The Child or Adolescent with Elevated Blood Pressure

Posted by • June 13th, 2014

Evaluation of children and adolescents with hypertension can detect evidence of the secondary systemic effects of hypertension (in particular, renal disease). Initial therapy is usually nonpharmacologic, but pharmacotherapy is used if other methods fail, hypertension is severe, or there are coexisting conditions such as diabetes mellitus.  NEJM Deputy Editor and Massachusetts General Hospital pediatrician Dr. Julie Ingelfinger is the author of this new Clinical Practice review article.

The prevalence of elevated blood pressure among children and adolescents has been increasing worldwide in concert with the marked increase in the prevalence of obesity among the young.

Clinical Pearls

How is hypertension defined in a child or adolescent?

Hypertension is diagnosed in a young person if the mean systolic blood pressure or diastolic blood pressure is above the 95th percentile for sex, age, and height on three or more occasions. Stage 1 hypertension is defined as blood pressure between the 95th and 99th percentile plus 5 mm Hg, and stage 2 hypertension is defined as blood pressure above the 99th percentile plus 5 mm Hg. Prehypertension is defined as a mean systolic or diastolic blood pressure at or above the 90th percentile but below the 95th percentile or blood pressure of 120/80 mm Hg or greater, even if the blood pressure is at or below the 90th percentile (and up to the 95th percentile).

Table 2. Classifications of Blood Pressure and Therapeutic Approaches.

In addition to a history and physical examination, what evaluation is recommended in children or adolescents with hypertension?

Evaluation of hypertension in children and adolescents is generally phased. In addition to a careful history taking and physical examination, a phase 1 evaluation to identify common secondary causes is recommended in patients with blood pressure that is persistently at or above the 95th percentile and in patients with diabetes, cardiac disease, and other chronic conditions if the blood pressure is above the 90th percentile. This evaluation includes basic laboratory tests (measurement of levels of blood urea nitrogen, creatinine, and electrolytes; a complete blood count; and a urinalysis and urine culture) and renal ultrasonography to assess for renal scarring, disparate kidney size, and congenital anomalies. About 80% of cases of secondary hypertension in children are attributed to renal disease, and another 10% are attributed to renovascular disease. Left ventricular mass should also be assessed; the interpretation must consider the patient’s height, body-surface area, and level of fitness.

Table 3. Continued Evaluation for Pediatric Hypertension.

Morning Report Questions

Q: What are the principles of nonpharmacologic therapy in childhood hypertension?

A: Lifestyle changes are recommended for children with prehypertension or stage 1 hypertension. These approaches include a program of dynamic exercise (i.e., exercise that involves substantial and recurrent body movement, such as bicycling or running); a balanced diet with a high intake of fruits, vegetables, and low-fat dairy products, as well as a reduction in dietary sodium; a weight-reduction program in patients who are overweight; and reinforcement of adherence to these practices. Several studies involving children and adolescents have suggested that successful weight loss is effective in decreasing blood-pressure levels. However, effecting such changes is often difficult. The inclusion of family participation appears to be useful, if not essential, particularly if the child needs to lose weight.

Q: When should medication be started in a child with hypertension and what is the best choice of agent?

A: If blood pressure does not improve with lifestyle changes, or if concerted efforts to encourage lifestyle modification are not successful, medication may be indicated. Medication should be initiated if there are symptoms or coexisting conditions or if there is an identified secondary cause of hypertension or evidence of end-organ damage in children or adolescents with stage 1 hypertension. In addition, drug therapy should be initiated routinely in young people with stage 2 hypertension. There is no consensus regarding the best initial therapy for hypertension in children and adolescents; comparative trials are lacking in the pediatric population. A survey of pediatric nephrologists indicated that 47% considered ACE inhibitors to be first-line therapy, 37% chose calcium-channel blockers, 15.3% chose diuretics, and 6.6% chose beta-blockers (some chose more than one medication as a first-line agent).

Table 4. Selected Oral Medications for Hypertension in Children and Adolescents.

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