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This new research provides a comprehensive review for clinicians on the latest scientific evidence regarding high blood pressure in children, along with recommendations for diagnosis, evaluation, and treatment of hypertension based on available evidence and consensus expert opinion of the working group when evidence was lacking. The report was also initially published in Pediatrics, 2004;114:555-576 .
Version History:
This new research provides a comprehensive review for clinicians on the latest scientific evidence regarding high blood pressure in children, along with recommendations for diagnosis, evaluation, and treatment of hypertension based on available evidence and consensus expert opinion of the working group when evidence was lacking. The report was also initially published in Pediatrics, 2004;114:555-576 .
Version History:
From the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents*
<TODO INSERT PDF FILE>
The updated blood pressure (BP) tables for children and adolescents are based on recently revised child height percentiles and also include the BP data from the 1999-2000 NHANES. The 50th, 90th, 95th, and 99th percentiles for systolic blood pressure (SBP) and diastolic blood pressure (DBP) according to height, sex, and age are given for boys and girls. The 50th percentile has been added to the tables to provide the clinician with the BP level at the midpoint of the normal range. Although the 95th percentile provides a BP level that defines hypertension, management decisions about children with hypertension should be determined by the degree or severity of hypertension. Therefore, the 99th percentile has been added to facilitate clinical decisionmaking in the plan for evaluation. 4 pages. May 2004.
* Full report expected in late Summer, 2004
In response to the request of the NHBPEP Chair and Director of the National Heart, Lung, and Blood Institute (NHLBI) regarding the need to update the JNC 7 report,2 some NHBPEP Coordinating Committee members suggested that the NHBPEP Working Group Report on Hypertension in Children and Adolescents should be revisited. Thereafter, the NHLBI Director directed the NHLBI staff to examine issues that might warrant a new report on children. Several prominent clinicians and scholars were asked to develop background manuscripts on selected issues related to hypertension in children and adolescents. Their manuscripts synthesized the available scientific evidence. During the spring and summer of 2002, NHLBI staff and the chair of the 1996 NHBPEP Working Group report on hypertension in children and adolescents reviewed the scientific issues addressed in the background manuscripts as well as contemporary policy issues. Subsequently, the staff noted that a critical mass of new information had been identified, thus warranting the appointment of a panel to update the earlier NHBPEP Working Group Report. The NHLBI Director appointed the authors of the background papers and other national experts to serve on the new panel. The chair and NHLBI staff developed a report outline and timeline to complete the work in 5 months.
The background papers served as focal points for review of the scientific evidence at the first meeting. The members of the Working Group were assembled into teams, and each team prepared specific sections of the report. In developing the focus of each section, the Working Group was asked to consider the peer-reviewed scientific literature published in English since 1997. The scientific evidence was classified by the system used in the JNC 7.2 The chair assembled the sections submitted by each team into the first draft of the report. The draft report was distributed to the Working Group for review and comment. These comments were assembled and used to create the second draft. A subsequent onsite meeting of the Working Group was conducted to discuss further revisions and the development of the third draft document. Amended sections were reviewed, critiqued, and incorporated into the third draft. After editing by the chair for internal consistency, the fourth draft was created. The Working Group reviewed this draft, and conference calls were conducted to resolve any remaining issues that were identified. When the Working Group approved the final document, it was distributed to the Coordinating Committee for review.
Chair
Bonita Falkner, MD
Thomas Jefferson University
Philadelphia, PA
Members
Stephen R. Daniels, MD, PhD
Cincinnati Children's Hospital Medical Center
Cincinnati, OH
Joseph T. Flynn, MD, MS
Montefiore Medical Center
Bronx, NY
Samuel Gidding, MD
DuPont Hospital for Children
Wilmington, DE
Lee A. Green, MD, MPH
University of Michigan
Ann Arbor, MI
Julie R. Ingelfinger, MD
MassGeneral Hospital for Children
Boston, MA
Ronald M. Lauer, MD
University of Iowa
Iowa City, IA
Bruce Z. Morgenstern, MD
Mayo Clinic
Rochester, MN
Ronald J. Portman, MD
University of Texas Health Science Center
Houston, TX
Ronald J. Prineas, MD, PhD
Wake Forest University School of Medicine
Winston-Salem, NC
Albert P. Rocchini, MD
University of Michigan
C.S. Mott Children's Hospital
Ann Arbor, MI
Bernard Rosner, PhD
Harvard School of Public Health
Boston, MA
Alan Robert Sinaiko, MD
University of Minnesota Medical School
Minneapolis, MN
Nicolas Stettler, MD, MSCE
Children's Hospital of Philadelphia
Philadelphia, PA
Elaine Urbina, MD
Cincinnati Children's Hospital Medical Center
Cincinnati, OH
Financial Disclosures
Dr. Joseph T. Flynn is a paid contributor to Pfizer, Inc., Novartis Pharmaceuticals, AstraZeneca, Inc., and ESP-Pharma.
The other authors have no financial relationships to disclose.
Title Page--Department of Health and Human Services
National Institutes of Health
National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program
The 4th Report on High Blood Pressure in Children and Adolescents Slide Set
SLIDE 1: National Heart, Lung, and Blood Institute National High Blood Pressure Education Program
The 4th Report on High Blood Pressure in Children and Adolescents Slide Set
SLIDE 2: Group on High Blood Pressure in Children and Adolescents
Bonita Falkner, M.D., CHAIR, Thomas Jefferson University
Stephen R. Daniels, M.D., Ph.D., Cincinnati Children's Hospital Medical Center
*Joseph T. Flynn, M.D., M.S., Montefiore Medical Center
Samuel Gidding, M.D., DuPont Hospital for Children
Lee A. Green, M.D., M.P.H., University of Michigan
Julie R. Ingelfinger, M.D., MassGeneral Hospital for Children
Ronald M. Lauer, M.D., University of Iowa
Bruce Z. Morgenstern, M.D., Mayo Clinic
Ronald J. Portman, M.D., The University of Texas Health Science Center at Houston
Ronald J. Prineas, M.D., Ph.D., Wake Forest University School of Medicine
Albert P. Rocchini, M.D., University of Michigan, C.S. Mott Children's Hospital
Bernard Rosner, Ph.D., Harvard School of Public Health
Alan Robert Sinaiko, M.D., University of Minnesota Medical School
Nicolas Stettler, M.D., M.S.C.E., The Children's Hospital of Philadelphia
Elaine Urbina, M.D., Cincinnati Children's Hospital Medical Center
National Institutes of Health Staff
Edward J. Roccella, Ph.D., M.P.H., National Heart, Lung, and Blood Institute
Tracey Hoke, M.D., M.Sc., National Heart, Lung, and Blood Institute
Carl E. Hunt, M.D., National Center for Sleep Disorders Research
Gail Pearson, M.D., Sc.D., National Heart, Lung, and Blood Institute
*Joseph T. Flynn, MD, MS, is a paid contributor to Pfizer, Inc, Novartis Pharmaceuticals, AstraZeneca, Inc, and ESP-Pharma.
SLIDE 3: National High Blood Pressure Education Program Coordinating Committee
American Academy of Family Physicians
American Academy of Insurance Medicine
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Physician Assistants
American Association of Occupational Health Nurses
American College of Cardiology
American College of Chest Physicians
American College of Occupational and Environmental Medicine
American College of Physicians-
American Society of Internal Medicine
American College of Preventive Medicine
American Dental Association
American Diabetes Association
American Dietetic Association
American Heart Association
American Hospital Association
American Medical Association
American Nurses Association
American Optometric Association
American Osteopathic Association
American Pharmaceutical Association
American Podiatric Medical Association
American Public Health Association
American Red Cross
American Society of Health-System Pharmacists
American Society of Hypertension
American Society of Nephrology
Association of Black Cardiologists
Citizens for Public Action on High Blood Pressure and Cholesterol, Inc.
Hypertension Education Foundation, Inc.
International Society on Hypertension in Blacks
National Black Nurses Association, Inc.
National Hypertension Association, Inc.
National Kidney Foundation, Inc.
National Medical Association
National Optometric Association
National Stroke Association
NHLBI Ad Hoc Committee on Minority Populations
Society for Nutrition Education
The Society of Geriatric Cardiology
Federal Agencies:
Agency for Healthcare Research and Quality
Centers for Medicare & Medicaid Services
Department of Veterans Affairs
Health Resources and Services Administration
SLIDE 4: Introduction
Purpose
SLIDE 5: Overview
SLIDE 6: Overview
SLIDE 7: Methods
SLIDE 8: Methods
SLIDE 9: Definition of Hypertension
SLIDE 10: Definition of Hypertension
SLIDE 11: Measurement of Blood Pressure in Children
SLIDE 12: Conditions Under Which Children <3 Years Old Should Have BP Measured
SLIDE 13: Conditions Under Which Children <3 Years Old Should Have BP Measured
SLIDE 14: >Recommended Dimensions for Blood Pressure Cuff Bladders
Age | Range Width (cm) | Length (cm) | Maximum Arm Circumference (cm)* |
---|---|---|---|
Newborn | 4 | 8 | 10 |
Infant | 6 | 12 | 15 |
Child | 9 | 18 | 22 |
Small adult | 10 | 24 | 26 |
Adult | 13 | 30 | 34 |
Large adult | 16 | 38 | 44 |
Thigh | 20 | 42 | 52 |
*Calculated so that the largest arm would still allow the bladder to encircle the arm by at least 80 percent.
*Calculated so that the largest arm would still allow the bladder to encircle the arm by at least 80 percent.
SLIDE 15: Ambulatory Blood Pressure Monitoring
SLIDE 16: Blood Pressure Tables
SLIDE 17: Blood Pressure Levels for Boys by Age and Height Percentile
Age | BP | SBP (mmHg) Percentile of Height |
DBP (mmHg) Percentile of Height |
||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
(Year) |
Percentile |
5th |
10th |
25th |
50th |
75th |
90th |
95th |
5th |
10th |
25th |
50th |
75th |
90th |
95th |
12 |
50th |
102 |
103 |
104 |
105 |
107 |
108 |
109 |
61 |
61 |
61 |
62 |
63 |
64 |
64 |
|
90th |
116 |
116 |
117 |
119 |
120 |
121 |
122 |
75 |
75 |
75 |
76 |
77 |
78 |
78 |
|
95th |
119 |
120 |
121 |
123 |
124 |
125 |
126 |
79 |
79 |
79 |
80 |
81 |
82 |
82 |
|
99th |
127 |
127 |
128 |
130 |
131 |
132 |
133 |
86 |
86 |
87 |
88 |
88 |
89 |
90 |
SLIDE 18: Blood Pressure Levels for Girls by Age and Height Percentile
Age | BP | SBP (mmHg) Percentile of Height |
DBP (mmHg) Percentile of Height |
||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
(Year) |
Percentile |
5th |
10th |
25th |
50th |
75th |
90th |
95th |
5th |
10th |
25th |
50th |
75th |
90th |
95th |
12 |
50th |
101 |
102 |
104 |
106 |
108 |
109 |
110 |
59 |
60 |
61 |
62 |
63 |
63 |
64 |
|
90th |
115 |
116 |
118 |
120 |
121 |
123 |
123 |
74 |
75 |
75 |
76 |
77 |
78 |
79 |
|
95th |
119 |
120 |
122 |
123 |
125 |
127 |
127 |
78 |
79 |
80 |
81 |
82 |
82 |
83 |
|
99th |
126 |
127 |
129 |
131 |
133 |
134 |
135 |
86 |
87 |
88 |
89 |
90 |
90 |
91 |
SLIDE 19: How To Use the BP Tables
SLIDE 20: How To Use the BP Tables
SLIDE 21: How To Use the BP Tables
SLIDE 22: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations
SBP or DBP Percentile |
|
---|---|
Normal |
<90th percentile |
Prehypertension |
90th percentile to <95th percentile, or if BP exceeds 120/80 even if below the 90th percentile up to <95th percentile |
Stage 1 hypertension |
95th percentile to the 99th percentile plus 5 mmHg |
Stage 2 hypertension |
>99th percentile plus 5 mmHg |
SLIDE 23: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations
|
Frequency of BP Measurement |
---|---|
Normal |
Recheck at next scheduled physical examination. |
Prehypertension |
Recheck in 6 months. |
Stage 1 hypertension |
Recheck in 1–2 weeks or sooner if the patient is symptomatic; if BP is persistently elevated on two additional occasions, evaluate or refer to source of care within 1 month. |
Stage 2 hypertension |
Evaluate or refer to source of care within 1 week or immediately if the patient is symptomatic. |
SLIDE 24: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations
|
Therapeutic Lifestyle Changes |
---|---|
Normal |
Encourage healthy diet, sleep, and physical activity. |
Prehypertension |
Recommend weight management counseling if overweight; introduce physical activity and diet management. |
Stage 1 hypertension |
Recommend weight management counseling if overweight; introduce physical activity and diet management. |
Stage 2 hypertension |
Recommend weight management counseling if overweight; introduce physical activity and diet management. |
SLIDE 25: Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations
|
Pharmacologic Therapy |
---|---|
Normal |
None |
Prehypertension |
Do not initiate therapy unless there are compelling indications such as chronic kidney disease (CKD), diabetes mellitus, heart failure, left ventricular hypertrophy (LVH). |
Stage 1 hypertension |
Initiate therapy based on indications for antihypertensive drug therapy or if there are compelling indications as above. |
Stage 2 hypertension |
Initiate therapy. |
SLIDE 26: Indications for Antihypertensive Drug Therapy in Children
SLIDE 27: Clinical Evaluation of Confirmed Hypertension
Study or Procedure |
Purpose |
Target Population |
---|---|---|
Evaluation for identifiable causes |
||
History, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking alcohol; physical examination |
History and physical examination help focus subsequent evaluation |
All children with persistent BP >95th percentile |
BUN, creatinine, electrolytes, urinalysis, urine culture |
R/O renal disease and chronic pyelonephritis |
All children with persistent BP >95th percentile |
CBC |
R/O anemia, consistent with chronic renal disease |
All children with persistent BP >95th percentile |
Renal ultrasound |
R/O renal scar, congenital anomaly, or disparate renal size |
All children with persistent BP >95th percentile |
SLIDE 28: Clinical Evaluation of Confirmed Hypertension
Study or Procedure |
Purpose |
Target Population |
---|---|---|
Evaluation for comorbidity |
||
Fasting lipid panel, fasting glucose |
To identify hyperlipidemia, identify metabolic abnormalities |
Overweight patients with BP at 90th–94th percentiles; all patients with BP >95th percentile Family history of hypertension or cardiovascular disease Child with chronic renal disease |
Drug screen |
To identify substances that might cause hypertension |
History suggestive of possible contribution by substances or drugs |
Polysomnography |
To identify sleep disorder in association with hypertension |
History of loud, frequent snoring |
SLIDE 29: Clinical Evaluation of Confirmed Hypertension
Study or Procedure |
Purpose |
Target Population |
---|---|---|
Evaluation for target-organ damage |
||
Echocardiogram |
Identify LVH and other indications of cardiac involvement |
Patients with comorbid risk factors* and BP at the 90th–94th percentiles; all patients with BP >95th percentile |
Retinal examination |
Identify retinal vascular changes |
Patients with comorbid risk factors and BP at the 90th–94th percentiles; all patients with BP >95th percentile |
Further evaluation as indicated |
|
|
Ambulatory BP monitoring |
Identify white-coat hypertension, abnormal diurnal BP pattern, BP load |
Patients in whom white-coat hypertension is suspected, and when other information on BP pattern is needed |
*Comorbid risk factors also include diabetes mellitus and kidney disease
SLIDE 30: Clinical Evaluation of Confirmed Hypertension
Study or Procedure |
Purpose |
Target Population |
---|---|---|
Plasma renin determination |
Identify low renin, suggesting mineralocorticoid-related disease |
Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension Positive family history of severe hypertension |
Renovascular imaging |
Identify renovascular disease |
Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension |
Plasma and urine steroid levels |
Identify steroid-mediated hypertension |
Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension |
Plasma and urine catecholamines |
Identify catecholamine-mediated hypertension |
Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension |
SLIDE 31: Primary Hypertension and Evaluation for Comorbidities
SLIDE 32: Evaluation for Secondary Hypertension
SLIDE 33: Evaluation for Secondary Hypertension
SLIDE 34: Evaluation for Secondary Hypertension
SLIDE 35: Additional Diagnostic Studies for Hypertension
Renin Profiling
Plasma renin level or plasma renin activity (PRA) is a useful screening test for mineralocorticoid-related diseases.
SLIDE 36: Evaluation for Possible Renovascular Hypertension
Evaluation for renovascular disease also should be considered in infants or children with other known predisposing factors, such as prior umbilical artery catheter placements or neurofibromatosis.
SLIDE 37: Invasive Studies
Digital subtraction angiography and formal arteriography are still considered the "gold standard," but these studies should be undertaken only when surgical or invasive interventional radiologic techniques are being contemplated for anatomic correction.
SLIDE 38: Target-Organ Abnormalities in Children with Hypertension
SLIDE 39: Clinical Recommendation
SLIDE 40: Formula for Calculating Left Ventricular Mass
LV Mass (g) =
0.80 [1.04 (IVS + LVED + LVPW)3 - (LVED)3] + 0.6
Echocardiographic measurements are in cm.
SLIDE 41: Left Ventricular Hypertrophy
SLIDE 42: Therapeutic Lifestyle Changes
SLIDE 43: Therapeutic Lifestyle Changes
SLIDE 44: Pharmacologic Therapy for Childhood Hypertension
SLIDE 45: Pharmacologic Therapy for Childhood Hypertension
SLIDE 46: Management Algorithm
Image of the management algorithm
SLIDE 47: Educational Materials Web Site www.nhlbi.nih.gov
Clinical Reference Tool for Palm OS
Complete Report
SLIDE 48: Web Site
Screen image of the website: http://www.nhlbi.nih.gov
SLIDE 49: Reference Tool for Palm OS
SLIDE 50: Complete Report