Managing high blood pressure in children: a clinical practice guideline

The American Academy of Pediatrics (AAP) has released an updated clinical practice guideline for the diagnosis and management of high blood pressure in children.

The pediatric hypertension guidelines, published in Pediatrics, are an update to the previous recommendations published in 2004. A subcommittee of experts conducted a systematic search and review of articles published between January 2004 and July 2016 and compiled 30 key action statements and 27 additional recommendations. The recommendations include level of evidence and the strength of the recommendation.

The AAP notes that the organization intends to update the document as new evidence becomes available, but other studies will need to be performed to fill evidence gaps, “including more rigorous validation studies of automated blood pressure devices in the pediatric population, expanded trials of lifestyle interventions, further comparative trials of antihypertensive medications, and studies of the clinical applicability of hypertensive target organ assessments.”

A summary of the guidelines is as follows:

• Blood pressure should be measured every year in children and adolescents greater than 3 years of age (grade C, moderate recommendation).
• Clinicians should check blood pressure in all children and adolescents greater than 3 years of age at every visit if they have obesity, are taking medications that could increase blood pressure, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes (grade C, moderate recommendation).
• Clinicians should make a diagnosis of hypertension if a patient has auscultatory-confirmed blood pressure readings greater than 95^th percentile at 3 different visits (grade C, moderate recommendation).
• Offices with electronic health records should consider including flags for abnormal blood pressure values (grade C, weak recommendation).
• Oscillometric devices can be used for blood pressure screening in children and adolescents (grade B, strong recommendation).
• Ambulatory blood pressure monitoring should be performed to confirm hypertension in children and adolescents with office blood pressure measurements in the elevated blood pressure category for more than 1 year or with stage 1 hypertension over 3 clinic visits (grade C, moderate recommendation).
• Routine ambulatory blood pressure monitoring should be strongly considered in children or adolescents with high-risk conditions (grade B, moderate recommendation).
• Ambulatory blood pressure monitoring should be performed with a standardized approach with monitors that have been validated in a pediatric population (grade C, moderate recommendation).
• Those with suspected white coat hypertension should undergo ambulatory blood pressure monitoring. The diagnosis is based on a systolic blood pressure (SBP) and diastolic blood pressure (DBP) less than 95^th percentile and SBP and DBP load less than 25%. (grade B, strong recommendation).
• Home blood pressure monitoring should not be used to diagnose hypertension, masked hypertension, or white coat hypertension, but may be useful in addition to office and ambulatory blood pressure measurements after a hypertension diagnosis (grade C, moderate recommendation).
• Children and adolescents greater than 6 years of age do not require extensive evaluation for secondary causes of hypertension if they have a family history of hypertension, are overweight or obese, or do not have history or physical examination findings that suggests a secondary cause of hypertension (grade C, moderate recommendation).
• Those who have undergone coarctation repair should undergo ambulatory blood pressure monitoring to detect hypertension (grade B, strong recommendation).
• For patients being evaluated for high blood pressure, clinicians should obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination to identify findings suggestive of secondary causes of hypertension (grade B, strong recommendation).
• Clinicians should not perform electrocardiography in patients with hypertension being evaluated for left ventricular hypertrophy (LVH; grade B, strong recommendation).
• Echocardiography should be performed to assess for cardiac target organ damage at the same time of consideration of pharmacologic treatment of hypertension. LVH should be defined as LV mass greater than 51 g/m in those older than age 8 years and defined by LV mass greater than 115 g/BSA for boys and LV mass greater than 95 g/BSA for girls. Repeat echocardiography may be performed to monitor improvement or progression of target organ damage at 6- to 12-month intervals. In patients without LV target organ injury at initial echocardiographic assessment, repeat echocardiography at yearly intervals may be considered in those with stage 2 hypertension, secondary hypertension, or chronic stage 1 hypertension incompletely treated to assess for the development of worsening LV target organ injury (grade C, moderate recommendation).
• Doppler renal ultrasonography can be used as a noninvasive screening study to evaluate possible renal artery stenosis in normal-weight patients greater than 8 years of age who are suspected of having renovascular hypertension and who will cooperate with the procedure (grade C, moderate recommendation).
• Computed tomographic angiography or magnetic resonance angiography can be performed in patients suspected of having renal artery stenosis (grade D, weak recommendation).
• Routine testing for microalbuminuria is not recommended for pediatric patients with primary hypertension (grade C, moderate recommendation).
• Treatment goals for hypertensive patients with nonpharmacologic and pharmacologic therapy should be a reduction in SBP and DBP to less than the 90th percentile and less than 130/80 mmHg in adolescents 13 years of age and older (grade C, moderate recommendation).
• Clinicians should provide advice on the DASH diet when patients are diagnosed with elevated blood pressure or hypertension and recommend moderate to vigorous physical activity at least 3 to 5 days per week (grade C, weak recommendation).
• In patients who have failed lifestyle modifications, clinicians should initiate pharmacologic treatment with an ACE inhibitor, angiotensin receptor blockers, long-acting calcium channel blocker, or thiazide diuretic (grade B, moderate recommendation).
• Ambulatory blood pressure monitoring can be used to assess treatment effectiveness in patients with hypertension, especially when clinic or home blood pressure measurements indicate insufficient blood pressure response to treatment (grade B, moderate recommendation).
• Patients with chronic kidney disease (CKD) should be evaluated for hypertension at each office visit. Those with both CKD and hypertension should be treated to lower 24-hour mean arterial pressure less than the 50th percentile by ambulatory blood pressure monitoring. Those with CKD and a history of hypertension should have blood pressure assessed by ambulatory blood pressure monitoring every year to screen for masked hypertension (B grade, strong recommendation).
• Those with CKD and hypertension should be evaluated for proteinuria (grade B, strong recommendation).
• Those with CKD, hypertension, and proteinuria should be treated with ACE inhibitor or angiotensin receptor blockers (grade B, strong recommendation).
• Patients with type 1 diabetes or type 2 diabetes should be evaluated for hypertension at each visit and treated if blood pressure is greater than the 95^th percentile or greater than 130/80 mmHg in adolescents 13 years of age and older (grade C, moderate recommendation).
• In patients with acute severe hypertension and life-threatening symptoms, immediate treatment with short-acting antihypertensive medication should be initiated, and blood pressure should be reduced by no more than 25% of the planned reduction over the first 8 hours (expert opinion, grade D, weak recommendation).
• Children and adolescents with hypertension can participate in competitive sports once hypertensive target organ effects and cardiovascular risk have been assessed (grade C, moderate recommendation).
• Patients with hypertension should receive treatment to lower blood pressure below stage 2 thresholds before participation in competitive sports (grade C, moderate recommendation).
• Adolescents with elevated blood pressure or hypertension should typically have their care transitioned to an appropriate adult care provider by 22 years of age. There should be a transfer of information regarding hypertension etiology and past manifestations and complications of the patient’s hypertension (grade X, strong recommendation).

Reference

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(3). doi:10.1542/peds.2017-1904