESSURE IN CHILDREN
Pediatrics 2017;140;
DOI: 10.1542/peds.2017-1904 originally published online August 21, 2017;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/140/3/e20171904
References This article cites 559 articles, 141 of which you can access for free
at:
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Clinical Practice Guideline for Screening and Management of High Blood
Pressure in Children and Adolescents
Joseph T. Flynn, David C. Kaelber, Carissa M. Baker-Smith, Douglas Blowey, Aaron
E. Carroll, Stephen R. Daniels, Sarah D. de Ferranti, Janis M. Dionne, Bonita Falkner,
Susan K. Flinn, Samuel S. Gidding, Celeste Goodwin, Michael G. Leu, Makia E.
Powers, Corinna Rea, Joshua Samuels, Madeline Simasek, Vidhu V. Thaker, Elaine
M. Urbina and SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF
HIGH BLOOD PRESSURE IN CHILDREN
Pediatrics 2017;140;
DOI: 10.1542/peds.2017-1904 originally published online August 21, 2017;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/140/3/e20171904
Data Supplement at:

http://pediatrics.aappublications.org/content/suppl/2018/11/28/peds.2017-1904.DC1
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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Guidance for the Clinician in Rendering Pediatric Care

CLINICAL PRACTICE GUIDELINE

Clinical Practice Guideline for

clinical practice guideline, endorsed by the American Heart Association, is

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Clinical Practice Guideline for Screening

PEDIATRICS Volume 140, number 3, September 2017

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Clinical Practice Guideline for Screening

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FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Practice Guideline for Screening

PEDIATRICS Volume 140, number 3, September 2017

Clinical Practice Guideline for Screening

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Clinical Practice Guideline for Screening

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ROUGH GALLEY PROOF

machine that has been validated for

BP devices, including whether they

are validated in the pediatric age

measured in the right arm by using

standard measurement practices

arch anatomy, such as right aortic

arch and aortic coarctation or left

subclavian artery (see Table 7).

Other important aspects of proper

used for accurate BP measurement.83

Researchers in 3 studies in the United

the lack of availability of an

appropriately sized cuff in both the

Pediatric offices should have access

to a wide range of cuff sizes, including

quantile regression on the basis of normal-weight children (BMI <85th percentile).77

children in whom the appropriate

the midpoint between the acromion

position and the elbow flexed to

90°86,95,96) should be obtained for an

cuff size (see Fig 2 and Table 7).95

If the initial BP is elevated (≥90th