Patient education: High blood pressure in children (Beyond the Basics)
- 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
- Patrick Niaudet, MD
Patrick Niaudet, MD
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Hôpital Necker-Enfants Malades, Paris, France
- David R Fulton, MD
David R Fulton, MD
- Section Editor — Pediatric Cardiology
- Associate Professor of Pediatrics
- Harvard Medical School
HIGH BLOOD PRESSURE OVERVIEW
Blood pressure refers to the pressure that blood applies to the inner walls of blood vessels. High blood pressure is also called hypertension. Although hypertension is more common in adults, it often develops during childhood and adolescence, and can increase the risk of early heart disease and stroke during adulthood. Fortunately, high blood pressure is easy to measure and can be treated.
WHAT IS BLOOD PRESSURE?
An individual's blood pressure is defined by two measurements:
●Systolic blood pressure is the pressure in the arteries produced when the heart contracts (at the time of a heartbeat).
●Diastolic blood pressure is the pressure in the arteries during relaxation of the heart between heartbeats.
Blood pressure is reported as the systolic blood pressure over diastolic blood pressure (eg, 120/70 or 120 over 70). The diagnosis of high blood pressure can be based upon either measurement as they are of equal importance.
Normal versus high blood pressure — In children, the normal range for blood pressure is determined by the child's gender, age, and height. The normal range is expressed as a percentile, similar to charts used to track children's growth.
As an example, if a child's blood pressure is in the 60th percentile, this means that 60 percent of other children who are that age, gender, and height have a lower blood pressure.
Blood pressure is separated into three categories based upon the child's blood pressure percentile:
Normal blood pressure — Both systolic and diastolic blood pressure <90th percentile.
Prehypertension — Systolic and/or diastolic blood pressure ≥90th percentile but <95th percentile or if blood pressure exceeds 120/80 mmHg (even if <90th percentile for age, gender, and height) for adolescents.
Hypertension — Hypertension is defined as either systolic and/or diastolic blood pressure ≥95th percentile measured on three or more separate occasions, or if blood pressure exceeds 140/90 mmHg for adolescents.
The degree of hypertension is further delineated by the two following stages.
●Stage 1 hypertension – Systolic and/or diastolic blood pressure between the 95th percentile and 5 mmHg above the 99th percentile.
●Stage 2 hypertension – Systolic and/or diastolic blood pressure ≥99th percentile plus 5 mmHg.
HIGH BLOOD PRESSURE SYMPTOMS
A slow increase in blood pressure does not usually cause any symptoms. However, a sudden increase in blood pressure in children and adolescents can cause headache, vomiting, seizures, or heart failure.
BLOOD PRESSURE MEASUREMENT
Expert groups recommend that all children over age three years have their blood pressure measured during routine office visits once per year. Blood pressure measurements may be recommended at an earlier age in children who have kidney or heart disease, or present with any of the above-mentioned symptoms that could indicate hypertension.
It is important for the health care provider to measure the blood pressure accurately, using the correct equipment and technique. Manual measurement gives more accurate reading than digital machines, which can be used for screening BP. Parents should be aware of the following:
●The blood pressure should be measured after the child has been sitting in a quiet environment for a few minutes. The child should be seated with his/her back and feet in a supported position. In infants, blood pressure is measured while the child lies on his/her back. It may be necessary to measure the blood pressure a few times (several minutes apart) to get the most accurate reading.
●The blood pressure should not be measured if the child is crying or unable to cooperate.
●An appropriate-size cuff should be used. A cuff that is too small can overestimate the blood pressure, and a larger cuff may give a lower reading.
●Blood pressure should be measured in the right arm.
●Stimulants such as cigarettes and caffeine should be avoided for several hours before the blood pressure is measured.
HIGH BLOOD PRESSURE DIAGNOSIS
In children with no symptoms, the diagnosis of hypertension is made when the blood pressure is at or greater than the 95th percentile on three separate measurements, which are separated by days or weeks. Waiting period with repeat measurements is not necessary in those with symptoms or clinical signs of hypertension.
When hypertension is diagnosed, testing is recommended to help determine the cause of the hypertension. The evaluation generally includes a medical history and physical examination, measurement of blood pressure in the arms and legs, laboratory tests, and an ultrasound of the heart and kidneys.
Diagnosis of prehypertension is important to prevent its progression to hypertension and for treatment in some patients, such as those with chronic kidney disease, cardiac problems, or diabetes.
TYPES OF HIGH BLOOD PRESSURE
If a child is diagnosed with high blood pressure, the next step is to determine if a cause of the hypertension can be determined. Patients in whom no cause can be identified by history, physical examination or laboratory tests have primary hypertension (formerly called "essential" hypertension), and those with an identifiable cause have secondary hypertension.
Primary hypertension — Primary hypertension has no identifiable cause. It is the most common cause of hypertension in older children and adults.
Primary hypertension is more likely in children who:
●Have completed puberty
●Have a family history of hypertension
●Are overweight or obese
●Have only mild hypertension (blood pressure at or just above the 95th percentile)
Secondary hypertension — Secondary hypertension has a known cause. The most common causes of secondary hypertension include kidney disease, endocrine disorders, heart disease, and some medications.
Secondary hypertension is more likely in children who:
●Are younger than 10 years of age
●Have a sudden increase in blood pressure when the blood pressure has previously been normal
●Have severe hypertension, defined as stage 2 hypertension (blood pressure >5 mmHg above the 99th percentile) (see 'Hypertension' above)
"White coat" hypertension — "White coat" hypertension is the name given to high blood pressure caused by anxiety when blood pressure is measured in clinic or office. Measuring the blood pressure by 24-hour ambulatory blood pressure monitoring, or several times during the office visit (to minimize anxiety), and/or measuring the blood pressure at home outside the clinician's office can help to determine if a person has white coat hypertension or is truly hypertensive.
HIGH BLOOD PRESSURE TREATMENT
Treatment of high blood pressure in children is discussed in detail in a separate topic review. (See "Patient education: High blood pressure treatment in children (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION
Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: High blood pressure in children (The Basics)
Patient education: High blood pressure in adults (The Basics)
Patient education: Controlling your blood pressure through lifestyle (The Basics)
Patient education: Polycystic kidney disease (The Basics)
Patient education: My child is overweight (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Ambulatory blood pressure monitoring in children
Definition and diagnosis of hypertension in children and adolescents
Epidemiology, risk factors, and etiology of hypertension in children and adolescents
Evaluation of hypertension in children and adolescents
Nonemergent treatment of hypertension in children and adolescents
The following organizations also provide reliable health information.
●National Library of Medicine
●The Nemours Foundation
●The National Kidney Foundation
- 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.
- 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.
- McNiece KL, Poffenbarger TS, Turner JL, et al. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr 2007; 150:640.
- Falkner B, Gidding SS, Portman R, Rosner B. Blood pressure variability and classification of prehypertension and hypertension in adolescence. Pediatrics 2008; 122:238.
- Lande MB, Flynn JT. Treatment of hypertension in children and adolescents. Pediatr Nephrol 2009; 24:1939.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.