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Pediatric Hypertension

  • Author: Edwin Rodriguez-Cruz, MD; Chief Editor: P Syamasundar Rao, MD  more...
 
Updated: Jul 17, 2015
 

Background

Hypertension in the pediatric population is now commonly observed. Hypertension is known to be a major cause of morbidity and mortality in the United States and in many other countries, and the long-term health risks to children with hypertension may be substantial. In the United States, extensive normative data on blood pressure (BP) in children are available.

The Task Force on Blood Pressure Control in Children, commissioned by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), developed standards for BP by using the results of 11 surveys of more than 83,000 person-visits of infants and children (including approximately equal numbers of boys and girls). The percentile curves were first published in 1987 and describe age-specific distributions of systolic and diastolic BP in infants and children, with corrections for height and weight.[1]

The Third Report of the Task Force, published in 1996, provided further details regarding the diagnosis and treatment of hypertension in infants and children.[2] In 2004, the Fourth Report added normative data and adapted the data to growth charts from the Centers for Disease Control and Prevention (CDC) for 2000.[3] In accordance with the recommendations of the Task Force, BP is considered normal when the systolic and diastolic values are less than the 90th percentile for the child’s age, sex, and height.

The Fourth Report introduced a new category, prehypertension, which is diagnosed when a child’s average BP is above the 90th percentile but below the 95th. Any adolescent whose BP is greater than 120/80 mm Hg is also given this diagnosis, even if the BP is below the 90th percentile. This classification was created to align the categories for children with the categories for adults from the recommendations of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Stage I hypertension is diagnosed if a child’s BP is greater than the 95th percentile but less than or equal to the 99th percentile plus 5 mm Hg. Stage II hypertension is diagnosed if a child’s BP is greater than the 99th percentile plus 5 mm Hg. It may be categorized as prehypertension if the BP is between 90th to 95th percentile.

If the systolic and diastolic pressures give rise to a discrepancy with respect to classification, the child’s condition should be categorized by using the higher value. Table 1 (see below) serves as a guide to the practicing physician. Full blood pressure tables for children and adolescents are available from the NHLBI.

Table 1. Ninety-Fifth Blood Pressure Percentiles for 50th and 75th Height Percentiles in Children and Adolescents[3] (Open Table in a new window)

Age, y 95th BP Percentile for Girls, mm Hg 95th BP Percentile for Boys, mm Hg
50th Height Percentile 75th Height Percentile 50th Height Percentile 75th Height Percentile
1 104/58 105/59 103/56 104/58
6 111/74 113/74 114/74 115/75
12 123/80 124/81 123/81 125/82
17 129/84 130/85 136/87 138/87
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Pathophysiology

BP is determined by the balance between cardiac output and vascular resistance. A rise in either of these variables, in the absence of a compensatory decrease in the other, increases mean BP, which is the driving pressure.

Factors that affect cardiac output include the following[4] :

  • Baroreceptors
  • Extracellular volume
  • Effective circulating volume - Atrial natriuretic hormones, mineralocorticoids, angiotensin
  • Sympathetic nervous syndrome

Factors that affect vascular resistance include the following[4] :

  • Pressors - Angiotensin II, calcium (intracellular), catecholamines, sympathetic nervous system, vasopressin
  • Depressors - Atrial natriuretic hormones, endothelial relaxing factors, kinins, prostaglandin E 2, prostaglandin I 2

Changes in electrolyte homeostasis, particularly changes in sodium, calcium, and potassium concentrations, affect some of these factors.

Under normal conditions, the amount of sodium excreted in the urine matches the amount ingested, resulting in near constancy of extracellular volume. Retention of sodium results in increased extracellular volume, which is associated with an elevation of BP. By means of various physical and hormonal mechanisms, this elevation triggers changes in both the glomerular filtration rate (GFR) and the tubular reabsorption of sodium, resulting in excretion of excess sodium and restoration of sodium balance.

A rise in the intracellular calcium concentration, due to changes in plasma calcium concentration, increases vascular contractility. In addition, calcium stimulates release of renin, synthesis of epinephrine, and sympathetic nervous system activity. Increased potassium intake suppresses production and release of renin and induces natriuresis, decreasing BP.

The complexity of the system explains the difficulties often encountered in identifying the mechanism that accounts for hypertension in a particular patient. These difficulties are the main reason why treatment is often designed to affect regulatory factors rather than the cause of the disease.

In a child who is obese, hyperinsulinemia may elevate BP by increasing sodium reabsorption and sympathetic tone.

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Etiology

Hypertension can be primary (ie, essential) or secondary. In general, the younger the child and the higher the BP, the greater the likelihood that hypertension is secondary to an identifiable cause (see Table 2 below). A secondary cause of hypertension is most likely to be found before puberty; after puberty, hypertension is likely to be essential.

Table 2. Common Causes of Hypertension by Age (Open Table in a new window)

Infants Children Adolescents
1-6 y 7-12 y
Thrombosis of renal artery or vein



Congenital renal anomalies



Coarctation of aorta



Bronchopulmonary dysplasia



Renal artery stenosis



Renal parenchymal disease



Wilms tumor



Neuroblastoma



Coarctation of aorta



Renal parenchymal disease



Renovascular abnormalities



Endocrine causes



Essential hypertension



Essential hypertension



Renal parenchymal disease



Endocrine causes



A review of the literature revealed that most of the young patients with secondary hypertension had a renal parenchymal abnormality; in the remaining patients, the causes of hypertension (in order of frequency) were renal artery stenosis, coarctation of the aorta, pheochromocytoma, and a variety of other conditions.[5, 6]

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Epidemiology

United States statistics

The true incidence of hypertension in the pediatric population is not known. This vagueness partly stems from the somewhat arbitrary definition of hypertension and is in part related to incomplete blood pressure screening during routine pediatric clinical visits. The prevalence of systemic hypertension in children appears to be increasing and is estimated to be 2% to 5%, especially in view of the growing population of children with obesity.

In adults, hypertension is defined on the basis of data from extensive studies that allowed correlation of BP with adverse events, such as heart failure or stroke. Similar studies have not been performed in children, although reports from small populations of children provided compelling evidence of a relation between hypertension and both ventricular hypertrophy and atherosclerosis.

In children, the definition of hypertension is based exclusively on frequency-distribution curves for BP. As a consequence, estimates of the prevalence of pediatric hypertension lack a scientific basis. The number of children who might be defined as having hypertension and the frequency with which they develop complications during adulthood remain unknown. However, recent evidence indicates that hypertension in adults originates in childhood, because childhood blood pressure predicts blood pressure in the adult.[7, 8]

International statistics

Because of differences in genetic and environmental factors, incidences vary from country to country and even from region to region in the same country.

Age-related demographics

Height and weight affect BP. However, these relations do not become evident until children reach school age. The Task Force on Blood Pressure Control in Children considered these factors when they published their normative data in 1987.[1]

Numerous investigators have noted a correlation between the BP of parents and that of their offspring. Familial aggregation of BP is detectable early in life. Some data relate this association to concomitant obesity in both parent and child.

Sex-related demographics

There are no significant differences in BP between girls and boys younger than 6 years. From that age until puberty, BP is slightly higher in girls than in boys. At puberty and beyond, BP is slightly higher in male adolescents and men than in comparably aged female adolescents and women.

Race-related demographics

The Task Force on Blood Pressure Control in Children noted no differences in BP between African American and white children. However, both peripheral vascular resistance and sensitivity of BP to salt intake appear to be greater in African American children than in white children, at any age.

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Prognosis

High blood pressure is a precursor of heart attacks and strokes, as has been well established in the adult literature.

Obese children have approximately a 3-fold higher risk for hypertension than nonobese children.[9] As many as 41% of children with high BP have left ventricular hypertrophy (LVH).[10] Almost 60% of children with persistent elevated BP have relative weights greater than 120% of the median for their sex, height, and age. As in adults, in whom abdominal girth correlates to elevated blood pressure, studies show that this measurement is also to be considered in the assessment of a teenager with suspected BP elevation at an early age.[11]

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Patient Education

Parents, caregivers, and children themselves must be properly advised about restriction of exercise, when appropriate. They must also be informed about the potential adverse effects of medication. Finally, it is vital to educate parents, caregivers, and children about the potential complications of persistent hypertension.

For patient education resources, see the Diabetes Center, as well as High Blood Pressure

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Contributor Information and Disclosures
Author

Edwin Rodriguez-Cruz, MD Director, Section of Cardiology, Department of Pediatrics, San Jorge Children’s Hospital, Puerto Rico; Private Practice in Interventional Pediatric Cardiology and Internal Medicine, Centro Pedíatrico y Cardiovascular

Edwin Rodriguez-Cruz, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Pediatric Echocardiography, American College of Physicians-American Society of Internal Medicine, American Medical Association, Puerto Rico Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: St Jude's Medical Co.<br/>Received grant/research funds from NOVARTIS for investigator; Received consulting fee from St. Jude Medical Corp. for speaking and teaching.

Chief Editor

P Syamasundar Rao, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

Leigh M Ettinger, MD, MS Clinical Assistant Professor, Division of Pediatric Nephrology, The Joseph M Sanzari Children's Hospital, Hackensack University Medical Center

Disclosure: Nothing to disclose.

Ira H Gessner, MD Professor Emeritus, Pediatric Cardiology, University of Florida College of Medicine

Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

John W Moore, MD, MPH Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital

John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Adrian Spitzer, MD Clinical Professor Emeritus, Department of Pediatrics, Albert Einstein College of Medicine

Adrian Spitzer, MD is a member of the following medical societies: American Academy of Pediatrics, American Federation for Medical Research, American Pediatric Society, American Society of Nephrology, American Society of Pediatric Nephrology, International Society of Nephrology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. [Guideline] Task Force. Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics. 1987 Jan. 79(1):1-25. [Medline].

  2. [Guideline] Task Force. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control. Pediatrics. 1996 Oct. 98(4 Pt 1):649-58. [Medline].

  3. [Guideline] NHLBI. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004 Aug. 114(2 Suppl 4th Report):555-76. [Medline]. [Full Text].

  4. Gruskin AB. Factors affecting blood pressure. Drukker A, Gruskin AB, eds. Pediatric Nephrology: Pediatric and Adolescent Medicine. 3rd ed. Basel, Switzerland: Karger; 1995. 1097.

  5. Gavrilovici C, Boiculese LV, Brumariu O, Dimitriu AG. [Etiology and blood pressure patterns in secondary hypertension in children]. Rev Med Chir Soc Med Nat Iasi. 2007 Jan-Mar. 111(1):70-81. [Medline].

  6. Kapur G, Ahmed M, Pan C, Mitsnefes M, Chiang M, Mattoo TK. Secondary hypertension in overweight and stage 1 hypertensive children: a Midwest Pediatric Nephrology Consortium report. J Clin Hypertens (Greenwich). 2010 Jan. 12(1):34-9. [Medline].

  7. Sun SS, Grave GD, Siervogel RM, Pickoff AA, Arslanian SS, Daniels SR. Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics. 2007 Feb. 119 (2):237-46. [Medline].

  8. Banker A, Gupta-Malhotra M, Syamasundar Rao P. Childhood hypertension: a review. J Hypertens. Dec 2013. 2(4):128. [Full Text].

  9. Dhuper S, Buddhe S, Patel S. Managing Cardiovascular Risk in Overweight Children and Adolescents. Paediatr Drugs. 2013 Apr 12. [Medline].

  10. Hanevold C, Waller J, Daniels S, Portman R, Sorof J. The effects of obesity, gender, and ethnic group on left ventricular hypertrophy and geometry in hypertensive children: a collaborative study of the International Pediatric Hypertension Association. Pediatrics. 2004 Feb. 113(2):328-33. [Medline].

  11. Leung LC, Sung RY, So HK, et al. Prevalence and risk factors for hypertension in Hong Kong Chinese adolescents: waist circumference predicts hypertension, exercise decreases risk. Arch Dis Child. 2011 Sep. 96(9):804-9. [Medline].

  12. Rao PS, Seib PM. Coarctation of the Aorta. Medscape Drugs & Diseases from WebMD. Available at http://emedicine.medscape.com/article/895502-overview. Updated Sep 25, 2014; Accessed: July 17, 2015.

  13. [Guideline] University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2009 Feb. [Full Text].

  14. Meyers RS, Siu A. Pharmacotherapy Review of Chronic Pediatric Hypertension. Clin Ther. 2011 Oct 7. [Medline].

  15. Schaefer F, Litwin M, Zachwieja J, Zurowska A, Turi S, Grosso A, et al. Efficacy and safety of valsartan compared to enalapril in hypertensive children: a 12-week, randomized, double-blind, parallel-group study. J Hypertens. 2011 Oct 21. [Medline].

  16. Sezer SS, Narin N, Ozyurt A, et al. Cardiovascular changes in children with coarctation of the aorta treated by endovascular stenting. J Hum Hypertens. 2014 Jun. 28(6):372-7. [Medline].

  17. Forbes TJ, Kim DW, Du W, et al, for the CCISC Investigators. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: an observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol. 2011 Dec 13. 58 (25):2664-74. [Medline].

  18. Aeberli I, Spinas GA, Lehmann R, l'Allemand D, Molinari L, Zimmermann MB. Diet determines features of the metabolic syndrome in 6- to 14-year-old children. Int J Vitam Nutr Res. 2009 Jan. 79(1):14-23. [Medline].

  19. Gonzalez-Juanatey JR, Paz FL, Eiras S, Teijeira-Fernandez E. [Adipokines as novel cardiovascular disease markers. Pathological and clinical considerations]. Rev Esp Cardiol. 2009 Jun. 62 Suppl 2:9-16. [Medline].

  20. Kshatriya S, Reams GP, Spear RM, Freeman RH, Dietz JR, Villarreal D. Obesity hypertension: the emerging role of leptin in renal and cardiovascular dyshomeostasis. Curr Opin Nephrol Hypertens. 2009 Oct 21. [Medline].

  21. Nakamura Y, Ueshima H, Okuda N, et al. Relation of serum leptin to blood pressure of Japanese in Japan and Japanese-Americans in Hawaii. Hypertension. 2009 Dec. 54(6):1416-22. [Medline].

  22. Moledina S, Pandya B, Bartsota M, Mortensen KH, McMillan M, Quyam S, et al. Prognostic Significance of Cardiac Magnetic Resonance Imaging in Children with Pulmonary Hypertension. Circ Cardiovasc Imaging. 2013 Apr 9. [Medline].

  23. Maxey DM, Ivy DD, Ogawa MT, Feinstein JA. Food and Drug Administration (FDA) Postmarket Reported Side Effects and Adverse Events Associated with Pulmonary Hypertension Therapy in Pediatric Patients. Pediatr Cardiol. 2013 Mar 27. [Medline].

 
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Management algorithm. AMC = Apparent mineralocorticoid excess; GRA = Glucocorticoid remedial aldosteronism; VMA = Vanillylmandelic acid.
Table 1. Ninety-Fifth Blood Pressure Percentiles for 50th and 75th Height Percentiles in Children and Adolescents [3]
Age, y 95th BP Percentile for Girls, mm Hg 95th BP Percentile for Boys, mm Hg
50th Height Percentile 75th Height Percentile 50th Height Percentile 75th Height Percentile
1 104/58 105/59 103/56 104/58
6 111/74 113/74 114/74 115/75
12 123/80 124/81 123/81 125/82
17 129/84 130/85 136/87 138/87
Table 2. Common Causes of Hypertension by Age
Infants Children Adolescents
1-6 y 7-12 y
Thrombosis of renal artery or vein



Congenital renal anomalies



Coarctation of aorta



Bronchopulmonary dysplasia



Renal artery stenosis



Renal parenchymal disease



Wilms tumor



Neuroblastoma



Coarctation of aorta



Renal parenchymal disease



Renovascular abnormalities



Endocrine causes



Essential hypertension



Essential hypertension



Renal parenchymal disease



Endocrine causes



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