Hypertension in children is defined as blood pressure at or above the 95th percentile for age, sex, and height on at least three occasions. It is categorized based on age and blood pressure readings into normal, elevated, stage 1, or stage 2 levels. Blood pressure is measured using an appropriately sized cuff and after the child has relaxed. Causes can be primary or secondary to conditions affecting the kidneys, endocrine system, neurologic issues, vasculature, or other factors. Investigations include 24-hour ambulatory monitoring, basic lab tests, and studies tailored to clinical suspicion. Treatment focuses on lifestyle changes, managing underlying causes and comorbidities, and may include medications like ACE inhibitors or ARBs.

1. INPEDIATRICS Nov 21st, 2023

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Measurement
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Causes
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Investigations
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Treatment

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• Hypertension is high blood pressure
• But how high is too high??
• BP ≥ 95% for age, sex and height.
• On at least three di
ff
erent occasions

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Categories Age < 13 Age ≥ 13
Normal BP <90% < 120 / 80
Elevated BP 90 to 95% 120-130 / 80
Stage 1 HTN 95% to stage 2 130-140 / 80-90
Stage 2 HTN ≥ 95% + 12 ≥ 140 / 90

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Measurement
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• BP is measured with a manual or automatic sphygmomanometer:
• Show the child that there is a balloon in the cu
ff
and demonstrate
how it is blown up.
• Use largest cu
ff
that
fi
ts comfortably, covering at least two-thirds
of the length of the upper arm.
• An incorrectly sized cu
ff
is the most common cause of abnormal
blood pressure readings in children!
• The child must be relaxed and not crying.
• SBP is the easiest to determine and clinically the most useful.
• DBP May not be possible to discern in young children.

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Causes
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Essential = Primary (most common).
Secondary:
• Renal: GN, ATN, obstructive uropathy, PCKD, Wilms tumor.
• Endocrine: Cushing, Hyperaldosteronism, Hyperthyroidism,
Neuroblastoma, Pheochromocytoma.
• Neurologic: raised ICP, dysautonomia, increased sympathetic
activity (stress, anxiety, pain).
• Vascular: CoA, Renal artery stenosis or embolism, Renal vein
thrombosis, vasculitis.
• Others: OSA, Medication side e
ff
ect, drug abuse.

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Investigations
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1. Children with suspected HTN should ideally have a 24-hour ambulatory
blood pressure monitoring (ABPM) study to confirm the diagnosis and
rule out white coat hypertension (elevated BP in the office setting only).
2. Baseline assessment: urinalysis, electrolytes, BUN, creatinine, and
kidney ultrasound.
3. Focused studies based on clinical suspicion (e.g., plasma
metanephrines, renin, aldosterone, TFT, vascular imaging)
4. Assessment of other cardiovascular risk factors (lipids, FBS, HbA1C,
uric acid, sleep study)
5. Assessment for target organ damage (echo for LVH)

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Treatment
Treat the underlying cause if secondary
Treat associated comorbidities
Initiate lifestyle changes:
• Weight loss (most effective).
• Diet: DASH diet, ↓ sodium, ↑ potassium intake.
• Exercise: focus on aerobic exercises.

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Treatment
Medications choices: ACEi, ARBs, Thiazide, CCBs
Indications:
• No improvement with lifestyle changes.
• Symptomatic HTN (headaches, altered mental state)
• HTN with CKD, Proteinuria, DM, LVH.
*ARBs > ACEi for HTN but equal efficacy for proteinuria
*β-blockers are not recommended in children.

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