Applied Evidence

Pediatric hypertension: Often missed and mismanaged

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Delayed recognition of hypertension in children can have lasting consequences. The resources detailed here—including Web-based calculators and at-a-glance tables—can facilitate diagnosis and treatment.




› Screen for hypertension in all children over the age of 3 at every visit. C
› Order laboratory evaluation, echocardiography, and renovascular imaging for all children given a diagnosis of hypertension. C
› Advise parents that children with prehypertension and stage 1 hypertension without target-organ damage are eligible to participate in competitive athletics, but those with stage 2 hypertension, target-organ damage, or symptomatic hypertension should not engage in high-static sports (eg, gymnastics, weightlifting, wrestling) until BP is well controlled. 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

Childhood hypertension is on the rise: Recent data from the National Health and Nutrition Survey suggest 10% of children and adolescents have prehypertension and 4% have hypertension.1-4 Unfortunately, the condition often is missed. In a study of 14,187 children and adolescents who had at least 3 well-child visits at an outpatient academic medical center, 507 patients met the criteria for hypertension, yet only 131 (26%) had this diagnosis documented in their electronic health record.5

In a survey of 89 pediatricians, >50% of respondents said they were not familiar with the most current published recommendations for diagnosing and treating pediatric hypertension.6 Respondents also indicated that the most common reason for not initiating pharmacotherapy for children with hypertension was a lack of familiarity with appropriate antihypertensive agents (54%), followed by concern for adverse medication effects. Delayed diagnosis, evaluation, and treatment of hypertension in young patients can increase the likelihood of serious consequences, including target-organ damage such as left ventricular hypertrophy (LVH). In this review, we’ll describe the factors that put children and adolescents at risk for hypertension, and offer an evidence-based approach to diagnosis and treatment.

Obesity is a key risk factor

An estimated 17% of children aged 2 to 19 are obese.7 Obesity increases a child’s risk for hypertension by approximately 3- to 5-fold, and body mass index (BMI) is greater in children with primary hypertension compared with those with secondary hypertension.8 Hypertension is more common among Hispanic and non-Hispanic black male children and adolescents compared with their white counterparts; these ethnic disparities are not found in females.9,10 Poor diets and physical inactivity further contribute to obesity and hypertension risk. Children who were born preterm or had a very low birth weight also are at increased risk.11

Unchecked hypertension can lead to cardiac, vascular damage

Some children and adolescents with undiagnosed and untreated hypertension have evidence of target-organ damage, including cardiac dysfunction and pathologic vascular abnormalities. LVH is present in 20% to 41% of children and adolescents with hypertension.12,13 Carotid intima-media thickness, an established surrogate marker for atherosclerosis, is abnormally increased in children with hypertension, even after adjusting for BMI.14 Other target organ effects include impaired cognitive function, reduced glomerular filtration rate, microalbuminuria, and retinal arteriolar narrowing.15-17

Normal BP standards for children and adolescents are based on gender, age, and height percentile.Pediatric hypertension may persist into adulthood. A meta-analysis of more than 50 studies found that elevated blood pressure (BP) in childhood increases the risk for hypertension as an adult.18

NHLBI recommendations call for a BP check at every visit

The National Heart, Lung, and Blood Institute (NHLBI) Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (“the 4th Report”) recommends measuring BP in all children over age 3 during every health care visit.12 Children under age 3 should have their BP checked in certain circumstances, including preterm delivery, congenital heart disease, recurrent urinary tract infections, renal/urologic disease, organ transplantation, malignancy, and systemic illnesses associated with hypertension.12 The 4th Report is endorsed by the American Academy of Pediatrics (AAP); however, the American Academy of Family Physicians and the US Preventive Services Task Force have concluded that the evidence is insufficient to recommend for or against routine screening for hypertension in children and adolescents to reduce the risk of cardiovascular disease (CVD).19,20

Does the child have hypertension? That depends on several factors

Determining whether a child has hypertension requires that you consult national BP standards to determine if he or she is within the normal range. Normal BP standards for children and adolescents are based on gender, age, and height percentile, and provide a precise classification based on body size.12 These tables are available from the NHLBI Web site at Height percentiles in these tables correspond with the Centers for Disease Control and Prevention (CDC) growth charts published in 2000.21 The Baylor College of Medicine Children’s Nutrition Research Center has a web-based calculator to help physicians determine BP percentiles in children and adolescents; it is available at The International Pediatric Hypertension Association also offers BP charts and calculators at


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