Pediatric Hypertension Guidelines

Updated: Mar 09, 2017
  • Author: Edwin Rodriguez-Cruz, MD; Chief Editor: Syamasundar Rao Patnana, MD  more...
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Guidelines

Guidelines Summary

Guidelines on screening for hypertension in children and adolescents have been issued by the following organizations:

  • US Preventive Services Task Force (USPSTF)
  • American Heart Association(AHA)
  • National Heart, Lung and Blood Institute (NHLBI)
  • European Society of Hypertension (ESH)

A comparison of the recommendations are provided in Table 3, below.

Table 3. Guidelines for Blood Pressure Screening in Children and Adolescents

Table 3. (Open Table in a new window)

Issuing Organization Year Screening Populations Screening Measurement Screening Interval
US Preventive Services Task Force (USPSTF) [29]



(Endorsed by American Academy of Family Physicians)



2013 Asymptomatic children and adolescents Insufficient evidence to recommend for or against screening for primary prevention of hypertension N/A
American Heart Association (AHA) [30] 2014 Ages 3 to 17 years Office measurement of blood pressure; 24-hour ambulatory BP monitoring to confirm diagnosis Annually at well-child visits
National Heart, Lung and Blood Institute (NHLBI) [31]



(Endorsed by American Academy of Pediatrics)



2011 Ages 3 to 17 years Office measurement of BP Annually at well-child visits
European Society of Hypertension  (ESH) [32] 2009 Ages 3 to 17 years Office measurement of blood pressure; 24-hour ambulatory BP monitoring to confirm diagnosis prior to starting drug treatment When seen in a medical setting
National Heart, Lung and Blood Institute (NHLBI) [31]



(Endorsed by American Academy of Pediatrics)



2011 Age <3 years Office measurement of BP Under the following conditions:



Prematurity, very low birth weight, or other neonatal complication requiring intensive care; congenital heart disease (repaired or unrepaired); recurrent urinary tract infections, hematuria, or proteinuria; known renal disease or family history of congenital renal disease; organ transplant, malignancy or bone marrow transplant; treatment with drugs known to raise BP; other systemic illnesses associated with hypertension; or evidence of increased intracranial pressure



European Society of Hypertension  (ESH) [32] 2009 Age <3 years Office measurement of blood pressure; 24-hour ambulatory BP monitoring to confirm diagnosis prior to starting drug treatment When seen in a medical setting



Under special circumstances (eg, conditions requiring intensive care, congenital heart disease, renal disease, treatment with drugs known to raise BP and evidence of elevated intracranial pressure)



Specific recommendations (all of them graded as expert opinion) from the 2011 NHLBI Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents include the following lifestyle modifications for prevention and first-line intervention [31] :

  • The cardiovascular health integrated lifestyle diet (CHILD 1)
  • Increases in moderate to vigorous physical activity
  • Weight management
  • For children with stage 2 hypertension and stage 1 secondary hypertension or left ventricular hypertrophy, first-line therapy should also include antihypertensive medications
  • Antihypertensive medication is second-line therapy for children with stage 1 primary hypertension who show no improvement with lifestyle modifications
  • Insufficient evidence exists to recommend the use of specific antihypertensive agents for specific age groups
  • Losartan, amlodipine, felodipine, fosinopril, lisinopril, metoprolol, and valsartan are tolerated over short periods, and can reduce blood pressure in children from ages 6-17 years but predominantly are effective in adolescents
  • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should be limited to children aged 6 years or older with creatinine clearance of 30 mL/min/1.73 m 2 or greater; in black children, higher doses of fosinopril may be needed for effective blood pressure control
  • Calcium channel blockers are contraindicated in children less than 1 year old
  • Beta-blockers are contraindicated in children with asthma or insulin-dependent diabetes
  • Diuretics are useful as add-on therapy in patients being treated with drugs from other classes; however, potassium-sparing diuretics (spironolactione, triamterene, amiloride) may cause severe hyperkalemia, especially if given with an ACE inhibitor or ARB; all patients treated with diuretics should have electrolyte levels monitored shortly after initiating therapy and periodically thereafter
  • Vasodilators: Tachycardia and fluid retention are common side effects; hydralazine can cause lupuslike syndrome; minoxidil is usually reserved for patients with hypertension resistant to multiple drugs and its prolonged use can cause hypertrichosis

The 2009 European Hypertension Society (EHS) guidelines for blood pressure management in children are in agreement with those of the NHLBI, however, they offer more specific guidance as to the clinical conditions for which specific antihypertensive drugs are recommended or contraindicated. [32] See Table 4, below.

Table 4. European Society of Hypertension Recommendations for Hypertensive Medications in Pediatric Patients

Table 4. (Open Table in a new window)

Drug Class Indications Contraindications
Angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) Chronic kidney disease



Diabetes mellitus



Congestive heart failure



Bilateral renal artery stenosis



Renal artery stenosis in solitary kidney



Hyperkalemia



Pregnancy



Calcium channel blockers Post-transplantation Congestive heart failure
Beta-blockers Coarctation of the aorta Asthma
Potassium-sparing diuretics Hyperaldosteronism



Chronic renal failure



Chronic renal failure
Loop diuretics Congestive heart failure  
Vasodilators Life-threatening conditions