Definition and diagnosis of hypertension in children and adolescents
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
- Section Editors
- F Bruder Stapleton, MD
F Bruder Stapleton, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Nephrology
- Professor and Chair, Department of Pediatrics
- University of Washington School of Medicine
- David R Fulton, MD
David R Fulton, MD
- Section Editor — Pediatric Cardiology
- Associate Professor of Pediatrics
- Harvard Medical School
There is increasing evidence that adult hypertension (HTN) has its antecedents during childhood, as childhood blood pressure (BP) predicts adult BP [1,2]. HTN in childhood and adolescence may contribute to premature atherosclerosis and the early development of cardiovascular disease (CVD). As a result, identifying children with HTN and successfully treating their HTN may have an important impact on long-term outcomes of CVD. (See "Risk factors and development of atherosclerosis in childhood", section on 'Atherosclerotic changes in childhood' and "Risk factors and development of atherosclerosis in childhood", section on 'Hypertension' and "Nonemergent treatment of hypertension in children and adolescents", section on 'Rationale for intervention'.)
The definition and diagnosis of HTN in children will be reviewed here. The risk factors, epidemiology, etiology, evaluation, and treatment of HTN in children are discussed separately. (See "Epidemiology, risk factors, and etiology of hypertension in children and adolescents" and "Evaluation of hypertension in children and adolescents" and "Nonemergent treatment of hypertension in children and adolescents".)
United States — The National High Blood Pressure Education Program Working Group (NHBPEP) established guidelines for the definition of normal and elevated blood pressures in children in 1987 and were updated in 2004 [3,4].
The definition of childhood hypertension (HTN) is based upon the normative distribution of blood pressure (BP) in healthy children. This is in contrast to adult HTN, which is primarily defined by clinical outcome data (ie, risk of cardiovascular disease and mortality) from large trials of antihypertensive therapy [3-5]. This clinical definition cannot be applied to children because cardiovascular (CV) events other than left ventricular hypertrophy do not typically occur until adulthood. (See "Overview of hypertension in adults".)
Body size is the most important determinant of BP in children and adolescents. Thus, classification of BP is more accurate when the values are adjusted for height as well as age and gender to avoid misclassifying children at the extremes of normal growth [4,6].
- Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics 1989; 84:633.
- Sun SS, Grave GD, Siervogel RM, et al. Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics 2007; 119:237.
- Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics 1987; 79:1.
- National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114:555.
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507.
- Rosner B, Prineas RJ, Loggie JM, Daniels SR. Blood pressure nomograms for children and adolescents, by height, sex, and age, in the United States. J Pediatr 1993; 123:871.
- Falkner B, Gidding SS, Portman R, Rosner B. Blood pressure variability and classification of prehypertension and hypertension in adolescence. Pediatrics 2008; 122:238.
- Chiolero A, Bovet P, Paradis G, Paccaud F. Has blood pressure increased in children in response to the obesity epidemic? Pediatrics 2007; 119:544.
- Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation 2007; 116:1488.
- Watkins D, McCarron P, Murray L, et al. Trends in blood pressure over 10 years in adolescents: analyses of cross sectional surveys in the Northern Ireland Young Hearts project. BMJ 2004; 329:139.
- Rosner B, Cook N, Portman R, et al. Determination of blood pressure percentiles in normal-weight children: some methodological issues. Am J Epidemiol 2008; 167:653.
- Menghetti E, Virdis R, Strambi M, et al. Blood pressure in childhood and adolescence: the Italian normal standards. Study Group on Hypertension' of the Italian Society of Pediatrics'. J Hypertens 1999; 17:1363.
- Blake KV, Gurrin LC, Evans SF, et al. Reference ranges for blood pressure in preschool Australians, obtained by oscillometry. J Paediatr Child Health 2000; 36:41.
- Jackson LV, Thalange NK, Cole TJ. Blood pressure centiles for Great Britain. Arch Dis Child 2007; 92:298.
- Xi B, Zhang M, Zhang T, et al. Hypertension screening using blood pressure to height ratio. Pediatrics 2014; 134:e106.
- Xi B, Zong X, Kelishadi R, et al. Establishing International Blood Pressure References Among Nonoverweight Children and Adolescents Aged 6 to 17 Years. Circulation 2016; 133:398.
- Daniels SR. How to Define Hypertension in Children and Adolescents. Circulation 2016; 133:350.
- Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2016; 34:1887.
- Lo JC, Sinaiko A, Chandra M, et al. Prehypertension and hypertension in community-based pediatric practice. Pediatrics 2013; 131:e415.
- Sorof JM, Lai D, Turner J, et al. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 2004; 113:475.
- McNiece KL, Poffenbarger TS, Turner JL, et al. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr 2007; 150:640.
- Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA 2007; 298:874.
- Brady TM, Solomon BS, Neu AM, et al. Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics 2010; 125:e1286.
- Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 2005; 111:697.
- Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics 2011; 128 Suppl 5:S213.
- Moyer VA, U.S. Preventive Services Task Force. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics 2013; 132:907.
- Urbina EM, de Ferranti S, Steinberger J. Observational studies may be more important than randomized clinical trials: weaknesses in US Preventive Services Task Force recommendation on blood pressure screening in youth. Hypertension 2014; 63:638.
- Brady TM, Redwine KM, Flynn JT, American Society of Pediatric Nephrology. Screening blood pressure measurement in children: are we saving lives? Pediatr Nephrol 2014; 29:947.
- Lande MB, Flynn JT. Treatment of hypertension in children and adolescents. Pediatr Nephrol 2009; 24:1939.
- Shear CL, Burke GL, Freedman DS, Berenson GS. Value of childhood blood pressure measurements and family history in predicting future blood pressure status: results from 8 years of follow-up in the Bogalusa Heart Study. Pediatrics 1986; 77:862.
- Katz SH, Hediger ML, Schall JI, et al. Blood pressure, growth and maturation from childhood through adolescence. Mixed longitudinal analyses of the Philadelphia Blood Pressure Project. Hypertension 1980; 2:55.
- Beckett LA, Rosner B, Roche AF, Guo S. Serial changes in blood pressure from adolescence into adulthood. Am J Epidemiol 1992; 135:1166.
- Falkner B, Kushner H, Onesti G, Angelakos ET. Cardiovascular characteristics in adolescents who develop essential hypertension. Hypertension 1981; 3:521.
- Redwine KM, Acosta AA, Poffenbarger T, et al. Development of hypertension in adolescents with pre-hypertension. J Pediatr 2012; 160:98.
- Park MK, Troxler RG. Systemic hypertension. In: Pediatric Cardiology for Practitioners, 4th ed, Park MK (Ed), Mosby, St. Louis 2002. p.408.
- Williams CL, Hayman LL, Daniels SR, et al. Cardiovascular health in childhood: A statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 2002; 106:143.
- Clark JA, Lieh-Lai MW, Sarnaik A, Mattoo TK. Discrepancies between direct and indirect blood pressure measurements using various recommendations for arm cuff selection. Pediatrics 2002; 110:920.
- Arafat M, Mattoo TK. Measurement of blood pressure in children: recommendations and perceptions on cuff selection. Pediatrics 1999; 104:e30.
- Recommendations for routine blood pressure measurement by indirect cuff sphygmomanometry. American Society of Hypertension. Am J Hypertens 1992; 5:207.
- Shah AS, Dolan LM, D'Agostino RB Jr, et al. Comparison of mercury and aneroid blood pressure measurements in youth. Pediatrics 2012; 129:e1205.
- Beevers G, Lip GY, O'Brien E. ABC of hypertension: Blood pressure measurement. Part II-conventional sphygmomanometry: technique of auscultatory blood pressure measurement. BMJ 2001; 322:1043.
- Sinaiko AR, Gomez-Marin O, Prineas RJ. Diastolic fourth and fifth phase blood pressure in 10-15-year-old children. The Children and Adolescent Blood Pressure Program. Am J Epidemiol 1990; 132:647.
- Knecht KR, Seller JD, Alpert BS. Korotkoff sounds in neonates, infants, and toddlers. Am J Cardiol 2009; 103:1165.
- Bailey RH, Bauer JH. A review of common errors in the indirect measurement of blood pressure. Sphygmomanometry. Arch Intern Med 1993; 153:2741.
- Gillman MW, Cook NR. Blood pressure measurement in childhood epidemiological studies. Circulation 1995; 92:1049.
- Sinaiko AR, Gomez-Marin O, Prineas RJ. Prevalence of "significant" hypertension in junior high school-aged children: the Children and Adolescent Blood Pressure Program. J Pediatr 1989; 114:664.
- Hartley RM, Velez R, Morris RW, et al. Confirming the diagnosis of mild hypertension. Br Med J (Clin Res Ed) 1983; 286:287.
- Watson RD, Lumb R, Young MA, et al. Variation in cuff blood pressure in untreated outpatients with mild hypertension--implications for initiating antihypertensive treatment. J Hypertens 1987; 5:207.
- Chiolero A, Cachat F, Burnier M, et al. Prevalence of hypertension in schoolchildren based on repeated measurements and association with overweight. J Hypertens 2007; 25:2209.
- Woroniecki RP, Flynn JT. How are hypertensive children evaluated and managed? A survey of North American pediatric nephrologists. Pediatr Nephrol 2005; 20:791.
- Duncombe SL, Voss C, Harris KC. Oscillometric and auscultatory blood pressure measurement methods in children: a systematic review and meta-analysis. J Hypertens 2017; 35:213.
- Park MK, Menard SW, Yuan C. Comparison of auscultatory and oscillometric blood pressures. Arch Pediatr Adolesc Med 2001; 155:50.
- Podoll A, Grenier M, Croix B, Feig DI. Inaccuracy in pediatric outpatient blood pressure measurement. Pediatrics 2007; 119:e538.
- Kaufmann MA, Pargger H, Drop LJ. Oscillometric blood pressure measurements by different devices are not interchangeable. Anesth Analg 1996; 82:377.
- Flynn JT, Pierce CB, Miller ER 3rd, et al. Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr 2012; 160:434.
- Lurbe E, Sorof JM, Daniels SR. Clinical and research aspects of ambulatory blood pressure monitoring in children. J Pediatr 2004; 144:7.
- Flynn JT. Ambulatory blood pressure monitoring in children: imperfect yet essential. Pediatr Nephrol 2011; 26:2089.
- Flynn JT, Daniels SR, Hayman LL, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension 2014; 63:1116.
- Wühl E, Witte K, Soergel M, et al. Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions. J Hypertens 2002; 20:1995.
- Flynn JT, Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertens (Greenwich) 2012; 14:372.
- United States
- - Severity
- - Limitations
- Other countries
- Screening and monitoring BP
- - Timing of follow-up
- - Tracking
- MEASUREMENT OF BLOOD PRESSURE
- Cuff size
- - Technique of BP measurement
- - Number of measurements
- Oscillometric devices
- Our approach
- AMBULATORY BP MEASUREMENTS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS