Pediatric Hypertension Guidelines

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