What is the initial approach to managing hypertension in pediatric patients?

Initial Management of Pediatric Hypertension

Begin with lifestyle modifications for all children with elevated blood pressure or stage 1 hypertension, and reserve pharmacological treatment for stage 2 hypertension, symptomatic hypertension, or failure of lifestyle interventions after 3-6 months. 1, 2

Diagnostic Confirmation

Before initiating any treatment, confirm the diagnosis properly:

• Measure blood pressure at each routine visit using an appropriately-sized cuff with the child seated and relaxed 1, 2
• Confirm hypertension on at least three separate days before starting treatment 1, 2
• Elevated BP is defined as systolic or diastolic BP ≥90th percentile for age, sex, and height (or ≥120/80 mmHg in adolescents ≥13 years) 1, 2
• Hypertension is defined as systolic or diastolic BP ≥95th percentile for age, sex, and height (or ≥130/80 mmHg in adolescents ≥13 years) 1, 2

Initial Approach: Lifestyle Modifications First

All children with elevated BP or stage 1 hypertension should start with lifestyle interventions before considering medications 1, 2:

Dietary Modifications

• Implement the DASH diet with sodium restriction 1, 2
• Limit calories from fat to 25-30%, saturated fat to <7%, and cholesterol <200 mg/day 1
• Focus on weight reduction if the child is overweight or obese 1

Physical Activity

• Recommend moderate to vigorous physical activity at least 3-5 days per week for 30-60 minutes per session 1
• Encourage regular exercise as part of a comprehensive lifestyle change 1, 2

Timeline for Lifestyle Intervention

• Allow 3-6 months of lifestyle modifications before considering pharmacological treatment for elevated BP or stage 1 hypertension 1
• If target BP is not reached within this timeframe, proceed to pharmacological therapy 1

When to Initiate Pharmacological Treatment

Start medications immediately in the following situations 1, 2:

• Stage 2 hypertension (BP ≥95th percentile + 12 mmHg, or ≥140/90 mmHg in adolescents ≥13 years) 1
• Symptomatic hypertension regardless of stage 1
• Hypertension with diabetes mellitus or chronic kidney disease 1, 2
• Left ventricular hypertrophy on echocardiography 1
• Failure of lifestyle modifications after 3-6 months 1

The 2017 AAP guideline allows for an optional trial of weight reduction in obese children with stage 2 hypertension before starting medications, but this should not delay treatment in symptomatic patients or those with target organ damage 1.

First-Line Pharmacological Agents

ACE inhibitors or ARBs are the preferred first-line medications for pediatric hypertension 1, 2:

• Start with an ACE inhibitor as the initial agent 1, 2
• Use an ARB if the ACE inhibitor is not tolerated 1, 2
• Alternative first-line options include long-acting calcium channel blockers or thiazide diuretics 1

Critical Caveat: Reproductive Counseling

Provide reproductive counseling to adolescents of childbearing potential before prescribing ACE inhibitors or ARBs due to teratogenic effects 1, 2. Consider alternative agents (calcium channel blockers, beta-blockers) when appropriate 1.

Special Consideration for African American Children

African American children may not respond as robustly to ACE inhibitors, so consider a higher initial ACE inhibitor dose or start with a thiazide diuretic or long-acting calcium channel blocker 1.

Medication Dosing Strategy

Start with a single medication at the low end of the dosing range 1:

• Titrate the dose every 2-4 weeks until BP is controlled, maximum dose is reached, or adverse effects occur 1
• See the patient every 4-6 weeks until BP normalizes 1
• If BP is not controlled with a single agent at maximum dose, add a second agent and titrate similarly 1

Treatment Goals

Target BP should be consistently <90th percentile for age, sex, and height, or <120/80 mmHg in children ≥13 years 1, 2:

• For adolescents ≥13 years, the goal is <130/80 mmHg per the 2017 AAP guideline 1
• Regular monitoring is essential to assess treatment efficacy 2

Identifying Secondary Hypertension

Evaluate for secondary causes, especially in younger children and those with severe hypertension (BP ≥20 mmHg above the 95th percentile) 1:

• Secondary forms are more common in younger children 1
• The probability of secondary hypertension is inversely proportional to age and directly proportional to BP severity 3
• Consider appropriate assessment for target organ damage, including echocardiography for left ventricular hypertrophy, in children with significant and persistent hypertension 1

Common Pitfalls to Avoid

• Do not use beta-blockers as initial treatment due to expanded adverse effect profile and lack of association with improved outcomes compared to other agents 1
• Avoid short-acting nifedipine for hypertensive emergencies or urgencies due to risk of precipitating renal, cerebral, or coronary ischemia 1
• Do not delay treatment in symptomatic patients or those with target organ damage while attempting lifestyle modifications 1
• Do not forget to confirm diagnosis on three separate occasions before labeling a child as hypertensive 1, 2