Pediatric Hypertension¶

Learning Objectives¶

Core Knowledge & Clinical Reasoning¶

[ ] Apply 2017 AAP BP classification criteria (elevated BP, Stage 1, Stage 2) using appropriate tables
[ ] Determine when to transition from pediatric percentile-based to adult threshold-based criteria (age ≥13)
[ ] Analyze clinical and laboratory findings to differentiate primary from secondary hypertension
[ ] Evaluate indications for ambulatory BP monitoring (ABPM) and interpret results

Pharmacotherapy¶

[ ] Select appropriate first-line antihypertensive therapy based on etiology and comorbidities
[ ] Formulate dose titration and monitoring plan for antihypertensive medications

Communication & Counseling¶

[ ] Counsel families on lifestyle modifications (diet, exercise, weight management, sodium restriction)
[ ] Discuss long-term cardiovascular risk associated with childhood hypertension

Systems-Based Practice¶

[ ] Coordinate evaluation for secondary causes with appropriate subspecialties (nephrology, endocrine)
[ ] Ensure appropriate BP measurement technique is used (correct cuff size, positioning)

Key Guidelines¶

2017 AAP Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents Pediatrics. 2017;140(3):e20171904

Key Changes from 2004 Fourth Report¶

"Elevated BP" replaces "prehypertension"
NEW normative BP tables based on normal-weight children only
Simplified screening table for primary care
Age ≥13 years: Use adult criteria (120/80 threshold)
BP screening only at preventive care visits
Expanded role for ABPM
Updated medication recommendations
Treatment goal: <90th percentile (or <130/80 for adolescents ≥13)

BP Classification¶

Children 1-12 Years (Use Pediatric Tables)¶

Category	Systolic AND/OR Diastolic
Normal	<90th percentile
Elevated BP	≥90th to <95th percentile OR 120/<80 (whichever is lower)
Stage 1 HTN	≥95th percentile to <95th + 12 mmHg OR 130/80 to 139/89
Stage 2 HTN	≥95th percentile + 12 mmHg OR ≥140/90

Adolescents ≥13 Years (Use Adult Criteria)¶

Category	Systolic	Diastolic
Normal	<120	AND <80
Elevated BP	120-129	AND <80
Stage 1 HTN	130-139	OR 80-89
Stage 2 HTN	≥140	OR ≥90

Measurement Technique¶

Appropriate cuff size (bladder width 40% of arm circumference)
Seated, back supported, feet on floor
Right arm preferred (coarctation detection)
3-5 minutes of rest before measurement
Auscultatory method preferred for diagnosis confirmation
Oscillometric devices require validation

Evaluation¶

When to Evaluate¶

Elevated BP on 3 separate occasions
Stage 2 HTN at initial visit warrants immediate evaluation

Initial Workup (All Children with HTN)¶

History: diet, activity, sleep, medications, family history
Physical exam: including 4-extremity BP (rule out coarctation)
Labs: BMP, urinalysis, lipid panel, CBC
Renal ultrasound (if <6 years or abnormal UA/renal function)

Extended Workup (Secondary HTN Suspected)¶

Plasma renin/aldosterone
Urine catecholamines
Thyroid function
Drug screen
Polysomnography (if OSA suspected)
Renal artery Doppler or CTA/MRA

ABPM Indications¶

Confirm HTN before starting therapy
White coat hypertension suspected
Masked hypertension suspected
High-risk conditions (CKD, diabetes, s/p CoA repair)
Assess efficacy of antihypertensive treatment
Clinical symptoms suggesting hypertension

ABPM Interpretation¶

Ambulatory HTN: Mean SBP or DBP ≥95th percentile
Load: % readings above threshold (>25% abnormal)
Dipping: Normal = 10-20% drop during sleep

Management¶

Lifestyle Modifications (All Patients)¶

Weight loss if overweight/obese
DASH diet
Regular aerobic exercise (30-60 min/day)
Limit sedentary activities (<2 hrs screen time)
Adequate sleep

Pharmacotherapy Indications¶

Stage 1 HTN + symptoms or target organ damage
Stage 2 HTN
Stage 1 HTN persistent despite lifestyle modifications
HTN with diabetes, CKD, or heart disease

First-Line Medications¶

Class	Examples	Notes
ACE inhibitors	Lisinopril, enalapril	Preferred if proteinuria, DM
ARBs	Losartan	ACEi alternative
CCBs	Amlodipine	Good for primary HTN
Thiazide diuretics	Chlorthalidone, HCTZ	Good for primary HTN

Treatment Goals¶

Children: <90th percentile
Adolescents ≥13: <130/80
CKD with proteinuria: <50th percentile

2023 ESH Guidelines Comparison¶

Feature	AAP 2017	ESH 2023
Adult criteria age	≥13 years	≥16 years
BP tables	Normal-weight only	Include overweight
Classification	Similar	Similar

Board Pearls¶

Pearl: Use adult criteria (120/80) starting at age 13

Per 2017 AAP guidelines; ESH uses 16 years

Pearl: 2017 tables use NORMAL-WEIGHT children only

Major change from 2004 Fourth Report

Pearl: ABPM before starting medication

Confirm diagnosis; rule out white coat HTN

Self-Assessment¶

Q1: A 10-year-old has BP readings of 122/76, 118/74, and 120/78 on three visits. Height is 50th percentile. How is this classified?

Answer

**Answer**: Elevated BP **Rationale**: For children <13 years, use the pediatric tables. The 95th percentile for a 10-year-old at 50th height percentile is approximately 122/82. Readings consistently ≥90th percentile but <95th percentile = Elevated BP. Note: if 120/<80 is lower than the 90th percentile, use 120/<80 as the threshold.

Q2: A 15-year-old has BP of 134/82. What is the classification and initial management?