Hypertension in Children

See Also

Epidemiology

Prevalence under age 18 years old
1. Prehypertension: 3.4%
2. Hypertension: 3.6%
Prevalence in Overweight or obese adolescents
1. Hypertension in up to 10% of children with Obesity
2. Prehypertension may be present in up to 30% of obese children (esp. boys)

Precautions

Hypertension in Children is underdiagnosed
1. Only 26% of patients with criteria consistent with Hypertension are formally diagnosed
2. Hansen (2007) JAMA 298(8): 874-9 [PubMed]

Causes

See Hypertension Causes in Children
Renovascular disease is most common cause in children
Features most suggestive of Secondary Hypertension
1. Hypertension under age 10 years
2. Stage 2 Hypertension in Children

Risk Factors

Obesity
1. Increased Body Mass Index
2. Increased abdominal circumference
Metabolic Syndrome or Diabetes Mellitus
Black ethnicity
Hispanic ethnicity
Snoring or other findings of Obstructive Sleep Apnea
Chronic Kidney Disease
Male gender
Low birth weight
Maternal Tobacco use during pregnancy
Family History
1. Essential Hypertension
2. Renovascular disease
  1. Kidney disease
  2. Deafness
3. Endocrinopathy
  1. Diabetes Mellitus
  2. Thyroid disorder
  3. Adrenal disease

Associated Conditions

History

See Family History above
See Medication Causes of Hypertension (includes OTC Medications and Illicit Drugs)
General
1. Weight change
2. Disordered sleep (e.g. Obstructive Sleep Apnea)
Lung
1. Dyspnea on exertion
Cardiovascular
1. Chest Pain
2. Palpitations
Renal
1. Hematuria
2. Recurrent Urinary Tract Infection
Extremities
1. Edema
2. Joint Pain or swelling
3. Myalgias
Neurologic
1. Headaches
Endocrine
1. Profuse sweating
2. Hot or cold intollerance

Examination
Secondary Hypertension clues

General
1. Growth Delay (Chronic Kidney Disease)
2. Body Mass Index
Eyes
1. Fundoscopic exam
Throat
1. Tonsil or adenoid hypertrophy (Sleep Apnea)
Neck
1. Thyromegaly (Hyperthyroidism)
Cardiovascular
1. Tachycardia (Hyperthyroidism, Pheochromocytoma)
2. Blood Pressure in both arms while seated and in one leg while prone (Aortic Coarctation)
Abdomen
1. Abdominal mass (renal lesion)
2. Abdominal bruit (Renal Artery Stenosis)
Genitourinary exam
1. Ambiguous Genitalia (Congenital Adrenal Hyperplasia)
Extremities
1. Cold legs with diminished pulses (Aortic Coarctation)
2. Joint Swelling (Systemic Lupus Erythematosus)
Skin
1. Acne Vulgaris, Hirsutism (Cushing's Disease)
2. Malar Rash (Systemic Lupus Erythematosus)
3. Profuse sweating (Pheochromocytoma)
Neurologic
1. Proximal Motor weakness (Hyperaldosteronism)
Endocrine
1. Truncal Obesity, moon facies (Cushing's Syndrome)

Diagnosis

See Hypertension Criteria
See Blood Pressure for proper technique
Routine Blood Pressure screening over age 3 years
Obtain 3 elevated Blood Pressures on different days
1. Consider Ambulatory Blood Pressure Monitoring (more accurate than clinic Blood Pressures)
2. Hypertension if BP >95% for age, gender, height
  1. Rough estimates
    1. Blood Pressure >110/60 if age >1 year old
    2. Blood Pressure >130/80 if age >13 years old
  2. Stage 1 Hypertension
    1. Blood Pressure <=12 mmHg of 95% upper limit of normal for SBP and DBP
    2. Blood Pressure <140/90 if age >13 years old
  3. Stage 2 Hypertension
    1. Blood Pressure >12 mmHg of 95% upper limit of normal for SBP and DBP
    2. Blood Pressure >140/90 if age >13 years old
  4. Hypertensive Emergency (hospital admitted)
    1. Blood Pressure >30 mmHg of 95% upper limit of normal for SBP and DBP
    2. Contrast with Asymptomatic Hypertension in adults which is managed non-aggressively

Labs

Complete Blood Count
1. Includes Leukocyte differential and Platelet Count
Chemistry panel
Urine testing
1. Urinalysis
2. Urine Drug Screen (if indicated)
3. Urine Culture
4. Consider Urine Microalbumin
Endocrine tests
1. Thyroid Stimulating Hormone (TSH)
2. Consider 24 hour Urine Cortisol
3. Consider plasma renin level
4. Consider 24 hour Urine VMA and metanephrines
Other Cardiovascular Risk screening
1. Lipid Profile
Secondary Hypertension Evaluation indications (see endocrine tests above)
1. Hypertension in age <6 years
2. Hypertension in age > 6 years old and other risk factors
  1. Not Overweight or obese
  2. No Family History Hypertension
  3. Abnormal history or exam
  4. Signs or symptoms or specific Secondary Hypertension

Diagnostics

Electrocardiogram
Echocardiogram
1. Obtain in all children with confirmed Hypertension
Renal Ultrasound indications
1. Age <6 years old with Hypertension
2. Children with abnormal Renal Function test or Urinalysis
Other studies to consider
1. Sleep Study or Polysomnogram (if Sleep Apnea suspected)
2. MRA of renal arteries

Screening

Children and adolescents at no increased Hypertension risk
1. Start at age 3 years old and screen every year (AAP 2017) to every 2 years (European Society Hypertension 2016)
2. Other organizations (USPTF and AAFP, 2013) have cited insufficient evidence for recommendations
Children with Hypertension risk factors (see above, or known Secondary Hypertension cause)
1. Screen for Hypertension at every healthcare visit starting at time of known risk (regardless of age)

Management
Emergency Department

Stage 1 Hypertension
1. Criteria
  1. Blood Pressure <=12 mmHg of 95% upper limit of normal for SBP and DBP
  2. Blood Pressure <140/90 if age >13 years old
2. Management
  1. Follow-up primary provider
  2. Initiate non-pharmacologic management as below
Stage 2 Hypertension
1. Criteria
  1. Blood Pressure >12 mmHg of 95% upper limit of normal for SBP and DBP
  2. Blood Pressure >140/90 if age >13 years old
2. Management
  1. Established chronic disease causes for Hypertension may be managed with primary provider
  2. Acute presentations may require Hypertension workup and initiation of Antihypertensives
Hypertensive Emergency
1. Criteria
  1. Blood Pressure >30 mmHg of 95% upper limit of normal for SBP and DBP
  2. Contrast with Asymptomatic Hypertension in adults which is managed non-aggressively
2. Presentations
  1. Neurologic (most common)
    1. Severe Headache
    2. Cranial Nerve palsy
    3. Seizures
    4. Vision Change
    5. Retinal Hemorrhage
  2. Miscellaneous
    1. Congestive Heart Failure (common)
    2. Acute Kidney Injury
3. Management
  1. Consider pediatric nephrology Consultation
  2. Initiate Hypertensive Emergency Blood Pressure control (e.g. Nicardipine, Labetalol)
  3. Avoid excessive Blood Pressure reduction
    1. Goal initial Blood Pressure reduction is 25%
    2. After 24 to 48 hours, Blood Pressure reduction may be advanced toward target Blood Pressure
References
1. Claudius and Uspal (2024) Pediatric Hypertension, EM:Rap, 11/18/2024

Management
Non-Pharmacologic Lifestyle Changes

Involve the entire family in lifestyle changes
Mnemonic: 5-2-1-0
1. Five fruits and vegetables per day
2. Maximum of 2 hours per day Screen Time daily
3. One hour or more of Physical Activity daily
4. No sugary drinks
Continue monitoring Blood Pressure at least every 6 months
1. Home Blood Pressure Monitoring with properly sized cuff and proper technique
Evaluate for Obesity
1. Consider secondary Hypertension Evaluation if weight is normal
2. Weight loss if Overweight
  1. Target 5-10% in a year OR
  2. Maintain current weight without gaining weight despite increased linear growth
Evaluate Cardiovascular Risks
1. Obtain Lipid profile
2. Obtain Fasting Glucose
Cardiovascular Risk management
1. Regular Exercise program of 30-60 minutes on most days
  1. Farpour-Lambert (2009) J Am Coll Cardiol 54(25): 2396-2406 [PubMed]
2. Limit sedentary activities to <2 hours per day
3. Low Fat Diet
4. Low Sodium Diet (e.g. DASH Diet)
5. Fruits and vegetables at least 5 daily
6. Tobacco Cessation
7. Avoid Alcohol

Management
Pharmacologic

Indications
1. Symptomatic Hypertension (e.g. Headaches, cognitive changes)
2. Secondary Hypertension
3. Stage 1 Hypertension refractory to general measures (for at least 3-6 months)
  1. Or no significant modifiable risk factors (e.g. Obesity, sedentary lifestyle)
4. Stage 2 Hypertension
5. Significant comorbidity
  1. Diabetes Mellitus
  2. Chronic Kidney Disease
6. End-organ involvement
Goal Blood Pressures
1. Less than 90% for age, height, gender if age <13 years old or
2. Less than 130/80 if age >13 years old
Agents FDA approved in children
1. Approach
  1. Start at the lowest recommended dose and titrate every 2-4 weeks until at target BP
  2. Initiate a second medication if goal not reached despite maximal dose of first medication
2. Special Indications
  1. See Hypertension Management for Specific Populations
  2. Diabetes Mellitus or Kidney disease
    1. ACE Inhibitors
    2. Angiotensin Receptor Blockers (ARB agents)
  3. Teen girls at risk for pregnancy (avoiding Teratogenic agents)
    1. Calcium Channel Blocker (e.g. Amlodipine)
    2. Hydrochlorothiazide
3. ACE Inhibitors (age 6 and over unless otherwise specified)
  1. Captopril
    1. Infant: 0.05 mg/kg/dose every 6 hours (max: 6 mg/kg/day)
    2. Child: 0.5 mg/kg/dose every 8 hours (max: 6 mg/kg/day)
  2. Lisinopril 0.07 mg/kg/day up to 5 mg daily (max: 0.6/mg/kg up to 40 mg/day)
  3. Benazepril (Lotensin) 0.2 mg/kg up to 10 mg (max: 0.6 mg/kg up to 40 mg/day)
  4. Enalapril (Vasotec) 0.08 mg/kg up to 5 mg (max: 0.6 mg/kg up to 40 mg/day)
    1. Has been used in age >1 month of age
  5. Fosinopril (Monopril)
    1. Weight >50 kg (111 lb): 5-10 mg daily (max: 40 mg day)
    2. Weight <50 kg (111 lb): 0.1 mg/kg/day up to 5 mg
  6. Ramipril 1.6 mg/m2 once daily (max: 6 mg/m2/day)
4. Angiotensin Receptor Blockers (age 6 and over, unless otherwise specified)
  1. Losartan 0.7 mg/kg/day (max: 1.4 mg/kg or 100 mg daily)
  2. Irbesartan (Avapro) 75 to 150 mg daily for ages 6 to 12 years old
    1. Use adult dosing for age 13 and over
  3. Valsartan (Diovan) 1.3 mg/kg/day up to 40 mg/day (max: 2.7 mg/kg/day up to 160 mg/day)
  4. Olmesartan
    1. Age >6 and <35 kg (77 lb): 10 mg (max: 20 mg)
    2. Age >6 and <35 kg (77 lb): 20 mg (max: 40 mg)
  5. Candesartan
    1. Age 1-5 y: 0.02 mg/kg/day up to 4 mg/day (max: 0.4 mg/kg/day up to 16 mg/day)
    2. Age >6 y and <50 kg (111 lb): 4 mg/day (max: 16 mg/day)
    3. Age >6 y and >50 kg (111 lb): 8 mg/day (max: 32 mg/day)
5. Calcium Channel Blockers
  1. Amlodipine
    1. Age 1-5 y: 0.1 mg/kg daily (max: 0.6 mg/kg/day up to 5 mg/day)
    2. Age >6 y: 2.5 to 5 mg/day (max: 10 mg/day)
  2. Felodipine 2.5 mg/day (max: 10 mg/day) if age 6 years old or older
  3. Nifedipine XR 0.2 to 0.5 mg/kg/day (max: 3 mg/kg up to 120 mg/day)
6. Beta Blockers (age 6 years old and over)
  1. Use other agents first-line, unless other indications (e.g. Migraine Prophylaxis)
  2. Propranolol 1-2 mg/kg/day (max: 4 mg/kg or 640 mg/day)
  3. Metoprolol XL 1 mg/kg up to 50 mg (max: 2 mg/kg or 200 mg/day)
7. Thiazide Diuretics
  1. Hydrochlorothiazide 1 mg/kg/day (max: 2 mg/kg/day or 37.5 mg/day)
  2. Chlorthalidone 0.3 mg/kg (max: 2 mg/kg/day up to 50 mg/day)
8. Miscellaneous: Second-line agents
  1. Clonidine (Catapres) 0.1 to 0.2 mg twice daily up to 2.4 mg/day (if age 12 years or older)

Complications

Left Ventricular Hypertrophy
1. May present as early as childhood
Cardiovascular disease
1. Premature onset in young adults (RR 2)
2. Robinson (2024) JAMA Pediatr 178(7): 688-98 [PubMed]
Peripheral Vascular Disease
1. Carotid intima-media thickness increase

References

(2023) Presc Lett 30(7): 41-2
(2017) Presc Lett 24(10):57
(2004) Pediatrics 114:555-76 [PubMed]
Bartosh (1999) Pediatr Clin North Am 46:235-52 [PubMed]
Flynn (2005) Adolesc Med Clin 16:11-29 [PubMed]
Flynn (2017) Pediatrics 140(3): e20171904 [PubMed]
Luma (2006) Am Fam Physician 73(9):1558-66 [PubMed]
Riley (2012) Am Fam Physician 85(7): 693-700 [PubMed]
Riley (2018) Am Fam Physician 98(8): 486-94 [PubMed]