These pediatric hypertension guidelines are an update of the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents."
Key changes:
- Update of the term “prehypertension” to “elevated blood pressure”
- New normative pediatric blood pressure (BP) tables based on children with normal weight
- Simplified screening table for identifying BPs that require further evaluation
- Simplified BP classification in adolescents (≥ 13 years old)
- A more limited recommendation to perform BP screening only at preventive care visits
- Streamlined recommendations on initial evaluation and management of abnormal BPs
- Focus on ambulatory BP monitoring in the diagnosis and management of hypertension (HTN) among the pediatric population
- Update on when to perform echocardiography in newly diagnosed hypertensive pediatric patients and revised definition of left ventricular hypertrophy
Summary of Key Action Statements
| Key Action Statement 1 | Yearly BP measurement in children and adolescents ≥ 3 years of age |
|---|---|
| Key Action Statement 2 | BP should be monitored in children and adolescents ≥ 3 years of age if they have obesity, are taking medications that may increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes |
| Key Action Statement 3 | Diagnosis of HTN should be made if a child or adolescent has auscultatory-confirmed BP readings ≥ 95th percentile on 3 different occasions |
| Key Action Statement 4 | Organisations with electronic health records should consider including flags for abnormal BP vales during data entry and when they are being viewed |
| Key Action Statement 5 | Validated oscillometric devices may be used for BP screening in children and adolescents, where subsequent auscultation to confirm suspected BP elevation is required |
| Key Action Statement 6 | Ambulatory blood pressure monitoring (ABPM) should be performed to confirm HTN in children and adolescents who had office BP measurements in the elevated BP category for ≥ 1 year, or those with stage 1 HTN over 3 clinic visits |
| Key Action Statement 7 | Routine ABPM should be strongly considered in high-risk children and adolescents to evaluate HTN severity and to determine if abnormal circadian BP patterns are present |
| Key Action Statement 8 | ABPM should be performed by using a standardized approach with validated monitors, while results should be interpreted by using pediatric normative data |
| Key Action Statement 9 | Children and adolescents with suspected white coat hypertension (WCH) should undergo ABPM. Diagnosis is made if mean SBP and DBP < 95th percentile and SBP and DBP load < 25% |
| Key Action Statement 10 | Home BP monitoring should not be used to diagnose HTN, WCH or masked hypertension (MH), but may serve as a useful adjunct to office and ambulatory BP measurement after HTN has been diagnosed |
| Key Action Statement 11 | Children and adolescents ≥ 6 years of age with a positive family history of HTN, are overweight or obese, and/or do not have a history or physical examination findings suggestive of a secondary cause of HTN, do not require an extensive evaluation for secondary causes of HTN |
| Key Action Statement 12 | Children and adolescents who had coarctation repair should undergo ABPM to screen for HTN |
| Key Action Statement 13 | Provider should obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination, to identify possible secondary causes of HTN in children and adolescents who are being evaluated for high BP |
| Key Action Statement 14 | Electrocardiography should not be performed in hypertensive children and adolescents being assessed for left ventricular hypertrophy |
| Key Action Statement 15 | Echocardiography for the assessment of cardiac target organ damage at the time of consideration of pharmacologic treatment of HTN |
| Key Action Statement 16 | Doppler renal ultrasonography may be used as a non-invasive screening tool for the evaluation of possible renal artery stenosis (RAS) in children with normal weight and adolescents ≥ 8 years of age who are suspected of having renovascular HTN |
| Key Action Statement 17 | In children and adolescents suspected of having RAS, clinicians may perform computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) as a noninvasive imaging study, while nuclear renography should generally be avoided |
| Key Action Statement 18 | Routine testing for microalbuminuria (MA) is not recommended for children and adolescents diagnosed with primary HTN |
| Key Action Statement 19 | The treatment goal should be a reduction in SBP and DBP to < 90th percentile and < 130/88 mmHg in adolescents ≥ 13 years old diagnosed with HTN |
| Key Action Statement 20 | After the diagnosis of elevated BP or HTN, clinicians should provide advice on the DASH diet and recommend regular physical activity (moderate to vigorous level, 30-60 minutes per session, at least 3 to 5 days per week) |
| Key Action Statement 21 | In those who failed lifestyle modifications, clinicians should initiate pharmacologic treatment with an ACE inhibitor, angiotensin receptor blockers (ARB), long-acting calcium channel blocker, or thiazide diuretic |
| Key Action Statement 22 | ABPM may be used to assess the effectiveness of treatment in children and adolescents with HTN |
| Key Action Statement 23 | Children and adolescents with chronic kidney disease (CKD) should be evaluated for HTN every time; Those with both CKD and HTN should be treated to lower 24-hour mean arterial pressure (MAP) to < 50th percentile by ABPM; While patients with CKD and a history of HTN should have BP assessed by ABPM at least annually to screen for MH |
| Key Action Statement 24 | Children and adolescents with CKD and HTN should be assessed for proteinuria |
| Key Action Statement 25 | Children and adolescents with CKD, HTN, and proteinuria should be treated with either ACE inhibitor or ARB |
| Key Action Statement 26 | Children and adolescents with type 1 or type 2 diabetes mellitus (T1DM or T2DM) should be assessed for HTN every time and treated if BP is ≥ 95th percentile or > 130/80 mmHg in adolescents ≥ 13 years of age |
| Key Action Statement 27 | Short-acting antihypertensive medication should be initiated immediately for children and adolescents with acute severe HTN and life-threatening symptoms, where BP should be reduced by no more than 20% of the planned reduction over the first 8 hours |
| Key Action Statement 28 | Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and risk have been evaluated |
| Key Action Statement 29 | Before participating in competitive sports, children and adolescents with HTN should receive treatment to lower BP below stage 2 |
| Key Action Statement 30 | Adolescents with elevated BP or HTN should have their care transitioned to a adult care provider by 22 years of age |
Reference
Flynn JT, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904.
Link to full publication: http://pediatrics.aappublications.org/content/early/2017/08/21/peds.2017-1904
