Patient education: High blood pressure treatment 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
This topic discusses the treatment options for children and adolescents with high blood pressure. The causes and diagnosis of high blood pressure (hypertension) in children are discussed separately. (See "Patient education: High blood pressure in children (Beyond the Basics)".)
WHY TREAT HYPERTENSION?
There are several important reasons to treat high blood pressure in children:
●To prevent/treat complications of hypertension in childhood, such as seizures or heart failure.
●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.
The first step in the treatment of hypertension is to treat any underlying cause for hypertension (secondary hypertension).
If treating the underlying cause does not adequately reduce blood pressure, or if there is no known underlying cause (primary, formerly called "essential", hypertension), treatments to reduce the blood pressure are recommended. (See "Patient education: High blood pressure in children (Beyond the Basics)", section on 'Types of high blood pressure'.)
Treatment includes lifestyle changes (diet changes, regular exercise, and if appropriate, weight loss) and/or medications.
Lifestyle changes are recommended for children with hypertension (defined as blood pressure >95th percentile) or prehypertension (defined as blood pressure >90th to the 95th percentile or if blood pressure exceeds 120/80 mmHg in adolescents).
Lifestyle changes include:
●Dietary changes, including reducing salt intake and avoiding alcohol
●Although cigarette smoke does not directly affect blood pressure, exposure to cigarette smoke (including secondhand exposure) is a risk factor for cardiovascular disease and should be avoided
●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 30 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 competitive sports. Children and adolescents with high blood pressure are advised to avoid weight lifting until the blood pressure is better controlled.
Exceptions to these recommendations include children with uncontrolled severe hypertension (stage 2 hypertension, see below) or those with abnormalities due to high pressure in their echocardiogram (cardiac ultrasound) such as thickened wall of the left ventricular chamber of the heart, 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 hypertension. 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 education: Low-sodium diet (Beyond the Basics)".)
Smoking and alcohol — Children and adolescents who have hypertension should not smoke because it significantly increases their risk of heart disease and lung cancer. Family members of a child with hypertension are encouraged to quit smoking as well because exposure to secondhand smoke also increases the child's risk of developing heart disease. (See "Patient education: Quitting smoking (Beyond the Basics)".)
Multiple studies in adults have shown that drinking more than two alcoholic beverages per day significantly increases the risk of developing hypertension. Although studies in children are not available, children and adolescents should avoid alcohol for many other health and safety reasons.
In children and adolescents, one or more medications may be recommended to reduce high blood pressure in the following circumstances:
●Hypertension associated with symptoms that are related to elevated blood pressure, such as headaches or seizures.
●Stage 2 hypertension, defined as blood pressure levels that are 5 mmHg greater than the 99th percentile.
●Stage 1 hypertension, defined as blood pressure level between the 95th percentile and stage 2, that persists after four to six months of nonpharmacologic therapy.
●There are physical signs of hypertension, such as a thickened wall of the left ventricular chamber of the heart.
●Stage 1 hypertension in patients with diabetes mellitus or other conditions that increase the risk of heart disease or stroke, such as high cholesterol or lipids, obesity, or chronic kidney disease.
●Prehypertension with more than one risk factor for heart disease (obesity, abnormal cholesterol or lipid levels, diabetes, or chronic kidney disease).
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 — The mechanism of blood pressure lowering effect is not known, but is believed to be due to decreased peripheral resistance after prolonged and consistent administration.
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. These medications are most effective in combination with a low salt diet. (See 'Diet' above.)
ACE inhibitors/ARBs — Angiotensin converting enzyme (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.
Angiotensin receptor blockers (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. In sexually active girls on this medication, these drugs should be avoided due to the potential risk of harm to the fetus if the girl became pregnant. However, for those who receive these medications, regular urine pregnancy tests are obtained during office visits or in between if pregnancy is suspected.
Beta blockers — Beta blockers reduce some of the effects of the sympathetic nervous system. 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 heart block and should be used with caution in children with asthma.
Calcium channel blockers — Muscle cells require calcium to contract. Calcium channel blockers 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 hypertension (primary 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 blood pressure monitored every four to six months. Those with hypertension are generally monitored more often depending upon the severity of their hypertension.
The goal blood pressure for most children with hypertension is less than the 95th percentile. If the child is obese or has high cholesterol, diabetes, or has organ damage related to hypertension, the blood pressure 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.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare 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: Glomerular disease (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.