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Getting hypertension under control in the youngest of patients

The Journal of Family Practice. 2021 June;70(5):220-228 | 10.12788/jfp.0201
June 16, 2021|Family Medicine
Dustin K. Smith, DO, FAAFP;Stephen M. McMullan, MD;Matthew J. Martin, DO
Author and Disclosure Information

Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville, FL (Drs. Smith and Martin); Mayo Clinic Florida, Jacksonville (Dr. McMullan); Uniformed Services University of Health Sciences, Bethesda, MD (Dr. Smith)
dustinksmith@yahoo.com

The authors reported no potential conflict of interest relevant to this article.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of the Navy, US Department of Defense, or the government of the United States.

After confirmation of the diagnosis, follow up with recommendations for lifestyle adjustment and, in certain clinical situations, pursue medical therapy.

PRACTICE RECOMMENDATIONS

› Measure the blood pressure (BP) of all children 3 years and older annually; those who have a specific comorbid condition (eg, obesity, diabetes, renal disease, or an aortic-arch abnormality) or who are taking medication known to elevate BP should have their BP checked at every health care visit. C

› Encourage lifestyle modification as the initial treatment for elevated BP or hypertension in children. A

› Utilize pharmacotherapy for (1) children with stage 1 hypertension who have failed to meet BP goals after 3 to 6 months of lifestyle modification and (2) children with stage 2 hypertension who do not have a modifiable risk factor, such as obesity. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Testing. TABLE 36,23 summarizes the diagnostic testing recommended for all children and for specific populations; TABLE 26 indicates when to obtain diagnostic testing. Patients 6 years and older who are overweight or obese and have a family history of hypertension likely have primary hypertension; they do not require an extensive work-up for secondary hypertension unless findings of the comprehensive history and physical examination lead in that direction.6,23

Diagnostic testing in children with hypertension

TABLE 42,12,13,24 outlines the basis of primary and of secondary hypertension and common historical and physical findings that suggest a secondary cause.

What is the etiology of pediatric hypertension?

Mapping out the treatment plan

Pediatric hypertension should be treated in patients with stage 1 or higher hypertension.6 This threshold for therapy is based on evidence that reducing BP below a goal of (1) the 90th percentile (calculated based on age, sex, and height) in children up to 12 years of age or (2) of < 130/80 mm Hg for children ≥ 13 years reduces short- and long-term morbidity and mortality.5,6,25

Ambulatory BP monitoring should be performed initially in all patients with persistently elevated BP and routinely in children and adolescents with a high-risk comorbidity.

Choice of initial treatment depends on the severity of BP elevation and the presence of comorbidities (FIGURE6,20,25-28). The initial, fundamental treatment recommendation is lifestyle modification,6,29 including regular physical exercise, a change in nutritional habits, weight loss (because obesity is a common comorbid condition), elimination of tobacco and substance use, and stress reduction.25,26 Medications can be used as well, along with other treatments for specific causes of secondary hypertension.

Management of confirmed pediatric hypertension

Referral to a specialist can be considered if consultation for assistance with treatment is preferred (TABLE 26) or if the patient has:

  • treatment-resistant hypertension
  • stage 2 hypertension that is not quickly responsive to initial treatment
  • an identified secondary cause of ­hypertension.

Continue to: Lifestyle modification can make a big difference

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