What are the symptoms and causes of high blood pressure in children. How is pediatric hypertension diagnosed and treated. What are the long-term consequences of untreated hypertension in youth.

Understanding Pediatric Hypertension: Prevalence and Risk Factors

Hypertension in children and adolescents is a growing concern in pediatric healthcare. While once considered rare, the prevalence of high blood pressure among youth has been steadily increasing in recent years. This rise is largely attributed to the growing obesity epidemic and changes in lifestyle factors affecting children worldwide.

What exactly constitutes high blood pressure in children? Unlike adults, where a single threshold defines hypertension, blood pressure norms in children vary based on age, sex, and height. Generally, blood pressure readings consistently above the 95th percentile for a child’s age, sex, and height are considered hypertensive.

Several risk factors contribute to the development of hypertension in children:

• Overweight or obesity
• Male sex
• Family history of hypertension
• Low birth weight or intrauterine growth restriction
• Prematurity
• Excess dietary salt intake
• Physical inactivity
• Chronic health conditions (e.g., chronic kidney disease, diabetes)

Understanding these risk factors is crucial for early identification and intervention in pediatric hypertension cases.

Primary vs. Secondary Hypertension in Children: Key Differences

When discussing hypertension in children, it’s important to distinguish between primary (essential) and secondary hypertension. What’s the difference between these two types?

Primary hypertension is the most common form in children over 6 years old. It’s generally associated with obesity or a family history of hypertension. This type of hypertension doesn’t have an identifiable underlying cause and is often linked to lifestyle factors and genetic predisposition.

Secondary hypertension, on the other hand, is more prevalent in younger children (under 6 years old). This form of hypertension is caused by an underlying medical condition, with renal disease being the most common culprit. Children with secondary hypertension are at a higher risk of experiencing hypertensive emergencies due to their underlying conditions.

Causes of Secondary Hypertension in Children

Secondary hypertension can stem from various causes, including:

• Renal parenchymal diseases (e.g., glomerulonephritis, polycystic kidneys)
• Cardiac and vascular conditions (e.g., renal artery stenosis, coarctation of the aorta)
• Endocrine disorders (e.g., diabetes, thyroid disease, congenital adrenal hyperplasia)
• Autoimmune diseases (e.g., thrombotic thrombocytopenic purpura, Henoch-Schönlein purpura)
• Genetic syndromes (e.g., neurofibromatosis, Williams syndrome, Turner syndrome)
• Malignancies (e.g., Wilms tumor, neuroblastoma, pheochromocytoma)
• Intracranial pathologies (e.g., intracranial hemorrhage, raised intracranial pressure)
• Respiratory conditions (e.g., chronic lung disease, obstructive sleep apnea)
• Drug-induced hypertension (e.g., corticosteroids, oral contraceptives, stimulants)

Identifying the underlying cause of secondary hypertension is crucial for effective management and treatment.

Recognizing Symptoms of Hypertension in Children

Hypertension in children can often be asymptomatic, making regular blood pressure screenings crucial. However, when symptoms do occur, they can vary widely. What are the common signs that might indicate hypertension in a child?

• Headaches
• Vomiting
• Blurred vision
• Changes in mental state
• Seizures
• Chest pain or palpitations
• Shortness of breath
• Signs of cardiac failure

It’s important to note that these symptoms can be indicative of various conditions, not just hypertension. Therefore, a thorough medical evaluation is necessary for accurate diagnosis.

Hypertensive Emergencies in Children

In some cases, hypertension in children can lead to a medical emergency. How can you recognize a hypertensive emergency in a child? Signs of a hypertensive emergency include:

• Severe headache
• Confusion or altered mental status
• Seizures
• Visual changes or blindness
• Nausea and vomiting
• Chest pain
• Heart failure

Hypertension associated with encephalopathy is considered a medical emergency and requires immediate medical attention.

Diagnosing Hypertension in Children: Proper Measurement Techniques

Accurate blood pressure measurement is crucial for diagnosing hypertension in children. What are the key considerations when measuring a child’s blood pressure?

• Use an appropriately sized cuff for accurate measurement
• Preferably use manual blood pressure measurement to confirm abnormal machine readings
• Measure blood pressure annually in healthy children
• Take multiple readings over time to confirm persistent elevation
• Consider 24-hour ambulatory blood pressure monitoring for more comprehensive assessment

It’s important to note that blood pressure norms in children are based on age, sex, and height percentiles. Therefore, interpreting blood pressure readings in children requires reference to standardized charts.

The Importance of Four-Limb Blood Pressure Measurement

Why is it important to measure blood pressure in all four limbs? Four-limb blood pressure measurement can help detect conditions such as coarctation of the aorta, a congenital heart defect that can cause hypertension. A significant discrepancy between upper and lower limb blood pressures may indicate this condition.

Assessing End-Organ Damage in Pediatric Hypertension

Chronic hypertension, even in children, can lead to end-organ damage. What are the key areas to assess for potential damage?

• Heart: Look for left ventricular hypertrophy through echocardiography
• Eyes: Perform fundoscopy to check for hypertensive retinopathy
• Kidneys: Assess for proteinuria and changes in kidney function
• Brain: Consider neuroimaging if there are signs of neurological involvement

Early detection of end-organ damage is crucial for preventing long-term complications and guiding treatment decisions.

Treatment Approaches for Pediatric Hypertension

The management of hypertension in children typically involves a combination of lifestyle modifications and, in some cases, pharmacological interventions. What are the primary treatment approaches?

Lifestyle Modifications

For many children with primary hypertension, lifestyle changes can be highly effective. These may include:

• Weight management for overweight or obese children
• Increased physical activity
• Dietary modifications, including reduced salt intake
• Stress reduction techniques

Pharmacological Treatment

When lifestyle modifications are insufficient or in cases of secondary hypertension, medication may be necessary. What are the common classes of antihypertensive medications used in children?

• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers
• Beta-blockers
• Diuretics

The choice of medication depends on various factors, including the underlying cause of hypertension, the presence of comorbidities, and potential side effects.

Long-Term Monitoring and Follow-Up for Pediatric Hypertension

Managing hypertension in children is a long-term commitment. What does ongoing monitoring and follow-up entail?

• Regular blood pressure checks
• Periodic assessment of end-organ damage
• Monitoring of growth and development
• Adjustment of treatment plans as needed
• Transition planning for adolescents moving to adult care

The frequency of follow-up visits depends on the severity of hypertension, the presence of complications, and the child’s response to treatment.

The Role of Home Blood Pressure Monitoring

Home blood pressure monitoring can play a crucial role in the management of pediatric hypertension. How can it be implemented effectively?

• Use an appropriately sized, validated home blood pressure device
• Teach parents and children proper measurement techniques
• Establish a regular schedule for measurements
• Keep a log of readings to share with healthcare providers

Home monitoring can provide valuable insights into blood pressure patterns and help guide treatment decisions.

Preventing Hypertension in Children: Strategies for Families and Healthcare Providers

Prevention is key in addressing the rising prevalence of pediatric hypertension. What strategies can families and healthcare providers implement to reduce the risk of hypertension in children?

Promoting Healthy Lifestyles

• Encourage regular physical activity
• Promote a balanced, nutritious diet
• Limit screen time and sedentary behaviors
• Ensure adequate sleep
• Teach stress management techniques

Regular Health Screenings

How often should children have their blood pressure checked? The American Academy of Pediatrics recommends:

• Annual blood pressure screenings for children 3 years and older
• More frequent screenings for children with risk factors
• Blood pressure checks at every healthcare visit for children with chronic conditions

Education and Awareness

Raising awareness about pediatric hypertension is crucial. Healthcare providers can play a key role by:

• Educating families about the importance of blood pressure monitoring
• Providing information on risk factors and prevention strategies
• Addressing misconceptions about hypertension in children

By implementing these preventive strategies, we can work towards reducing the incidence of hypertension in children and promoting better cardiovascular health for future generations.

Hypertension in children and adolescents

See also

Online paediatric BP centile calculator 

BP by age and height centile tables: boys girls

Key points

1. Severe hypertension requires urgent consultation and management.  Hypertension associated with encephalopathy is a medical emergency
2. All hypertension in children requires monitoring and follow-up
3. Blood pressure should be measured annually in healthy children
4. Where possible, abnormal machine BP measurement should be confirmed, preferably with a manual BP, ensuring appropriately sized cuff is used for accurate measurement

Background

• This guideline will focus on the paediatric population aged 1–17 years (not infants)
• Hypertension in childhood is a key predictor of risk for hypertension, cardiovascular disease and end organ damage in adulthood
• Primary/essential hypertension accounts for the majority of hypertension in children >6 years old and is generally associated with obesity or a family history of hypertension
• Secondary hypertension is more common in younger children (<6 years old) with renal disease being the most prevalent cause. This population is at greater risk of hypertensive emergencies due to an underlying condition

Assessment

Risk factors:

• Overweight/obesity
• Male sex
• Family history of hypertension
• Low birth weight/intrauterine growth restriction
• Prematurity
• Excess dietary salt intake
• Physical inactivity
• Chronic health concerns, eg chronic kidney disease, diabetes

History

• Headache/vomiting
• Blurred vision
• Change in mental state
• Seizures
• Chest pain/palpitations
• Shortness of breath
• Cardiac failure
• Past history of Acute Kidney Injury (AKI)

Examination

• Confirm hypertension (See measuring blood pressure section below)
• Vitals: tachycardia, four limb BP for upper and lower limb discrepancy
• Height and weight: obesity, growth retardation
• Signs of end organ damage
• Fundoscopy: hypertensive retinopathy
• Cardiovascular: apical heave, hepatomegaly, oedema
• Chronic renal failure: palpable kidneys
• Focal neurology (eg facial nerve palsies)

• Signs of underlying cause
• General appearance: Cushingoid, proptosis, goitre, webbed neck (Turner syndrome), elfin facies (William syndrome)
• Skin: Cafe-au-lait spots, neurofibromas, acanthosis nigricans, hirsutism, striae, acne, rash (vasculitis)
• Cardiovascular: murmurs +/- radiation, apical heave, reduced femoral pulses, oedema, hepatomegaly (CCF)
• Abdomen: masses, palpable kidneys, flank bruits
• Genitourinary: ambiguous/virilised genitalia (eg CAH)

Key points when measuring blood pressure
(See video)

Ensure the correct cuff size is selected for each patient, favouring a larger rather than smaller cuff (smaller cuff creates artificial hypertension)

• BP cuff width should be 40% of the length of the arm measure from the shoulder tip to the elbow
• Abnormal oscillatory BP measurement needs checking with a manual BP from the child’s arm

The table below identifies BP levels requiring further evaluation, starting with repeating the BP manually ensuring accurate measurement

*90^th centile for a child at average height

Assessment of severity

Interpreting blood pressure measurement

An
online blood pressure centile calculator specific for gender, age and height can be used to determine the severity of hypertension

Management

Emergency management of severe hypertension

• Discuss with renal team and retrieval/ICU team  

Hypertensive urgency

If medically stable, consider short acting oral agents while investigating cause

• Nifedipine
• Commence 0. 25–0.5 mg/kg/day (max 20 mg) and titrate up as required to a maximum of 3 mg/kg/day (max 120 mg)

Hypertensive emergency

• Intravenous therapy; discuss with renal team and retrieval/ICU team
• Aim to gradually reduce BP to the patient’s estimated 95^th centile
• Decrease BP by 25% of the original value every 24 hours till target BP reached. Reduce rate of decrease if patient becomes symptomatic

Hypertension without severe features

Investigations

First-line investigations

• UEC, CMP, urinalysis +/- renal ultrasound
• Consider LFT, Hb1Ac, fasting lipids particularly in children with BMI >95^th centile

Further investigations should only be considered in consultation with a general or renal paediatrician

Consider further testing if child meets one of the following criteria:

• 
  <6 years
• Concerns for secondary causes on history/examination
• Abnormal first-line investigations

Further Investigations

• Bloods: FBE, Bicarbonate, renin/aldosterone ratio, TFT, plasma metanephrins, cortisol, fasting glucose
• Urine: microscopy, protein/creatinine ratio, catecholamines, drug screen
• Imaging: renal doppler ultrasound, DMSA, CTA/MRA
• Other: echocardiogram, sleep study

Lifestyle counselling

Dietary modifications

• Rich in fresh fruit and vegetables/legumes, fish, poultry, lean red meat and low fat dairy
• Limit intake of high sodium, fat or sugar containing foods

Lifestyle modifications

• Increase physical activity, aiming 40 minutes moderate to vigorous exercise 3-5 days/week
• Consider counselling/behavioural techniques to help address weight management and metabolic risk

Medical management

Should be commenced if:

• Conservative measures have failed
• Symptomatic hypertension develops
• Stage 2 hypertension with no modifiable risk factors
• Hypertension in setting of chronic kidney disease/diabetes

Medical management should only be commenced in consultation with a general or renal paediatrician

• Long-acting calcium channel blockers such as amlodipine are recommended as first line therapy. Other medication may be preferred in children with BMI >95^th centile, diabetes or proteinuria

Consider consultation with local paediatric team when

• Red flags (see history section above) or ongoing concerns are present
• Hypertensive urgency or hypertensive emergency
• Medical management of hypertension is required

Consider transfer when

Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see

Retrieval Services

Consider discharge when

Hypertensive children without severe features may be discharged with appropriate follow-up (See flowchart)

Parent information

See
Parent resources

Additional notes

How to Measure Blood Pressure – American Academy of Pediatrics (video)

Last updated June 2021

Blood pressure of children and youth, 2012 to 2015

View the most recent version.

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Release date: October 13, 2016

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On this page

• Blood pressure and body composition
• About blood pressure
• Data
• Notes

The results of the 2012 to 2015^Note 1 Canadian Health Measures Survey (CHMS) indicate that the average resting blood pressure of children and youth aged 6 to 19 was 97/62 mmHg. Among this group, 93% had a measured blood pressure that was considered normal and 7% had results considered borderline or elevated (data not shown).

In children aged 6 to 11, average resting blood pressure was 94/62 mmHg, while youth aged 12 to 19 had an average resting blood pressure of 99/63 mmHg.

The proportion of girls aged 12 to 19 with blood pressure in the normal range was significantly higher than that of girls aged 6 to 11 (Chart 1).

Data table for Chart 1

Data table for chart 1

Table summary

This table displays the results of Data table for chart 1 Normal and Borderline or elevated, calculated using percent units of measure (appearing as column headers).

		Normal	Borderline or elevated
		percent
Total	6 to 11 years	91	9
	12 to 19 years	94. 8	5,2Note E: Use with caution
Boys	6 to 11 years	92.7	7.3
	12 to 19 years	93.7	5,3Note E: Use with caution
Girls	6 to 11 years	89.1	10.9
	12 to 19 years	95.9	4,1Note E: Use with caution

Blood pressure and body composition

Height and weight were measured for all CHMS respondents. Children and youth who were classified as being overweight (99/62 mmHg) or obese (102/64 mmHg) had a significantly higher average blood pressure than normal weight children (95/61 mmHg). Average systolic blood pressure was significantly higher in overweight and obese children compared with those in the normal weight category (Chart 2). As well, overweight and obese children had significantly higher average diastolic blood pressure when compared with their normal weight counterparts (Chart 3).^{Note 2Note 3Note 4Note 5}

Data table for Chart 2

Data table for Chart 3

Data table for chart 3

Table summary

This table displays the results of Data table for chart 3 Thinness/normal weight, Overweight and Obese, calculated using mmHg units of measure (appearing as column headers).

		Thinness/normal weight	Overweight	Obese
		mmHg
Total	6 to 11 years	61	62	65
	12 to 19 years	61	62	64
Boys	6 to 11 years	61	61	65
	12 to 19 years	61	63	64
Girls	6 to 11 years	61	62	65
	12 to 19 years	61	62	64

Start of text box

About blood pressure

Blood pressure is a measure of the force of blood against the artery walls, and is expressed as systolic pressure/diastolic pressure in millimetres of mercury (e. g., 120/80 mmHg). The systolic pressure (top number) is the pressure when the heart contracts and pushes the blood out, and the diastolic pressure (bottom number) is the lowest pressure when the heart relaxes between beats.

Resting blood pressure was measured in the CHMS using an automated device (BPTru™) following a five-minute rest period. The BPTru™ recorded six measurements, one minute apart. The average systolic and diastolic blood pressure were calculated using the last five out of six measurements.

The criteria for blood pressure classification in children and adults are as follows:

Table

The criteria for blood pressure classification in adults are as follows:

Table summary

This table displays the results of The criteria for blood pressure classification in adults are as follows:. The information is grouped by Category (appearing as row headers), Description (appearing as column headers).

Category	Description
	Ages 6 to 17Note 2	Ages 18 and 19Note 3
Normal	SBP and DBP < 90th percentile	Mean SBP/DBP < 120/80 mmHg
Borderline	SBP or DBP ≥ to the 90th percentile, but < the 95th percentile OR Measured mean SBP/DBP > 120/80 mmHg	Mean SBP of 120-139 mmHg and mean DBP of 80-89 mmHg OR Mean SBP of 120-139 mmHg and mean DBP Mean SBP
Elevated	SBP or DBP ≥ 95th percentile OR Respondent reported using blood pressure medication within the past month	Mean SBP/DBP of ≥ 140/90 mmHg OR Respondent reported using blood pressure medication within the past month

Data

Canadian Health Measures Survey data related to this fact sheet are available in CANSIM tables 117-0004, 117-0008 and 117-0009.

For more information on the Canadian Health Measures Survey, please contact Statistics Canada’s Statistical Information Service (toll-free 1-800-263-1136; 514-283-8300; [email protected]).

ISSN: 1920-9118

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Statistics Canada is committed to serving its clients in a prompt, reliable and courteous manner. To this end, the Agency has developed standards of service which its employees observe in serving its clients.

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Published by authority of the Minister responsible for Statistics Canada.

© Minister of Industry, 2016

All rights reserved. Use of this publication is governed by the Statistics Canada Open Licence Agreement.

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Blood pressure in children. (Advice from a cardiologist)

Arterial hypertension has no age. High blood pressure today is increasingly common not only in young people, but even in children and adolescents. This problem is by no means the result of their workload at school.

Excess weight, sedentary lifestyle and bad habits turn children into little “old men” who complain of headaches and feeling unwell.

Experts say that arterial hypertension is a disease of our time. The younger generation walks a little, indulges in cigarettes, hardly goes in for sports, while spending too much time with the phone and computer, prefers harmful, high-calorie food. Such a lifestyle does not go unnoticed. Sooner or later, such teenagers are brought by their parents to see a cardiologist.

– Arterial hypertension has a number of characteristic symptoms that adults should pay attention to. But children may not complain, and the problem is revealed by chance – Svetlana Viktorovna Mulyakina, a cardiologist at the Children’s Doctor medical clinic, tells. – The most common story: a headache at school, a child went to the doctor, measured the pressure … For teenagers, its increase to 139 millimeters of mercury is an alarming indicator that negatively affects the functioning of the heart, kidneys, central nervous system … Without control, this condition leads to an imbalance of the whole organism and takes on the form of a much more serious, hypertension disease.

• According to statistics, 18% of teenagers have arterial hypertension today. As a rule, these are overweight boys. These guys have an 85% chance of high blood pressure. Not the last role is played by bad habits, such as smoking. Heredity also matters. But cardiologists see the main threat to the health of young people in their sedentary lifestyle. Meanwhile, it has been proven that just 30-40 minutes of daily exercise is comparable in effect to taking the very “magic pill” that children and their parents always dream of.

– It has been proven that physical activity reduces blood pressure numbers, – continues Svetlana Mulyakina. – But modern schoolchildren often attend only one physical education or even take certificates to be exempted from this lesson. And this is a huge mistake. Today, the diagnosis of “arterial hypertension” is not a reason for exclusion from sports. Observing such patients at the first stages, we just focus on non-drug treatment: regimen, physical activity, nutrition, correction of the psycho-emotional state, physiotherapy . .. In a word, everything possible is done so as not to switch to serious drugs that are prescribed to adults – hypertensive patients. Recommendations and treatment regimen for each child is determined separately. Some people can’t do without medication…

For such patients today there are a variety of diagnostic methods. This is an electrocardiogram, ultrasound of the heart and blood vessels, daily monitoring of blood pressure and much more. For each patient, the doctor prescribes a list of necessary studies individually. Its main task is to exclude secondary arterial hypertension, which can be a symptom of serious diseases and anomalies in the development of the kidneys, blood vessels, endocrine disorders and even tumors. In such situations, a specialized specialist deals with the patient, and the cardiologist helps him.

– In other cases, the child is observed by a cardiologist, – says Svetlana Viktorovna. – Arterial hypertension in adolescence is treated quite successfully, but a favorable outcome largely depends on the willingness of the child and his family to reconsider the usual, not always correct, way of life. This is a lot of work, but it pays off, and allows the patient to forget about high pressure for many years, to feel like a healthy and active person …

Signs of arterial hypertension:

• headaches
• fatigue
• dizziness
• epistaxis
• transient visual impairment
• nausea
• chills
• poor exercise tolerance
• emotional lability
• sleep disturbance

Scientists have found out which blood pressure is dangerous for teenagers – Gazeta.Ru

Scientists have found out what kind of blood pressure is dangerous for teenagers – Gazeta.Ru | News

March 11, 2023, 22:35

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Scientists from the University of Eastern Finland found that blood pressure is higher than 130/85 mm Hg. Art. can lead to heart damage in adolescents. The study is published in Journal of Pediatrics .

In adults, high blood pressure damages the kidneys, heart, blood vessels, and brain and increases the risk of death. The European Society of Cardiology consider a pressure of 130/85 mm Hg. Art. high normal, and pressure 140/90 mm Hg. Art. regarded as hypertension. At the same time, in the USA, the pressure is 130/80 mm Hg. Art. considered hypertension.

A 2022 study found that elevated systolic blood pressure in childhood is associated with a risk of premature death after age 40.

1856 adolescents took part in the new study. At the age of 17, their heart function and blood pressure were assessed, and then the studies were repeated when they were 24 years old. Taking into account other factors (gender, age, obesity and other diseases), the researchers found that at a pressure of 130/85 mm Hg. Art. damage to the heart occurs in both men and women.

Signs of structural damage to the heart are left ventricular hypertrophy and high relative wall thickness, while signs of cardiac dysfunction are left ventricular diastolic dysfunction and increased left ventricular filling pressure.