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8. High Blood Pressure

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on the evaluation and treatment of high blood pressure (BP) in their child and adolescent patients. Because a recent National Heart, Lung, and Blood Institute (NHLBI) task force report addresses this subject,[1] this section differs from the rest of the sections in the Guidelines in that the evidence review was limited to the past 6 years, as described below. The results of this limited evidence review are summarized by the Expert Panel in this section, with detailed information from each study extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm. The conclusions of the Expert Panel's review of the evidence are summarized, and the section ends with age-specific recommendations for BP measurement and diagnosis and treatment of hypertension.

BACKGROUND

In 2004, an NHLBI Task Force published The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (Fourth Report).[1]  This report was based on a complete review of the current evidence on BP management up to that time and included detailed recommendations for diagnosing and managing high BP throughout childhood. Those expert consensus recommendations were used as the basis for the recommendations for this section of these Guidelines. The review of the science was considered complete until 2003, when the review of the Fourth Report ended. Therefore, the evidence review on high BP for these Guidelines was limited to studies published between January 1, 2003, and June 30, 2007,with the addition of selected studies through June 30, 2008, identified by the Expert Panel that met all the criteria for inclusion. Repeating the review performed by the Fourth Report Task Force was not believed to be either necessary, given the relatively short time since publication of the Fourth Report, or to be a judicious use of the resources available for the development of these Guidelines. The randomized controlled trials (RCTs) identified from 2003 to 2008 for this evidence review were graded individually and can be viewed in the evidence tables, which will be available at http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm.

OVERVIEW OF THE EVIDENCE ON TREATMENT OF HIGH BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS

The evidence review for the defined period identified 9 observational studies, 13 RCTs, and 3 meta-analyses. Eight RCTs evaluated medications for hypertension control that had not previously been studied in childhood:  amlodipine, felodipine, fosinopril, lisinopril, losartan, metoprolol, and valsartan.[2],[3],[4],[5],[6],[7],[8],[9]  Each of these medications was found to be well-tolerated for relatively short periods in children from ages 6 to 17 years, but primarily in adolescents. Most of the trials lasted 3–8 weeks; 1 trial for adolescents lasted 52 weeks. One trial evaluated valsartan in children ages 1–5 years, but data on the use of other drugs in younger children are lacking. All studies tended to determine tolerability and efficacy on reducing BP levels. In one study, African American children were found to require greater doses of fosinopril to obtain the same BP control as Caucasian children.[4]

Several studies addressed the roles of diet and lifestyle as they relate to BP. A meta-analysis of RCTs testing reduction of salt intake on BP in children and adolescents found that a modest reduction in salt intake did decrease BP, with a significant effect size of -1.17 millimeters of mercury (mmHg) for systolic BP and -2.47 mmHg for diastolic BP in children ages 8–16 years who were normotensive or had high normal BP. The meta-analysis included three trials in infants; results for this age group indicated that salt reduction decreased systolic BP by 2.47 mmHg.[10]  In the Coronary Artery Risk Development in Young Adults study, higher intake of plant foods (whole grains, fruits, vegetables) and lower intake of meat products were associated with lower BP on a population basis among individuals ages 18–30 years.[11]  An RCT of the Dietary Approaches to Stop Hypertension (DASH) diet was conducted in 57 adolescents with prehypertension or hypertension. At 3-month follow up, the DASH group had a significantly greater decrease in systolic BP, associated with higher intake of fruits and vegetables and low-fat dairy products and lower intake of total fat, than did the usual-care group. In the intervention group, intake of potassium and magnesium was significantly higher than in usual-care controls, but there was no difference in sodium intake.[12]  Another RCT found that a 4-month transcendental meditation intervention was effective in lowering BP assessed by ambulatory BP monitoring of African American adolescents with high-normal baseline BP measurements at 8-month followup.[13]

Four studies evaluated the late effects of feeding style in infants. A 6-year followup of an RCT in infants showed that increased intake of polyunsaturated fatty acids (PUFA) in infant formula was associated with a significantly lower BP than a standard formula-fed control group; in a breast-fed reference group, diastolic BP was significantly lower than in the nonsupplemented group but did not differ from the PUFA-supplemented group.[14]  Maternal fish oil supplementation in lactating mothers was not associated with any difference in BP or pulse wave velocity at 2.5-year followup compared with either a control group whose mothers received olive oil or a breast-fed reference group.[15]  In small-for-gestational-age babies, a nutrient-enriched diet that promoted more rapid weight gain in infancy was associated with higher BP in childhood 6–8 years later.[16]  In a meta-analysis of 15 studies, breastfeeding in infancy was found to be associated with lower BP at followup 3–60 years later, with a small but significant effect size for both systolic and diastolic BP.[17]

A series of epidemiologic studies provide important information. Long-term followup studies suggest that low birth weight is inversely associated with BP later in adult life[18] and that differences in birth weight may explain the origin of "Black/White" differences in BP.[19]  A weighted analysis of BP data from national surveys in 8- to 17-year-olds obtained from 1963 to 2002 demonstrated that BP, prehypertension, and hypertension trended downward from 1963 to 1988 but upward thereafter.[20]  At least part of this increase was explained by the rise in obesity, with the upward shift in BP occurring approximately 10 years after the upward trend in the prevalence of obesity. There were racial/ethnic differences, with non-Hispanic Blacks and Mexican Americans showing a greater prevalence of hypertension and prehypertension than non-Hispanic Whites and males showing a greater prevalence than females. BP variability was assessed in an analysis of longitudinal data from the National Childhood Blood Pressure database.[21]  Among subjects designated as having prehypertension at baseline, 14 percent of boys and 12 percent of girls had hypertension 2 years later. Among subjects classified as hypertensive at baseline, 31 percent of boys and 26 percent of girls were still hypertensive after 2 years, and 47 percent of boys and 26 percent of girls were in the prehypertension category. Baseline BP z-score, baseline body mass index (BMI), and change in BMI were significant independent determinants of subsequent BP. Finally, a meta-analysis of 50 cohort studies confirmed that BP consistently tracks from childhood into adulthood, with the strength of tracking increasing with baseline age and decreasing with followup length.[22]

CONCLUSIONS OF THE EVIDENCE REVIEW UPDATE:  2003–2008

  • The evidence review for the defined time period resulted in no major changes in the approach to BP evaluation and management.
  • In epidemiologic surveys of children and adolescents over the past 20 years, BP levels are increasing, and the prevalences of hypertension and prehypertension are increasing; these findings are explained partially by the rise in obesity.
  • Prehypertension progresses to hypertension at the rate of approximately 7 percent per year; hypertension persists in almost one-third of boys and one-fourth of girls on 2-year longitudinal followup.
  • From the evidence review, both breastfeeding and supplementation of formula with PUFA in infancy are associated with lower BP at followup.
  • A DASH-style diet—which is rich in fruits, vegetables, low-fat or fat-free dairy products, whole grains, fish, poultry, beans, seeds, and nuts and lower in sweets and added sugars, fats, and red meats than the typical American diet—is associated with lower BP, as in adults. The Cardiovascular Health Integrated Lifestyle Diet (CHILD 1) combined with the DASH eating plan (described in Section V. Nutrition and Diet) is an appropriate diet for children that meets the DASH study and Dietary Guidelines for Americans 2010 (2010 DGA) nutrient goals.
  • Lower dietary sodium intake is associated with lower BP levels in infants, children, and adolescents.
  • Losartan, amlodipine, felodipine, fosinopril, lisinopril, metoprolol, and valsartan can be added to the list of medications that are tolerated over short periods, and can reduce BP in children from ages 6 to 17 years but predominantly is effective in adolescents. For African American children, greater doses of fosinopril may be needed for effective BP control. Trial durations, however, were short, and long-term safety is still in question. Antihypertensive medications are shown in Table 8–5.
  • In one study in small-for-gestational-age babies, a nutrient-enriched diet that promoted rapid weight gain was associated with higher BP on followup in late childhood. This potential risk should be considered when such diets are selected in the clinical setting.
  • In one study, transcendental meditation has been shown to effectively lower BP in nonhypertensive adolescents.

RECOMMENDATIONS

Recommendations regarding BP are all graded as expert opinion (Grade D) since they are based on the expert consensus conclusions of the Fourth Report.

The current recommendations focus on a developmental approach to the prevention of cardiovascular disease (CVD) by appropriate identification and amelioration of risk factors during routine pediatric care. For BP, the Fourth Report provided an algorithm and flow diagram to assist clinicians in identifying hypertension in children.[1]  For these Guidelines, these recommendations are stratified to provide age-appropriate approaches that are congruent with the risk factor recommendations in other sections; this is reflected in Table 8–1 and in revised algorithms (Figures 8–1 and 8–2). The BP norms for age, gender, and height are shown in Tables 8–3 and 8–4 and are taken directly from the Fourth Report.

For children from birth to age 3 years:

  • Routine measurement of BP is not recommended. Blood pressure should be measured when there is a suspicion of renal disease, coarctation of the aorta, or other condition that may be associated with BP elevation. Conditions under which children younger than age 3 years should have BP measured are listed in Table 8–2.
  • In these young patients, auscultation of BP is often quite difficult, so measurement with an oscillometric device using an appropriate size cuff is acceptable. The state of the infant or young child (e.g., sleeping, quiet, fussing, crying) is very important in the interpretation of BP measurement.
  • For younger patients, treatment of high BP is often directed at the underlying cause, since primary hypertension is uncommon.

For children, ages 3–11 years:

  • Routine measurement of BP during health care visits is recommended. This is true of visits for health maintenance and for visits when the child is ill.
  • Auscultation should be the method of choice for confirmation of elevated BP measurements using an oscillometric device. The BP percentiles from the Fourth Report based on age, gender, and height percentiles should be used to categorize BP as prehypertension or Stage 1 or Stage 2 Hypertension (Tables 8–3 and 8–4). BP elevation must be persistent to be considered hypertension; the process for establishing the BP category is outlined in Table 8–1 and in Figures 8–1 and 8–2.
  • In this age group, obesity is an increasingly important cause of BP elevation. When obesity is present, therapy should first be directed at improving diet and physical activity behaviors. This age group offers the opportunity to intervene early in the process of obesity development, allowing the clinician to focus on weight maintenance while the child grows, as opposed to weight loss. It also provides an important opportunity to introduce the DASH-style diet, which is described in Section V. Nutrition and Diet, as an example of CHILD 1. The DASH diet focuses on increased fruits and vegetables, low-fat dairy products, and whole-grain foods and meets all nutrient and energy requirements for children in this age range. Dietary sodium intake should also be limited.
  • BP category-specific management is outlined in Table 8–1 and Figure 8–2.

For adolescents, ages 12–17 years:

  • The approach to the evaluation of BP is similar to that of children ages 3 to younger than 12 years, but the prevalence of primary hypertension is much more common, and obesity is a major concern as an underlying factor. As shown in Tables 8–3 and 8–4, the percentiles of the Fourth Report should be used to evaluate BP.
  • Adolescents with obesity are at risk of type 2 diabetes mellitus. Diabetes is a condition for which more aggressive BP lowering is recommended; this is described in Section XI.  Diabetes Mellitus and Other Conditions Predisposing to the Development of Accelerated Atherosclerosis, which addresses the management of children with high-risk conditions.
  • In this age group, the level of BP indicating prehypertension is at least 120/80, the same as that for adults. This is because the 90th percentile for adolescents is higher than 120/80 for most ages and height percentiles.
  • For adolescents with increased BMI and elevated BP, weight loss is the cornerstone of therapy. Both dietary and physical activity behaviors should be addressed, aiming for appropriate energy balance, lower dietary sodium, and a DASH-like dietary pattern. Recommendations for the management of obesity are outlined in Section X. Overweight and Obesity.
  • BP category-specific management is outlined in Figures 8–1 and 8–2 and in Table 8–1.

For young adults, ages 18–21 years:

  • Adult cut points for BP in this age group are used to define hypertension, as per the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines.[23]
  • In this age range, institution of the adult DASH diet is recommended for individuals with prehypertension or hypertension, as is reduction of dietary sodium. Overweight continues to be a major concern in this age group; weight reduction should be promoted through enhanced energy expenditure coupled with reduced energy intake. Physical activity should be promoted, since moderate-to-vigorous physical activity reduces BP levels in adults.
  • The management of hypertension is as described in JNC 7.[23]

For all age groups, the assessment of left ventricular mass (LVM) by echocardiography is recommended as the best method to assess hypertensive target organ disease. Assessment should be done for patients with stage 2 hypertension and those with persistent stage 1 hypertension. Evaluation of LVM may be helpful in establishing the need for pharmacologic treatment of hypertension.

Table 8–5 shows medications that have been used to achieve BP control in children and adolescents. At present, no data support the use of specific antihypertensive agents for specific age groups, and long-term safety data are not available.

Table 8–1 Age-Specific Recommendations for Blood Pressure (BP) Measurement and Diagnosis of Hypertension 

BP recommendations are based on The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (Fourth Report), with the evidence review updated from 2003.

Recommendations are all graded as expert opinion (Grade D) as they are based on the expert consensus conclusions of the Fourth Report.

Birth-3 years No routine BP measurement
  • Measure BP if history (+) for neonatal complications, congenital heart disease, urinary/ renal abnormality, solid-organ transplant, malignancy, drug Rx, or condition known to raise BP or increase intracranial pressure (Table 8-2)
    • If BP > 90th %ile by oscillometry, confirm by auscultation
    • →If BP confirmed ≥ 90th %ile, initiate evaluation for etiology and treatment per algorithm.
      (Figure 8-2)
3-11 years Annual BP measurement in all, interpreted for age/sex/height per Tables 8-3 and 8-4 below
  • BP < 90th %ile, repeat in 1 year
  • BP ≥ 90th %ile:
    • Repeat BP X 2 by auscultation
    • Average replicate measurements → Re-evaluate BP category
→ If BP confirmed ≥ 90th %ile, < 95th %ile = Prehypertension (HTN)
  • Recommend weight management if indicated
  • Repeat BP in 6 months
→ If BP ≥ 95th %ile, < 99th %ile + 5mmHg
  • Repeat BP in 1-2 weeks, average all BP measurements"
  • Re-evaluate BP category
  • BP confirmed ≥ 95th %ile, < 99th %ile + 5 mmHg = Stage 1 HTN
    • Basic work-up per figure 8-2
→ If BP ≥ 99th %ile + 5 mmHg
  • Repeat BP by auscultation X 3 at that visit, average all BP measurements
  • Re-evaluate BP category
  • BP confirmed ≥ 99th %ile + 5 mmHg = Stage 2 HTN
    • Refer to pediatric HTN expert within 1 week OR
    • Begin BP treatment and initiate basic work-up, per Figure 8-2.
12-17 years Annual BP measurement in all, interpreted for age/sex/height per Tables 8-3 and 8-4 below
  • BP < 90th %ile, counsel on CHILD 1 diet, activity recommendations, and repeat BP in 1 year
  • BP ≥ 90th %ile or > 120/80:
    • Repeat BP X 2 by auscultation
    • Average replicate measurements → Re-evaluate BP category
→ If BP confirmed ≥ 90th %ile, < 95th %ile or ≥ 120/80 = Pre-HTN
  • CHILD 1 diet, activity recommendations, weight management if indicated
  • Repeat BP in 6 months
→ If BP ≥ 95th %ile, < 99th %ile + 5mmHg
  • Repeat BP in 1-2 weeks, average all BP measurements
  • Re-evaluate BP category
  • BP confirmed ≥ 95th %ile, < 99th %ile + 5 mmHg = Stage 1 HTN
    • Basic work-up per Figure 8-2
→ If BP ≥ 99th %ile + 5 mmHg
  • Repeat BP by auscultation X 3 at that visit, average all BP measurements
  • Re-evaluate BP category
  • BP confirmed ≥ 99th %ile + 5 mmHg = Stage 2 HTN
    • Refer to pediatric HTN expert within 1 week OR
    • Begin BP treatment and initiate work-up, per Figure 8-2
18-21 years Measure BP at all health care visits
  • BP ≥ 120/80 to 139/89 = Pre-HTN
  • BP ≥ 140/90 to 159/99 = Stage 1 HTN
  • BP ≥ 160/100 = Stage 2 HTN
Evaluation/ Treatment per JNC recommendations[23]

Table 8–2. Conditions Under Which Children < 3 Years Old Should Have BP Measured

  • History of prematurity, very low birth weight, or other neonatal complication requiring intensive care
  • Congenital heart disease (repaired or unrepaired)
  • Recurrent urinary tract infections, hematuria, or proteinuria
  • Known renal disease or urologic malformations
  • Family history of congenital renal disease
  • Solid-organ transplant
  • Malignancy or bone marrow transplant
  • Treatment with drugs know to raise BP
  • Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc.)
  • Evidence of increased intracranial pressure

Figure 8-1. Blood Pressure (BP) Measurement and Categorization

Figure of BP Measurement and Categorization flow chart. A text description follows this graphic.

Figure 8-1 Description

The figure is a flow chart with 21 labeled boxes linked by arrows. The chart is in one direction with all arrows pointing downward to one or more boxes.

Below the flow chart is described as lists in which the possible next steps are listed beneath each box label.

  1. Select appropriate BP cuff size. Meaure BP at each well child visit over 3 years of age* (auscultatory method preferred)
    1. Forward to Measure HT, WT & calculate BMI
  2. Measure HT, WT & calculate BMI
    1. Foward to Determine BP category for age, HT, gender (Tables 8-3 & 8-4)
  3. Determine BP category for age, HT, gender (Tables 8-3 & 8-4)
    Determine BMI category for age and gender (CDC growth charts)
    1. Forward to <90%ile (normal)
    2. Forward to ≥ 90th%ile or 120/80 mmHg to < 95th% (preHTN)
    3. Forward to ≥ 95th%ile < 99th% + 5 mmHg (stage 1)
    4. Forward to ≥ 99th%ile + 5 mmHg (stage 2)
  4. <90th%ile (normal)
    1. Forward to Normotensive
    2. Forward to Repeat BP at next visit, plus
    3. Forward to Educate on CHILD-1 activity levels**
  5. ≥ 90th%ile or 120/80 mmHg to < 95th% (preHTN)
    1. Foward to Repeat by auscultation if performed with oscillometric device
  6. ≥ 95th%ile < 99th% + 5 mmHg (stage 1)
    1. Foward to Repeat by auscultation if performed with oscillometric device
  7. ≥ 99th%ile + 5 mmHg (stage 2)
    1. Foward to Repeat by auscultation if performed with oscillometric device
  8. Repeat by auscultation if performed with oscillometric device
    1. Forward to Average replicate BP measurements at initial visit
  9. Average replicate BP measurements at initial visit
    Re-evaluate BP category
    1. Forward to Pre-Hypertensive
    2. Forward to Stage 1 Hypertension
    3. Forward to Stage 2 Hypertension
  10. Pre-Hypertensive
    1. Forward to Repeat BP in 6 months
  11. Stage 1 Hypertension
    1. Forward to Repeat BP in 1-2 weeks
  12. Stage 2 Hypertension
    1. Forward to Evaluate or refer for treatment within 1 week
  13. Repeat BP in 6 months, plus
    1. Forward to CHILD-1/activity education** &/or Weight management***
  14. Repeat BP in 1-2 weeks
    Average BP over all 3 visits, plus
    1. Forward to CHILD-1/activity education** &/or Weight management***
  15. Evaluate or refer for treatment within 1 week, plus
    1. Forward to CHILD-1/activity education** &/or Weight management***
  16. CHILD-1/activity education** &/or Weight management***
  17. CHILD-1/activity education** &/or Weight management***
  18. CHILD-1/activity education** &/or Weight management***

Figure 8-1 Legend:
* See Table 1;
Cardiovascular Health Integrated Lifestyle Diet - Section V. Nutrition and Diet;
** Section VI. Physical Activity;
*** Section X. Overweight and Obesity

Figure 8-2. Blood Pressure (BP) Management by Category

Figure of BP Measurement by Categorization flow chart. A text description follows this graphic.

Figure 8-2 Description

The figure is a flow chart with 29 labeled boxes linked by arrows. The chart is in one direction with all arrows pointing downward to one or more boxes.

Below the flow chart is described as lists in which the possible next steps are listed beneath each box label.

  1. Determine BP category from average of replicate readings at multiple visits (see measurement algorithm)
    1. Forward to Normotensive
    2. Forward to Pre-Hypertension
    3. Forward to Stage 1 Hypertension
    4. Forward to Stage 2 Hypertension
  2. Normotensive
    1. Forward to Assess other CV risk factors
  3. Pre-Hypertension
    1. Forward to Assess other CV risk factors*
  4. Stage 1 Hypertension
    1. Forward to Basic Work-up: Medical/Family/Sleep Hx, PEx, CBC, renal panel, U/A, Renal/Cardiac U/S, lipids, glucose
  5. Stage 2 Hypertension
    1. Forward to Basic Work-up: &/or refer to Ped HTN expert for extended work-up
  6. Assess other CV risk factors, plus
    1. Forward to CHILD-1/Activity Education**
  7. Assess other CV risk factors*, plus
    1. Forward to CHILD-1/activity education** &/or Weight management***
  8. Basic Work-up: Medical/Family/Sleep Hx, PEx, CBC, renal panel, U/A, Renal/Cardiac U/S, lipids, glucose, plus
    1. Forward to CHILD-1/activity education** &/or Weight management***
  9. Basic Work-up: &/or refer to Ped HTN expert for extended work-up
    1. Primary or Secondary HTN, forward to Anti-HTN Drug +/- Rx for 20 cause + Weight management*** &/or CHILD-1/activity education**
  10. CHILD-1/Activity Education**
    1. Forward to Re-evaluate at next visit
  11. CHILD-1/activity education** &/or Weight management***
    1. Forward to Monitor Q 6 Mo
  12. CHILD-1/activity education** &/or Weight management***
    1. Primary HTN No LVH, Forward to Monitor Q3 to 6 Months
    2. Secondary HTN or LVH, Forward to Rx for 20 cause + Anti-HTN Drug
  13. Anti-HTN Drug +/- Rx for 20 cause + Weight management*** &/or CHILD-1/activity education**
    1. Forward to Follow until BP controlled, Q 1-2 wks
  14. Monitor Q 6 Mo
    1. Forward to Re-evaluate BP cagegory**
  15. Monitor Q 3 to 6 Months
    1. Forward to Re-evaluate BP cagegory
  16. Rx for 20 cause + Anti-HTN Drug
    1. Forward to Monitor Q 3-6 Months
  17. Follow until BP controlled, Q 1-2 wks
    1. Monitor Q 1-3 Months
  18. Re-evaluate BP Category**
    1. <90th %ile, 90<95th%ile (≥95th%ile → Stage 1 W/U) ≥95th%ile, forward to Consider basic W/U + cardiac U/S for TOD*
  19. Re-evaluate BP category
    1. Forward to Anti-HTN Drug if no improvement
  20. Monitor Q3-6 Months
    1. Forward to Consider re-evaluation of BP Category if BP well controlled, ↓BMI or s/p Rx for 20 cause
  21. Monitor Q 1-3 Months
    1. Forward to Consider re-evaluation of BP Category if BP well controlled, ↓BMI or s/p Rx for 20 cause
  22. Consider basic W/U + cardiac U/S for TOD*
    1. Forward to Monitor Q 6 Mo
  23. Anti-HTN Drug if no improvement
    1. Forward to Continue moderate follow-up
  24. Consider re-evaluation of BP Category if BP well controlled, ↓BMI or s/p Rx for 20 cause
    1. Forward to Continue moderate follow-up
    2. Forward to Continue close follow-up
  25. Re-evaluate at next visit
    1. Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target Organ Damage
  26. Monitor Q 6 Mo
    1. Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target Organ Damage
  27. Continue moderate follow-up
    1. Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target Organ Damage
  28. Continue close follow-up
    1. Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target Organ Damage
  29. GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target Organ Damage

Figure 8-2 Legend:
*   Work up for target organ damage (TOD)/ LVH if obese or (+) for other CV risk factors;
 Cardiovascular Health Integrated Lifestyle Diet; See Section V. Nutrition and Diet;
** Activity Education. See Section VI. Physical Activity;
*** Weight management. See Section X. Overweight and Obesity.

Table 8-3. Blood Pressure (BP) Norms for Boys by Age and Height Percentiles (%iles)

Age, y

BP %ile

SBP, mm Hg,
%ile of Height,
5th

SBP, mm Hg,
%ile of Height,
10th

SBP, mm Hg,
%ile of Height,
25th

SBP, mm Hg,
%ile of Height,
50th

SBP, mm Hg,
%ile of Height,
75th

SBP, mm Hg,
%ile of Height,
90th

SBP, mm Hg,
%ile of Height,
95th

DBP, mm Hg,
%ile of Height,
5th

DBP, mm Hg,
%ile of Height,
10th

SBP, mm Hg,
%ile of Height,
25th

SBP, mm Hg,
%ile of Height,
50th

SBP, mm Hg,
%ile of Height,
75th

DBP, mm Hg,
%ile of Height,
90th

DBP, mm Hg,
%ile of Height,
95th

1

50th

80

81

83

85

87

88

89

34

35

36

37

38

39

39

1

90th

94

95

97

99

100

102

103

49

50

51

52

53

53

54

1

95th

98

99

101

103

104

106

106

54

54

55

56

57

58

58

1

99th

105

106

108

110

112

113

114

61

62

63

64

65

66

66

2

50th

84

85

87

88

90

92

92

39

40

41

42

43

44

44

2

90th

97

99

100

102

104

105

106

54

55

56

57

58

58

59

2

95th

101

102

104

106

108

109

110

59

59

60

61

62

63

63

2

99th

109

110

111

113

115

117

117

66

67

68

69

70

71

71

3

50th

86

87

89

91

93

94

95

44

44

45

46

47

48

48

3

90th

100

101

103

105

107

108

109

59

59

60

61

62

63

63

3

95th

104

105

107

109

110

112

113

63

63

64

65

66

67

67

3

99th

111

112

114

116

118

119

120

71

71

72

73

74

75

75

4

50th

88

89

91

93

95

96

97

47

48

49

50

51

51

52

4

90th

102

103

105

107

109

110

111

62

63

64

65

66

66

67

4

95th

106

107

109

111

112

114

115

66

67

68

69

70

71

71

4

99th

113

114

116

118

120

121

122

74

75

76

77

78

78

79

5

50th

90

91

93

95

96

98

98

50

51

52

53

54

55

55

5

90th

104

105

106

108

110

111

112

65

66

67

68

69

69

70

5

95th

108

109

110

112

114

115

116

69

70

71

72

73

74

74

5

99th

115

116

118

120

121

123

123

77

78

79

80

81

81

82

6

50th

91

92

94

96

98

99

100

53

53

54

55

56

57

57

6

90th

105

106

108

110

111

113

113

68

68

69

70

71

72

72

6

95th

109

110

112

114

115

117

117

72

72

73

74

75

76

76

6

99th

116

117

119

121

123

124

125

80

80

81

82

83

84

84

7

50th

92

94

95

97

99

100

101

55

55

56

57

58

59

59

7

90th

106

107

109

111

113

114

115

70

70

71

72

73

74

74

7

95th

110

111

113

115

117

118

119

74

74

75

76

77

78

78

7

99th

117

118

120

122

124

125

126

82

82

83

84

85

86

86

8

50th

94

95

97

99

100

102

102

56

57

58

59

60

60

61

8

90th

107

109

110

112

114

115

116

71

72

72

73

74

75

76

8

95th

111

112

114

116

118

119

120

75

76

77

78

79

79

80

8

99th

119

120

122

123

125

127

127

83

84

85

86

87

87

88

9

50th

95

96

98

100

102

103

104

57

58

59

60

61

61

62

9

90th

109

110

112

114

115

117

118

72

73

74

75

76

76

77

9

95th

113

114

116

118

119

121

121

76

77

78

79

80

81

81

9

99th

120

121

123

125

127

128

129

84

85

86

87

88

88

89

10

50th

97

98

100

102

103

105

106

58

59

60

61

61

62

63

10

90th

111

112

114

115

117

119

119

73

73

74

75

76

77

78

10

95th

115

116

117

119

121

122

123

77

78

79

80

81

81

82

10

99th

122

123

125

127

128

130

130

85

86

86

88

88

89

90

11

50th

99

100

102

104

105

107

107

59

59

60

61

62

63

63

11

90th

113

114

115

117

119

120

121

74

74

75

76

77

78

78

11

95th

117

118

119

121

123

124

125

78

78

79

80

81

82

82

11

99th

124

125

127

129

130

132

132

86

86

87

88

89

90

90

12

50th

101

102

104

106

108

109

110

59

60

61

62

63

63

64

12

90th

115

116

118

120

121

123

123

74

75

75

76

77

78

79

12

95th

119

120

122

123

125

127

127

78

79

80

81

82

82

83

12

99th

126

127

129

131

133

134

135

86

87

88

89

90

90

91

13

50th

104

105

106

108

110

111

112

60

60

61

62

63

64

64

13

90th

117

118

120

122

124

125

126

75

75

76

77

78

79

79

13

95th

121

122

124

126

128

129

130

79

79

80

81

82

83

83

13

99th

128

130

131

133

135

136

137

87

87

88

89

90

91

91

14

50th

106

107

109

111

113

114

115

60

61

62

63

64

65

65

14

90th

120

121

123

125

126

128

128

75

76

77

78

79

79

80

14

95th

124

125

127

128

130

132

132

80

80

81

82

83

84

84

14

99th

131

132

134

136

138

139

140

87

88

89

90

91

92

92

15

50th

109

110

112

113

115

117

117

61

62

63

64

65

66

66

15

90th

122

124

125

127

129

130

131

76

77

78

79

80

80

81

15

95th

126

127

129

131

133

134

135

81

81

82

83

84

85

85

15

99th

134

135

136

138

140

142

142

88

89

90

91

92

93

93

16

50th

111

112

114

116

118

119

120

63

63

64

65

66

67

67

16

90th

125

126

128

130

131

133

134

78

78

79

80

81

82

82

16

95th

129

130

132

134

135

137

137

82

83

83

84

85

86

87

16

99th

136

137

139

141

143

144

145

90

90

91

92

93

94

94

17

50th

114

115

116

118

120

121

122

65

66

66

67

68

69

70

17

90th

127

128

130

132

134

135

136

80

80

81

82

83

84

84

17

95th

131

132

134

136

138

139

140

84

85

86

87

87

88

89

17

99th

139

140

141

143

145

146

147

92

93

93

94

95

96

97

SD = standard deviation
The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.

Table 8–4. Blood Pressure (BP) Norms for Girls by Age and Height Percentiles (%iles)

Age, y

BP %ile

SBP, mm Hg,
%ile of Height,
5th

SBP, mm Hg,
%ile of Height,
10th

SBP, mm Hg,
%ile of Height,
25th

SBP, mm Hg,
%ile of Height,
50th

SBP, mm Hg,
%ile of Height,
75th

SBP, mm Hg,
%ile of Height,
90th

SBP, mm Hg,
%ile of Height,
95th

DBP, mm Hg,
%ile of Height,
5th

DBP, mm Hg,
%ile of Height,
10th

SBP, mm Hg,
%ile of Height,
25th

SBP, mm Hg,
%ile of Height,
50th

SBP, mm Hg,
%ile of Height,
75th

DBP, mm Hg,
%ile of Height,
90th

DBP, mm Hg,
%ile of Height,
95th

1

50th

83

84

85

86

88

89

90

38

39

39

40

41

 41

42

1

90th

97

97

98

100

101

102

103

52

53

53

54

55

 55

56

1

95th

100

101

102

104

105

106

107

56

57

57

58

59

 59

60

1

99th

108

108

109

111

112

113

114

64

64

65

65

66

 67

67

2

50th

85

85

87

88

89

91

91

43

44

44

45

46

 46

47

2

90th

98

99

100

101

103

104

105

57

58

58

59

60

 61

61

2

95th

102

103

104

105

107

108

109

61

62

62

63

64

 65

65

2

99th

109

110

111

112

114

115

116

69

69

70

70

71

 72

72

3

50th

86

87

88

89

91

92

93

47

48

48

49

50

 50

51

3

90th

100

100

102

103

104

106

106

61

62

62

63

64

 64

65

3

95th

104

104

105

107

108

109

110

65

66

66

67

68

 68

69

3

99th

111

111

113

114

115

116

117

73

73

74

74

75

 76

76

4

50th

88

88

90

91

92

94

94

50

50

51

52

52

 53

54

4

90th

101

102

103

104

106

107

108

64

64

65

66

67

 67

68

4

95th

105

106

107

108

110

111

112

68

68

69

70

71

 71

72

4

99th

112

113

114

115

117

118

119

76

76

76

77

78

 79

79

5

50th

89

90

91

93

94

95

96

52

53

53

54

55

 55

56

5

90th

103

103

105

106

107

109

109

66

67

67

68

69

 69

70

5

95th

107

107

108

110

111

112

113

70

71

71

72

73

 73

74

5

99th

114

114

116

117

118

120

120

78

78

79

79

80

 81

81

6

50th

91

92

93

94

96

97

98

54

54

55

56

56

57

58

6

90th

104

105

106

108

109

110

111

68

68

69

70

70

71

72

6

95th

108

109

110

111

113

114

115

72

72

73

74

74

75

76

6

99th

115

116

117

119

120

121

122

80

80

80

81

82

83

83

7

50th

93

93

95

96

97

99

99

55

56

56

57

58

58

59

7

90th

106

107

108

109

111

112

113

69

70

70

71

72

72

73

7

95th

110

111

112

113

115

116

116

73

74

74

75

76

76

77

7

99th

117

118

119

120

122

123

124

81

81

82

82

83

84

84

8

50th

95

95

96

98

99

100

101

57

57

57

58

59

60

60

8

90th

108

109

110

111

113

114

114

71

71

71

72

73

74

74

8

95th

112

112

114

115

116

118

118

75

75

75

76

77

78

78

8

99th

119

120

121

122

123

125

125

82

82

83

83

84

85

86

9

50th

96

97

98

100

101

102

103

58

58

58

59

60

61

61

9

90th

110

110

112

113

114

116

116

72

72

72

73

74

75

75

9

95th

114

114

115

117

118

119

120

76

76

76

77

78

79

79

9

99th

121

121

123

124

125

127

127

83

83

84

84

85

86

87

10

50th

98

99

100

102

103

104

105

59

59

59

60

61

62

62

10

90th

112

112

114

115

116

118

118

73

73

73

74

75

76

76

10

95th

116

116

117

119

120

121

122

77

77

77

78

79

80

80

10

99th

123

123

125

126

127

129

129

84

84

85

86

86

87

88

11

50th

100

101

102

103

105

106

107

60

60

60

61

62

63

63

11

90th

114

114

116

117

118

119

120

74

74

74

75

76

77

77

11

95th

118

118

119

121

122

123

124

78

78

78

79

80

81

81

11

99th

125

125

126

128

129

130

131

85

85

86

87

87

88

89

12

50th

102

103

104

105

107

108

109

61

61

61

62

63

64

64

12

90th

116

116

117

119

120

121

122

75

75

75

76

77

78

78

12

95th

119

120

121

123

124

125

126

79

79

79

80

81

82

82

12

99th

127

127

128

130

131

132

133

86

86

87

88

88

89

90

13

50th

104

105

106

107

109

110

110

62

62

62

63

64

65

65

13

90th

117

118

119

121

122

123

124

76

76

76

77

78

79

79

13

95th

121

122

123

124

126

127

128

80

80

80

81

82

83

83

13

99th

128

129

130

132

133

134

135

87

87

88

89

89

90

91

14

50th

106

106

107

109

110

111

112

63

63

63

64

65

66

66

14

90th

119

120

121

122

124

125

125

77

77

77

78

79

80

80

14

95th

123

123

125

126

127

129

129

81

81

81

82

83

84

84

14

99th

130

131

132

133

135

136

136

88

88

89

90

90

91

92

15

50th

107

108

109

110

111

113

113

64

64

64

65

66

67

67

15

90th

120

121

122

123

125

126

127

78

78

78

79

80

81

81

15

95th

124

125

126

127

129

130

131

82

82

82

83

84

85

85

15

99th

131

132

133

134

136

137

138

89

89

90

91

91

92

93

16

50th

108

108

110

111

112

114

114

64

64

65

66

66

67

68

16

90th

121

122

123

124

126

127

128

78

78

79

80

81

81

82

16

95th

125

126

127

128

130

131

132

82

82

83

84

85

85

86

16

99th

132

133

134

135

137

138

139

90

90

90

91

92

93

93

17

50th

108

109

110

111

113

114

115

64

65

65

66

67

67

68

17

90th

122

122

123

125

126

127

128

78

79

79

80

81

81

82

17

95th

125

126

127

129

130

131

132

82

83

83

84

85

85

86

17

99th

133

133

134

136

137

138

139

90

90

91

91

92

93

93

SD = standard deviation
The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.

Table 8-5. Anti-hypertensive Medications with Pediatric

Angiotensin-converting enzyme (ACE) inhibitor

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

Angiotensin-converting enzyme (ACE) inhibitor

Benazepril

0.2 mg/kg/day up to 10 mg/day

0.6 mg/kg/day up to 40 mg/day

qd

Randomized controlled trial

Yes

Angiotensin-converting enzyme (ACE) inhibitor

Captopril

0.3-0.5 mg/kg/dose (>12 months)

6 mg/kg/day

tid

Randomized controlled trial, Case series

No

Angiotensin-converting enzyme (ACE) inhibitor

Fosinopril**

Children >50 kg:

5-10 mg/day

40 mg/day

qd

Randomized controlled trial

Yes

Angiotensin-converting enzyme (ACE) inhibitor

Lisinopril**

0.07 mg/kg/day up to 5 mg/day

0.6 mg/kg/day up to 40 mg/day

qd

Randomized controlled trial

Yes

Angiotensin-converting enzyme (ACE) inhibitor

Quinapril

5-10 mg/day

80 mg/day

qd

Randomized controlled trial, Expert opinion

No

Comments§

  1. All ACE inhibitors are contraindicated in pregnancy; females of childbearing age should use reliable contraception.
  2. Check serum potassium and creatinine periodically to monitor for hyperkalemia and azotemia.
  3. Cough and angioedema are reportedly less common with newer members of this class than with captopril.
  4. Benezapril and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension.
  5. FDA approval for ACE inhibitors with pediatric labeling is limited to children ≥6 years of age and to children with creatinine clearance ≥30 mL/min/1.73m2.
  6. Initial dose of fosinopril of 0.1 mg/kg/day may be effective, although African American patients may require a higher dose.

Angiotensin-receptor blocker (ARB)

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

Angiotensin-receptor blocker (ARB)

Irbesartan

6-12 years: 75-150 mg/day; ≥13 years: 150-300mg/day

300 mg/day

qd

Case series

Yes

Angiotensin-receptor blocker (ARB)

Losartan**

0.7 mg/kg/day up to 50 mg/day

1.4 mg/kg/day up to 100 mg/day

qd-bid

Randomized controlled trial

Yes

Angiotensin-receptor blocker (ARB)

Valsartan**

5-10 mg/day

0.4 mg/kg/day

40-80 mg/day

3.4 mg/kg/day

qd

Randomized controlled trial

No

Comments§

  1. All ARBs are contraindicated in pregnancy; females of childbearing age should use reliable contraception
  2. Check serum potassium and creatinine periodically to monitor for hyperkalemia and azotemia.
  3. Losartan label contains information on the preparation of a suspension.
  4. FDA approval for ARBs is limited to children ≥6 years of age and to children with creatinine clearance ≥30 mL/min/1.73m2 .

Alpha- and beta-antagonist

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

alpha- and beta-antagonist

Labetalol

1-3 mg/kg/day

10-12 mg/kg/day up to 1,200 mg/day

bid

Case series, Expert opinion

No

Comments§

  1. Asthma and overt heart failure are relative contraindications.
  2. Heart rate is dose limiting.
  3. May impair athletic performance in athletes.
  4. Should not be used in insulin-dependent diabetics.

Beta-antagonist

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

beta-antagonist

Atenolol

0.5-1 mg/kg/day

2 mg/kg/day up to

100 mg/day

qd-bid

Case series

No

beta-antagonist

Bisoprolol/
HCTZ

2.5-6.25 mg/day

10/6.25 mg/day

qd

Randomized controlled trial

No

beta-antagonist

Metoprolol**

Children >6 years: 1 mg/kg/day (12.5-50 mg/day)

2 mg/kg/day up to

200 mg/day

bid

Case series

Yes***

beta-antagonist

Propranolol

1-2 mg/kg/day

4 mg/kg/day up to

640 mg/day

bid-tid

Randomized controlled trial, Expert opinion

Yes

Comments§

  1. Noncardioselective agents (propranolol) are contraindicated in asthma and heart failure.
  2. Heart rate is dose limiting.
  3. May impair athletic performance in athletes.
  4. Should not be used in insulin-dependent diabetics.
  5. A sustained-release, once-daily formulation of propranolol is available.

Calcium channel blocker

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

Calcium channel blocker

Amlodipine**

Children 6-17 years: 2.5 mg/day

5 mg/day

qd

Randomized controlled trial

Yes

Calcium channel blocker

Felodipine

2.5 mg/day

10 mg/day

qd

Randomized controlled trial, Expert opinion

No

Calcium channel blocker

Isradipine

0.15-0.2 mg/kg/day

0.8 mg/kg/day up to 20 mg/day

tid-qid

Case series, Expert opinion

No

Calcium channel blocker

Extended-release nifedipine

0.25-0.5 mg/kg/day

3 mg/kg/day up to

120 mg/day

qd-bid

Case series, Expert opinion

No

Comments§

  1. Amlodipine and isradipine can be compounded into stable  extemporaneous suspensions.
  2. Felodipine and extended-release nifedipine tablets must be swallowed whole.
  3. Isradipine is available in both immediate-release and sustained-release formulations; sustained release form is dosed qd or bid.
  4. May cause tachycardia.
  5. Doses up to 10 mg of amlodipine have been evaluated in children.
  6. Contraindicated for children <1 year of age.

Central alpha-agonist

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

Central alpha-agonist

Clonidine

Children ≥12 years: 0.2 mg/day

2.4 mg/day

bid

Expert opinion

Yes

Comments§

  1. May cause dry mouth and/or sedation.
  2. Transdermal preparation is available.
  3. Sudden cessation of therapy can lead to severe rebound hypertension.

Diuretic

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

Diuretic

HCTZ

1 mg/kg/day

3 mg/kg/day up to

50 mg/day

qd

Expert opinion

Yes

Diuretic

Chlorthalidone

0.3 mg/kg/day

2 mg/kg/day up to

50 mg/day

qd

Expert opinion

No

Diuretic

Furosemide

0.5-2.0 mg/kg/ dose

6 mg/kg/day

qd-bid

Expert opinion

`No

Diuretic

Spironolactone

1 mg/kg/day

3.3 mg/kg/day up to 100 mg/day

qd-bid

Expert opinion

No

Diuretic

Triamterene

1-2 mg/kg/day

3-4 mg/kg/day up to 300 mg/day

bid

Expert opinion

No

Diuretic

Amiloride

0.4-0.625 mg/kg/day

20 mg/day

qd

Expert opinion

No

Comments§

  1. All patients treated with diuretics should have electrolytes monitored shortly after initiating therapy and periodically thereafter.
  2. Useful as add-on therapy in patients being treated with drugs from other drug classes.
  3. Potassium-sparing diuretics (spironolactione, triamterene, amiloride) may cause severe hyperkalemia, especially if given with ACE inhibitor or ARB.
  4. Furosemide is labeled only for treatment of edema but may be useful as add-on therapy in children with resistant hypertension, particularly in children with renal disease.
  5. Chlorthalidone may precipitate azotemia in patients with renal diseases and should be used with caution in those with severe renal impairment.

Peripheral alpha-antagonist

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

Peripheral alpha-antagonist

Doxazosin

1 mg/day

4 mg/day

qd

Expert opinion

No

Peripheral alpha-antagonist

Prazosin

0.05-0.1 mg/kg/ day

0.5 mg/kg/day

tid

Expert opinion

No

Peripheral alpha-antagonist

Terazosin

1 mg/day

20 mg/day

qd

Expert opinion

No

Comments§

  1. May cause first-dose hypotension.

Vasodilator

Class

Drug

Initial Dose*

Maximal Dose

Dosing Interval

Evidence

FDA

Vasodilator

Hydralazine

0.75 mg/kg/day

7.5 mg/kg/day up to 200 mg/day

qid

Expert opinion

Yes

Vasodilator

Minoxidil

Children <12 years: 0.2 mg/kg/ day; children > 12 years: 5 mg/day

Children <12 years:

50 mg/day; children ≥12 years: 100 mg/day

qd-tid

Case series, Expert opinion

Yes

Comments§

  1. Tachycardia and fluid retention are common side effects.
  2. Hydralazine can cause a lupus-like syndrome in slow acetylators.
  3. Prolonged use of minoxidil can cause hypertrichosis.
  4. Minoxidil is usually reserved for patients with hypertension resistant to multiple drugs.

RCT = randomized controlled trial
CS = case series
EO = expert opinion
* The maximal recommended adult dose should not be exceeded in routine clinical practice.
Level of evidence on which recommendations are based.
U.S. Food and Drug Administration (FDA) -approved pediatric labeling information is available for treatment of hypertension. Recommended doses for agents with FDA-approved pediatric labels contained in this table are the doses contained in the approved labels. Even when pediatric labeling information is not available, the FDA-approved label should be consulted for additional safety information.
§ Comments apply to all members of each drug class except where otherwise stated.
** Indicates drug added since The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (2004).
*** Study did not reach primary end point (dose response for reduction in systolic blood pressure). Some prespecified secondary end points demonstrated effectiveness.


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[12] Couch SC, Saelens BE, Levin L, Dart K, Falciglia G, Daniels SR. The efficacy of a clinic-based behavioral nutrition intervention emphasizing a DASH-type diet for adolescents with elevated blood pressure. J Pediatr 2008;152(4):494-501. (PM:18346503)

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