Indian Pediatr 2019;56:317-321|
American Academy of
Pediatrics Clinical Practice Guidelines for Screening and
Management of High Blood Pressure in Children and Adolescents:
What is New?
and Joshua Samuels3
From 1Institute of Child Health, Division of Paediatric
Nephrology, Kolkata, and 2Division of Pediatric Nephrology,
Lady Hardinge Medical College, New Delhi, India; and 3Childrens
Memorial Hermann Hospital, University of Texas, Health Science Center,
Correspondence to: Dr Rajiv Sinha, 37, G Bondel Road, Institute of
Child Health, Kolkata 700 017, India.
Childhood hypertension has become a
significant health concern. There have been a slew of important new
findings in this field over the last decade. This has led to an update
by the American Academy of Pediatrics of the original recommendation of
United States Fourth Working Group on blood pressure. We herein describe
the important changes in the guideline, which include an updated
normative data, change in blood pressure classification, strong
endorsement of ambulatory blood pressure measurement and the reduction
in the blood pressure target for both chronic kidney disease and
non-chronic kidney disease hypertensive children.
Keywords: Classification, Diagnosis,
Published in 2004, the Fourth
Working Group Report from the National High Blood Pressure Education
Program in United States of America has long been the cornerstone of
childhood hypertension evaluation and management . After a gap of 13
years, the American Academy of Pediatrics (AAP) recently updated the
clinical practice guidelines . After conducting a systematic review
they generated 30 key action statements and 27 additional consensus
opinion recommendations, which we have summarized herein.
Definition and Classification
In contrast to adults, childhood blood pressure (BP)
continues to be based on normative population distribution curve rather
than hard clinical outcomes . One of the major changes in the recent
guideline has been the updated blood pressure percentiles for both boys
and girls. The updated normative data excluded overweight or obese
children, which constituted nearly 20% of population, used for obtaining
the previous data . Increasing its user friendliness, the BP charts
now have height in centimeter rather than in percentile. In addition,
the guideline has also given simplified blood pressure tables for
initial screening by allied health professionals. For newborns, it has
recommended tables compiled by Dionne, et al.  and for
infants, the normative BP values published by the Task Force in 1987
Another major change has been alteration of previous
blood pressure classification. Pre- hypertension has been relabeled as
elevated blood pressure and stage 1 and 2 hypertension has been
redefined (Table I). For adolescents
³13 years, instead of
percentile-based definitions, hypertension is now defined as per adult
TABLE I New Definition of Hypertension in Children and Adolescents and Subsequent Action Plan
Children aged 1-12 y
(mm Hg based)
< 90th percentile
No additional action needed. Measure the BP at the next routine
well-child care visit.
Elevated BP(Previously called pre-hypertension)
percentile to<95th percentile or 120/80mm Hg to
<95th percentile (whichever is lower)
120/<80 to 129/<80mm Hg
Step1: Lifestyle modification; repeat BP after
6 mo. Step 2: If still elevated, check UL/LL
BP. If these are normal lifestyle modification continued and
BP re-checked again after 6 mo. Step3: If BP
still elevated, ABPM should be ordered (if available), and
consider diagnostic evaluation. If BP normalizes at any point,
return to annual BP screening at well-child care visits.
Stage 1 Hypertension
percentile to<95th percentile + 12 mmHg or 130/80 to 139/89 mm
Hg(whichever is lower).Previous Stage 1: 95thpercentile to the
99thpercentile plus 5 mmHg)
130/80 to 139/89mm Hg
Step1: If asymptomatic, provide lifestyle
counselling and recheck the BP in 1 to 2 wk byauscultation.
Step 2: If the BP reading is still atthe stage
1 level, UL/LL BP should be checked and if normal
nutrition and/or weight management initiated and BP rechecked in
3 months. Step 3: If BP continues
to be at the stage1 HTN level after 3 visits, ABPM should
be ordered (if available), diagnostic evaluation should be
conducted, and treatment should be initiated. Subspecialty
referral should be considered. If symptomatic, early
initiation /referral should be considered.
Stage 2 Hypertension
percentile + 12 mm Hg,or ³140/90 mm Hg (whichever is
lower)Previous Stage 2: >99th percentile plus 5 mmHg
³140/90 mm Hgchecked, lifestyle recommendations given, and
Step 1: If asymptomatic: UL /LL BP should be
the BP rechecked within 1 week (Alternatively, the patient could
be referred to subspecialty carewithin 1 week).
Step2: If the BP reading is still at the stage 2 HTN
level when repeated, then diagnostic evaluation, including ABPM,
should be conducted and treatment should be initiated, or the
patient should be referred to subspecialty care within 1 week.
If symptomatic, or the BP is >30mm Hg above the 95th
percentile(or >180/ 120 mm Hg in an adolescent), refer to an
immediate source of care, such as an emergency department.
BP: Blood pressure, ABPM: Ambulatory blood pressure measurement,
LL: lower limb, UL: Upper limb. Based on Reference 2.
Measuring Blood Pressure in Children
The guideline recommends annual blood pressure
measurement for children ³3
years and has identified sub-groups (obese, on medications known to
increase blood pressure, renal disease, history of coarctation, or
diabetes) for more frequent checks. Children younger than 3 years
warrant regular measurements if they have any of the followings:
congenital heart disease, recurrent urinary tract infection, urological
malformation, solid organ transplant, bone marrow transplant,
malignancy, neurofibromatosis, tuberous sclerosis or sickle cell
disease. Small for gestational age newborns, premature (<32 weeks), or
very low birth weight babies and those with umbilical arterial
catheterization also require regular checks.
Similar to the Fourth Task Force, standardized
procedures for measurement of blood pressure in office practice were
recommended. These include:
(a) Child should be seated for 3-5 minutes
with uncrossed legs in a quiet room.
(b) BP should be measured in right arm at the
(c) Length of the bladder cuff should be
80%-100% of arm circumference, width at least 40% with lower end of the
cuff around 2-3 cm above the antecubital fossa and stethoscope placed
over brachial artery.
Blood pressure readings obtained in the school
setting were recommended not to be used for diagnosis of hypertension.
Oscillometric devices were accepted as a screening
tool across pediatric age group, with the caveat that any elevated blood
pressure needs confirmation by auscultatory method as target organ
damage are best predicted by auscultatory method. In case of an initial
elevated BP, two additional readings should be taken in the same visit
and its average taken as final record. In office setting, hypertension
should only be diagnosed based on readings on three different occasions.
Forearm and/or wrist blood pressure measurements were not recommended.
Subsequent management of elevated blood pressure should be decided based
on its classification as per Table I. Organizations with
electronic health records were advised to consider flagging abnormal BP
Office blood pressure readings have multiple
drawbacks, including chances of missing White coat hypertension (WCH:
office BP ³95th
percentile but ambulatory BP <95th percentile with less than 25% BP
load) or Masked hypertension (MH: office BPs are <95th percentile but
ambulatory BP ³95th
percentile with more than 25% BP load) . The updated guideline
recommend routine use of Ambulatory blood pressure monitoring (ABPM) as
it avoids some of these pitfalls and has been shown to correlate better
with target organ damage. However, it should be remembered that
reference data for 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. Regular use of ABPM was
advocated for children with chronic kidney disease (CKD), secondary
hypertension, type 1 or 2 diabetes mellitus (DM), obstructive sleep
apnea syndrome (OSAS), a history of prematurity, and in children who
have undergone solid-organ transplant or coarctation repair. The
guideline advocated the use of the 2014 American Heart Association
staging scheme for interpreting ABPM data. Repeat ABPM was advised for
WCH as they have been found to have higher left ventricular mass in
comparison to normal BP cohorts and increased risk of progressing to
sustained hypertension . Home monitoring of BP was not recommended as
a diagnostic aid.
History and Examination: As expected, proper
history and physical examination was given paramount importance. It
suggested that children over 6 years need not undergo extensive
investigations if there is family history of hypertension and basic
history/clinical examination are not suggestive of secondary etiology.
Appropriate emphasis has been put on dietary as well as history of
physical activity and psychosocial factors.
Investigations: Laboratory investigations have
been summarized in one of the tables published in the guideline .
Suppressed plasma renin activity or elevated aldosterone renin ratio (ng/dL
and ng/mL per hour, respectively) >10, especially in presence of family
history of early-onset hypertension or associated hypokalemia highlights
need for genetic work up. A new addition is the clear recommendation in
favor of echocardiogram vis-a-vis electrocardiogram
as it correlates better with left ventricular hypertrophy (LVH). In
absence of sufficient normative data, routine measurement of other
surrogate markers such as carotid intimal media thickness or pulse wave
velocity were not recommended. The update also provides guidance as to
when to suspect renovascular hypertension in children (stage 2
hypertension, significant diastolic hypertension, discrepant kidney
sizes on ultrasound, hypokalemia, or an epigastric and/or upper
abdominal bruit on physical examination). For suspected renovascular
hypertension, doppler ultrasonography was suggested to be reliable only
in non-obese cooperative children above 8 years and when done by
experienced hands. Although renal angiography remains the gold standard;
both CT angiography and Magnetic Resonance Angiography has been accepted
as non-invasive imaging modality. In contrast to previous guideline, the
current guideline advised against use of nuclear renogram for
renovascular hypertension and did not recommend routine check for
microalbuminuria or uric acid.
The guideline did not support any alteration in
management of hypertension on racial, ethnic or sex differences.
Target blood pressure: The target blood pressure
has been revised to less than 90th
percentile in light of recent reports [9,10] of target organ damage even
in children with blood pressure between 90th
and 95th percentile, as well
as evidence of improving left ventricular mass index with this lower
threshold. For those with CKD BP targets were revised to below 50th
Non-pharmacological interventions: Dietary inter-vention
(DASH diet including more of fruits, vegetables, low fat milk products
and low salt content) and increased physical activity has been strongly
supported. Importance of weight loss has been stressed and motivational
interview for weight reduction were mentioned) along with encouraging
patient and family educations.
Indications for starting pharmacological
interventions: Starting a child on anti-hypertensive medicine is a
major decision particularly since there are inadequate data on long term
safety. Anti-hypertensive medications were suggested for those who
remain hypertensive despite a trial of lifestyle modifications or who
have symptomatic hypertension, stage 2 hypertension without a clearly
modifiable factor (e.g., obesity), or any stage of hypertension
associated with CKD or diabetes mellitus (DM). With evidences primarily
from adult studies, beta blockers was discouraged as first line
Monitoring while on anti-hypertensive agents: For
children on only life style changes, a longer follow-up (3- 6 months)
was suggested. If on anti-hypertensive, more frequent review (every 4-6
weeks) was suggested for dose adjustments and/or addition of more
anti-hypertensive medications till target BP is achieved. Use of 24-hour
ABPM was also supported for monitoring treatment efficacy.
Treatment of resistant hypertension (persistent
hypertension despite treatment with 3 or more anti-hypertensive agents
of different classes) advocated were primarily based on adult studies
and included: initial re-confirmation by appropriate size cuff and by
ABPM, dietary sodium restriction, elimination of substances known to
elevate blood pressure, identification of previously undiagnosed
secondary causes of hypertension, optimization of current therapy and
addition of additional agents as needed.Use of existing pediatric lipid
guidelines was suggested for any dyslipidemia.
Treatment for special population: Current
guideline highlighted the importance of controlling BP in children with
CKD and DM as well as need for controlling proteinuria in CKD
population. As hypertension has been linked to adverse cardiac outcomes
in Type 2 DM, the updated guideline emphasized the need for close
monitoring of BP in these children and targeting BP <90th
percentile. 24-hour ABPM was also suggested for Obstructive sleep apnea
syndrome (nocturnal hypertension is common) and in children
post-transplantation (high prevalence of masked hypertension).
In presence of life threatening complications like
encephalopathy or heart failure, a controlled drop of BP by 25% within
first 8 hour was advised, preferably by use of intravenous agents.
Regarding participation in competitive sports, the
guideline states that children with stage 2 hypertension be restricted
from static sports until their BP is in the normal range. Children with
evidence of target organ damage needs proper specialist assessment prior
taking a call on their participation in competitive sports.
Prevention of Hypertension
In presence of mounting evidence supporting tracking
of blood pressure in children , the recent guideline stressed on the
need for early implementation of strategies to prevent development of
hypertension. In children and adolescents, these are primarily based on
lifestyle modification including appropriate diet, regular exercise and
treatment of obesity.
Transition of Care
In keeping with worldwide focus on transition of
adolescent to adult service, the current guideline has added a segment
on its importance.
The recent guideline by AAP has quite a few changes (Box
1). Most important being the updated normative data, change in
BP classification, endorsement of ABPM and the reduction in the BP
target for both CKD and non- CKD hypertensive children. The guideline is
likely to alter clinical practice across the globe and hopefully help in
identifying children with elevated BP at an earlier stage. At the same
time, it also raises some important concerns and queries. Utility of
ABPM needs to be further assessed in resource-constrained set-ups. In
addition, we need better clarity on the most appropriate investigations
for diagnosing secondary hypertension, appropriate use of ABPM
(including more inclusive ABPM normative data), importance of lifestyle
modifications in pediatric hypertension, and more research on pediatric
Important Changes/New Statements in the Clinical Practice
Guideline on Elevated Blood Pressure by American Academy of
New blood pressure charts for boys and girls.
Blood pressure classification has been
Stepwise guidelines given for managing
children with increased blood pressure (BP).
Increased stress on importance of
Ambulatory blood pressure monitoring (ABPM) in diagnosis and
management of childhood hypertension
ABPM has been strongly recommended for
confirming a diagnosis of hypertension (HTN) in children and
adolescents if they have office BP measurements in the elevated
BP category for 1 year or more or with stage 1 HTN over 3 clinic
ABPM should be done for suspected
White-coat hypertension or Masked hypertension.
Its use was particularly recommended in
special group of populations such as chronic kidney disease and
y of age were recommended to not routinely require extensive
investigation for secondary causes of HTN if they have a
positive family history of HTN, are overweight or obese, and/or
do not have history or physical examination findings suggestive
of a secondary cause of HTN.
Monogenic HTN should be suspected in
patients with a family history of early-onset HTN, hypokalemia,
suppressed plasma renin, or an elevated Aldosterone Renin Ratio
Renovascular HTN should be suspected in
children with stage 2 HTN, significant diastolic HTN, discrepant
kidney sizes on ultrasound, hypokalemia on screening
investigations, or an epigastric and/or upper abdominal bruit on
Electrocardiogram not recommended for
assessing left ventricular hypertrophy.
Echocardiography strongly recommended to
assess for target organ damage at the time of consideration of
pharmacologic treatment of HTN.
Doppler renal ultrasonography may be useful
in evaluation of renal artery stenosis in normal weight children
years of age who will cooperate with the procedure.
Indication to initiate treatment
In hypertensive children and adolescents
who have failed lifestyle modifications.
Those with target organ damage such as left
Symptomatic HTN, or stage 2 hypertension
without a clearly modifiable factor(eg, obesity).
Target BP: Reduction in systolic BP and
diastolic BP to <90th percentile
Beta blocker should not be used as initial anti-
hypertensive. Usual choice of anti-hypertensive should include
ACEi, ARB, long-acting calcium channel blocker, or thiazide
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