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Hypertension in children and adolescents

  • See also

    American Academy of Pediatrics
    Online paediatric blood pressure centile calculator

    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

    Causes of Hypertension

    Primary Hypertension

    Situational Hypertension

    Stress, pain, anxiety

    Secondary Hypertension

    Renal parenchymal disease

    GN, polycystic kidneys, CKI

    Cardiac, Vascular

    Renal artery stenosis, Coarctation repair (pre and post)

    Endocrine

    Diabetes, thyroid disease, CAH, Diabetes, thyroid disease, CAH, Cushings

    Autoimmune

    Thrombotic thrombocytopenic purpura, Haemolytic Uraemic Syndrome, Henoch-Schönlein Purpura

    Genetic/Syndromic

    Neurofibromatosis, Williams Syndrome, Turners Syndrome

    Malignancy

    Wilms tumour, neuroblastoma, pheochromocytoma

    Intracranial pathology

    Intracranial haemorrhage/stroke,  pituitary adenoma, raised ICP

    Respiratory

    Chronic lung disease, OSA

    Drug-induced

    Corticosteroids, OCP, stimulants

    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 discrepency
    • 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/virilized 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

    *Screening BP Values Requiring Further Evaluation

    Age (years)

    Blood pressure (mmHg)

     

    Boys

    Girls

     

    Systolic

    Diastolic

    Systolic

    Diastolic

    1

    98

    52

    98

    54

    2

    100

    55

    101

    58

    3

    101

    58

    102

    60

    4

    102

    60

    103

    62

    5

    103

    63

    104

    64

    6

    105

    66

    105

    67

    7

    106

    68

    106

    68

    8

    107

    69

    107

    69

    9

    107

    70

    108

    71

    10

    108

    72

    109

    72

    11

    110

    74

    111

    74

    12

    113

    75

    114

    75

    ≥13

    120

    80

    120

    80

    *90th 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

    Blood pressure classification in children and adolescents

     

    For children aged 1 to 13 years

    For children aged 13-17 years

    Normal blood pressure

    <90th centile

    <120/<80 mmHg

    Elevated blood pressure

    ≥90th centile to <95th centile or 120/80
    mmHg to <95th centile (whichever is lower)

    120/<80 to 129/<80 mmHg

    Stage 1 Hypertension

    ≥95th centile to <95th centile + 12 mmHg or 130/80 to 139/89 mmHg (whichever is lower)

    130/80 to 139/89 mmHg

    Stage 2 Hypertension

    ≥95th centile + 12 mmHg, or ≥140/90 mmHg (whichever is lower)

    ≥140/90 mmHg

     Severe Hypertension

    Hypertensive Urgency

    >95th centile + 30 mmHg without symptoms/signs of target end organ damage (See Examination)

    >180/120
    without symptoms/signs of target end organ damage (See Examination)

    Hypertensive Emergency

    >95th centile + 30 mmHg associated with encephalopathy,
    eg headache vomiting, vision changes and neurological symptoms (facial nerve palsy, lethargy, seizures, coma) +/- target-end organ damage

    >180/120
    associated with encephalopathy,
    eg headache vomiting, vision changes and neurological symptoms (facial nerve palsy, lethargy, seizures, coma) +/- target-end organ damage

    Management

    Emergency management of severe hypertension

    Emergency management of severe hypertension diagram

    • 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 95th 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

     Hypertension without severe features

    Investigations

    First-line investigations

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

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    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

  • Reference List

    1. Dionne, J. Updated guideline may improve the recognition and diagnosis of hypertension in children and adolescents; review of the 2017 AAP blood pressure clinical practice guideline. Current Hypertension Reports. 2017. vol 19 (10), p84. 
    2. Flynn, J.T et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017 vol 140 (3)