What's New With Kids and High Blood Pressure?

The High Blood Pressure in Children and Adolescents Working Group recently published their fourth report on the diagnosis, evaluation, and treatment of high blood pressure (BP) in children and adolescents ¹ (analogous to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC 7] ² in adults). Its purpose is to “update clinicians on the latest scientific evidence regarding BP in children and to provide recommendations for diagnosis, evaluation, and treatment of hypertension (HTN) based on available evidence and consensus expert opinion of the working group when evidence was lacking.” We thought it would be useful to highlight those recommendations of this report that address the diagnosis of pediatric HTN.

Like the JNC 7 guidelines, the Working Group classified elevated BP in children into three categories: prehypertension, stage 1 HTN, and stage 2 HTN (Table) based on the BP distribution by age, gender, and height. Normal BP is defined as both systolic BP and diastolic BP below 90%. In a recent issue of The Journal of Clinical Hypertension, specific BP levels in children and adolescents that fall within this percentile were listed. ³ Prehypertension includes systolic BP or diastolic BP between 90% and 95%, as well as any BP that exceeds 120/80 mm Hg, even if such a level is below 90%, as might be the case in teenagers. Stage 1 HTN includes those measurements between 95% and 99%, and stage 2 HTN includes measurement above 99%. The Working Group points out that the difference between 95% and 99% is only 7 mm Hg to 10 mm Hg, and is, thus, not large enough—particularly in view of the variability in BP measurements—to adequately distinguish mild from more severe HTN. Consequently, they further refined the definitions of stages 1 and 2 HTN so that anyone with BPs within 5 mm Hg above the 90% would still be classified as having stage 1.

Table.

Classification of Hypertension in Children and Adolescents With Measurement Frequency and Therapy Recommendations

Classification	SBP or DBP*	Frequency of BP Measurement	Therapeutic Lifestyle Changes	Pharmacologic Therapy
Normal	<90%	Recheck at next scheduled physical examination	Encourage healthy diet, sleep, and physical activity	None
Prehypertension	90%–<95%, or if BP exceeds 120/80 mm Hg evenif<90%–<95%**	Recheck in 6 months	Weight‐management counseling if overweight; introduce physical activity and diet management†	None unless compelling indications such as CKD, DM, HF, or LVH exist
Stage 1 hypertension	95%–99% plus 5 mm Hg	Recheck in 1—2 weeks or sooner if the patient is symptomatic, if persistently elevated on two additional occasions, and evaluate or refer to source of care within 1 month	Weight‐management counseling if overweight; introduce physical activity and diet management‡	Initiate therapy based on indications including symptomatic HTN, secondary HTN, targetorgan damage, DM, or persistent HTN, despite nonpharmacologic measures
Stage 2 hypertension	>99% plus 5 mm Hg	Evaluate or refer to source of care within 1 week or immediately if the patient is symptomatic	Weight‐management counseling if overweight; introduce physical activity and diet management‡	Initiate therapy‡
BP=blood pressure; SBP=systolic blood pressure; DBP=diastolic blood pressure; CKD=chronic kidney disease; DM=diabetes mellitis; HF=heart failure; LVH=left ventricular hypertrophy; HTN=hypertension; *for gender, age, and height measured on at least three separate occasions; if systolic and diastolic categories are different, categorize by the higher value; **typically occurs at 12 years of age for SBP and at 16 years of age for DBP; †parents and children trying to modify the eating plan to the Dietary Approaches to Stop Hypertension Study eating plan could benefit from consultation with a registered or licensed nutritionist to get them started; ‡more than one drug may be required

In order to accurately make a diagnosis of HTN, the child whose BP is being measured should have avoided stimulant drugs or foods, have been sitting quietly for 5 minutes, and have been seated with his or her back supported with the right arm at the level of the heart. Unlike adults, where the dominant arm is used for BP measurement, the right arm is preferred in children due to the possibility of false low readings in the left arm of children with unrecognized coarctation of the aorta. The cuff bladder should cover 80%–100% of the arm circumference, and its width should be at least 40% of the arm circumference. The bladder width‐to‐length ratio should be at least 1:2. Cuff size is particularly important in children and the report includes a table of the recommended dimensions for BP cuff bladders based on the child's age and arm circumference. Finally, the report recommends that BP be measured by auscultation. Although the use of automated oscillometric devices is acceptable, elevated readings obtained with such a device should be verified by auscultation.

As with adults, an accurate assessment of BP is an important aspect of pediatric medical care. With the growing problem of obesity in children and the clear role of increased body mass in the development of high BP at any age, the recognition of children with elevated BP invites potential intervention in lifestyle factors that, when successful, may benefit other components of the metabolic syndrome, in addition to the BP.