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Definition and diagnosis of hypertension in children and adolescents

Tej K Mattoo, MD, DCH, FRCP
Section Editors
F Bruder Stapleton, MD
David R Fulton, MD
Deputy Editor
Melanie S Kim, MD


There is increasing evidence that adult hypertension (HTN) has its antecedents during childhood, as childhood blood pressure (BP) predicts adult BP [1-3]. 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 — In 2017, the American Academy of Pediatrics (AAP) published revised guidelines for screening and managing high blood pressure (BP) for children and adolescents (table 1)[4]. As was true with previous guidelines, high BP, including HTN, is defined from normative distribution of BP data in healthy children that includes children from the National Health and Nutrition Examination Survey (NHANES) and other screening studies. This is in contrast to adult HTN, which is primarily defined by clinical outcome data (ie, risk of cardiovascular disease [CVD] and mortality) from large trials of antihypertensive therapy. However, these outcome measures cannot be applied to children because cardiovascular (CV) events other than left ventricular hypertrophy do not typically occur in childhood. (See "Overview of hypertension in adults".)

Because height and gender are important determinants of pediatric BP, BP levels are interpreted based on gender, age, and height. In the 2017 AAP guidelines, normative tables (table 2 and table 3) were revised by using data only from normal-weight children. The revised tables excluded BP data from overweight and obese children (ie, children with BMI ≥85th percentile) that were previously included in normative BP databases. As a result, BP values are several mmHg lower than similar tables in previously published normative values by the National High Blood Pressure Education Program (NHBPEP) Working Group [4,5].

In children, definitions that categorize BP values were modified by the 2017 AAP guidelines (table 1) into two age groups [4]. Of note, the newly revised definitions for adolescents are aligned with adult guidelines for the detection of chronic elevated BP. With an acute elevation of BP, it is the magnitude and the rate of increase above baseline that determines the risk of serious morbidity and, at times, mortality. (See "Management of hypertensive emergencies and urgencies in children".)

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Literature review current through: Nov 2017. | This topic last updated: Oct 17, 2017.
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  1. Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics 1989; 84:633.
  2. 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.
  3. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation 2008; 117:3171.
  4. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  5. 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.
  6. Falkner B, Gidding SS, Portman R, Rosner B. Blood pressure variability and classification of prehypertension and hypertension in adolescence. Pediatrics 2008; 122:238.
  7. 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.
  8. 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.
  9. Jackson LV, Thalange NK, Cole TJ. Blood pressure centiles for Great Britain. Arch Dis Child 2007; 92:298.
  10. Dong Y, Ma J, Song Y, et al. National Blood Pressure Reference for Chinese Han Children and Adolescents Aged 7 to 17 Years. Hypertension 2017; 70:897.
  11. 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.
  12. Daniels SR. How to Define Hypertension in Children and Adolescents. Circulation 2016; 133:350.
  13. 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.
  14. Lo JC, Sinaiko A, Chandra M, et al. Prehypertension and hypertension in community-based pediatric practice. Pediatrics 2013; 131:e415.
  15. 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.
  16. 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.
  17. Beckett LA, Rosner B, Roche AF, Guo S. Serial changes in blood pressure from adolescence into adulthood. Am J Epidemiol 1992; 135:1166.
  18. Falkner B, Kushner H, Onesti G, Angelakos ET. Cardiovascular characteristics in adolescents who develop essential hypertension. Hypertension 1981; 3:521.
  19. Redwine KM, Acosta AA, Poffenbarger T, et al. Development of hypertension in adolescents with pre-hypertension. J Pediatr 2012; 160:98.
  20. 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.
  21. 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.
  22. 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.
  23. Park MK, Troxler RG. Systemic hypertension. In: Pediatric Cardiology for Practitioners, 4th ed, Park MK (Ed), Mosby, St. Louis 2002. p.408.
  24. 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.
  25. 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.
  26. Canzanello VJ, Jensen PL, Schwartz GL. Are aneroid sphygmomanometers accurate in hospital and clinic settings? Arch Intern Med 2001; 161:729.
  27. Recommendations for routine blood pressure measurement by indirect cuff sphygmomanometry. American Society of Hypertension. Am J Hypertens 1992; 5:207.
  28. 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.
  29. 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.
  30. Bailey RH, Bauer JH. A review of common errors in the indirect measurement of blood pressure. Sphygmomanometry. Arch Intern Med 1993; 153:2741.
  31. Gillman MW, Cook NR. Blood pressure measurement in childhood epidemiological studies. Circulation 1995; 92:1049.
  32. 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.
  33. Hartley RM, Velez R, Morris RW, et al. Confirming the diagnosis of mild hypertension. Br Med J (Clin Res Ed) 1983; 286:287.
  34. 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.
  35. Woroniecki RP, Flynn JT. How are hypertensive children evaluated and managed? A survey of North American pediatric nephrologists. Pediatr Nephrol 2005; 20:791.
  36. 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.
  37. Park MK, Menard SW, Yuan C. Comparison of auscultatory and oscillometric blood pressures. Arch Pediatr Adolesc Med 2001; 155:50.
  38. Podoll A, Grenier M, Croix B, Feig DI. Inaccuracy in pediatric outpatient blood pressure measurement. Pediatrics 2007; 119:e538.
  39. Kaufmann MA, Pargger H, Drop LJ. Oscillometric blood pressure measurements by different devices are not interchangeable. Anesth Analg 1996; 82:377.
  40. 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.
  41. Lande MB, Flynn JT. Treatment of hypertension in children and adolescents. Pediatr Nephrol 2009; 24:1939.
  42. Lurbe E, Sorof JM, Daniels SR. Clinical and research aspects of ambulatory blood pressure monitoring in children. J Pediatr 2004; 144:7.
  43. Flynn JT. Ambulatory blood pressure monitoring in children: imperfect yet essential. Pediatr Nephrol 2011; 26:2089.
  44. 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.
  45. 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.
  46. Flynn JT, Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertens (Greenwich) 2012; 14:372.