Pediatric hypertension (CME)

A primer for pediatricians on how to approach hypertension in children and adolescents.

Nicholas, a 10-year-old boy with a history of intermittent asthma and attention deficit hyperactivity disorder, is seeing you for the first time for a well child visit. He has no complaints and his mom has no specific questions or concerns. On review of symptoms, Nicholas reports that he has some chest pain when he has an asthma exacerbation. Current medications include methylphenidate once daily and an albuterol metered-dose inhaler as needed. His family history reveals hypertension (HTN) in his father and paternal grandfather, and diabetes mellitus in his paternal grandfather. His mother and 12-year-old sister are healthy with no chronic medical problems. On physical exam, his anthropometrics and vital signs are as follows:

Height: 140 cm (50%)Weight: 45 kg (95%) Body mass index (BMI): 23 (>95%) Temperature 37 °C Heart rate: 85 bpm Blood pressure (BP): 124/82 mm Hg by automated cuffPhysical exam is normal

You reference the BP tables published in the Fourth Report by the National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents,1 and discover that the BP norms for a child of this age, gender, and height percentile are as follows:

This clinical scenario of a child found to have an elevated initial blood pressure is not uncommon. Pediatric hypertension, previously reported to affect only 0.3% to 1.2% of children in the 1970s and 1980s,2,3 now affects up to 5% of all children.4 One possible explanation for this increase may be the current growing population of obese children.5 The prevalence of hypertension in children increases with increasing BMI percentile,4 placing obese children at three-times higher risk of becoming hypertensive when compared to non-obese children.5

Regardless of the cause for this increase, a child with hypertension can be a dilemma for many primary care providers. It is essential for providers to understand when to screen for hypertension, how to conduct an initial work-up, how to manage these patients, and when to refer them to a subspecialist.

Which children should get their blood pressure checked?

Current recommendations state that all children 3 years of age and older should have their blood pressure measured at all health care encounters, including both well child care and acute care or sick visits. Certain children younger than 3 with comorbid conditions should also have their BP measured at each visit. This population includes children under 3 with1 :