Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Nonemergent treatment of hypertension in children and adolescents

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


It has become clear that hypertension (HTN) begins in childhood and adolescence and that it contributes to the early development of cardiovascular disease (CVD). In hypertensive adults, multiple randomized trials have shown that reduction of blood pressure (BP) by antihypertensive therapy reduces cardiovascular morbidity and mortality. Based upon these observations, identifying children with HTN and successfully treating their HTN should have an important impact on long-term outcomes of CVD. (See "Hypertension: Who should be treated?".)

Issues related to the ambulatory (outpatient) treatment of persistent HTN in children and adolescents will be reviewed here. The epidemiology, etiology, diagnosis, and evaluation of HTN are discussed separately. (See "Epidemiology, risk factors, and etiology of hypertension in children and adolescents" and "Definition and diagnosis of hypertension in children and adolescents" and "Evaluation of hypertension in children and adolescents".)

The treatment of hypertensive emergencies and urgencies in children is also presented elsewhere. (See "Management of hypertensive emergencies and urgencies in children".)


In children, definitions based upon the 2017 American Academy of Pediatrics (AAP) guidelines for screening and managing high blood pressure for children and adolescents for high blood pressure (BP) in children and adolescents are used to classify BP measurements for two different age groups in the United States (table 1) [1]. BP percentiles are based upon gender, age, and height (table 2 and table 3). (See "Definition and diagnosis of hypertension in children and adolescents", section on 'Definition'.)

Childhood HTN is also divided into two categories depending upon whether or not an underlying cause can be identified (table 4):

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Oct 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. 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.
  2. Thompson M, Dana T, Bougatsos C, et al. Screening for hypertension in children and adolescents to prevent cardiovascular disease. Pediatrics 2013; 131:490.
  3. Juhola J, Magnussen CG, Berenson GS, et al. Combined effects of child and adult elevated blood pressure on subclinical atherosclerosis: the International Childhood Cardiovascular Cohort Consortium. Circulation 2013; 128:217.
  4. Leiba A, Twig G, Levine H, et al. Hypertension in late adolescence and cardiovascular mortality in midlife: a cohort study of 2.3 million 16- to 19-year-old examinees. Pediatr Nephrol 2016; 31:485.
  5. Li S, Chen W, Srinivasan SR, Berenson GS. Childhood blood pressure as a predictor of arterial stiffness in young adults: the bogalusa heart study. Hypertension 2004; 43:541.
  6. Aatola H, Magnussen CG, Koivistoinen T, et al. Simplified definitions of elevated pediatric blood pressure and high adult arterial stiffness. Pediatrics 2013; 132:e70.
  7. Mahoney LT, Burns TL, Stanford W, et al. Coronary risk factors measured in childhood and young adult life are associated with coronary artery calcification in young adults: the Muscatine Study. J Am Coll Cardiol 1996; 27:277.
  8. Davis PH, Dawson JD, Mahoney LT, Lauer RM. Increased carotid intimal-medial thickness and coronary calcification are related in young and middle-aged adults. The Muscatine study. Circulation 1999; 100:838.
  9. Raitakari OT, Juonala M, Taittonen L, et al. Pulse pressure in youth and carotid intima-media thickness in adulthood: the cardiovascular risk in young Finns study. Stroke 2009; 40:1519.
  10. Sorof JM, Alexandrov AV, Cardwell G, Portman RJ. Carotid artery intimal-medial thickness and left ventricular hypertrophy in children with elevated blood pressure. Pediatrics 2003; 111:61.
  11. Daniels SR, Witt SA, Glascock B, et al. Left atrial size in children with hypertension: the influence of obesity, blood pressure, and left ventricular mass. J Pediatr 2002; 141:186.
  12. Daniels SR, Loggie JM, Khoury P, Kimball TR. Left ventricular geometry and severe left ventricular hypertrophy in children and adolescents with essential hypertension. Circulation 1998; 97:1907.
  13. Litwin M, Niemirska A, Sladowska-Kozlowska J, et al. Regression of target organ damage in children and adolescents with primary hypertension. Pediatr Nephrol 2010; 25:2489.
  14. Seeman T, Gilík J, Vondrák K, et al. Regression of left-ventricular hypertrophy in children and adolescents with hypertension during ramipril monotherapy. Am J Hypertens 2007; 20:990.
  15. Seeman T, Dostálek L, Gilík J. Control of hypertension in treated children and its association with target organ damage. Am J Hypertens 2012; 25:389.
  16. Matteucci MC, Chinali M, Rinelli G, et al. Change in cardiac geometry and function in CKD children during strict BP control: a randomized study. Clin J Am Soc Nephrol 2013; 8:203.
  17. Kupferman JC, Aronson Friedman L, Cox C, et al. BP control and left ventricular hypertrophy regression in children with CKD. J Am Soc Nephrol 2014; 25:167.
  18. 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.
  19. Kelly RK, Thomson R, Smith KJ, et al. Factors Affecting Tracking of Blood Pressure from Childhood to Adulthood: The Childhood Determinants of Adult Health Study. J Pediatr 2015; 167:1422.
  20. Sorof J, Daniels S. Obesity hypertension in children: a problem of epidemic proportions. Hypertension 2002; 40:441.
  21. Rocchini AP, Katch V, Anderson J, et al. Blood pressure in obese adolescents: effect of weight loss. Pediatrics 1988; 82:16.
  22. Rocchini AP, Key J, Bondie D, et al. The effect of weight loss on the sensitivity of blood pressure to sodium in obese adolescents. N Engl J Med 1989; 321:580.
  23. Wabitsch M, Hauner H, Heinze E, et al. Body-fat distribution and changes in the atherogenic risk-factor profile in obese adolescent girls during weight reduction. Am J Clin Nutr 1994; 60:54.
  24. Holm JC, Gamborg M, Neland M, et al. Longitudinal changes in blood pressure during weight loss and regain of weight in obese boys and girls. J Hypertens 2012; 30:368.
  25. Cai L, Wu Y, Wilson RF, et al. Effect of childhood obesity prevention programs on blood pressure: a systematic review and meta-analysis. Circulation 2014; 129:1832.
  26. Hansen HS, Froberg K, Hyldebrandt N, Nielsen JR. A controlled study of eight months of physical training and reduction of blood pressure in children: the Odense schoolchild study. BMJ 1991; 303:682.
  27. Rocchini AP, Katch V, Schork A, Kelch RP. Insulin and blood pressure during weight loss in obese adolescents. Hypertension 1987; 10:267.
  28. Kelley GA, Kelley KS, Tran ZV. The effects of exercise on resting blood pressure in children and adolescents: a meta-analysis of randomized controlled trials. Prev Cardiol 2003; 6:8.
  29. Gidding SS, Barton BA, Dorgan JA, et al. Higher self-reported physical activity is associated with lower systolic blood pressure: the Dietary Intervention Study in Childhood (DISC). Pediatrics 2006; 118:2388.
  30. Farpour-Lambert NJ, Aggoun Y, Marchand LM, et al. Physical activity reduces systemic blood pressure and improves early markers of atherosclerosis in pre-pubertal obese children. J Am Coll Cardiol 2009; 54:2396.
  31. Knowles G, Pallan M, Thomas GN, et al. Physical activity and blood pressure in primary school children: a longitudinal study. Hypertension 2013; 61:70.
  32. Mark AE, Janssen I. Dose-response relation between physical activity and blood pressure in youth. Med Sci Sports Exerc 2008; 40:1007.
  33. Mitchell BM, Gutin B, Kapuku G, et al. Left ventricular structure and function in obese adolescents: relations to cardiovascular fitness, percent body fat, and visceral adiposity, and effects of physical training. Pediatrics 2002; 109:E73.
  34. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001; 344:3.
  35. Cooper R, Van Horn L, Liu K, et al. A randomized trial on the effect of decreased dietary sodium intake on blood pressure in adolescents. J Hypertens 1984; 2:361.
  36. Howe PR, Cobiac L, Smith RM. Lack of effect of short-term changes in sodium intake on blood pressure in adolescent schoolchildren. J Hypertens 1991; 9:181.
  37. Couch SC, Saelens BE, Levin L, et al. The efficacy of a clinic-based behavioral nutrition intervention emphasizing a DASH-type diet for adolescents with elevated blood pressure. J Pediatr 2008; 152:494.
  38. Moore LL, Bradlee ML, Singer MR, et al. Dietary Approaches to Stop Hypertension (DASH) eating pattern and risk of elevated blood pressure in adolescent girls. Br J Nutr 2012; 108:1678.
  39. Günther AL, Liese AD, Bell RA, et al. Association between the dietary approaches to hypertension diet and hypertension in youth with diabetes mellitus. Hypertension 2009; 53:6.
  40. Chaturvedi S, Lipszyc DH, Licht C, et al. Pharmacological interventions for hypertension in children. Cochrane Database Syst Rev 2014; :CD008117.
  41. Shahinfar S, Rippley R, Hogg RJ, et al. Multicenter study of enalapril pharmacokinetics in hypertensive children and infants. Pediatr Res 2000; 47:473A.
  42. Wells T, Frame V, Soffer B, et al. A double-blind, placebo-controlled, dose-response study of the effectiveness and safety of enalapril for children with hypertension. J Clin Pharmacol 2002; 42:870.
  43. Soffer B, Zhang Z, Miller K, et al. A double-blind, placebo-controlled, dose-response study of the effectiveness and safety of lisinopril for children with hypertension. Am J Hypertens 2003; 16:795.
  44. Hogg RJ, Delucchi A, Sakihara G, et al. A multicenter study of the pharmacokinetics of lisinopril in pediatric patients with hypertension. Pediatr Nephrol 2007; 22:695.
  45. US Food and Drug Administration. Center for Drug Evaluation and Research. Approved active moieties for which FDA has issued a written request for pediatric studies under Section 3 of the Best Pharmaceuticals for Children Act. www.fda.gov/cder/foi/esum/2003/19915s037.pdf (Accessed on November 01, 2007).
  46. Menon S, Berezny KY, Kilaru R, et al. Racial differences are seen in blood pressure response to fosinopril in hypertensive children. Am Heart J 2006; 152:394.
  47. MacGregor GA, Markandu ND, Singer DR, et al. Moderate sodium restriction with angiotensin converting enzyme inhibitor in essential hypertension: a double blind study. Br Med J (Clin Res Ed) 1987; 294:531.
  48. Sakarcan A, Tenney F, Wilson JT, et al. The pharmacokinetics of irbesartan in hypertensive children and adolescents. J Clin Pharmacol 2001; 41:742.
  49. Shahinfar S, Cano F, Soffer BA, et al. A double-blind, dose-response study of losartan in hypertensive children. Am J Hypertens 2005; 18:183.
  50. Trachtman H, Hainer JW, Sugg J, et al. Efficacy, safety, and pharmacokinetics of candesartan cilexetil in hypertensive children aged 6 to 17 years. J Clin Hypertens (Greenwich) 2008; 10:743.
  51. Schaefer F, Coppo R, Bagga A, et al. Efficacy and safety of valsartan in hypertensive children 6 months to 5 years of age. J Hypertens 2013; 31:993.
  52. Wells T, Blumer J, Meyers KE, et al. Effectiveness and safety of valsartan in children aged 6 to 16 years with hypertension. J Clin Hypertens (Greenwich) 2011; 13:357.
  53. Hazan L, Hernández Rodriguez OA, Bhorat AE, et al. A double-blind, dose-response study of the efficacy and safety of olmesartan medoxomil in children and adolescents with hypertension. Hypertension 2010; 55:1323.
  54. Flynn JT, Daniels SR. Pharmacologic treatment of hypertension in children and adolescents. J Pediatr 2006; 149:746.
  55. Herder SD, Weber E, Winkemann A, et al. Efficacy and safety of angiotensin II receptor type 1 antagonists in children and adolescents. Pediatr Nephrol 2010; 25:801.
  56. Blowey DL. Diuretics in the treatment of hypertension. Pediatr Nephrol 2016; 31:2223.
  57. Sorof JM, Cargo P, Graepel J, et al. Beta-blocker/thiazide combination for treatment of hypertensive children: a randomized double-blind, placebo-controlled trial. Pediatr Nephrol 2002; 17:345.
  58. Berenson GS, Shear CL, Chiang YK, et al. Combined low-dose medication and primary intervention over a 30-month period for sustained high blood pressure in childhood. Am J Med Sci 1990; 299:79.
  59. Ram CV, Garrett BN, Kaplan NM. Moderate sodium restriction and various diuretics in the treatment of hypertension. Arch Intern Med 1981; 141:1015.
  60. Singer DR, Markandu ND, Sugden AL, et al. Sodium restriction in hypertensive patients treated with a converting enzyme inhibitor and a thiazide. Hypertension 1991; 17:798.
  61. Tallian KB, Nahata MC, Turman MA, et al. Efficacy of amlodipine in pediatric patients with hypertension. Pediatr Nephrol 1999; 13:304.
  62. Flynn JT, Smoyer WE, Bunchman TE. Treatment of hypertensive children with amlodipine. Am J Hypertens 2000; 13:1061.
  63. Flynn JT, Newburger JW, Daniels SR, et al. A randomized, placebo-controlled trial of amlodipine in children with hypertension. J Pediatr 2004; 145:353.
  64. Andersen J, Groshong T, Tobias JD. Preliminary experience with amlodipine in the pediatric population. Am J Ther 2006; 13:198.
  65. Flynn JT. Efficacy and safety of prolonged amlodipine treatment in hypertensive children. Pediatr Nephrol 2005; 20:631.
  66. Trachtman H, Frank R, Mahan JD, et al. Clinical trial of extended-release felodipine in pediatric essential hypertension. Pediatr Nephrol 2003; 18:548.
  67. Falkner B, Lowenthal DT, Affrime MB. The pharmacodynamic effectiveness of metoprolol in adolescent hypertension. Pediatr Pharmacol (New York) 1982; 2:49.
  68. Kornbluth A, Frishman WH, Ackerman M. Beta-adrenergic blockade in children. Cardiol Clin 1987; 5:629.
  69. US Food and Drug Administration. Summaries of medical and clinical pharmacology reviews of pediatric studies. www.fda.gov/cder/pediatric/Summaryreview.htm (Accessed on October 05, 2007).
  70. 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.
  71. Feld LG, Waz WR. Treatment of hypertension. In: Pediatric Nephrology, Barratt TM, Avner ED, Harmon WE (Eds), Lippincott Williams & Wilkins, Philadelphia 1999. p.63.
  72. Ferguson MA, Flynn JT. Rational use of antihypertensive medications in children. Pediatr Nephrol 2014; 29:979.
  73. Hilgers KF, Dötsch J, Rascher W, Mann JF. Treatment strategies in patients with chronic renal disease: ACE inhibitors, angiotensin receptor antagonists, or both? Pediatr Nephrol 2004; 19:956.
  74. Flynn JT, Mitsnefes M, Pierce C, et al. Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study. Hypertension 2008; 52:631.
  75. McCambridge TM, Benjamin HJ, Brenner JS, et al. Athletic participation by children and adolescents who have systemic hypertension. Pediatrics 2010; 125:1287.