AAP Pediatric Hypertension Guidelines

Individual regression equations for boys/girls and SBP/DBP percentiles for children aged 1-12 years are published in Rosner 2008.

Multiple models were used to evaluate pediatric blood pressure data, and this data is based off of a quantile regression model.

These percentiles are based on normal weight children (BMI <85th percentile), as including overweight and obese children was thought to increase bias, knowing that these patients have a higher prevalence of high blood pressure. Therefore, the BP values in the new pediatric guidelines are several mmHg lower than previous youth hypertension guidelines.

Interpretation:

Use the higher of the two values; e.g. if a 14 year old has BP 135/90, diagnosis is Stage 2 HTN.

From Flynn 2017.

• Classifies blood pressure in pediatric patients, which varies based on age and gender.
• Measuring BP at routine well-child visits enables early detection of primary hypertension as well as detection of asymptomatic hypertension secondary to another underlying disorder. Hypertension is a known major contributor to cardiovascular disease.
• Can guide timing of:
• Blood pressure recheck.
• Diagnostic evaluation.
• Treatment initiation.

Children aged 1-17 years old.

• These values are based on auscultatory measurements, not oscillometric devices or ambulatory blood pressure measurements.
• Blood pressure should ideally be taken by auscultatory measurement after child has been seated for 3-5 minutes with back supported and legs uncrossed. Blood pressure should be measured on the right arm for consistency. Correct cuff size should be used to ensure accuracy of measurement.
• If the initial blood pressure is elevated, providers should take two additional measurements at the same visit and use the average value.
• For children ≥13 years of age, this calculator has been adjusted to meet definitions presented in the 2017 AHA/ACC adult hypertension guidelines in order to facilitate the management of older adolescents with high blood pressure.

If the patient is symptomatic (encephalopathy, acute kidney injury, congestive heart failure) with Stage 2 HTN level, OR the BP is >30 mmHg above the 95th percentile (or >180/120 mmHg in an adolescent), refer to emergency department immediately for evaluation and treatment of acute severe HTN.

AAP recommendations for management (from Flynn 2017):

Normal BP

• No additional action is needed.
• BP should be rechecked at the next routine well-child care visit.

Elevated BP

• Lifestyle interventions (nutrition, sleep, physical activity) should be initiated.
• BP should be rechecked by auscultatory measurement in 6 months.
• If it remains elevated at 6 months, upper and lower extremity BP should be checked and lifestyle measures should be repeated.
• If BP is still elevated after 12 months from initial measurement, ambulatory blood pressure monitoring (ABPM) should be ordered along with diagnostic evaluation, and subspecialty referral should be considered.

Stage 1 hypertension

• If asymptomatic, lifestyle interventions should be initiated.
• BP should be rechecked by auscultatory measurement in 1-2 weeks.
• If it remains classified as Stage 1 HTN at 1-2 weeks, upper and lower extremity BP should be checked, and BP should be checked in 3 months by auscultation with consideration for nutrition/weight management referral.
• If BP continues to be classified as Stage 1 HTN after 3 visits, ABPM should be ordered along with diagnostic evaluation, and treatment should be initiated with consideration for subspecialty referral.

Stage 2 hypertension

• If asymptomatic, lifestyle interventions should be initiated.
• BP should be rechecked by auscultatory measurement in 1 week OR the patient can be directly referred to a subspecialist within 1 week.
• If it remains classified as Stage 2 HTN at 1 week, ABPM should be ordered along with diagnostic evaluation, and treatment should be initiated OR the patient should be referred to subspecialty care within 1 week.

Additional note: any patient with evidence of LVH may not participate in sports until BP is normalized with therapy. Athletes with Stage 2 HTN (even without evidence of target organ injury) should not participate in sports until HTN is controlled by lifestyle modification or pharmacologic therapy.

• Screening for hypertension is recommended in children beginning at age 3 years.
• There are many etiologies for falsely elevated BP, such as anxiety or caffeine intake, and therefore the diagnosis of hypertension is made by checking multiple measurements over time.
• Hypertension is diagnosed if a child has auscultatory-confirmed BP readings ≥95th percentile on 3 different visits.