Getting hypertension under control in the youngest of patients
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
Important aspects of the psychosocial history include feelings of depression or anxiety, bullying, and body perception. Children older than 10 years should be asked about smoking, alcohol, and other substance use.
The family history should include notation of first- and second-degree relatives with hypertension.6
Inquire about medications that can raise BP, including oral contraceptives, which are commonly prescribed in this population.21,22
The physical exam should include measured height and weight, with calculation of the body mass index percentile for age; of note, obesity is strongly associated with hypertension, and poor growth might signal underlying chronic disease. Once elevated BP has been confirmed, the exam should include measurement of BP in both arms and in a leg (TABLE 26). BP that is lower in the leg than in the arms (in any given patient, BP readings in the legs are usually higher than in the arms), or weak or absent femoral pulses, suggest coarctation of the aorta.6
Focus the balance of the physical exam on physical findings that suggest secondary causes of hypertension or evidence of end-organ damage.
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