What is the initial approach to managing pediatric hypertension?

Initial Management of Pediatric Hypertension

The initial approach to pediatric hypertension begins with proper diagnostic confirmation through repeated blood pressure measurements on three separate occasions, followed by 3-6 months of intensive lifestyle modifications (DASH diet, physical activity, weight management) before considering pharmacologic therapy—unless the child has Stage 2 hypertension, symptomatic hypertension, or evidence of target organ damage, in which case medications should be started immediately alongside lifestyle changes. 1

Diagnostic Confirmation and Classification

• Confirm hypertension by measuring blood pressure on three separate days using an appropriately-sized cuff with the child seated and relaxed after 5 minutes of rest, with the right arm supported at heart level. 1

• Stage 1 hypertension in children ≥13 years is defined as systolic BP 130-139 mmHg or diastolic BP 80-89 mmHg. 1

• Stage 2 hypertension is defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg. 1

• For children under 13 years, hypertension is defined as blood pressure persistently above the 95th percentile for age, sex, and height. 2

Evaluation for Secondary Causes

• If blood pressure is persistently above the 95th percentile or severely elevated, evaluate for secondary causes including renal disease and coarctation of the aorta. 2

• Perform urinalysis to detect proteinuria or hematuria suggesting renal parenchymal disease. 1

• Check thyroid-stimulating hormone, liver function tests, renal function tests when blood pressure remains persistently elevated. 2

• Assess for target organ damage through echocardiography to detect left ventricular hypertrophy, evaluate for microalbuminuria, and check for retinal vascular abnormalities. 2

First-Line Treatment: Intensive Lifestyle Modifications

Initiate lifestyle modifications for 3-6 months before considering pharmacologic therapy in Stage 1 hypertension without complications. 1

Dietary Interventions

• Implement a DASH-type diet (high in fruits, vegetables, whole grains, and low-fat dairy, with decreased intake of foods high in saturated fat or sugar). 2, 1

• Reduce sodium intake in the diet and emphasize increased consumption of fruits and vegetables. 2

• Decrease intake of simple sugars, particularly in overweight children with insulin resistance. 2

Physical Activity

• Recommend 60 minutes per day of moderate to vigorous physical activity to maintain appropriate weight and independently lower blood pressure. 2

Weight Management

• For children at risk of overweight (85th percentile) or obesity (95th percentile), initiate a weight management program with appropriate energy balance achieved through changes in diet and physical activity. 2

• Use a family-centered, behavioral management approach directed at all family members who are overweight. 2

• Weight management should be done in collaboration with a trained dietitian. 2

Indications for Immediate Pharmacologic Therapy

Start medications immediately (alongside lifestyle modifications) if any of the following are present: 1

• Stage 2 hypertension (BP ≥140/90 mmHg in adolescents ≥13 years)
• Symptomatic hypertension
• Evidence of target organ damage (left ventricular hypertrophy, microalbuminuria, retinal vascular abnormalities)

First-Line Pharmacologic Agents

When pharmacologic therapy is indicated, preferred initial agents include: 1

• ACE inhibitors (e.g., lisinopril, enalapril)
• Angiotensin receptor blockers (ARBs) (e.g., candesartan)
• Long-acting calcium channel blockers (e.g., amlodipine)
• Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone)

Specific Dosing for Pediatric Patients

Lisinopril: 3

• For pediatric patients ≥6 years with glomerular filtration rate >30 mL/min/1.73m²: Start at 0.07 mg/kg once daily (up to 5 mg total)
• Adjust according to blood pressure response up to a maximum of 0.61 mg/kg (up to 40 mg) once daily
• Not recommended in children <6 years or with GFR <30 mL/min/1.73m²

Amlodipine: 4

• For pediatric patients ages 6-17 years: 2.5 mg to 5 mg once daily
• Doses exceeding 5 mg daily have not been studied in pediatric patients

Treatment Goals

• Target blood pressure to be <130/80 mmHg for adolescents ≥13 years, or consistently <90th percentile for age, sex, and height. 1

Collaboration and Monitoring

• Pharmacological management of hypertension should be accomplished in collaboration with a physician experienced in pediatric hypertension. 2

• Consider ambulatory blood pressure monitoring (ABPM) to confirm diagnosis and avoid overdiagnosis of white coat hypertension, which occurs in approximately 46% of children with elevated clinic blood pressure measurements. 2

Critical Pitfalls to Avoid

• Do not delay evaluation for secondary causes in children with Stage 2 hypertension or those with clinical red flags, as secondary hypertension is more common in pediatric populations than adults. 1

• Do not start pharmacologic therapy prematurely in Stage 1 hypertension without target organ damage—give lifestyle modifications a full 3-6 month trial first. 1

• Do not use incorrect blood pressure cuff size or improper measurement technique, as this leads to misdiagnosis and unnecessary treatment. 2

• Do not prescribe ACE inhibitors or ARBs to adolescent females without comprehensive reproductive counseling about teratogenic risks. 5