What is the management approach for a pediatric patient with hypertension?

Management of Pediatric Hypertension

All children with elevated blood pressure or hypertension should begin with lifestyle modifications, and pharmacologic therapy should be initiated for Stage 2 hypertension, symptomatic hypertension, left ventricular hypertrophy on echocardiography, or Stage 1 hypertension that fails to respond to 3-6 months of lifestyle changes. 1, 2

Initial Diagnostic Confirmation

• Hypertension must be confirmed on three separate occasions before making the diagnosis, as a single elevated reading is insufficient and leads to overdiagnosis 1, 2
• Blood pressure should be measured after 5 minutes of rest, with the patient seated and the right arm supported at heart level, using age-appropriate cuff size 1
• Compare measurements to age-, sex-, and height-specific percentile tables to classify blood pressure status 1, 2
• Ambulatory blood pressure monitoring (ABPM) should be performed to confirm the diagnosis and exclude white coat hypertension 1, 3

Blood Pressure Classification

• Elevated BP: systolic or diastolic ≥90th percentile (or ≥120/80 mmHg in adolescents ≥13 years) 2
• Stage 1 hypertension: BP ≥95th percentile but <95th percentile + 12 mmHg 1, 2
• Stage 2 hypertension: BP ≥95th percentile + 12 mmHg 1, 2

Lifestyle Modifications (First-Line for All Patients)

Every child with elevated BP or hypertension should receive intensive lifestyle counseling before or concurrent with medication initiation. 1, 2

• Dietary changes: Implement DASH diet emphasizing fruits and vegetables, restrict sodium intake, limit saturated fat to 7% of total calories and cholesterol to 200 mg/day 1, 2, 4
• Physical activity: Prescribe moderate to vigorous exercise 3-5 days per week for 30-60 minutes per session 1, 2, 4
• Weight management: If overweight or obese, target at least 5% body weight reduction through family-centered behavioral approaches 2, 4
• Follow-up schedule: See patients every 3-6 months when using lifestyle modifications alone to reinforce adherence and reassess need for medication 2

Evaluation for Secondary Causes and Target Organ Damage

Before initiating pharmacologic therapy, evaluate for secondary causes (particularly in young children, those with Stage 2 hypertension, or minimal family history) and assess for target organ damage. 1, 2, 4

• Obtain urinalysis and renal function tests to screen for renal disease 1
• Perform echocardiography to assess for left ventricular hypertrophy, defined as LV mass >51 g/m²·⁷ for children >8 years, or >115 g/BSA for boys and >95 g/BSA for girls 1, 2, 4
• Consider renal ultrasonography with Doppler in normal-weight children ≥8 years suspected of having renovascular hypertension 1
• Evaluate for coarctation of the aorta and endocrine disorders in younger children with significant hypertension 1, 2

Indications for Pharmacologic Therapy

Start antihypertensive medication in the following situations: 1, 2, 4

• Stage 2 hypertension without a clearly modifiable factor (e.g., obesity)
• Symptomatic hypertension (headaches, cognitive changes)
• Left ventricular hypertrophy on echocardiography
• Stage 1 hypertension that persists after 3-6 months of lifestyle modifications
• Any stage of hypertension in patients with chronic kidney disease or diabetes mellitus

First-Line Medication Selection

The preferred initial antihypertensive agents are ACE inhibitors, ARBs, long-acting calcium channel blockers, or thiazide diuretics. 1, 2, 4

Specific Population Considerations:

• For children with CKD, proteinuria, or diabetes: ACE inhibitors or ARBs are mandatory first-line agents due to renal and cardiovascular protective effects 1, 2, 4
• For African American children: Consider higher initial ACE inhibitor doses or alternatively start with thiazide diuretic or long-acting calcium channel blocker, as ACE inhibitors may be less effective as monotherapy 2, 5
• β-blockers are NOT recommended as initial treatment due to expanded adverse effect profile and lack of improved outcomes compared to other agents 2, 4

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 2, 4

Medication Dosing and Titration Strategy

• Start at the low end of the dosing range and titrate every 2-4 weeks until blood pressure normalizes 2, 4
• For lisinopril specifically: pediatric patients <50 kg receive 0.625-20 mg daily; those >50 kg receive 1.25-40 mg daily, with antihypertensive efficacy demonstrated at doses >1.25 mg (0.02 mg/kg) 5
• See patients every 4-6 weeks for dose adjustments until blood pressure is normalized 2, 4
• Use home blood pressure monitoring between visits to guide medication titration 2
• If BP is not controlled with a single agent at maximal dose, add a second agent from a different class 2

Treatment Goals

The target blood pressure is <90th percentile for age, sex, and height (or <130/80 mmHg in adolescents ≥13 years, whichever is lower). 1, 2, 4

Special Population Goals:

• For children with CKD: Target 24-hour mean arterial pressure <50th percentile by ABPM, as this slower target demonstrated reduced CKD progression in the ESCAPE trial 1, 4
• For children with diabetes or CKD with proteinuria: More aggressive BP targets are warranted 1, 2

Monitoring and Follow-Up

• After BP control is achieved, extend follow-up visits to every 3-4 months 2, 4
• Monitor for ACE inhibitor/ARB adverse effects including cough, hyperkalemia, and renal function changes 4
• Monitor electrolytes with thiazide diuretics 4
• ABPM may be used to assess treatment effectiveness, especially when clinic or home measurements suggest insufficient response 1, 2
• Repeat echocardiography at 6-12 month intervals to monitor improvement or progression of left ventricular hypertrophy 1

Common Pitfalls to Avoid

• Do not diagnose hypertension based on a single elevated reading—always confirm on three separate days 1, 2
• Do not use β-blockers as first-line therapy 2, 4
• Do not prescribe ACE inhibitors or ARBs to adolescent females without reproductive counseling 2, 4
• Do not delay evaluation for secondary causes in young children with significant hypertension or those with minimal family history 1, 2
• Do not perform electrocardiography for LVH assessment—echocardiography is the appropriate test 1