From the Guidelines
Pediatric hypertension should be managed with lifestyle modifications and, when necessary, pharmacologic treatment with ACE inhibitors or ARBs as first-line medications, aiming for blood pressure goals below the 90th percentile or <130/80 mmHg in adolescents. The management of pediatric hypertension requires careful evaluation and consideration of age-specific blood pressure thresholds. Children with blood pressure readings consistently above the 95th percentile for age, sex, and height should be diagnosed with hypertension. Initial management includes lifestyle modifications such as:
- Weight management
- Increased physical activity
- Reduced sodium intake
- A DASH-style diet rich in fruits, vegetables, and low-fat dairy For pharmacological treatment, the choice of medication depends on comorbidities; ACE inhibitors or ARBs are preferred for children with diabetes or kidney disease but should be avoided in pregnancy, as noted in the 2025 standards of care in diabetes 1. Regular monitoring is essential, with a focus on identifying and addressing secondary causes of hypertension, including renal disease, coarctation of the aorta, and endocrine disorders, especially in younger children or those with severe hypertension. The goal of treatment, as outlined in the 2025 standards of care in diabetes, is to achieve blood pressure <90th percentile for age, sex, and height or, in adolescents aged ≥13 years, <130/80 mmHg 1. Early intervention is crucial as childhood hypertension often persists into adulthood, increasing the risk of cardiovascular disease. According to the most recent guideline, ACE inhibitors or ARBs should be started for treatment of confirmed hypertension, in addition to lifestyle modification 1.
From the FDA Drug Label
Enalapril, which crosses the placenta, has been removed from neonatal circulation by peritoneal dialysis with some clinical benefit, and theoretically may be removed by exchange transfusion, although there is no experience with the latter procedure. Antihypertensive effects of enalapril maleate have been established in hypertensive pediatric patients age 1 month to 16 years Enalapril maleate is not recommended in neonates and in pediatric patients with glomerular filtration rate <30 mL/ min/1.73 m 2, as no data are available.
Pediatric Hypertension: Enalapril maleate can be used to treat hypertension in pediatric patients aged 1 month to 16 years. However, it is not recommended for neonates and pediatric patients with a glomerular filtration rate <30 mL/min/1.73 m^2 due to lack of data. Key considerations include:
- Age range: 1 month to 16 years
- Contraindications: Neonates, glomerular filtration rate <30 mL/min/1.73 m^2
- Supporting evidence: Adequate and well-controlled studies in pediatric and adult patients, as well as published literature in pediatric patients 2
From the Research
Definition and Prevalence of Pediatric Hypertension
- Pediatric hypertension is a significant and growing health concern, with an incidence rate of about 3.5% 3.
- The prevalence of pediatric hypertension is increasing, largely due to the obesity epidemic, with primary or idiopathic hypertension becoming more prevalent compared to secondary causes 3.
- Pediatric hypertension is a major risk factor for adverse cardiovascular events later in life, making early diagnosis and management essential 4.
Diagnosis and Management of Pediatric Hypertension
- Practitioners need to be aware of screening recommendations for early recognition and management of pediatric hypertension 5.
- Lifestyle modifications, such as weight management, dietary modifications, and daily physical activity, should be addressed early, and specialty referral considered if the child is not improving 5.
- Further work-up to rule out secondary causes of pediatric hypertension should also be considered in any child with stage 2 hypertension and in those with persistently elevated blood pressures 5.
Treatment Approaches for Pediatric Hypertension
- Novel and often underutilized approaches to the treatment of hypertension in pediatrics include psychological counseling for behavior modification, circadian nutrition, consistent use of interdisciplinary teams, manipulation of macronutrients, stress management, technology-infused interventions, and systemic changes to the food environment 6.
- Emerging treatment trends may provide non-traditional and more effective non-pharmacologic routes to blood pressure management in pediatric patients 6.
- While pharmacological interventions, such as calcium channel blockers, may be effective in lowering blood pressure, lifestyle modifications can sometimes be as effective and should be considered as a first-line approach 6, 7.