Table 7.

Summary of the statements.

Definition of HTN in children and adolescents	To define HTN, we recommend using the normative BP tables developed according to age, height and gender, a simplified version of which is provided in Table 1 (Grade C class 1)
Epidemiology	a) Before the age of 3 years, we recommend to measure BP systematically in the following cases: - History of low birth weight <2,500 grams; - Kidney disease or urological abnormality; - Congenital heart disease; - Solid organ or bone marrow transplantation; - Intracranial HTN; - Exposure to medicines known to cause HTN; - Systemic disease which may be complicated by HTN (neurofibromatosis, tuberous sclerosis, etc.) (Grade C class 1).
	b) After the age of 3 years, we recommend to measure BP systematically at least once a year in the same way as weight, height and BMI as HTN is most often asymptomatic (Grade C class 1)
Method of BP measurement	a) In children, we recommend to measure BP using an auscultatory method and an aneroid sphygmomanometer (Grade C, class 1) b) In the event of an abnormal BP reading with an oscillometric BP monitor (which tends to overestimate BP), we recommend to check the measurement using an auscultatory manual method (Grade C, class 1) c) We recommend to measure BP in a calm place in a child who has been sitting for 5 min with his/her feet on the floor (not suspended), whose back and arms are supported, and whose antecubital fossa is at heart level. An appropriately sized cuff and a BP monitor that has been validated in children must be used (Grade C, class 1) d) We recommend to measure BP in the right arm (site spared in case of coarctation of the aorta) (Grade C, class 1) e) In the event of elevated BP during a 1st visit, we recommend in asymptomatic patients to repeat measurements during 2 other visits 1 month apart (Grade C, class 1) or closer together in high-risk cases (Grade B, class 1) f) 24 h Ambulatory Blood Pressure Monitoring (ABPM) can be performed in selected situations by experts in paediatric HTN, on a case-by-case basis (Grade B, class 1) for children >120 cm in height, but it may not be well-tolerated; ABPM is not recommended in children who measure <120 cm g) We recommend to only use Home Blood Pressure Monitoring (HBPM) for the monitoring of known HTN (Grade C, class 1) given the lack of reference values for the diagnosis of HTN
Clinical examination	In children and adolescents being evaluated for high BP, the practitioner should perform a physical examination to identify findings suggestive of secondary causes of HTN listed in Table 3 (Grade B, class 1)
Additional tests	a) We recommend to perform the following tests in all children and adolescents regardless of the results of the clinical examinations: blood electrolytes (serum potassium), serum creatinine, assessment of glomerular filtration (using the Schwartz formula in children), urine sediment examination of the first morning urine (haematuria), urine protein to creatinine ratio (normal <50 mg/mmol before 2 years of age and <20 mg/mmol after 2 years of age) (Grade A, class 1) b) The following tests should also be requested in overweight or obese children or adolescents (BMI >95th percentile) and in those with a family history of dyslipidaemia: fasting blood sugar, fasting lipid profile including total cholesterol, HDL and LDL, triglycerides, AST, and ALT (Grade A, class 1) c) Once these initial examinations have been requested, we recommend to seek the opinion of a paediatric cardiologist and/or nephrologist and/or endocrinologist (Grade C, class 1) d) We recommend to seek the expertise of a skilled paediatric cardiologist to interpret ECGs in children under 12 years of age (Grade B, class 1) e) We recommend to systematically perform cardiac echocardiography to screen for LVH and isthmic coarctation of the aorta (Grade A, class 1) f) We recommend to systematically perform Doppler ultrasound and kidney ultrasound to determine whether HTN can be attributed to a renal cause (asymmetry, renal hypoplasia) (Grade A, class 1)
Secondary causes of HTN	a) Regardless of the age of the child, we recommend to carefully check for a secondary cause of HTN (Grade B, class 1) b) We suggest focusing the search for secondary HTN on renal or cardiac causes as they account for 2/3 of the causes of secondary HTN (Grade B, class 2)
Healthcare pathway	a) After a first diagnosis of HTN generally made by the attending physician or the paediatrician, we suggest to refer children or adolescents more specifically to a paediatric nephrologist or nephrologist when they present with (Grade C, class 2): - Family history of kidney disease (kidney failure, renovascular dysplasia, acute pyelonephritis); - History of uropathy, tubulopathy; - Kidney failure, urine sediment disorders; proteinuria - Vascular murmur in the renal area; - Asymmetric kidney size or a single kidney b) We suggest to refer children or adolescents more specifically to a paediatric cardiologist or cardiologist when they present with (Grade B, class 2): - Clinical signs such as tachycardia, malaise, or heart murmur on auscultation; - Absence or weak pulse in the legs which suggests aortic coarctation; - Family history of heart disease; - Williams-Beuren syndrome or Turner or Alagille syndromes which predispose to the risk of aortic coarctation
	c) We suggest to refer children or adolescents more specifically to a paediatric endocrinologist or endocrinologist when they present with (Grade B, class 2): - Clinical signs of hypercortisolism (weight gain and growth failure, facial and truncal obesity, proximal amyotrophy, vertical purple stretch marks, facial erythrosis +/– hirsutism); - Short stature (Turner syndrome) or abnormal tallness (acromegaly); - Goitre; - Severe obesity
Principles of therapeutic strategy	a) We recommend a change in lifestyle and dietary habits in all cases of childhood HTN (Grade C, class 1) b) We recommend that a paediatrician or a physician with experience in the treatment of HTN in children and adolescents initiates it (Grade C, class 1) c) Pharmacological treatment should be initiated in cases of (Grade A, class 1): * Symptomatic or stage 2 HTN * Secondary HTN * Damage to target organs (heart, eyes) * Kidney failure * Concomitant type 1 or type 2 diabetes * Persistence of HTN despite a change in lifestyle and dietary habits, regardless of the cause as the symptoms have an impact on target organs
	d) In children, we recommend to use long-acting calcium channel blockers or angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) (Grade B, class 1) e) We recommend to target a BP under the 75th age percentile, and even below the 50th percentile in cases of kidney failure and/or concomitant proteinuria (Grade B, class 1)
Special cases	We recommend that children presenting with a hypertensive emergency be managed in a specialised continuous care/intensive care unit with paediatric experience (Grade A, class 1)
Contraception in teenagers	a) We recommend measuring BP at the initiation of CHC treatment, then periodically, at 3 months and 6 months, and then annually during follow-up visits (Grade B, class 1) b) We recommend measuring BP in patients presenting with headaches, whether migraine headaches or not, at the initiation of CHC treatment to screen for HTN (Grade B, class 1) c) In case of confirmed HTN or stage 3 HTN during a visit (>180/110 mm Hg), we recommend to replace the CHC by a progestin-only birth control method (pill, implant, or IUD) (Grade A, class 1) d) In adolescents, we suggest to avoid the first-line prescription of CHCs delivered by alternative routes [transdermal (patch) or vaginal (ring)] (Grade C, class 2) e) When an oral contraceptive is prescribed, patients should be advised to also use condoms (Grade C, class 2)
Contraception in adolescents with HTN	a) We recommend not to prescribe combined hormonal contraceptives, regardless of the route of administration (oral, vaginal or transdermal), to adolescents with uncomplicated mild HTN or severe stage 2 or 3 HTN that may/may not be complicated by target organ damage and/or concomitant cardiovascular disease (Grade B, class 1) b) We recommend to offer hypertensive adolescents an effective progestin-only contraceptive that can be administered by various routes (oral, subcutaneous or intrauterine routes) or a copper IUD, providing there are no gynaecological contraindications (Grade C, class 2)