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Hypertension in children and adolescents

  • Simple table to identify children and adolescents needing further evaluation of blood pressure


    Any reading equal to or above the readings in the simplified table indicates potentially abnormal blood pressures in one of three ranges: prehypertension; stage 1 hypertension; or stage 2 hypertension and identifies blood pressures that requires additional evaluation.

    PEDIATRICS Vol. 123 No. 6 June 2009, pp. e972-e974

    BP centile charts

    Boys Chart 
    Girls Chart 

    The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents 

    A very comprehensive resource 

    A Pocket Guide to Blood Pressure Measurement in Children 

    Useful classifications of BP by age and height - useful in short or tall children, and gives hypertension stages.

    Note: BP measurements repeated on several different occasions are required to diagnose hypertension. The cuff bladder should cover at least 3/4 of the child's arm length, and the child should be quiet and calm.


    • Essential hypertension

    Obesity may complicate the accurate measurement of blood pressure and be a contributing factor.

    Secondary causes

    • Renal (75%) - post-infectious glomerulonephritis, chronic glomerulonephritis, obstructive uropathy, reflux nephropathy, reno-vascular, haemolytic uraemic syndrome, polycystic kidney disease
    • Cardiovascular (15%) - coarctation of the aorta
    • Endocrine (5%) - phaeochromocytoma, hyperthyroidism, congenital adrenal hyperplasia, primary hyperaldosteronism, Cushing syndrome
    • Other (5%) - neuroblastoma, neurofibromatosis, steroid therapy, raised intracranial pressure.


    • Appearance - Cushingoid, obese
    • Height and weight
    • Upper and lower limb BP measurement
    • Skin: Cafe-au-lait spots, neurofibromas, hirsutism, vasculitis
    • Fundoscopy: hypertensive retinopathy
    • CVS examination: left ventricular hypertrophy, murmurs (particularly interscapular)
    • Abdomen: renal / adrenal masses, renal bruits
    • Full neurological examination


    Initially: urine analysis, urine microscopy, urea and electrolytes, creatinine

    Further investigations may include: urinary catecholamines, chest X-ray, ECG, renal ultrasound, gluconate scan, plasma renin pre- and post- captopril, thyroid function tests, cortisol / aldosterone levels, 17-hydroxy progesterone, renal angiography.


    Asymptomatic hypertension

    No treatment required acutely. Investigate and manage as out-patient. Refer to General Paediatric Outpatient Clinic.

    Acute severe hypertension

    These patients require admission to ICU for urgent treatment.

    Hypertensive encephalopathy presents as severe headache, visual disturbance and vomiting, progressing to focal neurological deficits, seizures and impaired conscious state, with grossly elevated BP, papilloedema and retinal haemorrhages. These patients almost always have chronic renal disease and are on dialysis. The differential diagnosis includes uraemic encephalopathy and metabolic disturbance. BP should be lowered in a controlled fashion, with anticonvulsants given for  seizures.


    Choice includes (list not exhaustive):

    • Sublingual / oral nifedipine:
      • tabs - 0.5 - 1.0 mg/kg/dose (max. 40 mg) 12-hourly
      • Side effects include tachycardia, flushing and fluid retention.
    • Intravenous labetalol:
      • 0.2 mg/kg initially; later 0.4 mg/kg by slow push every 10 min up to 3 - 4
        mg/kg (max. 100 mg) total dose. Avoid if there is heart failure, asthma or
    • Intravenous hydralazine:
      • 0.1 - 0.2 mg/kg (max. 10 mg) stat, then 4 - 6 micrograms/kg/min (max 300micrograms/min).
      • Hydralazine may cause tachycardia, nausea and fluid retention.
    • Oral captopril:
      • 0.1 mg/kg initially, increasing to a maximum of 1 mg/kg (max. 50 mg).
      • Thereafter 0.1-1.0 mg/kg/dose 8-hourly. Captopril is usually effective within 30 - 60 min.
  • 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)