Patient information: High blood pressure treatment in children

HIGH BLOOD PRESSURE OVERVIEW

This topic discusses the treatment options for children and adolescents with high blood pressure. The causes and diagnosis of high blood pressure in children are discussed separately. (See "Patient information: High blood pressure in children".)

WHY TREAT HIGH BLOOD PRESSURE?

There are several important reasons to treat high blood pressure in children:

• To prevent/treat complications of HTN in childhood, such as seizures or heart failure
• High blood pressure (hypertension) that begins in childhood and adolescence may persist into adulthood. Adult hypertension is a major risk factor contributing to early heart attack or stroke.

HIGH BLOOD PRESSURE TREATMENT

The first step in the treatment of high blood pressure is to treat any underlying cause for HTN.

If treating the underlying cause does not adequately reduce blood pressure, or if there is no known underlying cause, treatments to reduce the blood pressure are recommended.

Treatment may include lifestyle changes (diet changes, regular exercise, and if appropriate, weight loss) and/or medications.

LIFESTYLE CHANGES

Lifestyle changes are recommended for children with hypertension (defined as BP >95th percentile) or prehypertension (defined as BP >90th to the 95th percentile or if BP exceeds 120/80 mmHg).

Lifestyle changes include:

• Weight loss for obesity-related HTN.
• Regular exercise
• Dietary changes, including reducing salt intake and avoiding alcohol
• Although cigarette smoke does not directly affect blood pressure, exposure to exposure to cigarette smoke (including second hand exposure) is a risk factor for cardiovascular disease and should be avoided.

Weight loss — A child is said to be obese or overweight based upon the body mass index (BMI), which can be calculated here for boys (calculator 1) and here for girls (calculator 2).

Children who are between the 85th and 95th percentile are said to be overweight while children who are above the 95th percentile are said to be obese.

In children who are obese or overweight, losing weight can help to lower blood pressure. In some cases, the child will be referred to a nutritionist, who can work with the child and parents to formulate a healthy eating plan.

Weight loss is most effective at reducing the blood pressure when it is combined with exercise.

Exercise — Regular exercise can help to lower blood pressure in children and adolescents. Although exercise recommendations for an individual child may vary, general recommendations include the following:

• Twenty to thirty minutes of aerobic exercise per day most days of the week. Aerobic exercise includes walking, swimming, and biking, but not weight lifting or strength training.
• Sedentary activities (watching television and/or playing video and computer games) should be limited to less than two hours per day.

Participation in sports — Children who have controlled high blood pressure are generally allowed to participate in sports. Children and adolescents with high blood pressure are advised to avoid weight lifting.

Exceptions to these recommendations include children with uncontrolled stage 2 HTN, who are generally advised to avoid competitive sports.

Diet — Reducing salt intake and eating more fresh fruits and vegetables and low-fat dairy products can help to reduce blood pressure in children and adolescents with HTN. When possible, the entire family should make these changes to encourage the child to develop healthy eating habits.

To reduce salt intake, some experts recommend using a no-salt added diet and avoiding or eating fewer foods with a high salt content. A full discussion of a low salt diet is available separately. (See "Patient information: Low sodium diet".)

Smoking and alcohol — Children and adolescents who have HTN should not smoke because it significantly increases their risk of heart disease and lung cancer. Family members of a child with HTN are encouraged to quit smoking as well because exposure to second-hand smoke also increases the child's risk of developing heart disease. (See "Patient information: Smoking cessation".)

Multiple studies in adults have shown that drinking more than two alcoholic beverages per day significantly increases the risk of developing HTN. Although studies in children are not available, children and adolescents should avoid alcohol for many other health and safety reasons.

HIGH BLOOD PRESSURE MEDICATIONS

In children and adolescents, one or more medications may be recommended to reduce high blood pressure in the following circumstances:

• HTN is associated with symptoms that are related to elevated blood pressure, such as headaches or seizures
• Stage 2 HTN, defined as BP levels that are 5 mmHg greater than the 99th percentile.
• Stage 1 HTN that persists after four to six months of nonpharmacologic therapy.
• There are physical signs of high blood pressure, such as a thickened wall of the left ventricular chamber of the heart.
• Stage 1 HTN in patients with diabetes mellitus or other conditions that increase the risk of heart disease or stroke, such as high cholesterol or lipids.
• Prehypertension with more than one additional risk factor for heart disease or stroke

Classes of antihypertensive medications — There are several classes of antihypertensive medications commonly used to treat children. These include thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), calcium channel blockers, and beta blockers.

Thiazide diuretics — It is thought that diuretics lower blood pressure primarily by causing the kidneys to excrete more water and sodium, which reduces fluid volume throughout the body. Thiazide diuretics are safe and effective, and are most effective when used in combination with a low salt diet. (See 'Diet' above.)

The most commonly used thiazide diuretics in children are hydrochlorothiazide (HCTZ) and chlorothiazide. These medications are usually taken by mouth once or twice per day. Side effects are uncommon with low doses of thiazide diuretics.

ACE inhibitors/ARBs — ACE inhibitors block production of the hormone angiotensin II, a compound in the blood that causes narrowing of blood vessels and increases blood pressure. By reducing production of angiotensin II, ACE inhibitors cause dilation (widening of the blood vessels), which lowers blood pressure. The most common side effect of ACE inhibitors is a dry cough.

ARBs block the effects of angiotensin II on cells in the heart and blood vessels. Similar to ACE inhibitors, ARBs dilate blood vessels and lower blood pressure. Some people who take ARBs experience dizziness, drowsiness, headache, nausea, dry mouth, abdominal pain, or other side effects.

The most commonly used ACE inhibitors in children include enalapril and lisinopril. Losartan is an ARB that is approved for children. These drugs are not recommended for sexually active girls due to the potential risk of harm to the fetus if the girl became pregnant.

Beta blockers — Beta blockers reduce some of the effects of the sympathetic nervous system, such as increases in the heart rate and blood pressure. Beta blockers lower blood pressure in part by decreasing the rate and force with which the heart pumps blood. Commonly used beta blockers include metoprolol, atenolol, and bisoprolol.

Side effects of beta blockers can include fatigue, dizziness, insomnia, a decreased ability to exercise, a slow heart rate, rash, and cold hands or feet due to reduced blood flow to the limbs. Beta blockers should not be used in children with asthma or heart block.

Calcium channel blockers — Muscle cells require calcium to contract. Calcium channel blockers drugs reduce the amount of calcium that enters the smooth muscle in blood vessel walls and heart muscle. Thus, by inhibiting the flow of calcium across muscle cell membranes, calcium channel blockers cause muscle cells to relax and blood vessels to dilate, reducing blood pressure.

Side effects of calcium channel blockers can include headache, dizziness, flushing, nausea, overgrowth of the gum tissue (gingival hyperplasia), or swelling of the lower legs or feet.

How long are medications needed? — It is difficult to know how long a child will require antihypertensive medication(s). The length of treatment depends upon the type of HTN (essential versus secondary), the success of nonpharmacologic treatments, and the ability to reverse any underlying medical problems.

BLOOD PRESSURE MONITORING AND GOALS

Children and adolescents with prehypertension who are treated with nonpharmacologic therapies usually have their BP monitored every four to six months. Those with HTN are generally monitored more often depending upon the severity of their HTN.

The goal blood pressure for most children with HTN is less than the 95th percentile. If the child is obese or has high cholesterol, diabetes, or has organ damage related to HTN, the BP goal is less than the 90th percentile. Blood pressure percentiles can be calculated here for boys (calculator 3) and here for girls (calculator 4).

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: High blood pressure in children
Patient information: Low sodium diet
Patient information: Smoking cessation

Professional Level Information:
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
Treatment of hypertension in children and adolescents

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The Nemours Foundation

      (http://kidshealth.org/parent/medical/heart/hypertension.html)

• The National Kidney Foundation

      (www.kidney.org/atoz/atozItem.cfm?id=164)

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