Hypertension in children and adolescents (2024)

Key points

Severe hypertension requires urgent consultation and management. Hypertension associated with encephalopathy is a medical emergency
All hypertension in children requires monitoring and follow-up
Blood pressure should be measured annually in healthy children
Where possible, abnormal machine BP measurement should be confirmed, preferably with a manual BP, ensuring appropriately sized cuff is used for accurate measurement

Background

This guideline will focus on the paediatric population aged 1–17 years (not infants)
Hypertension in childhood is a key predictor of risk for hypertension, cardiovascular disease and end organ damage in adulthood
Primary/essential hypertension accounts for the majority of hypertension in children >6 years old and is generally associated with obesity or a family history of hypertension
Secondary hypertension is more common in younger children (<6 years old) with renal disease being the most prevalent cause. This population is at greater risk of hypertensive emergencies due to an underlying condition

Assessment

Risk factors

Overweight/obesity
Male sex
Family history of hypertension
Low birth weight/intrauterine growth restriction
Prematurity
Excess dietary salt intake
Physical inactivity
Chronic health concerns, eg chronic kidney disease, diabetes

Causes of Hypertension
Primary Hypertension
Situational Hypertension
Stress, pain, anxiety
Secondary Hypertension
Renal parenchymal disease	GN, polycystic kidneys, CKI
Cardiac, Vascular	Renal artery stenosis, Coarctation repair (pre and post)
Endocrine	Diabetes, thyroid disease, CAH, Diabetes, thyroid disease, CAH, Cushings
Autoimmune	Thrombotic thrombocytopenic purpura, Haemolytic Uraemic Syndrome, Henoch-Schönlein Purpura
Genetic/Syndromic	Neurofibromatosis, Williams Syndrome, Turners Syndrome
Malignancy	Wilms tumour, neuroblastoma, pheochromocytoma
Intracranial pathology	Intracranial haemorrhage/stroke, pituitary adenoma, raised ICP
Respiratory	Chronic lung disease, OSA
Drug-induced	Corticosteroids, OCP, stimulants

History

Headache/vomiting
Blurred vision
Change in mental state
Seizures
Chest pain/palpitations
Shortness of breath
Cardiac failure
Past history of Acute Kidney Injury (AKI)

Examination

Confirm hypertension (See measuring blood pressure section below)
Vitals: tachycardia, four limb BP for upper and lower limb discrepancy
Height and weight: obesity, growth retardation
Signs of end organ damage

Fundoscopy: hypertensive retinopathy
Cardiovascular: apical heave, hepatomegaly, oedema
Chronic renal failure: palpable kidneys
Focal neurology eg facial nerve palsies

Signs of underlying cause

General appearance: Cushingoid, proptosis, goitre, webbed neck (Turner syndrome), elfin facies (William syndrome)
Skin: Cafe-au-lait spots, neurofibromas, acanthosis nigricans, hirsutism, striae, acne, rash (vasculitis)
Cardiovascular: murmurs +/- radiation, apical heave, reduced femoral pulses, oedema, hepatomegaly (CCF)
Abdomen: masses, palpable kidneys, flank bruits
Genitourinary: ambiguous/virilised genitalia eg CAH

Key points when measuring blood pressure (See video)
Ensure the correct cuff size is selected for each patient, favouring a larger rather than smaller cuff (smaller cuff creates artificial hypertension)

BP cuff width should be 40% of the length of the arm measure from the shoulder tip to the elbow
Abnormal oscillatory BP measurement needs checking with a manual BP from the child's arm

The table below identifies BP levels requiring further evaluation, starting with repeating the BP manually ensuring accurate measurement

*Screening BP Values Requiring Further Evaluation
Age (years)	Blood pressure (mmHg)
	Boys		Girls
	Systolic	Diastolic	Systolic	Diastolic
1	98	52	98	54
2	100	55	101	58
3	101	58	102	60
4	102	60	103	62
5	103	63	104	64
6	105	66	105	67
7	106	68	106	68
8	107	69	107	69
9	107	70	108	71
10	108	72	109	72
11	110	74	111	74
12	113	75	114	75
≥13	120	80	120	80

*90^th centile for a child at average height

Assessment of severity

Interpreting blood pressure measurement
An online blood pressure centile calculator specific for gender, age and height can be used to determine the severity of hypertension

Management

Emergency management of severe hypertension

Discuss with renal team and retrieval/ICU team

Hypertensive urgency

If medically stable, consider short acting oral agents while investigating cause

Nifedipine
Commence 0.25–0.5 mg/kg/day (max 20 mg) and titrate up as required to a maximum of 3 mg/kg/day (max 120 mg)

Hypertensive emergency

Intravenous therapy; discuss with renal team and retrieval/ICU team
Aim to gradually reduce BP to the patient's estimated 95^th centile
Decrease BP by 25% of the original value every 24 hours till target BP reached. Reduce rate of decrease if patient becomes symptomatic

Hypertension without severe features

Investigations

First-line investigations

Lifestyle counselling

Dietary modifications

Rich in fresh fruit and vegetables/legumes, fish, poultry, lean red meat and low fat dairy
Limit intake of high sodium, fat or sugar containing foods

Lifestyle modifications

Increase physical activity, aiming 40 minutes moderate to vigorous exercise 3-5 days/week
Consider counselling/behavioural techniques to help address weight management and metabolic risk

Medical management

Should be commenced if:

Conservative measures have failed
Symptomatic hypertension develops
Stage 2 hypertension with no modifiable risk factors
Hypertension in setting of chronic kidney disease/diabetes

Medical management should only be commenced in consultation with a general or renal paediatrician

Long-acting calcium channel blockers such as amlodipine are recommended as first line therapy. Other medication may be preferred in children with BMI >95^th centile, diabetes or proteinuria

Consider consultation with local paediatric team when

Red flags (see history section above) or ongoing concerns are present
Hypertensive urgency or hypertensive emergency
Medical management of hypertension is required

Consider transfer when

Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Hypertensive children without severe features may be discharged with appropriate follow-up (See flowchart)

Parent information

See Parent resources

Additional notes

How to Measure Blood Pressure – American Academy of Pediatrics (video)

Last updated June 2021

Blood pressure classification in children and adolescents
	For children aged 1 to 13 years	For children aged 13-17 years
Normal blood pressure	<90^th centile	<120/<80 mmHg
Elevated blood pressure	≥90^th centile to <95^th centile or 120/80 mmHg to <95^th centile (whichever is lower)	120/<80 to 129/<80 mmHg
Stage 1 Hypertension	≥95^th centile to <95^th centile + 12 mmHg or 130/80 to 139/89 mmHg (whichever is lower)	130/80 to 139/89 mmHg
Stage 2 Hypertension	≥95^th centile + 12 mmHg, or ≥140/90 mmHg (whichever is lower)	≥140/90 mmHg
Severe Hypertension
Hypertensive Urgency	>95^th centile + 30 mmHg without symptoms/signs of target end organ damage (See Examination)	>180/120 without symptoms/signs of target end organ damage (See Examination)
Hypertensive Emergency	>95^th centile + 30 mmHg associated with encephalopathy, eg headache vomiting, vision changes and neurological symptoms (facial nerve palsy, lethargy, seizures, coma) +/- target-end organ damage	>180/120 associated with encephalopathy, eg headache vomiting, vision changes and neurological symptoms (facial nerve palsy, lethargy, seizures, coma) +/- target-end organ damage