AAP: Identifying the child with hypertension

October 14, 2008

Over the last few years, the incidence of hypertension (HTN) in children has risen, noted Beth Vogt, MD, of Rainbow Babies and Children’s Hospital in Cleveland, as she spoke in Boston to a packed room of concerned pediatricians. In addition to a rise in HTN, the average blood pressure (BP) of American children is also increasing. Several studies have shown that elevated blood pressure is under-recognized; the increase in HTN may also be associated with the childhood obesity. The recommendations below offer some insight in how to identify the child with elevated BP, and how to approach treatment.

Over the last few years, the incidence of hypertension (HTN) in children has risen,noted Beth Vogt, MD, of Rainbow Babies and Children’s Hospital in Cleveland,as she spoke in Boston to a packed room of concerned pediatricians. In additionto a rise in HTN, the average blood pressure (BP) of American children is alsoincreasing. Several studies have shown that elevated blood pressure is under-recognized;the increase in HTN may also be associated with the childhood obesity. The recommendationsbelow offer some insight in how to identify the child with elevated BP, and howto approach treatment.

Early blood pressure screening
Children three years of age or older should have their BP measured. Timing isvery important when checking children for blood pressure. Children 3 and overshould be checked at every health care visit, whether well or unwell.

Children under 3 years of age should be checked if there is a history of prematurity,very low birth weight, a NICU stay, congenital heart disease, recurrent urinarytract infections, renal disease, organ transplant, treatment with drugs that increaseBP, systemic illness with HTN, and increased intracranial pressure.

Technique
The preferred BP measurement is auscultation. Automated devices are acceptableas well, but elevated BP should be confirmed by auscultation. It is also suggestedthat the physician try to have the child sit quietly for at least five minutesprior to taking the BP. Use the appropriate cuff size, try to use the right arm,measure the BP several times in the same visit, and confirm the elevated bloodpressure with three measurements.

How to define blood pressure in children
--Normal blood pressure (less than the 90th percentile): less than 115/75
--Prehypertension (the 90th to 95th percentile): less than 120/80
--Stage 1 hypertension: more than 119/80 to 132/93
--Stage 2 hypertension: more than 132/93

Child visits and BP measurements
If the best blood pressure is normal, the pediatrician should see the child inone year.

If the child has prehypertension, the follow-up should be in six months. A childwith Stage 1 should be seen for follow-up in one to two weeks. Stage 2 or symptomatic?Evaluate or refer the child within one week. Further evaluation should look forcauses of HTN, comorbidities, and target organ damage.

Treatment
Treatment of a child with HTN requires a lifestyle modification. It includes dietarysodium restriction, the DASH (Dietary Approaches to Stop Hypertension) diet tolower fat and increase potassium, increased physical activity, weight reduction,tobacco and alcohol cessation, caffeine reduction, and, where necessary, pharmacologictherapy.