HTN classification

2. Powerpoint Templates
Hypertension in children
definition & diagnosis
Alaleh Gheissari, MD
Professor of Paediarics, Pediatric Nephrologist
IUMS

3. Blood Pressure History
The circulation of blood?
A subject of study for many thousands of years
• Ancient China,
Blood circulated through the blood vessels
• Scholars in India
The circulatory system, pulse and its dynamic
nature

4. Broader underestanding of circulation:
• Early 1600’s
• William Harvey
• The first publication in 1628 entitled
“Exercitatio Anatomica de Motu Cordis et
Sanguinis in Animalibus” (On the
Movement of the Heart and Blood in
Animals).
• His work became a foundation for the study of the
circulatory system, and is still highly regarded even
to this day.

5. BP measurment & Instument:
• In 1733 Reverend Stephen Hales recorded the first
blood pressure measurement on a horse.
• In 1881, the first sphygmomanometer was invented
by Samuel Siegfried Karl Ritter von Basch.

6. Modern BP measurment
• Modern blood pressure measurement was not
developed until 1905, when Dr. Nikolai Korotkoff
discovered the difference between systolic blood
pressure and diastolic blood pressure.

7. Hypertension in Children:
• From a rare possibility
• To serious public health challenge.
• Increases the risk of end organ damage, including
coronary artery calcifications,ventricular hypertrophy,
and increased carotid intima–media thickness.
• HBP in childhood can be progressive into
adulthood and is the strongest predictor of
adulthood HBP.

8. Hypertension in Children:
• Report of the task force on blood pressure
control in children. S Blumenthal, R P Epps, R
Heavenrich, R M Lauer, E Lieberman, B Mirkin, S
C Mitchell, V Boyar Naito, D O'Hare, W McFate
Smith, R C Tarazi, D Upson.
1977 May;59(5 2 suppl):I-II, 797-820.
• Updated on 2017 AAP guideline

9. Hypertension in Children:
• In 2017, the American Academy of Pediatrics
(AAP) and its Council on Quality Improvement
and Patient Safety developed a new pediatric
Clinical Practice Guideline (CPG).

10. Significant changes in the Forth guideline
• 1- The replacement of the term “prehypertension”
with the term “elevated blood pressure.”
• 2- New normative pediatric BP tables based on
normal-weight children at all weight levels.
• 3- A simplified screening table for identifying BPs
needing further evaluation
• 4- A simplified BP classification in adolescents ≥13
years of age that aligns with the forthcoming
American Heart Association and American College of
Cardiology adult BP guidelines.

11. Significant changes in the Forth guideline
• 5- A more limited recommendation to perform screening BP
measurements only at preventive care visits
• 6- Streamlined recommendations on the initial evaluation
and management of abnormal BPs
• 7- An expanded role for ambulatory BP monitoring in the
diagnosis and management of pediatric hypertension
• 8- Revised recommendations on when to perform
echocardiography in the evaluation of newly diagnosed
hypertensive pediatric patients (generally only before
medication initiation), along with a revised definition of left
ventricular hypertrophy.

13. What Is the Prevalence of Childhood Hypertension?
It Depends on the Definition
• Sharma et al9 demonstrate that using the new clinical
practice guidelines results in an increase in the
prevalence of elevated blood pressure from 11.8% to
14.2%.
• Dong et al found that using new guideline among
50336 Chinese children and adolescents resulted in a
higher HBP prevalence, compared with that defined by
the Fourth Report, which was developed with a reference
population with children and youths of all body weights.

14. Hypertension Prevalence in Children:
• The actual prevalence: ∼3.5%
• The prevalence of persistently elevated BP
(formerly termed “prehypertension,” including
BP values from the 90th to 94th percentiles or
between 120/80 and 130/80 mmHg in
adolescents) is also ∼2.2% to 3.5% with higher
rates among children and adolescents who have
overweight and obesity.

15. Classification & more definition
• According to the etiology
• Essential or primary HTN - when an underlying cause
cannot be dentified.
• Secondary HTN - when an organic cause is
established.
• Other definitions of HTN include:
• White coat HTN - elevated BP during health care
visits, which then normalizes after relaxation or in
nonmedical settings(32-46%)
• Masked HTN - normal BP during health care visits but
elevated in the ambulatory setting (Kidney diseases).

16. BP measurement
• Auscultation method Vs Oscillometric method
• Right arm, resting comfortably in the sitting
position.
• Using the correct size BP cuff.
• The inflatable cuff should cover 80% of the
arm circumference and 40% of the arm length.

17. BP measurement
• ABPM was obtained only from children with
height >120 cm and of primarily Caucasian
origin.
• ABPM should be performed in children more
than 5 years of age for confirmation of
hypertension if the BP is in the “elevated”
category for at least 1 year or with stage 1
hypertension across three clinic visits.

19. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of Recommendation
BP measuring annually beginning at 3 years of
age. Repeat at every health care for obese
children, known case of kidney or heart disease,
COA, DM, consumption of certain medication
C moderate
When available, ABPM should be used to confirm
hypertension in children and adolescents.
C moderate

20. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of
Recommendation
Trained health care professionals in the office setting should
make a diagnosis of HTN if a child or adolescent has
auscultatory confirmed BP readings ≥95th percentile at 3
different visits.
C moderate
Oscillometric devices may be used for BP screening in
children and adolescents. When doing so, providers should use
a device that has been validated in the pediatric age group. If
elevated BP is suspected on the basis of oscillometric
readings, confirmatory measurements should be obtained by
auscultation.
B strong

21. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of Recommendation
Home BP monitoring should not be used to diagnose HTN,
MH, or WCH but may be a useful adjunct to office and
ambulatory BP measurement after HTN has been diagnosed.
C moderate
Doppler renal ultrasonography may be used as a
noninvasive screening study for the evaluation of possible
RAS in normal children and adolescents ≥8 y of age who are
suspected of having renovascular HTN and who will
cooperate with the procedure.
C moderate

22. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of Recommendation
• Clinicians should not perform electrocardiography in
hypertensive children and adolescents being
evaluated for LVH.
B Strong
• It is recommended that echocardiography be
performed to assess for cardiac target organ
damage (LV mass, geometry, and function) at the
time of consideration of pharmacologic treatment of
HTN.
C moderate

23. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of
Recommendation
• LVH should be defined as LV mass >51 g/m2.7 (boys and
girls) for children and adolescents older than age 8 y and
defined by LV mass >115 g/BSA for boys and LV mass >95
g/BSA for girls.
• Repeat echocardiography may be performed to monitor
improvement or progression of target organ damage at 6- to
12-mo intervals.
• Indications to repeat echocardiography include persistent
HTN despite treatment, concentric LV hypertrophy, or
reduced LV ejection fraction.
C moderate

24. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of
Recommendation
• In patients without LV target organ injury at initial
echocardiographic assessment, repeat
echocardiography at yearly intervals may be
considered in those with stage 2 HTN, secondary
HTN, or chronic stage 1 HTN incompletely treated
(noncompliance or drug resistance) to assess for the
development of worsening LV target organ injury.
C moderate

25. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of
Recommendation
• Children and adolescents with CKD should be
evaluated for HTN at each medical encounter.
• Children or adolescents with both CKD and HTN
should be treated to lower 24-hr MAP <50th
percentile by ABPM.
• Regardless of apparent control of BP with office
measures, children and adolescents with CKD and a
history of HTN should have BP assessed by ABPM at
least yearly to screen for MH.
B strong

26. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of Recommendation
Children and adolescents with CKD and HTN should
be evaluated for proteinuria.
B strong
Children and adolescents with CKD, HTN, and
proteinuria should be treated with an ACE inhibitor or
ARB.
B strong

27. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of Recommendation
All hypertensive children should be screened for
hyperlipidemia and underlying renal disease (U/A,
BUN/Cr, and electrolytes.)
C moderate
DO US for children<6 years and those with abnormal
tests results
C moderate

28. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of Recommendation
Obese children and adolescents with hypertension
should be evaluated for diabetes mellitus and fatty
liver.
C modertae
All children with elevated blood pressure or
hypertension should make therapeutic lifestyle
changes.
C moderate

29. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality,
Strength
of Recommendation
Children and adolescents with T1DM or T2DM
should be evaluated for HTN at each medical
encounter and treated if BP ≥95th
percentile or >130/80 mmHg in adolescents ≥13 y of
age.
C moderate
Children and adolescents with HTN should receive
treatment to lower BP below stage 2 thresholds
before participation in competitive sport
C moderate

30. KEY RECOMMENDATIONS FOR PRACTICE
Key Action Statement Evidence Quality, Strength
of Recommendation
Children with symptomatic
hypertension, stage 2 hypertension
without a modifiable factor such as
obesity, evidence of left ventricular
hypertrophy on echocardiography, any
stage of hypertension associated with
chronic kidney disease or diabetes, or
persistent hypertension despite a trial
of lifestyle modifications
require antihypertensive
medications.
C moderate

31. AGE year
BP measure
BOYS GIRLS
SYS BP DBP SYS BP DBP
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

32. A simplified Table of Blood Pressure Normal Cutoffs in Childr
• Systolic blood pressure (95th centile)
• 1–17 years = 100 + (age in years × 2)
• Diastolic blood pressure (95th centile)
• 1–10 years = 60 + (age in years × 2)
• 11–17 years = 70 + (age in years).
•Somu et al. Early detection of hypertension in general
practice. Arch Dis Child. 2003

33. A simplified Table of Blood Pressure Normal Cutoffs in
Children
• Badeli et al. Simple Formulas for Screening Abnormal
Blood Pressure in Children and Adolescents. IJKD
2010.
Age year
Hypertension
Systolic Diastolic
3-7 age + 96 2 × age + 55
8-13 2 × age + 91 age + 63
≥ 14 ≥ 120 ≥ 75

34. Suspicious patient?????
• Based on the guideline
• Based on the medical history
• birth history; growth and development; and
screening for previous urologic, renal, cardiac,
endocrine, or neurologic diseases, different
medications, sleep disorders, neuro-psychotic
problems.
• Dysuria, polyuria, polydipsia, Visual disturbance,
headache, claudication, seizure.

35. Suspicious patient?????
• Monogenic HTN
• FH of early-onset HTN
• Hypokalemia,suppressed plasma renin, or an
elevated Aldosterone- Renin Ratio (ARR) >10.
• Central obesity
• Abnormal phenotype
• Syndromin such as Williams, Turner

36. Suspicious patient?????
• Based on the physical examination
• Mostly normal
• BMI
• 4 limbs BP
• Murmur and bruit
• Ambiguous genitalia
• Muscle weakness
• Skin vascular lesion
• Incidental findings
• ophthalmoscopic findings, End organ
damage, microalbuminuria

37. Time to Referral to a Nephrology Clinic
• Years typically passed from first EBP to nephrology referral.
• Most patients (68%) reached diagnostic criteria for HTN
prior to referral;
• Many pediatricians either fail to routinely check for HTN in
their patients or to utilize appropriate reference materials.
• The Fourth Report and the recent update set a standard for
diagnosis, evaluation, and treatment of pediatric HTN; yet
many physicians are unaware of these standards and feel
uncomfortable making such diagnosis.
• Hamby et al. Time to referral to a nephrology clinic for
pediatric hypertension. Pediatric Nephrology. 2020.

38. Take-Home
Message
• Pediatric HTN is often undiagnosed and has a
significant effect on long term cardiovascular
outcomes.
• Accurate diagnosis relies on multiple manual
measurements and can be confirmed with the
use of ABPM.
• Diagnostic workup for an underlying etiology of
hypertension should be tailored based on level
of
• suspicion

39. Take-Home
Message
• Use BP charts for children one to 12 years of age
in healthy children of normal weight and
interpret on the basis of sex, age, and height
(normative population
• distribution curve).
• Consider Primary hypertension (now accounts
for most cases of childhood hypertension).

40. References
• 1- Thomas et al. Pediatric hypertension: Review of the definition,
diagnosis, and initial management. International Journal of Pediatrics
and Adolescent Medicine. 2020.
• 2- Riley et al. High Blood Pressure in Children and Adolescents. Am
Fam Physician. 2018.
• 3- Sinha et al. American Academy of Pediatrics Clinical Practice
Guidelines for Screening and Management of High Blood Pressure in
Children and Adolescents:What is New?. Indian ped. 2019.
• 4- Göknar et al. New guidelines for the diagnosis, evaluation, and
treatment of pediatric hypertension. Turk Pediatri Ars. 2020.
• 5- 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.

41. References
• 6- Sharma AK, Metzger DL, Rodd CJ. Prevalence and severity of high
blood pressure among children based on the 2017 American
Academy of Pediatrics guidelines [published online April 23,
2018].JAMA Pediatr.
• 7- Messerli FH, Bangalore S. Lowering the thresholds of diseases: is
anyone still healthy? J Am Coll Cardiol. 2018;71(2):119-121.
• 8- Dong et al. Updates to pediatric hypertension guidelines: influence
on classification of high blood pressure in children and adolescents.
Journal of Hypertension. 2019.

42. Research Gaps & opportunities
• Epidemiology and/or observational studies
• Measurement and/or equipment
• Clinical trials, including lifestyle interventions
• Pharmacologic studies