Hypertension Management in Children

Diagnosis and Classification

The American Academy of Pediatrics recommends that blood pressure should be measured at each routine visit and compared to age-, sex-, and height-specific percentile tables to determine if hypertension is present in children, such as a 4-year-old female with a height of 107cm 1, 2
Elevated blood pressure is defined as systolic or diastolic blood pressure ≥90th percentile for age, sex, and height, according to the American Academy of Pediatrics 3
Stage 1 hypertension is defined as blood pressure ≥95th percentile but <95th percentile + 12 mmHg, as stated by the American Academy of Pediatrics 1, 2
Stage 2 hypertension is defined as blood pressure ≥95th percentile + 12 mmHg, according to the American Academy of Pediatrics 1, 2
Hypertension must be confirmed on three separate occasions before diagnosis, as recommended by the American Heart Association 4, 3

The American Academy of Pediatrics recommends that all children with elevated blood pressure or hypertension should begin with lifestyle modifications, including weight management if overweight, dietary sodium restriction, increased physical activity, and a DASH-style eating pattern emphasizing fruits and vegetables 1, 4, 2
Dietary modifications should include sodium restriction and increased consumption of fruits and vegetables, as suggested by the American Heart Association 4
Regular physical activity should be encouraged, according to the American Heart Association 4
If the child is overweight, weight management through a family-centered behavioral approach is essential, as recommended by the American Heart Association 4
Follow-up visits should occur every 3-6 months when using lifestyle modifications alone to reinforce adherence and reassess need for medication, as stated by the American Academy of Pediatrics 1, 2

The American Academy of Pediatrics recommends that pharmacologic treatment should be initiated in children with Stage 2 hypertension, symptomatic hypertension, left ventricular hypertrophy on echocardiography, or Stage 1 hypertension that fails to respond to 3-6 months of lifestyle modifications 1, 2
The preferred initial antihypertensive agents are ACE inhibitors, ARBs, long-acting calcium channel blockers, or thiazide diuretics, as recommended by the American Academy of Pediatrics 1, 5, 2
ACE inhibitors or ARBs are specifically recommended as first-line therapy in children with chronic kidney disease, proteinuria, or diabetes mellitus, according to the American Academy of Pediatrics 1, 5
For African American children, consider a higher initial ACE inhibitor dose or alternatively start with a thiazide diuretic or long-acting calcium channel blocker, as suggested by the American Academy of Pediatrics 1
β-blockers are not recommended as initial treatment due to expanded adverse effect profile and lack of association with improved outcomes compared to other agents, as stated by the American Academy of Pediatrics 1

Patients should be seen every 4-6 weeks for dose adjustments until blood pressure is normalized, with medication titrated every 2-4 weeks using home blood pressure measurements, as recommended by the American Academy of Pediatrics 1, 5, 2
If blood pressure is not controlled with a single agent at maximal dose, add a second agent from a different class, according to the American Academy of Pediatrics 1, 5
After blood pressure control is achieved, follow-up visits can be extended to every 3-4 months, as stated by the American Academy of Pediatrics 1, 2
Home blood pressure monitoring should be used to assess treatment effectiveness between visits, as recommended by the American Academy of Pediatrics 5, 2
Laboratory monitoring should be performed at each follow-up visit, according to the American Academy of Pediatrics 5, 2

Before initiating pharmacologic therapy, evaluate for secondary causes of hypertension, particularly in young children, including renal disease, coarctation of the aorta, and endocrine disorders, as recommended by the American Heart Association 4
Obtain urinalysis and renal function tests, according to the American Heart Association 4
Consider echocardiography to assess for left ventricular hypertrophy and coarctation, as suggested by the American Academy of Pediatrics 1, 2
Evaluate for target organ damage before starting treatment, according to the American Academy of Pediatrics 1, 2

The goal of treatment is to achieve blood pressure consistently below the 90th percentile for age, sex, and height, as recommended by the American Diabetes Association 3
In children with chronic kidney disease or diabetes, more aggressive blood pressure targets may be warranted, according to the American Academy of Pediatrics 2
Ambulatory blood pressure monitoring may be used to assess treatment effectiveness, especially when clinic or home measurements suggest insufficient response, as suggested by the American Academy of Pediatrics 2

Do not diagnose hypertension based on a single elevated reading; confirm on three separate days, as recommended by the American Heart Association 4, 3
Do not use β-blockers as first-line therapy, according to the American Academy of Pediatrics 1
Do not prescribe ACE inhibitors or ARBs to adolescent females without reproductive counseling, as recommended by the American Academy of Pediatrics 1, 3
Do not delay evaluation for secondary causes in young children with significant hypertension, according to the American Heart Association 4