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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|The Journal of Family Practice
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

When an initial reading is elevated, whether by oscillometric or auscultatory measurement, 2 more auscultatory BP measurements should be taken during the same visit; these measurements are averaged to determine the BP category.18

TABLE 16 defines BP categories based on age, sex, and height. We recommend using the free resource MD Calc (www.mdcalc.com/aap-pediatric-hypertension-guidelines) to assist in calculating the BP category.

TABLE 26 describes the timing of follow-up based on the initial BP reading and diagnosis.

Ambulatory BP monitoring (ABPM) is a validated device that measures BP every 20 to 30 minutes throughout the day and night. ABPM should be performed initially in all patients with persistently elevated BP and routinely in children and adolescents with a high-risk comorbidity (TABLE 26). Note: Insurance coverage of ABPM is limited.

Initial measurement of BP determines the timing and elements of follow-up

Children older than 10 years who have been given a diagnosis of hypertension should be asked about smoking, alcohol, and other substance use.

ABPM is also used to diagnose so-called white-coat hypertension, defined as BP ≥ 95th percentile for age, sex, and height in the clinic setting but < 95th percentile during ABPM. This phenomenon can be challenging to diagnose.

Continue to: Home monitoring

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