Pediatric High Blood Pressure Management
Lifestyle modifications should be initiated first for all pediatric hypertension cases, with pharmacologic therapy reserved for specific high-risk situations: persistent hypertension despite lifestyle changes (especially with abnormal echocardiogram), symptomatic hypertension, Stage 2 hypertension without modifiable risk factors, or any stage of hypertension in patients with diabetes mellitus or chronic kidney disease (CKD). 1
Blood Pressure Treatment Goals
Target blood pressure should be <90th percentile for age or <130/80 mmHg (whichever is lower) for most pediatric patients ≥13 years old. 1, 2 This target is based on evidence showing that hypertensive target organ damage (TOD) can appear at BP levels between the 90th and 95th percentiles, and that BP reduction below the 90th percentile can reverse left ventricular hypertrophy (LVH). 1
Special Population: CKD Patients
For children and adolescents with chronic kidney disease, BP should be monitored by ambulatory blood pressure monitoring (ABPM), with a goal 24-hour mean arterial pressure <50th percentile. 1, 3 This more aggressive target is based on the ESCAPE trial, which demonstrated slower CKD progression with this lower target compared to <90th percentile. 1
Indications for Pharmacologic Therapy
The 2017 AAP Clinical Practice Guideline specifies four clear indications for starting antihypertensive medications: 1
- Persistent hypertension despite lifestyle modification, especially with an abnormal echocardiogram 1
- Symptomatic hypertension 1
- Stage 2 hypertension without a modifiable risk factor 1
- Any stage of hypertension in patients with diabetes mellitus or CKD 1
First-Line Medication Selection
Primary Hypertension
For pediatric patients with primary hypertension, four drug classes are equally acceptable as initial therapy: ACE inhibitors, ARBs, long-acting calcium channel blockers, or thiazide diuretics. 1, 2 All have demonstrated pediatric efficacy and safety data. 1
High-Risk Conditions (CKD, Diabetes, Proteinuria)
ACE inhibitors or ARBs are strongly recommended as the mandatory initial agent for hypertensive patients with CKD, diabetes mellitus, or proteinuria. 1, 4, 3, 2 This represents a strong recommendation based on renal and cardiovascular protective effects in these populations. 1
Critical Contraindication
ACE inhibitors and ARBs are absolutely contraindicated in pregnancy and require reproductive counseling before initiation in females of childbearing potential due to teratogenic effects. 4, 2
Medication Dosing Strategy
Start at the low end of the dosing range and titrate every 2-4 weeks until blood pressure normalizes. 4, 2 For example, lisinopril can be started at 5 mg daily in adolescents, with demonstrated antihypertensive efficacy at doses >1.25 mg (0.02 mg/kg) in pediatric patients 6-16 years of age. 5
Lifestyle Modifications (All Patients)
Implement the DASH diet with saturated fat restricted to 7% of total calories and dietary cholesterol to 200 mg/day. 4 Additional dietary measures include eliminating added salt and reducing high-sodium foods. 4
Prescribe moderate to vigorous physical activity at least 3-5 days per week for 30-60 minutes per session. 4
Counsel weight loss of at least 5% of body weight if the patient is overweight. 4
Cardiac Evaluation
Echocardiography should be performed to assess for left ventricular hypertrophy, particularly before initiating pharmacologic treatment. 4 LVH is defined as LV mass >51 g/m²·⁷ for children and adolescents >8 years of age, or alternatively as LV mass >115 g/body surface area for boys and >95 g/body surface area for girls. 1
Repeat echocardiography at 6-12 month intervals if LVH is present, or yearly if Stage 2 hypertension persists. 4
Follow-Up Schedule
See patients every 4-6 weeks until blood pressure normalizes. 4, 2 After BP control is achieved, follow-up visits can be extended to every 3-4 months. 2
Measure blood pressure at each visit using proper technique with an appropriate-sized cuff with the patient seated and relaxed. 4
Monitoring for Adverse Effects
Monitor for ACE inhibitor/ARB-specific adverse effects including cough, hyperkalemia, and renal function changes. 4 With thiazide diuretics, monitor electrolytes. 2
Common Pitfalls
Beta-blockers are not recommended as initial therapy in pediatric hypertension due to expanded adverse effects and lack of improved outcomes compared to other agents. 2 If beta-blockers are necessary and a second drug is required, add a calcium channel blocker rather than a thiazide diuretic to reduce diabetes risk. 3
Non-selective beta-blockers should be avoided in children with asthma or reactive airway disease due to bronchospasm risk. 3