Hypertension

AHA SCIENTIFIC STATEMENT

Pediatric Primary Hypertension: An

Underrecognized Condition: A Scientific
Statement From the American Heart Association
Bonita Falkner, MD, FAHA, Chair; Samuel S. Gidding, MD, FAHA, Vice Chair; Carissa M. Baker-Smith, MD, MPH, FAHA;
Tammy M. Brady, MD, PhD, FAHA; Joseph T. Flynn, MD, MS, FAHA; Leslie M. Malle, MSN, FAHA; Andrew M. South, MD, MS, FAHA;
Andrew H. Tran, MD, MS, FAHA; Elaine M. Urbina, MD, MS, FAHA; on behalf of the American Heart Association Council on
Hypertension; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Kidney in Cardiovascular
Disease; Council on Lifestyle and Cardiometabolic Health; and Council on Cardiovascular and Stroke Nursing

ABSTRACT: The overall prevalence of hypertension in childhood is 2% to 5%, and the leading type of childhood hypertension is
primary hypertension, especially in adolescence. As in adults, the leading risk factors for children with primary hypertension
are excess adiposity and suboptimal lifestyles; however, environmental stress, low birth weight, and genetic factors may
also be important. Hypertensive children are highly likely to become hypertensive adults and to have measurable target
organ injury, particularly left ventricular hypertrophy and vascular stiffening. Ambulatory and home blood pressure monitoring
may facilitate diagnosis. Primordial prevention of hypertension through public health implementation of healthier diet and
increased physical activity will reduce the prevalence of primary hypertension, and evidence-based treatment guidelines
should be implemented when hypertension is diagnosed. Further research to optimize recognition and diagnosis and clinical
trials to better define outcomes of treatment are needed.
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Key Words: AHA Scientific Statements ◼ blood pressure ◼ cardiovascular diseases ◼ child ◼ hypertension ◼ obesity

T
here is now evidence that high blood pressure (BP) in and consequences of abnormal BP beginning in childhood.
childhood is associated with both cardiovascular dis- The evolving evidence has reshaped our perspective on
ease (CVD) events and intermediate markers of CVD abnormal BP in childhood to an understanding that adult
in adulthood.1,2 Before the mid-1970s, BP was not com- primary (essential) hypertension can originate in childhood.
monly measured in asymptomatic children. When BP was
measured, no pediatric BP reference data were available to
designate abnormal BP levels in children, and adult criteria DEFINITION, DIAGNOSIS, AND
were used to define hypertension. Therefore, children diag-
nosed with hypertension, according to the adult threshold PREVALENCE
in use at that time (140/90 mm Hg), had severe hyperten- The definition of childhood-onset hypertension in most
sion that was generally secondary to kidney disease, car- current pediatric guidelines is based on the percentile of
diac/vascular abnormality, or endocrinopathy. It was then the distribution of BP values in healthy children, typically
assumed that hypertension in childhood was always sec- based on age, sex, and height. Hypertension is defined
ondary in origin and that primary (essential) hypertension as systolic BP ≥95th percentile. Diastolic BP ≥95th per-
did not exist in childhood. The first report on BP control in centile also defines hypertension, as do both systolic and
children by Blumenthal et al3 in 1977 provided reference diastolic BPs ≥95th percentile (Table 1).4–6 As a result of
data on BP in childhood and defined hypertension as sys- variability in BP measurements, BP levels ≥95th percen-
tolic or diastolic BP ≥95th percentile. Subsequent epide- tile should be found on 3 separate visits.
miological and clinical research expanded the knowledge The American Academy of Pediatrics,4 European
on the prevalence of abnormal BP, associated risk factors, Society of Hypertension,5 and Hypertension Canada6

© 2023 American Heart Association, Inc.

Hypertension is available at www.ahajournals.org/journal/hyp

Hypertension. 2023;80:e101–e111. DOI: 10.1161/HYP.0000000000000228 June 2023   e101

 Falkner et al Pediatric Primary Hypertension

Table 1. Definitions of Normal and Abnormal Childhood BP Levels

CLINICAL STATEMENTS

BP category Age <13 y* Age ≥13 y

AND GUIDELINES

Normal BP <90th percentile for age, sex, and height <120/<80 mm Hg

Elevated BP 90th–<95th percentile for age, sex, and height ≥120/<80 to 129/<80 mm Hg
Stage 1 hypertension ≥95th percentile–95th percentile plus 11 mm Hg 130–139/80–89 mm Hg
Stage 2 hypertension ≥95th percentile plus 12 mm Hg ≥140/≥90 mm Hg
BP indicates blood pressure.
*And up to the BP levels for children ≥13 years of age.
Adapted with permission from Pediatrics.4 Copyright © 2017 the AAP.

all define hypertension as repeated BP readings ≥95th shown to identify white-coat hypertension, a condition
percentile for children. Where they differ are the ages at that may not require further immediate evaluation but
which static thresholds are adopted for the diagnosis of does require long-term monitoring. Masked hyperten-
hypertension adolescents: sion is a condition of concern and requires additional
• American Academy of Pediatrics4 adopts 130/80 monitoring, especially if other risk factors are present.
mm Hg starting at 13 years of age; ABPM is also useful for identifying youth at higher
• European Society of Hypertension5 adopts 140/90 risk of having secondary forms of hypertension or
mm Hg starting at 16 years of age; and hypertension-related TOI. Table 4 provides additional
• Hypertension Canada6 adopts 120/80 mm Hg for indications for ABPM.
6 to 11 years of age and 130/85 mm Hg for 12 to Data on the prevalence of childhood-onset primary
17 years of age. hypertension vary according to the setting (location, pop-
Use of the 95th percentile is attributable to the lack ulation), measurement techniques used, and definition of
of data for BP levels in childhood that predict later CVD high BP. Studies that are more rigorous have demon-
events (heart failure, kidney failure, stroke, and death), as strated an overall 2% to 5% hypertension prevalence and
there are in adults. It is possible that an outcomes-based ≈13% to 18% prevalence of elevated BP in the general
definition of childhood-onset hypertension may be on the pediatric population in the United States and other coun-
horizon as new data emerge linking childhood BP and tries.11,12 In an analysis of a large pediatric health care
target organ injury (TOI) to future adverse events.7 As in claims database, the prevalence of primary hypertension
was ≈10 times higher than the prevalence of secondary
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adults, the definition of primary hypertension in children

and adolescents is the absence of an identifiable cause
of secondary hypertension.
Table 2. Recommended Methods to Measure Manual and
Accurate diagnosis of childhood-onset hyperten- Automatic BP Accurately and Reliably in Youth
sion, in addition to the currently recommended mea-
1. Seat the patient in a quiet room at rest for 3–5 min with back supported
surement of BP on at least 3 different days, requires and feet flat on the floor (and uncrossed) before and during measurement.
an appropriate BP measurement technique.4,8 Table 2
2. Measure BP in the right arm unless contraindicated (presence of arteriove-
provides a summary of evidence-based methods to nous fistula). Support the arm so that the middle of the cuff when applied is
obtain accurate and reliable BP values with either at heart level. The upper arm should be bare under the cuff, taking care to
auscultatory or oscillometric methods. When the initial avoid the presence of a tightly rolled sleeve above the cuff. The patient and
health care professional should not speak during measurement, and the
BP measurement is abnormal, repeat measurement by patient should avoid reading, using electronic devices, or other distractions.
auscultation is recommended, within the same visit if 3. Measure the middle upper arm circumference at the midpoint between
possible and then within weeks if the screening BP the acromion and olecranon to determine the correct cuff size. When
is hypertensive or months if the screening BP is ele- BP is measured by manual auscultation, the bladder length should be
≥80% of the middle upper arm circumference, and bladder width should
vated. Because BP levels are variable, even within a be 37%–50% of the middle upper arm circumference. When BP is mea-
single visit, best practice is to obtain up to 3 BP mea- sured with an automated device, the cuff should be selected on the basis
surements and to record the average of the latter 2 of the designated arm-circumference range indicated on the cuff. Place
the cuff so that the midpoint of the inflatable portion of the cuff (typically
measurements unless the first measurement is nor- demarcated artery) is 2 cm above the palpated brachial artery in the ante-
mal. BP measurement is both a screening and a con- cubital fossa; this will ensure equal compression of the brachial artery
firmatory test, so methodological rigor is vital to detect during measurement. The cuff should be applied snugly so that no more
than 2 fingers can be placed between the cuff and the skin.
high BP accurately and to avoid false-positive screens
4. Manual auscultation: To determine the peak cuff inflation level, palpate the
and misclassification.9
radial artery pulse and inflate the cuff to 20–30 mm Hg above the point at
Further confirmation of diagnosis of hypertension which the pulse disappears. Palpate the brachial artery at the antecubital
can be obtained with 24-hour ambulatory BP moni- fossa and place either the stethoscope diaphragm or bell over the brachial
artery; ensure that it is not placed under the cuff. Inflate the cuff to the peak
toring (ABPM).4,5 When the combination of office/
inflation level. Deflate the cuff by 2–3 mm Hg/s. The first Korotkoff sound
clinic BP readings and the results of ABPM is used, (K1) is the systolic BP, and the last audible sound (K5) is the diastolic BP.
patients can be further categorized into a specific BP BP indicates blood pressure.
phenotype (Table 3).10 Such a classification has been Adapted with permission from Pediatrics.4 Copyright © 2017 the AAP.

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 Falkner et al Pediatric Primary Hypertension

Table 3. BP Phenotypes According to Office and Ambula- Table 4. Indications for Performance of ABPM in Children
tory BP and Adolescents

CLINICAL STATEMENTS
AND GUIDELINES
Phenotype Office BP Ambulatory BP Population Rationale
Normotensive Normal Normal Patients with office-confirmed hyper- Assess for white-coat hypertension
tension Assess for BP control on therapy
White-coat hypertension Hypertensive Normal
Patients with history of coarctation of Assess for masked hypertension
Ambulatory hypertension Hypertensive Hypertensive
the aorta
Masked hypertension Normal Hypertensive
Patients with chronic kidney disease, Assess for masked hypertension
BP indicates blood pressure. including patients with acquired soli- Assess for BP control on therapy
Adapted with permission from Flynn et al.10 Copyright © 2022 American Heart tary kidney
Association, Inc.
Patients with diabetes (types 1 and 2) Assess for masked hypertension
Assess for abnormal circadian
variation of BP
hypertension (0.2% versus 0.02%).13 However, there was Patients with genetic syndromes at Assess for masked hypertension
significant heterogeneity in BP measurement and evalu- increased risk of hypertension*
ation for secondary causes among the included studies. Patients with history of prematurity Assess for masked hypertension
Secondary hypertension is more common in younger Assess for abnormal circadian
children <6 years of age and children and adolescents variation of BP

with more severe hypertension.4–6 Primary hypertension Patients with obesity Assess for masked hypertension
Assess for abnormal circadian
is now considered the most prevalent type of hyperten- variation of BP
sion in childhood, especially in adolescents.
ABPM indicates ambulatory blood pressure monitoring; and BP, blood
pressure.
*Including neurofibromatosis type 1, Turner syndrome, and Williams syndrome.
CAUSE
The cause of primary hypertension remains unclear In addition, neurohormonal and renal cardiovascular
despite extensive research. It is a multifactorial condition, dysregulation such as altered baroreflex sensitivity and
with mechanistic contributions from inherited factors, salt-sensitive BP have been described in youth and
physiological traits, and environmental exposures (Fig- adults. Other mechanisms contribute to adverse cardio-
ure). Primary pediatric hypertension is the early phase vascular phenotypes, including insulin resistance, renin-
of a condition that exists on a continuum across the life angiotensin-aldosterone system dysregulation, and
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course, with higher BP exposure over time contributing inflammation. Once developed, hypertension-induced
to subclinical outcomes in childhood and young adult- TOI likely abets sustained hypertension, including car-
hood (eg, TOI in the heart, kidneys, and brain) and, later diac injury, microvascular narrowing, stiffening of larger
in life, CVD events, including heart failure, stroke, kidney arteries, and altered baroreceptor activity in response to
failure, and death.1 vascular stiffening.18

Heritability Early-Life Programming

Although hypertension frequently clusters within families Epidemiological studies have established that fetal
and appears to be at least partly heritable, genetic stud- exposures to a compromised intrauterine environment,
ies have been unable to identify specific genes or groups often resulting in low birth weight, can program car-
of genes that collectively could cause primary hyperten- diovascular alterations that increase the risk for later
sion.14,15 Genetic influences on BP may be attributable cardiometabolic disorders, including hypertension.19
to complex interactions among a large number of sus- Experimental data suggest numerous mechanisms,
ceptibility genes. Epigenetic factors likely play a role, including altered cardiovascular tissue structure and
especially in mediating environmental influences.16 Rare function and dysregulated hormonal pathways. Exam-
monogenic forms of hypertension are considered sec- ples of structural alterations include reduced nephron
ondary hypertension. number and reduced aortic size in those born prema-
turely or small for gestational age. It remains unknown
exactly which and to what extent these programming
Physiology mechanisms contribute to the development of primary
Increased cardiac output likely plays a larger role in hypertension.
driving high BP in youth compared with increased vas-
cular resistance seen in older individuals.17 Contributors
to higher cardiac output include increased sympathetic Tracking, Trajectories, and Early Outcomes
tone and sodium and fluid retention, all of which are In early childhood, individual BP levels are variable
more common in individuals with overweight or obesity. between measurements. By the middle of childhood

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 Falkner et al Pediatric Primary Hypertension
CLINICAL STATEMENTS
AND GUIDELINES

Figure. Risk factors for high BP in children and adolescents that are modifiable, including improving dietary intake and physical
activity and reducing excess adiposity.
Also shown are nonmodifiable risk factors. As shown on the right, there is evidence of target organ injury in the heart and blood vessels in
youth with primary hypertension. Primary hypertension onset in childhood is associated with adverse cardiovascular disease outcomes in
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adulthood. *Environment: Many environmental exposures, including excess dietary salt intake and air pollution, that are known to have an
adverse effect on blood pressure (BP) in youth and cardiovascular disease in adults are technically modifiable. However, efforts to mitigate
these exposures are challenging and require ongoing public health research, advocacy, and policy changes.

(age, 8–9 years), BP levels within individuals tend to (National Health and Nutrition Examination Series) data
track along the same percentile. According to evidence from 2015 to 2018 found that children with obesity were
of tracking (tracking coefficient ≥0.4), pediatric primary more likely to have hypertension compared with children
hypertension predicts adult hypertension.20 with normal weight.12 In addition, multiple pediatric stud-
Trajectory analyses examine not only tracking but ies of body mass index (BMI) and other measures of
also other factors that increase the likelihood of devel- adiposity show a positive association between obesity
oping higher BP as an adult. The presence of factors and hypertension.4 There does not appear to be a lower
associated with modifiable suboptimal health behaviors age limit for the influence of obesity on BP; elevated
and unmodifiable factors (genetics, low birth weight, BMI in infancy is associated with future high BP. In a
environmental deprivation) predicts higher BP trajec- longitudinal study of birth weight and cardiometabolic
tories over time.21,22 Individuals whose BPs track at factors, both low birth weight and high BMI influenced
higher levels from the middle of childhood or who have BP at 5 years of age, but by 10 years of age, BMI had
higher BP trajectories have evidence for TOI as young the stronger effect.23
adults, including higher carotid intima-media thick-
ness, increased pulse wave velocity, and left ventricular
structural changes.2 Suboptimal Diet
Diet can have an impact on BP in children. Children
with high sodium intake have increased risk for high
RISK FACTORS FOR PRIMARY BP, with a stronger association seen in children with
HYPERTENSION obesity. A recent meta-analysis of 18 studies with
high-quality data on sodium intake and BP measure-
Overweight/Obesity ments found that systolic BP increased by 0.8 mm Hg
As in adults, excess adiposity increases the risk for and diastolic BP increased by 0.7 mm Hg for every
pediatric primary hypertension. Analysis of NHANES additional gram of daily sodium intake.24 In the United

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 Falkner et al Pediatric Primary Hypertension

States, dietary sodium intake among children and TOI: EVIDENCE OF HEART AND VASCULAR

CLINICAL STATEMENTS
adolescents is far above recommended levels, largely
INJURY IN PEDIATRIC PRIMARY

AND GUIDELINES
because of the intake of processed foods.25 Con-
sumption of sugar-sweetened beverages and excess HYPERTENSION
calories is associated with increased BMI, which can Cardiac
contribute to abnormal BP. Alternatively, diets high in
Many cross-sectional studies have demonstrated associa-
potassium-rich foods such as fruits, vegetables, and
tions between TOI and high BP in youth.7 Echocardiography
legumes and increased intake of low-fat dairy prod-
to evaluate left ventricular mass (LVM) is the best clinical
ucts are associated with lower BP in children.26 The
method to assess BP-related TOI in pediatric patients.4
DASH (Dietary Approaches to Stop Hypertension)
The American Academy of Pediatrics 2017 clinical prac-
plan is currently recommended for children with hyper-
tice guideline (CPG) recommended LVM assessment on
tension and was proven to be effective in a random-
the basis of several factors, including (1) the close relation-
ized trial in adolescents.27
ship of LVM to BP and of left ventricular hypertrophy (LVH)
to CVD events in adults and (2) substantial pediatric data
Physical Fitness demonstrating a significant prevalence LVH in youth with
hypertension. In a recent multicenter, racially diverse study
Although it is well established that physical activity is
of the effects of BP on TOI in youth (N=303; mean age,
associated with health benefits, data on the associa-
15.6 years; 63% White; 55% male), a linear relationship was
tion between physical activity and BP in children are
found between mean clinic and daytime ambulatory systolic
mixed.25 There have been a large number of studies
BP and LVM index.33 The BP threshold for the development
on the relationship among sedentary time, physical
of an elevated LVM index was at 90th percentile for BP,
activity, and physical fitness, with some showing posi-
below the current clinical definition of hypertension. In the
tive findings and some showing minimal impact. A large
same cohort, a similar linear relationship between BP and
meta-analysis of the impact of levels of physical activity
systolic function (global longitudinal strain) and diastolic
on metabolic risk, including BP, showed that moder-
function (E/eʹ ratio) was found, indicating subclinical car-
ate to high physical activity was associated with lower
diac dysfunction at higher BP levels.34
BP.28 Overall, data suggest that regular physical activity
Best practices for echocardiography should be fol-
improves BP by ≈2 mm Hg.
lowed for image acquisition, measurements, and calcula-
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tions.4,35 LVM must be indexed to account for differences

Sleep in body size. The CPG defined LVH in those ≥9 years
of age as LVM >51 g/m2.7, or LVM >115 g per body
Disturbed sleep patterns in childhood, including poor
surface area for boys and LVM >95 g per body surface
sleep quality, interrupted sleep, and short sleep, are asso-
area for girls. These values are >95th percentile for
ciated with higher BP levels, especially in adolescents.
pediatric patients5 and are consistent with the thresh-
Obstructive sleep apnea is a pathological sleep condition
olds of LVM index associated with CVD events in adults.
common among children with obesity-associated hyper-
For children <9 years of age, pediatric reference values
tension. Episodic apnea and arousal are reported to be
should be used. The CPG also defined abnormal geom-
associated with 24-hour BP dysregulation and to con-
etry as relative left ventricular wall thickness >0.42 cm,
tribute to high BP.29
and decreased systolic function is left ventricular ejec-
tion fraction <53%,4 although these measurements are
Environmental Stress variably obtained on clinical pediatric echocardiograms.
For clinical purposes, the measure of BP-related TOI
Some environmental exposures may have an adverse
with the most evidence in youth is cardiac mass and func-
effect on BP in children. A study on air pollution with
tion. Consequently, the CPG recommended that echo-
measures of particulate matter (PM2.5) and other pollut-
cardiography be performed to assess for LVH before
ants reported an association with increased risk of abnor-
antihypertensives are started and that repeat echocar-
mal BP in youth.30 Exposure to phthalates, compounds
diography may be considered at 6- to 12-month inter-
commonly found in plastics and home care products,
vals to monitor improvement or progression, especially in
may affect endocrine function. Higher urinary phthalate
patients with persistent hypertension despite treatment,
concentration was reported in adolescents with ambula-
concentric LVH, or reduced systolic function at baseline.4
tory and white-coat hypertension compared with adoles-
cents with normotension.31 Significant adverse childhood
experiences, defined as subjectively perceived threats to
the safety or security of the child’s bodily integrity, family, Vascular
or social structures, have been reported among young Measures of vascular structure, including carotid intima-
adults with hypertension.32 media thickness, arterial stiffness (using pulse wave

Hypertension. 2023;80:e101–e111. DOI: 10.1161/HYP.0000000000000228 June 2023   e105

 Falkner et al Pediatric Primary Hypertension

velocity), and endothelial function (brachial flow-medi- exposure to multiple traumatic events have been asso-
CLINICAL STATEMENTS

ated dilation), predict CVD events in adults. Previous ciated with higher BP and hypertension development in
AND GUIDELINES

studies in youth demonstrated that higher BP levels youth and later adulthood, and strategies for targeting
were associated with intermediate markers of CVD, these risks to prevent hypertension are lacking.42,43 These
including thicker carotid intima-media thickness, higher factors can strongly affect whether an individual or fam-
pulse wave velocity, and lower flow-mediated dilation. ily has access to the resources needed to implement pri-
However, there are insufficient normative data to define mordial prevention strategies. Of interest are strategies to
clinical cut points, and routine assessment of vascular prevent or mitigate these conditions by improving access
parameters in youth with hypertension is not recom- to healthy foods and health care, increasing social sup-
mended as of this writing in 2022.4 port for families, and promoting resiliency with subsequent
Microvascular changes associated with BP, including effects on childhood BP and hypertension.
abnormal central retinal arteriolar and venular diameters, Public health efforts not only to study but also to
have been described in childhood.36 Children with higher achieve improvements in BP are difficult. The intrinsic
cardiorespiratory fitness had wider vessels regardless variability of BP, the likely small difference in BP achiev-
of BP, suggesting a lifestyle benefit in preventing BP- able in population-based interventions in healthy youth,
related microvascular injury in children. Microvascular the long follow-up duration needed to demonstrate an
dysfunction is one mechanism proposed for the observed impact, and cultural pressures that reinforce unhealthy
relationship between higher BP levels and subtle pre- behaviors suggest that well-conducted studies will be
clinical cognitive function changes in adolescents.37 costly and will require large sample sizes. The use of
These changes may not be permanent, however. Lande high-quality pediatric databases such as NHANES to
et al37 found that youth with hypertension whose BP monitor secular trends in BP in relation to population-
was controlled with medication had cognitive function based variations in obesity, physical activity, diet, unmet
scores comparable to those of control subjects with nor- social needs, and adverse childhood experiences may
motension. Further research is needed on the effects of be helpful but also may be limited by small effect sizes
increased BP on the retina and brain, including function and reliance on cross-sectional study designs. Stepped-
and imaging in the early phase of primary hypertension, wedge study designs, in which an intervention is rolled
before these studies can be applied to clinical practice. out sequentially to different study sites or environments,
may be useful alternatives to more standard randomized
trial designs and offer the opportunity for quality improve-
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PUBLIC HEALTH IMPLICATIONS: ment and adaptation to diverse settings.

Some modeling studies estimate that these public
PRIMORDIAL PREVENTION OF PRIMARY health interventions can lead to significant improve-
HYPERTENSION ments. Applying lower sodium content standards to
Primordial prevention is defined as preventing the devel- commercially processed and prepared foods in the
opment of elevated BP or hypertension. Primordial pre- United States could lead to a reduction of almost 700
vention is an important public health goal because a mg sodium per day in those ≥1 year of age.40 Pro-
population with lower BP will have fewer comorbidities viding healthier food choices in schools could avert
related to hypertension and CVD. Ongoing primordial >22 000 deaths attributable to cardiometabolic dis-
prevention efforts such as obesity prevention campaigns eases per year.44 With a decrease in sodium intake to
that promote increased physical activity and healthy recommended daily amounts, acute myocardial infarc-
diets such as the DASH diet may contribute to a reduced tion and stroke cases could be reduced by 4.8% and
prevalence of hypertension.26,38,39 Of the behavioral risk 5.8%, respectively.45 Underpinning the success of these
factors for hypertension in youth, poor diet has the high- initiatives is the concept that promoting the uptake of
est prevalence and may offer the greatest opportunity for heart-healthy behaviors early in life can lead to ideal
intervention.25,27 Consumption of ultraprocessed foods cardiovascular health preservation in childhood and sus-
increases dietary intake of sodium and added sugar.40 tained, long-term prevention of CVD in adulthood.
Conversely, consumption of fruits, vegetables, nuts, and
grains6 has been associated with beneficial markers of
cardiovascular health. In epidemiological studies, higher GAPS IN KNOWLEDGE AND CRITICAL
levels of physical fitness are inversely related to future AREAS IN NEED OF RESEARCH
hypertension in young adults, and physical fitness train-
Facilitating Recognition of High BP in Primary
ing lowers systolic BP, especially in youth with obesity.41
Within the social determinants of health framework, Care
there is increasing interest in primordial prevention strate- Clinical recognition of hypertension and appropriate
gies to mitigate the effect of other risk factors and adverse diagnosis of hypertension in youth remain suboptimal.
childhood experiences.42 For example, food insecurity and Reasons for low diagnostic rates are not fully known.

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 Falkner et al Pediatric Primary Hypertension

Clinicians may not consistently compare BP readings Furthermore, determining which devices have been

CLINICAL STATEMENTS
with reference data for BP classification unless they accuracy validated according to standardized protocols

AND GUIDELINES
suspect that the BP is high. Furthermore, the ability to is difficult. Expert groups and professional societies have
recognize high BP in youth is not consistent.46 worked to make this process simpler with publications
The CPG developed a simplified screening BP table to and websites50,51 to help identify these accurate devices.
facilitate identifying elevated BP in childhood (Table 5); Validated devices for out-of-office BP measurement in
and simplified the diagnostic thresholds for adolescents children are needed.
starting at 13 years of age.4 Electronic health record
alerts with and without clinical decision support, quality
improvement initiatives, smartphone applications (apps), Clinical Trials on the Treatment of Adolescents
electronic health record apps, and simplified tables for With Primary Hypertension
screening are other approaches that may improve recog- With the benefit of clinical and translational research
nition of high BP.47,48 on hypertension in children and adolescents, guide-
lines on clinical management have moved from expert
opinion to evidence-based recommendations on diag-
Instrumentation Issues nosis, evaluation, and treatment. One area of recom-
Adult hypertension guidelines recommend using auto- mended treatment that has a low level of evidence
mated BP devices for hypertension screening. This is pharmacological treatment of primary hypertension.
recommendation hinges on the use of a device that Many short-term clinical trials have demonstrated
has undergone rigorous independent testing, accord- the safety and efficacy of antihypertension drugs
ing to an established protocol, to confirm accuracy. For recommended for BP control in children.4 The only
children, there are barriers to using ABPM and home long-term randomized clinical trial that used an anti-
BP monitoring in primary care settings beyond device hypertensive drug on a specified outcome was con-
availability. The current ABPM procedure is difficult to ducted on children with chronic kidney disease and
conduct on young children, and some children cannot determined kidney function benefit in lowering BP.52
tolerate 24-hour ABPM. Other devices for out-of-office Considering that primary hypertension is now known
BP measurement in children are needed. Because to be the most frequent type of hypertension among
of the need for invasive reference BP measures for adolescents, longer randomized clinical trials focused
device validation in the youngest age group (<3 years),
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on a specific outcome on adolescents with primary

the perceived smaller market for BP measurement hypertension are needed to provide evidence-based
devices, and other challenges to including children in recommendations on pharmacological treatment of
research, few BP devices have been tested and found primary hypertension in youth.
to be accurate in children.49

CONSIDERATIONS FOR CLINICAL

Table 5. Screening Oscillometric BP Values Requiring Fur-
ther Evaluation PRACTICE
Boys, mm Hg Girls, mm Hg
Certain children and adolescents are known to be at
increased risk of developing hypertension (Table 6). BP
Age, y SBP DBP SBP DBP
in these children merits special attention because the
1 98 52 98 54
identification of high BP and the appropriate intervention
2 100 55 101 58 are likely to have clinical benefit.
3 101 58 102 60
4 102 60 103 62
Table 6. Predisposing Factors to the Development of Hyper-
5 103 63 104 64 tension in Children and Adolescents
6 105 66 105 67
Overweight and obesity
7 106 68 106 68
Family history of hypertension in a parent or grandparent
8 107 69 107 69
Abnormal birth history, including prematurity, small for gestational age,
9 107 70 108 71 maternal preeclampsia and eclampsia, and assisted reproductive tech-
nologies
10 108 72 109 72
Known kidney disease, repaired aortic coarctation, type 1 and 2 diabetes,
11 110 74 111 74
and genetic syndromes associated with hypertension (Williams syndrome,
12 113 75 114 75 neurofibromatosis, Turner syndrome, tuberous sclerosis)*
≥13 120 80 120 80 Treatment with medications known to increase BP (stimulant medications,
corticosteroids, calcineurin inhibitors)*
BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic
blood pressure. BP indicates blood pressure.
Adapted with permission from Pediatrics.4 Copyright © 2017 the AAP. *Applies to primary and secondary hypertension.

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 Falkner et al Pediatric Primary Hypertension

There are some exceptions to the recommendation medications for children and adolescents are provided
CLINICAL STATEMENTS

for BP ≥95th percentile at 3 separate visits for diagno- in the CPG.4

AND GUIDELINES

sis of hypertension. For example, if the BP measurement

is extremely high (eg, well above the stage 2 hyperten-
sion threshold) on the first visit, it would be reasonable CONCLUSIONS
to obtain an ABPM to confirm hypertension or to identify Substantial epidemiological and clinical evidence con-
white-coat hypertension. Another consideration could be firms that an early phase of primary hypertension can
using ABPM or even home BP monitoring to verify office develop in childhood. Amplified by the childhood obe-
readings of stage 1 hypertension, thus shortening the sity epidemic, primary hypertension is now the leading
time to completion of the hypertension diagnosis.53 type of pediatric hypertension, especially in adoles-
Improved clinical decision support tools, as discussed cents. Children with BP levels in the higher range of
previously, can facilitate the detection of childhood the BP distribution tend to maintain that level into
hypertension. These tools can take various formats, rang- adulthood, thus raising the risk for subsequent CVD
ing from the simplified screening table found in the CPG events.1,2 Lifestyle factors (suboptimal diet, sedentary
(Table 5) to alerts and other tools embedded in the elec- activity, excess body weight) can increase the risk of
tronic health records. high BP in youth and can be targets for interventions
It is also important to ensure that the staff who mea- to reduce BP levels. There is evidence that TOI is asso-
sure BP in children are trained on correct BP measure- ciated with BP levels consistently ≥95th percentile in
ment technique, as described in Table 2. children and adolescents. More recent findings indicate
Treatment of high BP in children and adolescents that the risk for TOI may exist even at levels <95th
is generally tailored to the underlying diagnosis, as percentile.33 In addition to primordial prevention, regu-
summarized in Table 7. Lifestyle changes are indicated lar clinical BP monitoring of all pediatric patients with
for all youth with high BP regardless of the underlying a standard measurement protocol is recommended to
diagnosis and include dietary modification (ideally with identify children with elevated BP and hypertension.
counseling from a pediatric dietitian) and increased Adolescents entering adulthood with a BP <120/80
physical activity. Because it is now recognized that mm Hg is an optimal goal.
some children with white-coat hypertension may prog-
ress to having confirmed hypertension, lifestyle mea-
sures are important to implement in this group as well. ARTICLE INFORMATION
Downloaded from http://ahajournals.org by on November 20, 2023

Antihypertensive medications are recommended to The American Heart Association makes every effort to avoid any actual or poten-
lower BP if lifestyle measures fail to improve BP in tial conflicts of interest that may arise as a result of an outside relationship or a
children and adolescents with primary hypertension. personal, professional, or business interest of a member of the writing panel. Spe-
cifically, all members of the writing group are required to complete and submit a
Details on the class and dose of antihypertension Disclosure Questionnaire showing all such relationships that might be perceived
as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science
Table 7. Approach to the Treatment of Childhood Hyperten- Advisory and Coordinating Committee on December 5, 2022, and the Ameri-
sion can Heart Association Executive Committee on January 24, 2023. A copy of
the document is available at https://professional.heart.org/statements by using
Diagnostic cat- either “Search for Guidelines & Statements” or the “Browse by Topic” area. To
egory Recommended measures purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@
Elevated BP Dietary changes: DASH diet, reduced sodium intake wolterskluwer.com.
Physical activity: vigorous exercise, reduced screen time The American Heart Association requests that this document be cited as
follows: Falkner B, Gidding SS, Baker-Smith CM, Brady TM, Flynn JT, Malle
White-coat Dietary changes: DASH diet, reduced sodium intake LM, South AM, Tran AH, Urbina EM; on behalf of the American Heart Asso-
hypertension Physical activity: vigorous exercise, reduced screen time ciation Council on Hypertension; Council on Lifelong Congenital Heart Disease
Primary hyper- Dietary changes: DASH diet, reduced sodium intake and Heart Health in the Young; Council on Kidney in Cardiovascular Disease;
tension Physical activity: vigorous exercise, reduced screen time Council on Lifestyle and Cardiometabolic Health; and Council on Cardiovascular
Initiation of antihypertensive medications if BP still high and Stroke Nursing. Pediatric primary hypertension: an underrecognized condi-
after 6–12 mo of dietary and physical activity measures* tion: a scientific statement from the American Heart Association. Hypertension.
2023;80:e101-e111. doi: 10.1161/HYP.0000000000000228
Secondary Dietary changes: DASH diet, reduced sodium intake The expert peer review of AHA-commissioned documents (eg, scientific
hypertension Physical activity: vigorous exercise as tolerated, reduced statements, clinical practice guidelines, systematic reviews) is conducted by the
screen time AHA Office of Science Operations. For more on AHA statements and guidelines
Initiation of antihypertensive medications on diagnosis of development, visit https://professional.heart.org/statements. Select the “Guide-
underlying cause and manage the underlying cause of lines & Statements” drop-down menu, then click “Publication Development.”
secondary hypertension* Permissions: Multiple copies, modification, alteration, enhancement, and dis-
BP indicates blood pressure; and DASH, Dietary Approaches to Stop Hyper- tribution of this document are not permitted without the express permission of the
tension. American Heart Association. Instructions for obtaining permission are located at
*Obtain an echocardiogram to assess cardiac mass before antihypertensive https://www.heart.org/permissions. A link to the “Copyright Permissions Request
medications are started. For stage 2 hypertension, evaluate for underlying cause Form” appears in the second paragraph (https://www.heart.org/en/about-us/
or refer, and start treatment to lower BP. statements-and-policies/copyright-request-form).

e108   June 2023 Hypertension. 2023;80:e101–e111. DOI: 10.1161/HYP.0000000000000228

 Falkner et al Pediatric Primary Hypertension

Disclosures

CLINICAL STATEMENTS
Writing Group Disclosures

AND GUIDELINES
Writing Other Speakers’ Consultant/
group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Bonita Thomas Jeffer- None None None None None None None
Falkner son University
Samuel S. Geisinger NIH† None None None None Esperion* Geisinger
Gidding Genomic Medi- Health (pro-
cine Institute fessor)†
Carissa M. Nemours’ Chil- None None Cardiometa- None None None None
Baker-Smith dren’s Health bolic Health
Cardiac Center Congress*;
NACE, CME
(unpaid)*
Tammy M. Johns Hopkins Resolve to Save Lives (grant support; None None None None None None
Brady University receives salary support from RTSL to
participate in research and publications
aimed at improving global cardiovascu-
lar health)†; NIH/NHLBI (grant support
for cross-sectional study investigating
association of diet and CVD)†
Joseph T. Seattle Chil- None None None None None None None
Flynn dren’s Hospital
Leslie M. Children’s Mercy None None None None None None None
Malle Hospital
Andrew M. Wake Forest Uni- NIH† None None None None None None
South versity, School of
Medicine
Andrew H. Nationwide Chil- None None None None None None None
Tran dren’s Hospital
The Heart Center
Elaine M. Self-employed; NIH (multiple PI)† International None None None American Cincinnati
Downloaded from http://ahajournals.org by on November 20, 2023

Urbina Cincinnati Chil- Pediatric Society of Children’s

dren’s Hospital Hyper- Preventive Hospital
Medical Center tension Cardiology* (director,
Association preventive
(chair)* cardiology)†
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Reviewer Disclosures

Other Speakers’ Consultant/

research bureau/ Expert Ownership advisory
Reviewer Employment Research grant support honoraria witness interest board Other
Stephen R. University of Colorado School None None None None None None None
Daniels of Medicine
Daniel T. Medical University of South None None None None None None None
Lackland Carolina
Joshua McGovern Medical School at None None None None None None None
Samuels the University of Texas Health
Science Center at Houston
Christine B. Cohen Children’s Medical NIH (I have a pending grant from None None None None None None
Sethna Center, Northwell Health NIH NHLBI on nocturnal blood
pressure dysregulation in children
with nephrotic syndrome)†
Alan Sinaiko University of Minnesota None None None None None None None
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-
tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any
12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of
the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
†Significant.

Hypertension. 2023;80:e101–e111. DOI: 10.1161/HYP.0000000000000228 June 2023   e109

 Falkner et al Pediatric Primary Hypertension

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