See also

Online paediatric BP centile calculator 

BP by age and height centile tables: boys girls

Key points

1. Severe hypertension requires urgent consultation and management.  Hypertension associated with encephalopathy is a medical emergency
2. All hypertension in children requires monitoring and follow-up
3. Blood pressure should be measured annually in healthy children
4. Where possible, abnormal machine BP measurement should be confirmed, preferably with a manual BP, ensuring appropriately sized cuff is used for accurate measurement

Background

• This guideline will focus on the paediatric population aged 1–17 years (not infants)
• Hypertension in childhood is a key predictor of risk for hypertension, cardiovascular disease and end organ damage in adulthood
• Primary/essential hypertension accounts for the majority of hypertension in children >6 years old and is generally associated with obesity or a family history of hypertension
• Secondary hypertension is more common in younger children (<6 years old) with renal disease being the most prevalent cause. This population is at greater risk of hypertensive emergencies due to an underlying condition

Assessment

Risk factors:

• Overweight/obesity
• Male sex
• Family history of hypertension
• Low birth weight/intrauterine growth restriction
• Prematurity
• Excess dietary salt intake
• Physical inactivity
• Chronic health concerns, eg chronic kidney disease, diabetes

History

• Headache/vomiting
• Blurred vision
• Change in mental state
• Seizures
• Chest pain/palpitations
• Shortness of breath
• Cardiac failure
• Past history of Acute Kidney Injury (AKI)

Examination

• Confirm hypertension (See measuring blood pressure section below)
• Vitals: tachycardia, four limb BP for upper and lower limb discrepancy
• Height and weight: obesity, growth retardation
• Signs of end organ damage
• Fundoscopy: hypertensive retinopathy
• Cardiovascular: apical heave, hepatomegaly, oedema
• Chronic renal failure: palpable kidneys
• Focal neurology (eg facial nerve palsies)

• Signs of underlying cause
• General appearance: Cushingoid, proptosis, goitre, webbed neck (Turner syndrome), elfin facies (William syndrome)
• Skin: Cafe-au-lait spots, neurofibromas, acanthosis nigricans, hirsutism, striae, acne, rash (vasculitis)
• Cardiovascular: murmurs +/- radiation, apical heave, reduced femoral pulses, oedema, hepatomegaly (CCF)
• Abdomen: masses, palpable kidneys, flank bruits
• Genitourinary: ambiguous/virilised genitalia (eg CAH)

Key points when measuring blood pressure (See video)
Ensure the correct cuff size is selected for each patient, favouring a larger rather than smaller cuff (smaller cuff creates artificial hypertension)

• BP cuff width should be 40% of the length of the arm measure from the shoulder tip to the elbow
• Abnormal oscillatory BP measurement needs checking with a manual BP from the child's arm

The table below identifies BP levels requiring further evaluation, starting with repeating the BP manually ensuring accurate measurement

*90^th centile for a child at average height

Assessment of severity

Interpreting blood pressure measurement
An online blood pressure centile calculator specific for gender, age and height can be used to determine the severity of hypertension

Management

Emergency management of severe hypertension

• Discuss with renal team and retrieval/ICU team  

Hypertensive urgency

If medically stable, consider short acting oral agents while investigating cause

• Nifedipine
• Commence 0.25–0.5 mg/kg/day (max 20 mg) and titrate up as required to a maximum of 3 mg/kg/day (max 120 mg)

Hypertensive emergency

• Intravenous therapy; discuss with renal team and retrieval/ICU team
• Aim to gradually reduce BP to the patient's estimated 95^th centile
• Decrease BP by 25% of the original value every 24 hours till target BP reached. Reduce rate of decrease if patient becomes symptomatic

Hypertension without severe features

Investigations

First-line investigations

• UEC, CMP, urinalysis +/- renal ultrasound
• Consider LFT, Hb1Ac, fasting lipids particularly in children with BMI >95^th centile

Further investigations should only be considered in consultation with a general or renal paediatrician

Consider further testing if child meets one of the following criteria:

• <6 years
• Concerns for secondary causes on history/examination
• Abnormal first-line investigations

Further Investigations

• Bloods: FBE, Bicarbonate, renin/aldosterone ratio, TFT, plasma metanephrins, cortisol, fasting glucose
• Urine: microscopy, protein/creatinine ratio, catecholamines, drug screen
• Imaging: renal doppler ultrasound, DMSA, CTA/MRA
• Other: echocardiogram, sleep study

Lifestyle counselling

Dietary modifications

• Rich in fresh fruit and vegetables/legumes, fish, poultry, lean red meat and low fat dairy
• Limit intake of high sodium, fat or sugar containing foods

Lifestyle modifications

• Increase physical activity, aiming 40 minutes moderate to vigorous exercise 3-5 days/week
• Consider counselling/behavioural techniques to help address weight management and metabolic risk

Medical management

Should be commenced if:

• Conservative measures have failed
• Symptomatic hypertension develops
• Stage 2 hypertension with no modifiable risk factors
• Hypertension in setting of chronic kidney disease/diabetes

Medical management should only be commenced in consultation with a general or renal paediatrician

• Long-acting calcium channel blockers such as amlodipine are recommended as first line therapy. Other medication may be preferred in children with BMI >95^th centile, diabetes or proteinuria

Consider consultation with local paediatric team when

• Red flags (see history section above) or ongoing concerns are present
• Hypertensive urgency or hypertensive emergency
• Medical management of hypertension is required

Consider transfer when

Child requiring care beyond the comfort level of the hospital

Consider discharge when

Hypertensive children without severe features may be discharged with appropriate follow-up (See flowchart)

Parent information

See Parent resources

Additional notes

How to Measure Blood Pressure – American Academy of Pediatrics (video)

Last updated June 2021