Screening and Management of High Blood Pressure in Children and Adolescents
Publication Date: September 1, 2017
Last Updated: March 14, 2022
Recommendations
Assessment
BP should be measured annually in children and adolescents ≥3 years of age. (CModerate)
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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. (CModerate)
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Trained health care professionals in the office setting should make a diagnosis of HTN if a child or adolescent has auscultatory-confirmed BP readings ≥95th percentile on 3 different visits. (CModerate)
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Organizations with EHRs used in an office setting should consider including flags for abnormal BP values both when the values are being entered and when they are being viewed. (CWeak)
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Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a 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. (BStrong)
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ABPM should be performed for the confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits. (CModerate)
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The routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage. (BModerate)
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ABPM should be performed by using a standardized approach with monitors that have been validated in a pediatric population, and studies should be interpreted by using pediatric normative data. (CModerate)
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Children and adolescents with suspected WCH should undergo ABPM. Diagnosis is based on the presence of mean SBP and DBP <95th percentile and SBP and DBP load <25%. (BStrong)
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Home BP monitoring should not be used to diagnose HTN, MH, or WCH but may be a useful adjunct to office and ambulatory BP measurement after HTN has been diagnosed. (CModerate)
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Children and adolescents ≥6 years of age do not require an extensive evaluation for secondary causes of HTN if they have a positive family history of HTN, are overweight or obese, and/or do not have history or physical examination findings suggestive of a secondary cause of HTN. (CModerate)
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Children and adolescents who have undergone coarctation repair should undergo ABPM for the detection of HTN (including masked hypertension [MH]). (BStrong)
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In children and adolescents being evaluated for high BP, the provider should obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination to identify findings suggestive of secondary causes of HTN (BStrong)
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Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for LVH. (BStrong)
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It is recommended that echocardiography be performed to assess for cardiac target organ damage (LV mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN;
- LVH should be defined as LV mass >51 g/m2. (boys and girls) for children and adolescents older than 8 years and defined by LV mass >115 g/BSA for boys and LV mass >95 g/BSA for girls;
- Repeat echocardiography may be performed to monitor improvement or progression of target organ damage at 6- to 12-month intervals. Indications to repeat echocardiography include persistent HTN despite treatment, concentric LV hypertrophy, or reduced LV ejection fraction; and
- 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.
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Doppler renal ultrasonography may be used as a noninvasive screening study for the evaluation of possible RAS in normal-weight children and adolescents ≥8 years of age who are suspected of having renovascular HTN and who will cooperate with the procedure. (CModerate)
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In children and adolescents suspected of having renal artery stenosis (RAS), either CTA or MRA may be performed as a noninvasive imaging study. Nuclear renography is less useful in pediatrics and should generally be avoided. (DWeak)
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Routine testing for MA is not recommended for children and adolescents with primary HTN. (CModerate)
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Management
In children and adolescents diagnosed with HTN, the treatment goal with nonpharmacologic and pharmacologic therapy should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥ 13 years old. (CModerate)
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At the time of diagnosis of elevated BP or HTN in a child or adolescent, clinicians should provide advice on the DASH diet and recommend moderate to vigorous physical activity at least 3 to 5 days per week (30–60 minutes per session) to help reduce BP. (CWeak)
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In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy 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. (BModerate)
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ABPM may be used to assess treatment effectiveness in children and adolescents with HTN, especially when clinic and/or home BP measurements indicate insufficient BP response to treatment. (BModerate)
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- Children and adolescents with CKD should be evaluated for HTN at each medical encounter.
- Children or adolescents with both CKD and HTN should be treated to lower 24-hr MAP <50th percentile by ABPM.
- 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.
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Children and adolescents with CKD and HTN should be evaluated for proteinuria. (BStrong)
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Children and adolescents with CKD, HTN, and proteinuria should be treated with an ACE inhibitor or ARB. (BStrong)
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Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP is ≥95th percentile or >130/80 mm Hg in adolescents ≥13 years of age. (CModerate)
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In children and adolescents with acute severe HTN and life-threatening symptoms, immediate treatment with short-acting antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 hours. (DWeak)
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Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and risk have been assessed. (CModerate)
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Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participating in competitive sports. (CModerate)
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Adolescents with elevated BP or HTN (whether they are receiving antihypertensive treatment) should typically have their care transitioned to an appropriate adult care provider by 22 years 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. (XStrong)
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Recommendation Grading
Overview
Title
Screening and Management of High Blood Pressure in Children and Adolescents
Authoring Organization
American Academy of Pediatrics
Publication Month/Year
September 1, 2017
Last Updated Month/Year
August 3, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research for pediatric hypertension
Target Patient Population
Pediatrics with hypertension
Inclusion Criteria
Male, Female, Adolescent, Child, Infant
Health Care Settings
Ambulatory, Childcare center, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management, Prevention
Diseases/Conditions (MeSH)
D006973 - Hypertension, D010372 - Pediatrics, D001794 - Blood Pressure, D015924 - Blood Pressure Monitors, D006776 - Hospitals, Pediatric
Keywords
hypertension, comprehensive lifestyle intervention, pediatric
Source Citation
Pediatrics September 2017, 140 (3) e20171904; DOI: https://doi.org/10.1542/peds.2017-1904
Methodology
Number of Source Documents
570
Literature Search Start Date
January 1, 2004
Literature Search End Date
July 1, 2016