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Résumé

Ces lignes directrices sur l'hypertension pédiatrique constituent une mise à jour du quatrième rapport de 2004 sur le diagnostic, l'évaluation et le traitement de de l’hypertension artérielle de l'hypertension artérielle chez les enfants et les adolescents. Parmi les modifications importantes apportées à ces recommandations, citons: 1) le remplacement du terme "pré-hypertension", 2) de nouveaux tableaux normatifs de la tension artérielle chez l'enfant fondés sur des enfants de poids normal (3) un tableau de dépistage simplifié pour identifier les PA nécessitant une évaluation plus poussée; (4) classification plus simplifiée pour les adolescents de 13 ans et plus, conformément aux lignes directrices relatives à la TA adulte de l'American Card Association et du Cardiology College (5); recommandation plus limitée pour le dépistage des mesures de la pression artérielle uniquement lors de visites de soins préventifs (6); recommandations harmonisées pour l'évaluation initiale et la gestion. 7) élargissement de la surveillance de la pression artérielle chez les enfants pour le diagnostic et le traitement de de l’hypertension artérielle de l'hypertension; et 8) recommandations révisées sur le moment opportun pour effectuer une échocardiographie dans l'évaluation des signe d’hypertension artérielle pulmonaires pédiatriques hypertendus nouvellement diagnostiqués (généralement uniquement avant le début du traitement de de l’hypertension artérielle) avec une définition révisée de l'hypertrophie ventriculaire gauche. Ces lignes directrices contiennent 30 rapports d'activités clés et 27 recommandations supplémentaires résultant d'un examen approfondi de près de 15 000 articles publiés entre janvier 2004 et juillet 2016. Chaque rapport d'activité clé contient le niveau de preuve, le ratio avantages / pertes et la force de la recommandation. Ce guide de pratique clinique, approuvé par l'American Heart Association, est conçu pour promouvoir les soins centrés sur le signe d’hypertension artérielle pulmonaire et la famille, réduire les interventions médicales inutiles et coûteuses, améliorer le diagnostic et les résultats pour les signe d’hypertension artérielle pulmonaires, soutenir la mise en œuvre et orienter les recherches futures.

  • Abréviations:
    PAA
    Académie américaine de pédiatrie
    MAPA
    surveillance de la pression artérielle ambulatoire
    ACC
    Collège américain de cardiologie
    ACE
    enzyme de conversion de l'angiotensine
    AHA
    American Heart Association
    ARB
    bloqueur des récepteurs de l'angiotensine
    ARR
    rapport aldostérone / rénine
    BP
    tension artérielle
    BSA
    zone du corps
    cIMT
    l'épaisseur de l'intimamedia carotidienne
    CKD
    hypertension artérielle pulmonaire rénale chronique
    CTA
    angiographie par tomographie par ordinateur
    CV
    cardiovasculaire
    CVD
    hypertension artérielle pulmonaire cardiovasculaire
    DASH
    Les régimes pour arrêter l'hypertension
    DBP
    pression artérielle diastolique
    ED
    service d'urgence
    DSE
    bilan de hypertension artérielle traitement naturel électronique
    Fièvre aphteuse
    dilatation induite par le flux
    HTN
    l'hypertension
    LVH
    hypertrophie ventriculaire gauche
    IMVG
    indice de masse ventriculaire gauche
    MA
    microalbuminurie
    MAP
    pression artérielle moyenne
    MH
    hypertension masquée
    MI
    entretien de motivation
    ARM
    angiographie par résonance magnétique
    NF-1
    Neurofibromatose de type 1
    EN PARTIE
    Syndrome d'apnées obstructives du sommeil
    PCC
    phéochromocytome
    PICOT
    Patient, intervention / indicateur, comparaison, résultat et temps
    PRA
    activité de la rénine plasmatique
    PWV
    vitesse de l'onde de pouls
    QALY
    année de vie ajustée en fonction de la qualité
    RAAS
    système rénine-angiotensine-aldostérone
    RAS
    sténose de l'artère rénale
    SBP
    pression artérielle systolique
    SDB
    troubles du sommeil
    T1DM
    Diabète de type 1
    T2DM
    Diabète de type 2
    UA
    acide urique
    WCH
    hypertension de la couche blanche
  • 1. Introduction

    1. Portée des directives de pratique clinique

    L'intérêt pour les enfants hypertendus (HNS) a augmenté depuis la publication du quatrième rapport de 2004 sur le diagnostic, l'évaluation et le traitement de de l’hypertension artérielle de l'hypertension artérielle chez les enfants et les adolescents (quatrième rapport).1 Consciente de l’écart actuel entre les preuves et de la nécessité d’un examen approfondi et actualisé de la littérature pertinente, l’American Pediatric Academy (AAP) et son conseil pour l’amélioration de la qualité et la sécurité des signe d’hypertension artérielle pulmonaires ont élaboré une ligne directrice pour cette pratique fournissant des informations actualisées sur les problèmes de diagnostic, d’évaluation et de traitement de de l’hypertension artérielle du HTN. . Il s’adresse principalement aux médecins ambulatoires des enfants et des adolescents. Cette directive est confirmée par l’American Heart Association.

    Dans les cas où des preuves suffisantes n’auraient pas pu être établies, les recommandations seront fondées sur un avis consensuel d’experts du dépistage et de la gestion de l’hypertension artérielle au sein du Sous-comité de la pratique clinique chez l’enfant (ci-après dénommé "le sous-comité"). Le sous-comité a l'intention de mettre à jour ces directives régulièrement lorsque de nouveaux éléments de preuve sont disponibles. Les outils de mise en œuvre de ce guide sont disponibles sur le site Web du PAA (https://www.aap.org/en-us/about-the-aap/Committees-Council-Sections/coqips/Pages/Implementation-Guide.aspx).

    1.1 Méthodologie

    Le sous-comité était présidé par un néphrologue et un pédiatre général pédiatrique et était composé de 17 membres, dont un représentant de haut rang. Tous les membres du sous-comité ont été priés de signaler les conflits d'intérêts financiers ou inhérents aux membres ou aux membres de leur famille au début et tout au long du processus de préparation du code. Les conflits d'intérêts potentiels ont été traités et résolus par le PAA. Une liste détaillée des membres du sous-comité et des parties prenantes est fournie dans la section Consortium à la fin de cet article. La liste des membres du sous-comité sur les conflits d'intérêts sera incluse dans le prochain rapport technique.

    Le sous-comité des épidémiologistes a élaboré un examen détaillé du contenu qui a été examiné et approuvé par le sous-comité. La revue comprenait une liste de sujets primaires et secondaires conçus pour guider la recherche documentaire approfondie et pour fournir un aperçu systématique actualisé de la littérature relative au diagnostic, au traitement de de l’hypertension artérielle et au traitement de de l’hypertension artérielle du HTN chez les enfants et à la prévalence des MNT et des hypertension artérielle pulmonaires associées.

    Environ 80% des sujets abordés dans le contexte ont été étudiés à l'aide du format signe d’hypertension artérielle pulmonaire, intervention / indicateur, comparaison, résultat et heure (PICOT) afin de traiter les problèmes clés suivants:

    1. Comment diagnostiquer le HTN systémique (par exemple, le HTN primaire, le HTN rénovasculaire, l'hypertension des cheveux blancs (WCH) et l'hypertension masquée (MH)) et quelle est l'approche optimale pour diagnostiquer le HTN chez l'enfant et l'adolescent?

    2. Quel est le traitement de de l’hypertension artérielle recommandé pour HTN? Comment pouvons-nous mieux identifier les étiologies sous-jacentes au HTN secondaire de l'enfance?

    3. Quelle est la pression artérielle systolique et / ou diastolique optimale chez les enfants et les adolescents?

    4. Chez les enfants âgés de 0 à 18 ans, le mode de vie et le traitement de de l’hypertension artérielle des médicament pour de l’hypertension artérielles antihypertenseurs sont affectés par la mesure indirecte des hypertension artérielle pulmonaires cardiovasculaires (MCV), telles que l'épaisseur de l'artère carotide intimamedia (cIMT), la dilatation induite par le flux (FMD), l'hypertrophie ventriculaire gauche (LVH). ) et d’autres marqueurs de dysfonctionnement vasculaire?

    Une recherche systématique et une revue de la littérature ont été entreprises pour traiter ces problèmes clés. La recherche initiale comprenait des articles publiés entre la publication du quatrième rapport (janvier 2004) et août 2015. Le processus utilisé pour mener une revue systématique était conforme aux recommandations de l'Institut médical concernant les revues systématiques.2

    Des recherches séparées ont été effectuées sur des sujets non étudiés au format PICOT. Tous les sujets n'étaient pas au format PICOT (par exemple, aspects économiques de HTN). La troisième et dernière recherche a été effectuée au moment de la création des principaux rapports d'activité (ACS) afin d'identifier d'autres articles pertinents publiés entre août 2015 et juillet 2016.

    Tableau 1

    Résumé des SAK sur le dépistage et la gestion de haute qualité chez les enfants et les adolescents

    Une description détaillée de la méthodologie utilisée pour effectuer la recherche documentaire et un examen systématique des lignes directrices de cette pratique clinique seront inclus dans le prochain rapport technique. En bref, un processus en plusieurs étapes a pris part à la sélection de la comparaison. Tout d'abord, les deux membres du sous-comité ont examiné les titres et résumés des références identifiées pour chaque problème clé. L'épidémiologiste a donné un vote décisif si nécessaire. Ensuite, les articles sélectionnés ont été examinés par deux membres du sous-comité et un épidémiologiste. Bien que de nombreux membres du sous-comité aient publié de nombreux articles sur les sujets traités dans ce guide, ils n’ont pas été choisis de préférence sur la base de leurs auteurs.

    Les articles sélectionnés à ce stade ont été rattachés au sujet principal du contact. Les membres du sous-comité ont ensuite été nommés pour écrire des groupes qui ont évalué la qualité des preuves pour les sujets sélectionnés et généré des KAS pertinentes conformément à la matrice de classification du PAA (voir la figure 1 et la discussion détaillée dans le prochain rapport technique).3 Des groupes de travail spéciaux ont été mis en place pour traiter de deux problèmes spécifiques pour lesquels il n'existait aucune preuve ni opinion d'experts permettant de créer les CCA, la définition de «HTN» et la définition de «LVH». sur la base de nouvelles recherches littéraires et examinées par les membres des épidémiologistes et des sous-comités désignés pour examen. Si nécessaire, les recherches ont été effectuées au format PICOT.

    FIGURE 1

    Matrice de classification AAP.

    En plus des 30 KAS ci-dessus, cette ligne directrice contient également 27 recommandations supplémentaires basées sur l'opinion d'experts du consensus du sous-comité. Ces recommandations, ainsi que leur emplacement dans le document, sont répertoriées dans le tableau 2.

    TABLEAU 2

    Avis consensuel supplémentaire et emplacements de texte

    2. Épidémiologie et importance clinique

    2.1 Prévalence de HTN chez les enfants

    Les informations sur la prévalence de l'hypertension artérielle chez les enfants sont en grande partie dérivées des données NHANES et sont généralement basées sur une session de mesure de la pression artérielle. Ces études, menées depuis 1988, montrent que l'incidence de l'hypertension artérielle chez l'enfant a augmenté, y compris l'HTN et l'hypertension artérielle.4,5 Une tension artérielle élevée est systématiquement plus élevée chez les garçons (15 à 19%) que chez les filles (7 à 12%). L'incidence de l'hypertension artérielle est plus élevée chez les enfants africains espagnols et non hispaniques que chez les non-espagnols chez les Blancs, chez les jeunes plus âgés que chez les jeunes enfants.6

    Cependant, dans les mesures cliniques et récurrentes de la pression artérielle, l'incidence de l'hypertension confirmée est en partie due à la variabilité de la pression artérielle et à la correction de la mesure de la pression artérielle (également appelée effet d'accommodation). Par conséquent, la prévalence réelle du HTN clinique chez les enfants et les adolescents est de 0,53,5%.7,8 La prévalence de l'hypertension persistante (anciennement connue sous le nom de "préhypertension", y compris les valeurs de BP allant de 90 à 94 centiles ou de 120/80 à 130/80 mm Hg chez les adolescents) est également de 2,2% à 3,5%, chez les enfants des taux d'obésité plus élevés et l'obésité chez les adolescents.7,9

    Les données sur la surveillance de la tension artérielle de l'enfance à l'âge adulte montrent qu'une tension artérielle élevée chez l'enfant est corrélée à une tension artérielle élevée à l'âge adulte et à l'émergence de HTN chez les jeunes adultes. La force de la relation de suivi est plus élevée chez les enfants plus âgés et les adolescents.10 Les données de trajectoire de la TA (y compris les mesures de répétition dans la petite enfance) confirment le lien entre une TA élevée et la HTN chez l'adolescent au début de l'âge adulte.11 et que, dans l’enfance, la BP normale est associée à l’absence de HTN au Moyen Âge.11

    2.2 Sensibilisation à la R & D, traitement de de l’hypertension artérielle et contrôle chez les enfants

    Sur 32,6% des adultes américains atteints de HTN, près de la moitié (17,2%) ne savent pas qu'ils en sont atteints; même parmi ceux qui sont au courant de leur état, environ la moitié seulement (54,1%) ont déjà consulté leur médecin.12 Malheureusement, il n’ya pas d’études majeures dans lesquelles les chercheurs ont systématiquement étudié la prise de conscience ou le contrôle des jeunes BP, bien que l’analyse des modèles nationaux de prescription ait montré une augmentation du nombre de prescriptions rédigées pour les jeunes BP entre 2004 et 2007. .13

    Dans l'étude Diabeet in the Youth, seuls 7,4% des jeunes atteints de diabète de type 1 (T1DM) et 31,9% de ceux de type 2 (DT2) présentaient leur statut BP.14 Même après le diagnostic, seulement 57,1% des signe d’hypertension artérielle pulmonaires atteints de DT1 et 40,6% des signe d’hypertension artérielle pulmonaires atteints de DT2 ont obtenu un bon contrôle de la TA.14 Prévenir le risque pour la hypertension artérielle traitement naturel des jeunes à risque des jeunes d'âge moyen atteints de diabète de type 2, au cours duquel une intervention en milieu scolaire visant à réduire le risque cardiovasculaire chez les collégiens a été examinée, avec une prévalence de 9,5% des HTN de stade 1 ou 2.15 Après l'intervention, il n'y a pas eu de diminution significative du HTN dans le groupe témoin; le groupe d'intervention a diminué de% 1% l'incidence de HTN, laissant 8.5% de plus que BP dans la plage idéale.

    Des chercheurs de plusieurs petits centres mononucléaires ont évalué le contrôle du HTN chez les enfants et les adolescents. Dans une étude, les changements de style de vie et les médicament pour de l’hypertension artérielles donnaient à 46 jeunes sur 65 (70%) un contrôle adéquat du HTN.16 Une autre étude dans laquelle des chercheurs ont utilisé la surveillance de la pression artérielle en consultation externe pour évaluer le contrôle de la pression artérielle chez 38 enfants (dont 84% étaient atteints d'insuffisance rénale chronique) a révélé que seuls 13 enfants (34%) avaient un contrôle suffisant de la pression artérielle, même parmi ceux ayant reçu plus d'un enfant. la médecine de l’hypertension artérielle.17 Une étude similaire a montré que des médicament pour de l’hypertension artérielles supplémentaires augmentaient le taux de contrôle de la TA chez les enfants atteints de néphropathie chronique.18

    2.3 La prévalence de HTN chez les enfants atteints de diverses hypertension artérielle pulmonaires chroniques

    Il est bien connu que les enfants atteints de certaines hypertension artérielle pulmonaires chroniques, notamment l'obésité, la détresse respiratoire, la néphropathie chronique et les naissances prématurées, présentent un taux de HTN plus élevé. Ceux-ci sont décrits ci-dessous.

    2.3a enfants obèses

    La prévalence de HTN dans l'obésité et l'obésité est de 3,8% à 24,8%. Les taux de HTN augmentent progressivement et l'obésité augmente.1924 Des relations similaires peuvent être observées entre HTN et l’augmentation du tour de taille.4,25,26 63 Revue systématique de l'étude BMI27 et 61 études de différentes mesures de la constipation28 a montré des liens entre ces conditions et HTN. L’obésité est également liée à l’absence de variabilité quotidienne de la PA,29,30 jusqu'à 50% des enfants obèses n'ont pas le plongeon BP attendu la nuit.3133

    Des études ont montré que l'obésité chez les enfants est également liée au développement futur du HTN.22 Un IMC élevé en est déjà à ses balbutiements, associé à une TA future plus élevée.34 Ce risque semble augmenter avec la gravité de l'obésité; L'augmentation du nombre de signe d’hypertension artérielle pulmonaires souffrant d'obésité grave (IMC> 99 centiles) dans la TA est quatre fois plus grande que la double augmentation chez les signe d’hypertension artérielle pulmonaires obèses (IMC 95 – 98 centiles) par rapport aux enfants et adolescents de poids corporel normal.35

    Les résultats de ces études transversales et longitudinales confirment fortement que la prévalence de HTN augmente avec le centile IMC. L’étude souligne également l’importance de la surveillance de la pression artérielle à toutes les réunions cliniques chez les enfants obèses et / ou obèses.

    L'obésité chez les enfants atteints de HTN peut être associée à des facteurs de risque cardiométaboliques supplémentaires (par exemple, dyslipidémie et altération du métabolisme du glucose).36,37 qui peut avoir un impact sur BP ou être identique aux hypertension artérielle pulmonaires sous-jacentes liées au mode de vie.25,38 Certains font valoir que la présence de plusieurs facteurs de risque, dont l'obésité et le HTN, entraîne un risque CV nettement plus élevé que les seuls facteurs de risque. Bien que ce phénomène soit difficile à démontrer, une étude cardiaque a montré que plusieurs adolescents indiens présentant des facteurs de risque cardiométaboliques présentaient une incidence plus élevée d’HVG (43,2% contre 11,7%) et de dilatation auriculaire gauche (63,1% contre 21,9%; P <0,001) et une fonction systolique et diastolique inférieure du VG par rapport aux signe d’hypertension artérielle pulmonaires sans facteurs de risque cardiométaboliques multiples.39 L'obésité et le HTN sont avant tout le moteur de leur CV, l'obésité étant un déterminant plus important des anomalies cardiaques que le HTN (coefficient 4,17 contre 1,03).

    2.3b Enfants avec SDB

    Le SDB est présent sur un spectre contenant (1) le ronflement primaire, (2) la fragmentation du sommeil et (3) le syndrome d'apnées obstructives du sommeil (SAOS). Dans plusieurs études, les chercheurs ont identifié un lien entre SDB et HTN chez les enfants.4042 Des études montrent que les enfants qui passent la nuit 7 heures ou moins courent un risque plus élevé de HTN.43 De petites études sur les jeunes souffrant de troubles du sommeil ont montré que la prévalence de l'hypertension artérielle se situait entre 3,6% et 14%.40,41 Plus vous êtes dur, plus il est probable que votre enfant soit atteint de HTN.45,46 Même une durée de sommeil insuffisante et un sommeil de mauvaise qualité ont été associés à une augmentation de la TA.43

    2.3c Enfants atteints de MRC

    HTN et CKD chez l'enfant ont des liens physiopathologiques bien établis. Certaines formes d'IRC peuvent conduire à l'HTN et l'HTN non traité peut causer l'IRC chez l'adulte, bien que les enfants n'en aient aucune preuve. Chez les enfants et les adolescents atteints d’IRC, il est connu que% 50% est hypertendu.4648 Chez les enfants et les adolescents atteints d'insuffisance rénale au stade terminal (dialyse ou post-greffe), environ 48% à 79% des signe d’hypertension artérielle pulmonaires sont hypertendus, 20% à 70% présentent un effet indésirable non contrôlé.4953 Près de 20% des HTN chez les enfants peuvent être causés par une insuffisance rénale chronique.54

    2.3d Enfants avec naissance prématurée

    Des antécédents postnatals anormaux – y compris une naissance prématurée et un faible poids à la naissance – ont été identifiés comme un facteur de risque de pneumopathie chez l'adulte et chez les autres adultes55; seul un faible poids à la naissance a été associé à une augmentation de la TA chez les enfants âgés de moins de 2 ans.56 Une étude de cohorte rétrospective a montré la prévalence de HTN chez les enfants de 3,3 ans nés prématurément.57 Les scientifiques du deuxième cas rétrospectif ont signalé une incidence élevée de HTN chez les enfants plus âgés ayant une naissance prématurée.58 Il semble également que la naissance prématurée peut causer des problèmes circulatoires circulaires dans l’enfance.59 Ces données sont intrigantes mais limitées. Des recherches supplémentaires sont nécessaires pour déterminer la fréquence à laquelle l'accouchement est prédit dans l'enfance.

    2.4 Importance du diagnostic de HTN chez les enfants et les adolescents

    De nombreuses études ont montré qu'une augmentation de la pression artérielle chez l'enfant augmente le risque de HTN et de syndrome métabolique chez l'adulte.10,6062 Les adolescents avec un niveau de pression artérielle plus élevé dans leur enfance sont également plus susceptibles d'avoir un HTN permanent chez l'adulte.60,63 Une étude récente a montré que les adolescents avec une TA élevée progressaient à un taux de 7% par an et qu'un IMC plus élevé prédisait une augmentation soutenue de la TA.64 En outre, un vieillissement vasculaire accéléré est susceptible de se produire chez les signe d’hypertension artérielle pulmonaires atteints de HTN. Autopsie65 et études d'image66 a montré des lésions CV liées à la CV chez les jeunes. Ces marqueurs CVD (par exemple, masse LV supérieure, t67 cIMT68 et la vitesse des ondes de pouls (PWV)69) est connu pour prédire les événements CV chez l’adulte, menant à un diagnostic précoce et au traitement de de l’hypertension artérielle du VIH.

    Quatre-vingt millions d'adultes américains (1/3) possèdent un HTN, principal contributeur aux MCV.12 L'American Heart Association (AHA) a identifié les principaux contributeurs à la hypertension artérielle traitement naturel cardiovasculaire comme "Life's Simple 7", comprenant 4 comportements de hypertension artérielle traitement naturel idéaux (non-fumeur, IMC normal, activité physique au niveau cible et régime alimentaire sain) et 3 facteurs de hypertension artérielle traitement naturel idéaux (non traité, normal). cholestérol total, glycémie à jeun normale et tension artérielle normale non traitée, définie par l’enfance ≤ 90 percentile ou <120/80 mm Hg). Il est à noter que l'hypertension artérielle élevée est le facteur de hypertension artérielle traitement naturel anormal le moins fréquent chez les enfants et les adolescents.70; 89% des jeunes (âgés de 12 à 19 ans) constituent la catégorie de PA idéale.6

    Compte tenu de la prévalence de facteurs significatifs connus chez les jeunes (exposition au tabac, obésité, inactivité et régime non comestible)12,71), les MCV chez l’adulte viennent de l’enfance. Un tiers des adolescents américains ont déclaré avoir essayé une cigarette au cours des 30 derniers jours.72 Près de la moitié (40 à 48%) des adolescents ont un IMC élevé et les taux d'obésité sévère (IMC> 99ème percentile) continuent d'augmenter, en particulier chez les filles et les adolescents.7375 L'activité physique mesurée par la mesure de l'accélération montre que moins de la moitié des garçons en âge d'être scolarisés et que seulement un tiers des filles en âge d'aller à l'école ont un niveau d'activité physique idéal.72 Plus de 80% des jeunes de 12 à 19 ans ont une nutrition médiocre (au sens des métadonnées AHA pour une hypertension artérielle traitement naturel cardiovasculaire idéale); 10% seulement mangent suffisamment de fruits et de légumes et 15% seulement <1500 mg de sodium par jour, qui sont les principaux nutriments de HTN.76

    Enfin, le test de la tension artérielle permet de détecter le HTN primaire et de détecter les réactions indésirables asymptomatiques de la hypertension artérielle pulmonaire secondaire en cas de visites normales d’enfants. La détection précoce de HTN est de la plus haute importance compte tenu de la prévalence relative plus élevée des causes secondaires dans la population pédiatrique par rapport aux adultes.

    3. Définition de HTN

    3.1 Définition de HTN (1 à 18 ans)

    Étant donné le manque de résultats, la définition actuelle de HTN chez les enfants et les adolescents est basée sur la distribution normative de la BP chez les enfants en bonne hypertension artérielle traitement naturel.1 Étant donné qu’il s’agit d’un facteur de croissance de la TA chez les enfants en croissance, la taille est incluse dans les données normatives depuis la publication du rapport du groupe de travail de 1996.1 Les niveaux de PA doivent être interprétés sur la base du sexe, de l'âge et de la taille pour éviter la classification erronée d'enfants extrêmement hauts ou très petits. Il convient de noter que les données normatives ont été collectées par la technique auscole,1 qui peut fournir des valeurs différentes de celles obtenues avec des appareils oscillométriques ou des MAPA.

    Le quatrième rapport définissait la «pression artérielle normale» comme SBP et DBP <90. percentile (basé sur l'âge, le sexe et la taille percentile). Pour la prépolarité, la «préhypertension» était définie comme étant égale ou supérieure à 90% des PAS et / ou du DBP et <95. percentile (basé sur les tables d'âge, de sexe et de hauteur). Les adolescents ont défini la «préhypertension» comme une TA ≥ 120/80 mm Hg à <95. percentile ou ≥90 et <95. centile, le plus bas des deux. HTN a été défini comme étant la clinique moyenne mesurée par le percentile ≥ 95% (percentile de l’âge, du sexe et de la taille) de la PAS et / ou du DBP, et classée en outre comme HTN de stade 1 ou 2.

    Il n'y a pas de données disponibles pour identifier un niveau spécifique de PA dans l'enfance, conduisant à un résultat CV défavorable à l'âge adulte. Par conséquent, le Sous-comité a décidé de maintenir la définition statistique du CTH chez l’enfant. Afin de simplifier la mise en œuvre par rapport au quatrième rapport, les critères étape par étape ont été revus pour les phases 1 et 2 du CRJ. Pour les enfants de 13 ans et plus, ce schéma d'arrêt est parfaitement intégré aux directives 2017 de la HTHA pour adultes de l'AHA et de l'American College of Cardiology (ACC). * En outre, le terme "préhypertension" a été remplacé par le terme "hypertension", conformément aux directives de l'AHA et de l'ACC, et à l'importance des mesures de protection du mode de vie pour prévenir le développement du HTN (voir tableau 3).

    TABLEAU 3

    Mises à jour de la catégorie et de l'étape BP

    3.2 Nouvelles tables de tiers

    De nouvelles tables normatives de TA basées sur les enfants de poids normal sont incluses dans ces recommandations (voir Tableaux 4 et 5). Comme les tableaux du quatrième rapport,1 Celles-ci incluent les valeurs SBP et DBP, classées par âge, sexe et taille (et taille en centile). Ces valeurs sont basées sur des mesures ausculturales de 50 000 enfants et adolescents. Dans ces tableaux, une nouvelle caractéristique est que les valeurs BP sont classées comme normales (50ème percentile), BP (> 90ème centile), HTN de stade 1 (> 95ème percentile) et HTN de phase 2 (≥ 95%), conformément au schéma du tableau 3. + 12 mm Hg). De plus, les hauteurs réelles en centimètres et en pouces sont données.

    Tableau 4

    Niveaux de PA par âge et taille des garçons

    Tableau 5

    Niveaux de TA pour les filles par âge et par taille

    Contrairement aux tables de quatrième rapport:1 les valeurs de PA figurant dans ces tableaux n'incluent pas les enfants et les adolescents obèses ou obèses (c.-à-d. ceux dont l'IMC est égal ou supérieur à 85%); par conséquent, ils représentent des valeurs de PA normatives pour les jeunes de poids normal. La décision de créer ces nouvelles tables était basée sur un lien étroit entre le surpoids et l'obésité, avec une TA et une HTN élevées. L'inclusion de signe d’hypertension artérielle pulmonaires obèses et obèses inclusifs dans les tables normatives de la pression artérielle serait à l'origine de préjugés. L’effet pratique de ce changement est que les valeurs de PA indiquées dans les tableaux 4 et 5 sont inférieures de plusieurs millimètres au mercure par rapport aux tableaux similaires du quatrième rapport.1 Ces tableaux sont basés sur les mêmes données de population, à l'exception des personnes obèses et obèses, et sur les mêmes méthodes que celles utilisées dans le quatrième rapport.1 Les méthodes et les résultats sont publiés ailleurs.77 Pour les scientifiques et autres personnes intéressées par les équations utilisées pour calculer les valeurs de PA des tableaux, la méthodologie détaillée et le code du système d'analyse statistique sont disponibles à l'adresse suivante: http://sites.google.com/a/channing.harvard.edu/bernardrosner / pédiatrie / tension artérielle / enfance la pression artérielle.

    Il existe de légères différences entre les valeurs réelles en centiles de ces tableaux et celles du tableau 3, en particulier pour les adolescents âgés de 13 ans. Les médecins doivent comprendre que le schéma présenté dans le tableau 3 a été sélectionné conformément aux nouvelles directives relatives aux adultes et facilite la prise en charge des adolescents plus âgés atteints de PA. Les valeurs en centiles présentées dans les tableaux 4 et 5 sont fournies pour aider les scientifiques et les autres personnes intéressées par une classification plus précise de la TA.

    3.2a. Table de PA simplifiée

    Cette ligne directrice contient un nouveau tableau simplifié de TA pour le dépistage initial (voir le tableau 6) basé sur le TA du 90e centile pour le 5e centile d'âge et de sexe, ce qui donne aux valeurs du tableau une valeur prédictive négative de> 99%.78 Ce tableau simplifié est conçu comme un outil de dépistage uniquement pour identifier les enfants et les adolescents qui ont besoin que leur TA soit davantage évaluée à partir de mesures répétées de la TA. Il ne doit pas être utilisé pour diagnostiquer une pression artérielle ou HTN élevée. Pour diagnostiquer l'hypertension artérielle ou l'hypertension artérielle élevée, il est important de connaître les interruptions réelles dans le tableau complet de l'hypertension artérielle, car les limitations de la SBP et de la DBP peuvent atteindre 9 mm Hg, en fonction de l'âge et de la taille de l'enfant. L’utilisation typique de ce tableau simplifié est que le personnel infirmier peut identifier rapidement la PA, ce qui peut nécessiter une évaluation plus poussée par un médecin. Pour les adolescents âgés de 13 ans et plus, le tableau simplifié 120/80 mm Hg est utilisé quel que soit le seuil sexuel, afin de l'adapter à la guidance adulte pour la détection d'une TA élevée.

    Tableau 6

    Dépistage des valeurs du tiers nécessitant une évaluation supplémentaire

    3.3 Définition d'un HTN chez le nouveau-né et le nourrisson (0 à 1 an)

    Bien qu'une définition relativement stricte du HTN ait été développée pour les enfants plus âgés, il est plus difficile pour les nouveau-nés de définir le HTN, étant donné les changements connus de la PA qui se produisent au cours des premières semaines de la vie.79 Ces modifications de la tension artérielle peuvent être significatives chez les bébés prématurés, pour lesquels elle dépend de nombreux facteurs, notamment l'âge post-menstruel, le poids à la naissance et le statut maternel.80

    Pour tenter de développer une approche normalisée de la définition du HTN chez les nouveau-nés prématurés et à temps, Dionne et al.79 préparé les données disponibles pour les nouveau-nés dans la TA et compilé un tableau récapitulatif des valeurs de la TA, y compris celles des nourrissons du 95e et du 99e centiles âgés de 26 à 44 semaines. Les auteurs ont suggéré que l'utilisation de ces valeurs chez les nouveau-nés, même lors de naissances prématurées, pourrait suivre une approche similaire pour identifier les enfants plus âgés présentant une TA élevée.

    Actuellement, aucune autre donnée n'a été développée et il n'y a aucune donnée disponible sur les résultats de cette population élevée dans cette population; par conséquent, il est raisonnable d'utiliser ces valeurs de PA compilées pour évaluer la valeur de PA élevée des nouveau-nés. Il convient de noter que le rapport de l’équipe de surveillance de la pression artérielle du deuxième enfant de 1987 a publié des courbes pour les valeurs normatives de la pression artérielle chez les nourrissons de moins d’un an.81 Ces valeurs normatives devraient continuer à être utilisées, compte tenu du manque de données plus récentes sur ce groupe d'âge.

    4. Mesure de la tension artérielle

    4.1 Méthode de mesure de la TA

    Dans l’enfance, la tension artérielle peut varier considérablement pendant les visites et même au cours de la même Les taux plasmatiques élevés isolés chez les enfants et les adolescents présentent de nombreuses étiologies potentielles, notamment des facteurs tels que l’anxiété et la consommation récente de caféine.82 Pour une visite ponctuelle, la pression artérielle diminue habituellement avec des mesures répétées,83 bien que la variabilité ne soit pas suffisamment élevée pour affecter la classification BP.84 Les mesures de la tension artérielle peuvent également varier pendant les visites64,85; Dans une étude sur des adolescents, seuls 56% de l'échantillon avaient le même HTN à trois moments différents.8 Par conséquent, il est important que plusieurs mesures soient prises au fil du temps avant le diagnostic de HTN.

    La mesure initiale de la pression artérielle peut être oscillométrique (en utilisant un tensiomètre à mercure ou anéroïde)86,87). (Statut de validation des dispositifs de tension oscillométrique, validé dans le groupe d'âge pédiatrique.) La pression artérielle doit être une archive aortique atypique. anatomie, tels que l’arc aortique droit et l’artère aortique (voir tableau 7). D'autres aspects importants de la vidéo AAP appropriée sont disponibles à l'adresse http://youtu.be/JLzkNBpqwi0. Il faut prendre soin de la technique de mesure précise et cohérente.88,89

    TABLEAU 7

    Meilleures pratiques de mesure de la pression artérielle

    Un brassard de taille appropriée doit être utilisé pour une mesure précise de la pression artérielle.83 Des chercheurs de 3 Royaume-Uni et 1 du Brésil ont documenté le manque de disponibilité et de paramètres d'hospitalisation.9194 Les bureaux de pédiatrie devraient avoir accès à un large éventail de tailles de brassards pour les enfants et les adolescents souffrant d'obésité grave. Pour les enfants du coude, l'épaule en position neutre et le coude fléchi à 90 °86,95,96(Voir Fig. 2 et Tableau 7).95

    FIGURE 2

    Détermination de la taille appropriée du brassard BP.95 A, épine de marquage s'étendant à partir du processus d'acromion. B, placement correct du ruban pour la longueur du bras. C, placement incorrect de la bande pour la longueur du bras. D, marquant le milieu de la longueur des bras.

    Si la TA initiale est élevée (≥ 90 e percentile), vous devez effectuer 2 mesures supplémentaires oscillométriques ou auscultatoires. Si vous utilisez l'auscultation, cette mesure moyenne est utilisée pour déterminer la catégorie de PA de l'enfant (c.-à-d. TA normale, élevée, HTN de stade 1 ou HTN de stade 2). Si la lecture oscillométrique moyenne est égale au ≥ 90 e percentile, 2 mesures auscultatoires doivent être prises et définies dans la catégorie BP (voir Fig. 3).

    FIGURE 3

    Algorithme de mesure de la PA modifié.

    4.1a Mesure de la tension artérielle chez le nouveau-né

    De nombreuses méthodes sont disponibles chez les nouveau-nés hospitalisés, y compris des mesures intra-artérielles directes utilisant la technique oscillométrique. In the office, however, the oscillometric technique typically is used at least until the infant is able to cooperate with manual BP determination (which also depends on the ability of the individual measuring the BP to obtain auscultatory BP in infants and toddlers). Normative values for neonatal and infant BP have generally been determined in the right upper arm with the infant supine, and a similar approach should be followed in the outsigne d’hypertension artérielle pulmonaire setting.

    As with older children, proper cuff size is important in obtaining accurate BP readings in neonates. The cuff bladder length should encircle 80% to 100% of the arm circumference; a cuff bladder with a width-to-arm circumference ratio of 0.45 to 0.55 is recommended.79,97,98 Offices that will be obtaining BP measurements in neonates need to have a variety of cuff sizes available. In addition, the oscillometric device used should be validated in neonates and programmed to have an initial inflation value appropriate for infants (generally ≤120 mm Hg). Auscultation becomes technically feasible once the infant’s upper arm is large enough for the smallest cuff available for auscultatory devices. Measurements are best taken when the infant is in a calm state; multiple readings may be needed if the first reading is elevated, similar to the technique recommended for older children.99,100

    4.2 BP Measurement Frequency

    It remains unclear what age is optimal to begin routine BP measurement in children, although available data suggest that prevention and intervention efforts should begin at a young age.10,60,101106 The subcommittee believes that the recommendation to measure BP in the ambulatory setting beginning at 3 years of age should remain unchanged.1 For otherwise healthy children, however, BP need only be measured annually rather than during every health care encounter.

    Some children should have BP measured at every health encounter, specifically those with obesity (BMI ≥95 percentile),5,27,107109 renal disease,46 diabeet,110,111 aortic arch obstruction or coarctation, or those who are taking medications known to increase BP (see Table 8 and the “Secondary Causes: Medication-related” section of this guideline).112,113

    TABLE 8

    Common Pharmacologic Agents Associated With Elevated BP in Children

    Children younger than 3 years should have BP measurements taken at well-child care visits if they are at increased risk for developing HTN (see Table 9).1

    TABLE 9

    Conditions Under Which Children Younger Than 3 Years Should Have BP Measured

    Key Action Statement 1

    BP should be measured annually in children and adolescents ≥3 years of age (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Early detection of asymptomatic HTN; prevention of short- and long-term HTN-related morbidity
    Risks, harm, cost Overtesting, misclassification, unnecessary treatment, discomfort from BP measurement procedure, time involved in measuring BP
    Benefit–harm assessment Benefit of annual BP measurement exceeds potential harm
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Increased visit time, discomfort of cuff
    Exclusions None
    Strength Moderate recommendation
    Key references 10,60,102,103

    Key Action Statement 2

    BP should be checked in all children and adolescents ≥3 years of age at every health care encounter if they have obesity, are taking medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes (see Table 9) (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Early detection of HTN and prevention of CV morbidity in predisposed children and adolescents
    Risks, harm, cost Time for and difficulty of conducting measurements
    Benefit–harm assessment Benefits exceed harm
    Intentional vagueness Frequency of evaluation
    Role of signe d’hypertension artérielle pulmonaire preferences Increased visit time, discomfort of cuff
    Exclusions Children and adolescents who are not at increased risk for HTN
    Strength Moderate recommendation
    Key references 27,46,107,110–112

    4.3 Patient Management on the Basis of Office BP

    4.3a Normal BP

    If BP is normal or normalizes after repeat readings (ie, BP <90th percentile), then no additional action is needed. Practitioners should measure the BP at the next routine well-child care visit.

    4.3b Elevated BP

    1. If the BP reading is at the elevated BP level (Table 3), lifestyle interventions should be recommended (ie, healthy diet, sleep, and physical activity); the measurement should be repeated in 6 months by auscultation. Nutrition and/or weight management referral should be considered as appropriate;

    2. If BP remains at the elevated BP level after 6 months, upper and lower extremity BP should be checked (right arm, left arm, and 1 leg), lifestyle counseling should be repeated, and BP should be rechecked in 6 months (ie, at the next well-child care visit) by auscultation;

    3. If BP continues at the elevated BP level after 12 months (eg, after 3 auscultatory measurements), ABPM should be ordered (if available), and diagnostic evaluation should be conducted (see Table 10 for a list of screening tests and the populations in which they should be performed). Consider subspecialty referral (ie, cardiology or nephrology) (see Table 11); et

    4. If BP normalizes at any point, return to annual BP screening at well-child care visits.

    TABLE 10

    Screening Tests and Relevant Populations

    TABLE 11

    Patient Evaluation and Management According to BP Level

    4.3c Stage 1 HTN

    1. If the BP reading is at the stage 1 HTN level (Table 3) and the signe d’hypertension artérielle pulmonaire is asymptomatic, provide lifestyle counseling and recheck the BP in 1 to 2 weeks by auscultation;

    2. If the BP reading is still at the stage 1 level, upper and lower extremity BP should be checked (right arm, left arm, and 1 leg), and BP should be rechecked in 3 months by auscultation. Nutrition and/or weight management referral should be considered as appropriate; et

    3. If BP continues to be at the stage 1 HTN level after 3 visits, ABPM should be ordered (if available), diagnostic evaluation should be conducted, and treatment should be initiated. Subspecialty referral should be considered (see Table 11).

    4.3d Stage 2 HTN

    1. If the BP reading is at the stage 2 HTN level (Table 3), upper and lower extremity BP should be checked (right arm, left arm, and 1 leg), lifestyle recommendations given, and the BP measurement should be repeated within 1 week. Alternatively, the signe d’hypertension artérielle pulmonaire could be referred to subspecialty care within 1 week;

    2. If the BP reading is still at the stage 2 HTN level when repeated, then diagnostic evaluation, including ABPM, should be conducted and treatment should be initiated, or the signe d’hypertension artérielle pulmonaire should be referred to subspecialty care within 1 week (see Table 11); et

    3. If the BP reading is at the stage 2 HTN level and the signe d’hypertension artérielle pulmonaire is symptomatic, or the BP is >30 mm Hg above the 95th percentile (or >180/120 mm Hg in an adolescent), refer to an immediate source of care, such as an emergency department (ED).

    Key Action Statement 3

    Trained health care professionals in the office setting should make a diagnosis of HTN if a child or adolescent has auscultatory-confirmed BP readings ≥95th percentile on 3 different visits (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Early detection of HTN; prevention of CV morbidity in predisposed children and adolescents; identification of secondary causes of HTN
    Risks, harm, cost Overtesting, misclassification, unnecessary treatment, discomfort from BP measurement, time involved in taking BP
    Benefit–harm assessment Benefits of repeated BP measurement exceeds potential harm
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Families may have varying levels of concern about elevated BP readings and may request evaluation on a different time line
    Exclusions None
    Strength Moderate recommendation
    Key references 8,84,85

    4.4 Use of Electronic Health Records

    Studies have demonstrated that primary care providers frequently fail to measure BP and often underdiagnose HTN.85,115,116 One analysis using nationally representative survey data found that providers measured BP at only 67% of preventive visits for children 3 to 18 years of age. Older children and children with overweight or obesity were more likely to be screened.117 In a large cohort study of 14 187 children, 507 signe d’hypertension artérielle pulmonaires met the criteria for HTN, but only 131 (26%) had the diagnosis documented in their electronic health records (EHRs). Elevated BP was only recognized in 11% of cases.7

    It is likely that the low rates of screening and diagnosis of pediatric HTN are related, at least in part, to the need to use detailed reference tables incorporating age, sex, and height to classify BP levels.118 Studies have shown that using health information technology can increase adherence to clinical guidelines and improve practitioner performance.119121 In fact, applying decision support in conjunction with an EHR in adult populations has also been associated with improved BP screening, recognition, medication prescribing, and control; pediatric data are limited, however.122125 Some studies failed to show improvement in BP screening or control,122,126 but given the inherent complexity in the interpretation of pediatric BP measurements, EHRs should be designed to flag abnormal values both at the time of measurement and on entry into the EHR.

    Key Action Statement 4

    Organizations with EHRs used in an office setting should consider including flags for abnormal BP values both when the values are being entered and when they are being viewed (grade C, weak recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Improved rate of screening and recognition of elevated BP
    Risks, harm, cost Cost of EHR development, alert fatigue
    Benefit–harm assessment Benefit of EHR flagging of elevated BP outweighs harm from development cost and potential for alert fatigue
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions None
    Strength Weak recommendation (because of a lack of pediatric data)
    Key references 7,117,120,125

    4.5 Oscillometric Versus Auscultatory (Manual) BP Measurement

    Although pediatric normative BP data are based on auscultatory measurements, oscillometric BP devices have become commonplace in health care settings.127 Ease of use, a lack of digit preference, and automation are all perceived benefits of using oscillometric devices. Unlike auscultatory measurement, however, oscillometric devices measure the oscillations transmitted from disrupted arterial flow by using the cuff as a transducer to determine mean arterial pressure (MAP). Rather than directly measuring any pressure that correlates to SBP or DBP, the device uses a proprietary algorithm to calculate these values from the directly measured MAP.127 Because the algorithms vary for different brands of oscillometric devices, there is no standard oscillometric BP.128

    Researchers in several studies have evaluated the accuracy of oscillometric devices127,129134 and compared auscultatory and oscillometric readings’ ability to predict target organ damage.135 These studies demonstrated that oscillometric devices systematically overestimate SBP and DBP compared with values obtained by auscultation.129,133 BP status potentially can be misclassified because of the different values obtained by these 2 methods, which may be magnified in the office setting.86,88,129 Target organ damage (such as increased LV mass and elevated PWV) was best predicted by BPs obtained by auscultation.135

    A major issue with oscillometric devices is that there appears to be great within-visit variation with inaccurately high readings obtained on initial measurement.136 An elevated initial oscillometric reading should be ignored and repeat measures averaged to approximate values obtained by auscultation.

    Key Action Statement 5

    Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a device that has been validated in the pediatric age group. If elevated BP is suspected on the basis of oscillometric readings, confirmatory measurements should be obtained by auscultation (grade B, strong recommendation).

    Aggregate Evidence Quality Grade B
    Benefits Use of auscultatory readings prevents potential misclassification of signe d’hypertension artérielle pulmonaires as hypertensive because of inaccuracy of oscillometric devices
    Risks, harm, cost Auscultation requires more training and experience and has flaws such as digit preference
    Benefit–harm assessment Benefit exceeds harm
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Patients may prefer the convenience of oscillometric monitors
    Exclusions None
    Strength Strong recommendation
    Key references 86,88,128–136

    4.6 Forearm and/or Wrist BP Measurement

    Wrist monitors have several potential advantages when compared with arm devices. They are smaller; they can be placed more easily; and, because wrist diameter is less affected by BMI, they do not need to be modified for signe d’hypertension artérielle pulmonaires with obesity.83,137 Several studies in adults have found excellent reproducibility of wrist BP measurements, equivalence to readings obtained by mercury sphygmomanometers or ABPM, and better correlation with left ventricular mass index (LVMI) than systolic office BP.138,139

    Although many wrist devices have been validated in adults,140142 some studies have shown greater variation and decreased accuracy in the resulting measurements.143146 These negative outcomes may possibly result from differences in the number of measurements taken,139 the position of the wrist in relation to the heart,147 flexion or extension of the wrist during measurement,148 or differences in pulse pressure.149 Technologies are being developed to help standardize wrist position.150,151

    Few studies using wrist monitors have been conducted in children. One study in adolescents compared a wrist digital monitor with a mercury sphygmomanometer and found high agreement between systolic measurements but lower agreement for diastolic measurements, which was clinically relevant.152 Researchers in 2 small studies conducted in PICUs compared wrist monitors with indwelling arterial lines and found good agreement between the 2 measurement modalities.153,154 No large comparative studies or formal validation studies of wrist monitors have been conducted in children, however. Because of limited data, the use of wrist and forearm monitors is not recommended in the diagnosis or management of HTN in children and adolescents at this time.

    4.7 ABPM

    An ambulatory BP monitor consists of a BP cuff attached to a box slightly larger than a cell phone, which records BP periodically (usually every 20–30 minutes) throughout the day and night; these data are later downloaded to a computer for analysis.155

    ABPM has been recommended by the US Preventive Services Task Force for the confirmation of HTN in adults before starting treatment.156 Although a growing number of pediatric providers have access to ABPM, there are still gaps in access and knowledge regarding the optimal application of ABPM to the evaluation of children’s BP.155,157 For example, there are currently no reference data for children whose height is <120 cm. Because no outcome data exist linking ABPM data from childhood to hard CV events in adulthood, recommendations either rely largely on surrogate outcome markers or are extrapolated from adult studies.

    However, sufficient data exist to demonstrate that ABPM is more accurate for the diagnosis of HTN than clinic-measured BP,158,159 is more predictive of future BP,160 and can assist in the detection of secondary HTN.161 Furthermore, increased LVMI and LVH correlate more strongly with ABPM parameters than casual BP.162166 In addition, ABPM is more reproducible than casual or home BP measurements.159 For these reasons, the routine application of ABPM is recommended, when available, as indicated below (see also Tables 12 and 13). Obtaining ABPM may require referral to a specialist.

    TABLE 12

    High-Risk Conditions for Which ABPM May Be Useful

    TABLE 13

    Recommended Procedures for the Application of ABPM

    Key Action Statement 6

    ABPM should be performed for the confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Avoids unnecessarily exposing youth with WCH to extensive diagnostic testing or medication
    Risks, harm, cost Risk of discomfort to signe d’hypertension artérielle pulmonaire. Some insurance plans may not reimburse for the test
    Benefit–harm assessment The risk of ABPM is lower than the risk of unnecessary treatment. The use of ABPM has also been shown to be more cost-effective than other approaches to diagnosing HTN
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Some signe d’hypertension artérielle pulmonaires may prefer repeat office or home measurements to ABPM
    Exclusions None
    Strength Moderate recommendation
    Key references 23,155,158,159

    For technical reasons, ABPM may need to be limited to children ≥5 years of age who can tolerate the procedure and those for whom reference data are available.

    Key Action Statement 7

    The routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions (see Table 12) to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage (grade B, moderate recommendation).

    Aggregate Evidence Quality Grade B
    Benefits Improved 24-h control of BP improves outcomes. Recognition of MH or nocturnal HTN might lead to therapeutic changes that will limit end organ damage
    Risks, harm, cost Risk of discomfort to signe d’hypertension artérielle pulmonaire. Some insurance plans may not reimburse for the test. The risk of diagnosing and labeling a signe d’hypertension artérielle pulmonaire as having MH or nocturnal HTN might lead to increased anxiety and cost of evaluation
    Benefit–harm assessment The risk of ABPM is much lower than the risk of inadequate treatment
    Intentional vagueness Frequency at which normal or abnormal ABPM should be repeated is not known
    Role of signe d’hypertension artérielle pulmonaire preferences Some signe d’hypertension artérielle pulmonaires may prefer repeat office or home measurements to ABPM
    Exclusions None
    Strength Moderate recommendation
    Key references 47,155,199–202

    Key Action Statement 8

    ABPM should be performed by using a standardized approach (see Table 13) with monitors that have been validated in a pediatric population, and studies should be interpreted by using pediatric normative data (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Validated monitors applied and interpreted correctly will provide the most accurate results
    Risks, harm, cost Risk of discomfort to signe d’hypertension artérielle pulmonaire. Some insurance plans may not reimburse for the test. Monitors validated in the pediatric population and expertise in reading pediatric ABPM may not be universally available
    Benefit–harm assessment There is substantial evidence showing incorrect application or interpretation reduces the accuracy of results
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Some signe d’hypertension artérielle pulmonaires may prefer repeat office or home measurements to ABPM
    Exclusions None
    Strength Moderate recommendation
    Key references 155

    4.7a Masked Hypertension

    MH occurs when signe d’hypertension artérielle pulmonaires have normal office BP but elevated BP on ABPM, and it has been found in 5.8% of unselected children studied by ABPM.199 There is growing evidence that compared with those with normal 24-hour BP, these signe d’hypertension artérielle pulmonaires have significant risk for end organ hypertensive damage.200,203 Patients who are at risk of MH include signe d’hypertension artérielle pulmonaires with obesity and secondary forms of HTN, such as CKD or repaired aortic coarctation. MH is particularly prevalent in signe d’hypertension artérielle pulmonaires with CKD48 and is associated with target organ damage.203 Children with CKD should be periodically evaluated using ABPM for MH as part of routine CKD management.201,204206

    4.7b White Coat Hypertension

    WCH is defined as BP ≥95th percentile in the office or clinical setting but <95th percentile outside of the office or clinical setting. WCH is diagnosed by ABPM when the mean SBP and DBP are <95th percentile and SBP and DBP load are <25%; load is defined as the percentage of valid ambulatory BP measurements above a set threshold value (eg, 95th percentile) for age, sex, and height.155,156,206 It is estimated that up to half of children who are evaluated for elevated office BP have WCH.207,208

    In adults, compared with normotension, WCH is associated with only a slightly increased risk of adverse outcomes but at a much lower risk compared with those with established HTN.209 Most (but not all) studies suggest that WCH is not associated with increased LV mass.200,207,210 Although the distinction between WCH and true HTN is important, abnormal BP response to exercise and increased LVM has been found to occur in children with WCH.207 Furthermore, the identification of WCH may reduce costs by reducing the number of additional tests performed and decreasing the number of children who are exposed to antihypertensive medications.208 Children and adolescents with WCH should have screening BP measured at regular well-child care visits with consideration of a repeat ABPM in 1 to 2 years.

    Key Action Statement 9

    Children and adolescents with suspected WCH should undergo ABPM. Diagnosis is based on the presence of mean SBP and DBP <95th percentile and SBP and DBP load <25% (grade B, strong recommendation).

    Aggregate Evidence Quality Grade B (Evidence Level A in Adults)
    Benefits Improved diagnosis of WCH and the benefit of fewer additional laboratory tests and/or treatment of primary HTN. Costs might be reduced if the treatment of those misdiagnosed as hypertensive is prevented
    Risks, harm, cost Additional costs; costs may not be covered by insurance companies. The ambulatory BP monitor is uncomfortable for some signe d’hypertension artérielle pulmonaires
    Benefit–harm assessment Benefit exceeds risk
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Important; some signe d’hypertension artérielle pulmonaires may not want to undergo ABPM. Benefits of the procedure should be reviewed with families to assist in decision-making
    Exclusions None
    Strength Strong recommendation
    Key references 206

    4.8 Measurement in Children With Obesity

    Accurate BP measurement can be challenging in individuals with obesity.23,211,212 Elevated BMI in children and adolescents is associated with an increase in the midarm circumference,96 requiring the use of a larger cuff to obtain accurate BP measurements.83 During NHANES 2007–2010, among children 9 to 11 years of age with obesity, one-third of boys and one-quarter of girls required an adult BP cuff, and a fraction required a large adult cuff or an adult thigh cuff for an accurate measurement of BP.213 Researchers in studies of adults have also noted the influence of the conical upper arm shape on BP measurements in people with obesity.214,215 ABPM is a valuable tool in the diagnosis of HTN in children with obesity because of the discrepancies between casual and ambulatory BP23,33 and the higher prevalence of MH.26,29,155,216,217

    4.9. At-Home Measurement

    Home measurement (or self-monitoring) of BP has advantages over both office and ambulatory monitoring, including convenience and the ability to obtain repeated measurements over time.83,218 Furthermore, automated devices with memory capacity are straightforward to use and avoid potential problems, such as observer bias, inaccurate reporting, and terminal digit preference (ie, overreporting of certain digits, like 0, as the terminal digit in recording BP).219,220

    Numerous studies have shown that it is feasible for families to conduct repeated measurements at home.221223 Home BP measurements appear to be more reproducible than those conducted in the office, likely because of the familiarity of the home environment and greater comfort with repeated measurements.159,223,224 Inaccuracies occur when measurements obtained at home are either excluded or inappropriately recorded.219 Inconsistencies in home, office, and ambulatory BP measurements seem to be influenced by both age and HTN status, with ABPM tending to be higher than home BP measurements in children.222,225227 Home BP measurements show no consistent pattern when compared with office measurements.228230

    There are several practical concerns with the use of home BP measurement, however. The only normative data available are from the relatively small Arsakeion School study.231 In addition, only a few automated devices have been validated for use in the pediatric population, and available cuff sizes for them are limited. Furthermore, there is no consensus regarding how many home measurements across what period of time are needed to evaluate BP.

    Key Action Statement 10

    Home BP monitoring should not be used to diagnose HTN, MH, or WCH but may be a useful adjunct to office and ambulatory BP measurement after HTN has been diagnosed (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Convenient, cost-effective, widely available, can be used over time
    Risks, harm, cost Risk of inaccurate diagnosis. Unclear what norms or schedule should be used. Few validated devices in children, and cuff sizes are limited
    Benefit–harm assessment Benefits outweigh harm when used as an adjunctive measurement technique
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Patients may find home BP more convenient and accessible than office or ambulatory BP
    Exclusions None
    Strength Moderate recommendation
    Key references 159,221–225,227,230

    4.10 School Measurement and the Role of School-Based Health Professionals

    There is limited evidence to support school-based measurement of children’s BP.8,232 Observational studies demonstrate that school measurements can be reliable233 and that longitudinal follow-up is feasible.8,232,234 Available data do not distinguish between the efficacy of school-based screening programs in which measurements are obtained by trained clinical personnel (not a school nurse) versus measurements obtained by the school nurse. Because of insufficient evidence and a lack of established protocols, the routine use of school-based measurements to diagnose HTN cannot be recommended. However, school-based BP measurement can be a useful tool to identify children who require formal evaluation as well as a helpful adjunct in the monitoring of diagnosed HTN. Note: School-based health clinics are considered part of systems of pediatric primary care, and these comments would not apply to them.

    5. Primary and Secondary Causes of HTN

    5.1 Primary HTN

    Primary HTN is now the predominant diagnosis for hypertensive children and adolescents seen in referral centers in the United States,235,236 although single-center studies from outside the United States still find primary HTN to be uncommon.237 Although prospective, multicenter studies are generally lacking, at least one large study in which researchers used insurance claims data confirmed that primary HTN is significantly more common than secondary HTN among American youth.238

    General characteristics of children with primary HTN include older age (≥6 years),239,240 positive family history (in a parent and/or grandparent) of HTN,236,237,240 and overweight and/or obesity.16,236,237,239 Severity of BP elevation has not differed significantly between children with primary and secondary HTN in some studies,235,237 but DBP elevation appears to be more predictive of secondary HTN,239,240 whereas systolic HTN appears to be more predictive of primary HTN.236,239

    Key Action Statement 11

    Children and adolescents ≥6 years of age do not require an extensive evaluation for secondary causes of HTN if they have a positive family history of HTN, are overweight or obese, and/or do not have history or physical examination findings (Table 14) suggestive of a secondary cause of HTN (grade C, moderate recommendation).

    TABLE 14

    Examples of Physical Examination Findings and History Suggestive of Secondary HTN or Related to End Organ Damage Secondary to HTN

    Aggregate Evidence Quality Grade C
    Benefits Avoidance of unnecessary diagnostic evaluation
    Risks, harm, cost Potential to miss some children with secondary HTN
    Benefit–harm assessment Benefit equals harm
    Intentional vagueness Not applicable
    Role of signe d’hypertension artérielle pulmonaire preferences Some families may want further testing performed
    Exclusions Hypertensive children <6 y of age
    Strength Moderate recommendation
    Key references 16,129,235–240

    5.2 Secondary Causes: Renal and/or Renovascular

    Renal disease and renovascular disease are among the most common secondary causes of HTN in children. Renal parenchymal disease and renal structural abnormalities accounted for 34% to 79% of signe d’hypertension artérielle pulmonaires with secondary HTN in 3 retrospective, single-center case series, and renovascular disease was present in 12% to 13%.101,240,241 The literature suggests that renal disease is a more common cause of HTN in younger children.239 Renal disorders (including vascular problems) accounted for 63% to 74% of children <6 years of age who were enrolled in 3 recent clinical trials of angiotensin receptor blockers (ARBs).239,242244 No increased frequency was seen in younger signe d’hypertension artérielle pulmonaires in a recent single-center case series, however.101 It is appropriate to have a high index of suspicion for renal and renovascular disease in hypertensive pediatric signe d’hypertension artérielle pulmonaires, particularly in those <6 years of age.

    5.3 Secondary Causes: Cardiac, Including Aortic Coarctation

    Coarctation of the aorta is a congenital abnormality of the aortic arch characterized by discrete narrowing of the aortic arch, generally at the level of the aortic isthmus. It is usually associated with HTN and right arm BP that is 20 mm Hg (or more) greater than the lower extremity BP. Repair in infants is often surgical; adolescents may be treated with angioplasty or stenting. Long-segment narrowing of the abdominal aorta can also cause HTN and should be considered in children with refractory HTN and a gradient between the upper and lower extremities in which the upper extremity SBP exceeds the lower extremity SBP by 20 mm Hg.245 Of note, children with abdominal aortic obstruction may have neurofibromatosis, Williams syndrome, Alagille syndrome, or Takayasu arteritis.

    Patients with coarctation can remain hypertensive or develop HTN even after early and successful repair, with reported prevalence varying from 17% to 77%.112 HTN can be a manifestation of recoarctation. Recoarctation in repaired signe d’hypertension artérielle pulmonaires should be assessed for by using 4 extremity BP measurements and echocardiography. HTN can also occur without recoarctation.246 The prevalence of HTN increases over time after successful coarctation repair.112

    Routine office BP measurement alone is often insufficient for diagnosing HTN after coarctation repair.113,246 Children who have undergone coarctation repair may have normal in-office BP but high BP out of the office, which is consistent with MH.58,112 Of children with a history of aortic coarctation, ∼45% have MH at ∼1 to 14 years after coarctation repair.58,113 Children with a history of repaired aortic coarctation and normal in-office BP are at risk for LVH,58 HTN, and MH.58,112

    ABPM has emerged as the gold standard for diagnosing HTN among individuals who have undergone coarctation repair, and it is likely more useful than casual BP.58,245247 Screening is recommended as a part of usual care on an annual basis beginning, at most, 12 years after coarctation repair. Earlier screening may be considered on the basis of risk factors and clinician discretion.

    Key Action Statement 12

    Children and adolescents who have undergone coarctation repair should undergo ABPM for the detection of HTN (including MH) (grade B, strong recommendation).

    Aggregate Evidence Quality Grade B (Aggregate Level of Evidence Equals B, Given 3 Studies With Similar Findings)
    Benefits Early detection of HTN
    Risks, harm, cost Additional costs related to the placement of ABPM
    Benefit–harm assessment Benefits exceed harms
    Intentional vagueness Frequency of measurement. Because the development of HTN after coarctation repair is influenced by many factors, the ideal onset of screening for HTN (including MH) is unknown
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions Individuals with a history of residual aortic arch obstruction
    Strength Strong recommendation
    Key references 58,112,113

    5.4 Secondary Causes: Endocrine HTN

    HTN resulting from hormonal excess accounts for a relatively small proportion of children with secondary HTN. Although rare (with a prevalence ranging from 0.05% to 6% in children101,237,239,240), an accurate diagnosis of endocrine HTN provides the clinician with a unique treatment opportunity to render a surgical cure or achieve a dramatic response with pharmacologic therapy.248 Known endocrine causes with associated molecular defects (when known) are summarized in Table 15.

    TABLE 15

    Endocrine Causes of HTN

    5.5 Secondary Causes: Environmental Exposures

    Several environmental exposures have been associated with higher childhood BP, although most studies are limited to small case series. Among the most prominent are lead, cadmium, mercury, and phthalates.

    • Lead: Long-term exposure to lead in adults has been associated with higher BP in population studies295,296 and in studies of industrial workers with high lead exposure,297 although findings have not been consistent.298 At least 1 cross-sectional study of 122 children demonstrated that children with higher blood lead concentrations had higher BP; lower socioeconomic status was also seen in this group, which may have confounded the BP results.299 Furthermore, in a randomized study of lead-exposed children, those who received chelation with succimer did not have lower BP than in those who received a placebo.300

    • Cadmium: Environmental cadmium exposure has been linked to higher BP levels and the development of HTN in adults, particularly among women.296,301303 Although cross-sectional studies have confirmed potential nephrotoxicity of cadmium in children,304 no definite effect on BP has been demonstrated.304,305

    • Mercury: Mercury is a known nephrotoxin, particularly in its elemental form.306,307 Severe mercury intoxication has been linked to acute HTN in children in several case reports; signe d’hypertension artérielle pulmonaires’ symptoms may resemble those seen in signe d’hypertension artérielle pulmonaires with pheochromocytoma (PCC).308310

    • Phthalates: Antenatal and childhood exposure to phthalates has recently been associated with higher childhood BP311313 but not with the development of overt HTN. Specific metabolites of these ubiquitous chemicals may have differential effects on BP,313 indicating that much more detailed study is needed to completely understand the effect of such exposure.

    5.6 Secondary Causes: Neurofibromatosis

    Neurofibromatosis type 1 (NF-1) (also known as Von Recklinghausen disease) is a rare autosomal dominant disorder characterized by distinct clinical examination findings. These include the following: cafe-au-lait macules, neurofibromas, Lisch nodules of the iris, axillary freckling, optic nerve gliomas, and distinctive bone lesions. Patients with NF-1 have several unique and potential secondary causes of HTN, most commonly renal artery stenosis (RAS); coarctation of the aorta, middle aortic syndrome, and PCC are also well described.314319

    Additionally, an increased incidence of idiopathic HTN has been documented in signe d’hypertension artérielle pulmonaires with NF-1, as high as 6.1% in a recent pediatric case series, which is a much greater incidence than in the general population.320 PCC has also been well described in signe d’hypertension artérielle pulmonaires with NF-1, although exact incidences are difficult to determine, and signe d’hypertension artérielle pulmonaires may not have classic symptoms of PCC.321,322

    Vascular causes of HTN and PCC all require specific treatment and follow-up, so maintaining a high index of suspicion for these disorders is important in evaluating hypertensive children and adolescents with NF-1.

    5.7 Secondary Causes: Medication Related

    Many over-the-counter drugs, prescription medications, alternative therapies (ie, herbal and nutritional supplements), dietary products, and recreational drugs can increase BP. Common prescription medications associated with a rise in BP include oral contraceptives,323325 central nervous system stimulants,326 and corticosteroids.1,327 When a child has elevated BP measurements, the practitioner should inquire about the intake of pharmacologic agents (see Table 8).

    Usually, the BP elevation is mild and reversible on discontinuation of the medication, but a significant increase in BP can occasionally occur with higher doses or as an idiosyncratic response. Over-the-counter cold medications that contain decongestants (eg, pseudoephedrine and phenylpropanolamine) may cause a mild increase in BP with the recommended dosing, but severe HTN has been observed as an idiosyncratic response with appropriate dosing as well as with excessive doses.

    Nonsteroidal anti-inflammatory drugs may antagonize the BP-lowering effect of antihypertensive medications (specifically, angiotensin-converting enzyme (ACE) inhibitors) but do not appear to have an impact on BP in those without HTN. The commonly used supplement ephedra (ma haung) likely contains some amount of ephedrine and caffeine that can cause an unpredictable rise in BP. Recreational drugs associated with HTN include stimulants (eg, cocaine and amphetamine derivatives) and anabolic steroids.

    5.8 Monogenic HTN

    Monogenic forms of HTN are uncommon, although the exact incidence is unknown. In a study of select hypertensive children without a known etiology, genetic testing for familial hyperaldosteronism type I (FH-I), or glucocorticoid-remediable aldosteronism, confirmed responsible genetic mutations in 3% of the population.263

    Other monogenic forms of HTN in children include Liddle syndrome, pseudohypoaldosteronism type II (Gordon syndrome), apparent mineralocorticoid excess, familial glucocorticoid resistance, mineralocorticoid receptor activating mutation, and congenital adrenal hyperplasia (see “Secondary Causes: Endocrine Causes of Hypertension”).328 All manifest as HTN with suppressed plasma renin activity (PRA) and increased sodium absorption in the distal tubule. Other features may include serum potassium abnormalities, metabolic acid-base disturbances, and abnormal plasma aldosterone concentrations, although the clinical presentations can be highly variable.263,328,329 In the study of FH-I, all affected children had suppressed PRA and an aldosterone to renin ratio (ARR) (ng/dL and ng/M1 per hour, respectively) of >10; the authors suggest that an ARR >10 is an indication to perform genetic testing in a hypertensive child.263 Monogenic forms of HTN should be suspected in hypertensive children with a suppressed PRA or elevated ARR, especially if there is a family history of early-onset HTN.

    6. Diagnostic Evaluation

    6.1 Patient Evaluation

    As with any medical condition, appropriate diagnostic evaluation is a critical component in the evaluation of a signe d’hypertension artérielle pulmonaire with suspected HTN. Evaluation focuses on determining possible causes of and/or comorbidities associated with HTN. Evaluation, as is detailed in the following sections, should include appropriate signe d’hypertension artérielle pulmonaire history, family history, physical examination, laboratory evaluation, and imaging.

    6.2 History

    The first step in the evaluation of the child or adolescent with elevated BP is to obtain a history. The various components of the history include the perinatal history, past medical history, nutritional history, activity history, and psychosocial history. Each is discussed in the following sections.

    6.2a Perinatal History

    As discussed, perinatal factors such as maternal HTN and low birth weight have been shown to influence later BP, even in childhood.56,330 Additionally, a high incidence of preterm birth among hypertensive children has recently been reported in 1 large case series.101 Thus, it is appropriate to obtain a history of pertinent prenatal information, including maternal pregnancy complications; gestational age; birth weight; and, if pertinent, complications occurring in the neonatal nursery and/or ICU. It is also appropriate to document pertinent procedures, such as umbilical catheter placement.

    6.2b Nutritional History

    High sodium intake has been linked to childhood HTN and increased LVMI and is the focus of several population health campaigns.4,331 In NHANES 2003–2008, among children 8 to 18 years of age (n = 6235), higher sodium intake (as assessed by dietary recall) was associated with a twofold increase in the combined outcome of elevated BP or HTN. The effect was threefold among participants with obesity.332 Limited data suggest the same effect is seen in younger children.333 One study found that high intake of total fat and saturated fat, as well as adiposity and central obesity, were also predictors of SBP.334336

    Nutrition history is an important part of the signe d’hypertension artérielle pulmonaire assessment because it may identify dietary contributors to HTN and detect areas in which lifestyle modification may be appropriate. The important components to discuss include salt intake (including salt added in the kitchen and at the table and sodium hidden in processed and fast food), consumption of high-fat foods, and consumption of sugary beverages.337,338 Infrequent consumption of fruits, vegetables, and low-fat dairy products should also be identified.

    6.2c Physical Activity History

    A detailed history of physical activity and inactivity is an integral part of the signe d’hypertension artérielle pulmonaire assessment, not only to understand contributors to the development of HTN but also to direct lifestyle modification counseling as an important part of management.339344

    6.2d Psychosocial History

    Providers should obtain a psychosocial history in children and adolescents with suspected or confirmed HTN. Adverse experiences both prenatally345 and during childhood (including maltreatment, early onset depression, and anxiety) are associated with adult-onset HTN.346,347 The identification of stress may suggest a diagnosis of WCH. The psychosocial history should include questions about feelings of depression and anxiety, bullying, and body perceptions. The latter is particularly important for signe d’hypertension artérielle pulmonaires with overweight or obesity because ∼70% of these children report having bullying and body perception concerns.348 Starting at 11 years of age, the psychosocial history should include questions about smoking,349,350 alcohol, and other drug use.351

    6.2e Family History

    Taking and updating the family history is a quick and easy way to risk-stratify pediatric signe d’hypertension artérielle pulmonaires with an increased risk for HTN. It is important to update the family history for HTN over the course of the pediatric signe d’hypertension artérielle pulmonaire’s lifetime in the practice (typically until 18–21 years of age) because first- and second-degree relatives may develop HTN during this time. All too often, the diagnosis of HTN in the pediatric signe d’hypertension artérielle pulmonaire stimulates the collection of a detailed family history of HTN, sometimes even years after the pediatric signe d’hypertension artérielle pulmonaire has had elevated BP, instead of the other way around.352

    6.3 Physical Examination

    A complete physical examination may provide clues to potential secondary causes of HTN and assess possible hypertensive end organ damage. The child’s height, weight, calculated BMI, and percentiles for age should be determined at the start of the physical examination. Poor growth may indicate an underlying chronic illness.

    At the second visit with confirmed elevated BP or stage 1 HTN or the first visit with confirmed stage 2 HTN, BP should be measured in both arms and in a leg. Normally, BP is 10 to 20 mm Hg higher in the legs than the arms. If the leg BP is lower than the arm BP, or if femoral pulses are weak or absent, coarctation of the aorta may be present. Obesity alone is an insufficient explanation for diminished femoral pulses in the presence of high BP.

    The remainder of the physical examination should pursue clues found in the history and should focus on body systems and findings that may indicate secondary HTN and/or end organ damage related to HTN. Table 14 lists important physical examination findings in hypertensive children.353 These are examples of history and physical findings and do not represent all possible history and physical examination findings. The physical examination in hypertensive children is frequently normal except for the BP elevation.

    Key Action Statement 13

    In children and adolescents being evaluated for high BP, the provider should obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination to identify findings suggestive of secondary causes of HTN (grade B, strong recommendation).

    Aggregate Evidence Quality Grade B
    Benefits Identify personal risk factors for HTN
    Risks, harm, cost None
    Benefit–harm assessment Identification of personal risk factors is useful in the assessment of childhood HTN
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions Children with normal BP
    Strength Strong recommendation
    Key references 56,330

    6.4 Laboratory Evaluation

    The purpose of the laboratory evaluation is to identify underlying secondary causes of HTN (eg, renal or endocrine disease) that would require specific treatment guided by a subspecialist. In general, such testing includes a basic set of screening tests and additional, specific tests; the latter are selected on the basis of clues obtained from the history and physical examination and/or the results of the initial screening tests.354 Table 10 provides a list of screening tests and the populations in which they should be performed.

    6.5 Electrocardiography

    Approximately one-half of adolescents with HTN have undergone electrocardiography at least once as an assessment for LVH.355 Unlike echocardiography, electrocardiography takes little time and is a relatively low-cost test. Electrocardiography has high specificity but poor sensitivity for identifying children and adolescents with LVH.356358 The positive predictive value of electrocardiography to identify LVH is extremely low.359

    Key Action Statement 14

    Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for LVH (grade B, strong recommendation).

    Aggregate Evidence Quality Grade B (Aggregate of Level of Evidence Equals B Because of Multiple Level of Evidence C References With Similar Findings)
    Benefits Electrocardiography is less expensive than echocardiography or other imaging modalities for identifying LVH
    Risks, harm, cost Electrocardiography has a low sensitivity for detecting LVH
    Benefit–harm assessment The risk of concluding that a child with HTN does not have LVH on the basis of a normal electrocardiogram means that a diagnosis of end organ injury is potentially missed
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Patients and families may prefer electrocardiography because of cost and convenience, but the sensitivity of the test is poor
    Exclusions None
    Strength Strong recommendation
    Key references 1,355–360

    6.6 Imaging Evaluation, Echocardiography: Detection of Target Organ Damage

    Echocardiography was identified in the Fourth Report as a tool to measure left ventricular (LV) target organ injury related to HTN in children.1 The basis for this assessment is as follows: (1) the relationship of LV mass to BP,361 (2) the independent and strong relationship of LVH to adverse CVD outcomes in adults,362364 and (3) that a significant percentage of children and adolescents with HTN demonstrate the degree of LVH associated with adverse outcomes in adults.365367 Antihypertensive treatment reduces LVH. Observational data suggest that the regression of LVH independently predicts outcomes in adults.368

    The best-studied measures of LV target organ injury are measures of LV structure (LV mass and the relationship of LV wall thickness or mass to LV cavity volume) and systolic function (LV ejection fraction). LV structure is usually stratified into 4 groups on the basis of LV mass (normal or hypertrophied) and relative LV wall thickness (normal or increased). These 4 are as follows: (1) normal geometry with normal LV mass and wall thickness, (2) concentric geometry with normal LV mass and increased LV wall thickness, (3) eccentric LVH with increased LV mass and normal LV wall thickness, and (4) concentric LVH with both increased LV mass and increased relative wall thickness.369,370

    The American Society of Echocardiography recommendations should be followed with regard to image acquisition and LV measurement for calculating LV ejection fraction, mass, and relative wall thickness.369,371 LV ejection fraction may be significantly decreased in severe or acute onset HTN with associated congestive heart failure.1 Rarely, LV ejection fraction may be mildly depressed in chronic HTN.

    Because the heart increases in size in relation to body size, indexing LV mass is required.361 Indexing LV mass is particularly important in infants and younger children because of their rapid growth.372,373 Physical training increases LV mass in a healthful manner. Lean body mass is more strongly associated with LV mass than fat mass.370 Because body composition is not routinely measured clinically, surrogate formulae for indexing are required. It is unclear whether expected values for LV mass should be derived from reference populations of normal weight and normotensive children or should include normotensive children who have overweight or obesity. The best method for indexing LV mass in children is an area of active investigation.

    For this document, the following definitions for LV target organ injury have been chosen regarding hypertrophy, relative wall thickness, and ejection fraction. These definitions are based on published guidelines from the American Society of Echocardiography and associations of thresholds for indexed LV mass with adverse outcomes in adults362,363,369:

    • LVH is defined as LV mass >51 g/m2,7 or LV mass >115 g per body surface area (BSA) for boys and LV mass >95 g/BSA for girls. (Note that the values for LVH are well above the 95th percentile for distributions of LV mass in children and adolescents.369 The clinical significance of values between the 95th percentile of a population-based distribution and these thresholds is uncertain372);

    • An LV relative wall thickness >0.42 cm indicates concentric geometry. LV wall thickness >1.4 cm is abnormal373; et

    • Decreased LV ejection fraction is a value <53%.

    There are a number of additional evidence gaps related to the echocardiographic assessment of LV target organ injury. The value of LV mass assessment in risk reclassification independent of conventional risk assessment has not been established in adults.364 The costs and benefits of incorporation of echocardiography into HTN care has not been assessed. Quality control regarding reproducibility of measurements across laboratories may be suboptimal.374 The most accurate method to measure LV mass (M-mode; two-dimensional; or, in the near future, three-dimensional techniques) requires further research.

    Key Action Statement 15

    It is recommended that echocardiography be performed to assess for cardiac target organ damage (LV mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN;

    LVH should be defined as LV mass >51 g/m2,7 (boys and girls) for children and adolescents older than 8 years and defined by LV mass >115 g/BSA for boys and LV mass >95 g/BSA for girls;

    Repeat echocardiography may be performed to monitor improvement or progression of target organ damage at 6- to 12-month intervals. Indications to repeat echocardiography include persistent HTN despite treatment, concentric LV hypertrophy, or reduced LV ejection fraction; et

    In signe d’hypertension artérielle pulmonaires without LV target organ injury at initial echocardiographic assessment, repeat echocardiography at yearly intervals may be considered in those with stage 2 HTN, secondary HTN, or chronic stage 1 HTN incompletely treated (noncompliance or drug resistance) to assess for the development of worsening LV target organ injury (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Severe LV target organ damage can only be identified with LV imaging. May improve risk stratification
    Risks, harm, cost Adds cost; improvement in outcomes from incorporating echocardiography into clinical care is not established
    Benefit–harm assessment Benefits exceed harms
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Patients may elect to not to have the study
    Exclusions None
    Strength Moderate recommendation
    Key references 361,363,364,367–369

    6.7 Vascular Structure and Function

    Emerging data demonstrate an association of higher levels of BP in youth with adverse changes in measures of vascular structure and function, including ultrasonography of the cIMT, PWV, a robust measure of central arterial stiffness66 that is related to hard CV events in adults (eg, stroke, myocardial infarction, etc),69 and FMD, which assesses endothelial function and describes the ability of the endothelium to release nitric oxide in response to stress.375

    Although there are multiple large studies of PWV in youth,376381 they all suffer from notable limitations, primarily the lack of racial and ethnic diversity and differences in measurement devices and protocols. Researchers in the largest study of PWV in youth to date (N = 6576) only evaluated 10 and 11 year olds and measured only carotid-radial PWV across the arm; this measure has not been linked to CV events in adults.382 Researchers in one large study of FMD performed in youth (N = 5809) only included 10- to 11-year-old children in England.382 The largest set of data for cIMT included 1155 European youth who were 6 to 18 years of age.383 No racial and ethnic breakdown was provided for this study. The wide heterogeneity in the methods for cIMT measurement hinders the pooling of data. For instance, researchers in the aforementioned article only measured common carotid,383 although the bulb and internal carotid are the sites of earliest atherosclerotic disease.384

    Many studies have had significant issues related to methodology. For example, carotid-femoral PWV is not measured identically with different devices and is not equivalent to other measures of PWV, such as brachial-femoral PWV.385,386 No direct comparisons have been made between carotid-femoral and brachial-ankle PWV, methods in which brachial-ankle PWV provide values considerably higher than carotid-femoral PWV.378 The brachial-ankle PWV measures stiffness along both a central elastic artery (aorta) and the medium muscular arteries of the leg.

    Therefore, insufficient normative data are available to define clinically actionable cut-points between normal and abnormal for these vascular parameters. The routine measurement of vascular structure and function to stratify risk in hypertensive youth cannot be recommended at this time.

    6.8 Imaging for Renovascular Disease

    6.8a Renal Ultrasonography

    The utility of Doppler renal ultrasonography as a noninvasive screening study for the identification of RAS in children and adolescents has been examined in at least 2 recent case series; sensitivity has been reported to be 64% to 90%, with a specificity of 68% to 70%.387,388 In another study that included both children and adults, sensitivity and specificity for the detection of renal artery stenoses was 75% and 89%, respectively.389 Factors that may affect the accuracy of Doppler ultrasonography include signe d’hypertension artérielle pulmonaire cooperation, the technician’s experience, the age of the child, and the child’s BMI. Best results are obtained in older (≥8 years),388 nonobese (BMI ≤85th percentile), cooperative children and adolescents who are examined in a facility with extensive pediatric vascular imaging experience. Doppler ultrasonography should probably not be obtained in signe d’hypertension artérielle pulmonaires who do not meet these criteria or in facilities that lack appropriate pediatric experience.

    There are no evidence-based criteria for the identification of children and adolescents who may be more likely to have RAS. Some experts will do a more extensive evaluation for RAS in children and adolescents with stage 2 HTN, those with significant diastolic HTN (especially on ABPM), those with HTN and hypokalemia on screening laboratories, and those with a notable size discrepancy between the kidneys on standard ultrasound imaging. Bruits over the renal arteries are also suggestive of RAS but are not always present. Consultation with a subspecialist is recommended to help decide which signe d’hypertension artérielle pulmonaires warrant further investigation and to aid in the selection of the appropriate imaging modality.

    Key Action Statement 16

    Doppler renal ultrasonography may be used as a noninvasive screening study for the evaluation of possible RAS in normal-weight children and adolescents ≥8 years of age who are suspected of having renovascular HTN and who will cooperate with the procedure (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Avoidance of complications of invasive procedure (angiography) or radiation from traditional or computed tomography angiography
    Risks, harm, cost Potential false-positive or false-negative results
    Benefit–harm assessment Potential for avoidance of an invasive procedure outweighs risk of false-negative or false-positive results
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions Children and adolescents without suspected renovascular HTN
    Strength Moderate recommendation
    Key references 387–390

    6.8b Computed Tomographic Angiography, Magnetic Resonance Angiography, and Renography

    Other noninvasive imaging studies that have been assessed for their ability to identify RAS include computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and nuclear medicine studies. Each of these has been compared with the gold standard, renal arteriography. CTA and MRA have generally been found to be acceptable as noninvasive imaging modalities for the identification of hemodynamically significant vascular stenosis. One study that included both pediatric and adult signe d’hypertension artérielle pulmonaires showed that the sensitivity and specificity for the detection of RAS was 94% and 93% for CTA and 90% and 94% for MRA, respectively.389

    Unfortunately, studies of either technique that include only pediatric signe d’hypertension artérielle pulmonaires are limited at best for CTA and are nonexistent for MRA. Despite this, expert opinion holds that either modality may be used for noninvasive screening for suspected RAS, but neither is a substitute for angiography.390 CTA typically involves significant radiation exposure, and MRA generally requires sedation or anesthesia in young children, which are factors that must be considered when deciding to use one of these modalities.

    Nuclear renography is based on the principle that after the administration of an agent affecting the renin-angiotensin-aldosterone system (RAAS), there will be reduced blood flow to a kidney or kidney segment affected by hemodynamically significant RAS. Such reduced blood flow can be detected by a comparison of perfusion before and after the administration of the RAAS agent. Limited pediatric nuclear renography studies exist that show variable sensitivity and specificity, ranging from 48% to 85.7% and 73% to 92.3%, respectively.391393 The utility of nuclear renography may be less in children then adults because children with RAS often have more complicated vascular abnormalities than adults.394 Given these issues, nuclear renography has generally been abandoned as a screening test for RAS in children and adolescents.390

    Key Action Statement 17

    In children and adolescents suspected of having RAS, either CTA or MRA may be performed as a noninvasive imaging study. Nuclear renography is less useful in pediatrics and should generally be avoided (grade D, weak recommendation).

    Aggregate Evidence Quality Grade D
    Benefits Avoidance of complications of an invasive procedure (angiography)
    Risks, harm, cost Potential false-positive or false-negative results
    Benefit–harm assessment Potential for avoidance of an invasive procedure outweighs risk of false-negative or false-positive results
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions Children and adolescents without suspected RAS
    Strength Weak recommendation; pediatric data are limited
    Key references 389,390

    6.9 Uric Acid

    Cross-sectional data have suggested a relationship between elevated serum uric acid (UA) levels and HTN. Two recent studies of adolescents included in NHANES 1999–2000 and a small study conducted in Italy found that elevated UA levels were associated with higher BP.395397 In the Italian study and in another US study of youth with obesity and HTN,397,398 elevated UA was also associated with other markers of CV risk. These findings suggest that the measurement of UA levels may best be viewed as 1 component of CV risk assessment, especially in those with obesity.

    A causative role for elevated UA in the development of childhood HTN has not been definitively established, although recent studies suggest that it may be on the causal pathway. A longitudinal study in which researchers followed a group of children for an average of 12 years demonstrated that childhood UA levels were associated with adult BP levels even after controlling for baseline BP.399 A few small, single-center clinical trials have also shown that lowering UA can decrease BP levels, and increased UA levels blunt the efficacy of lifestyle modifications on BP control.400404 No large-scale, multicenter study has yet been conducted to confirm these preliminary findings. Hence, there is currently not sufficient evidence to support the routine measurement of serum UA in the evaluation and management of children with elevated BP.

    6.10 Microalbuminuria

    Microalbuminuria (MA), which should be differentiated from proteinuria in CKD, has been shown to be a marker of HTN-related kidney injury and a predictor of CVD in adults.405408 MA has been shown to be effectively reduced via the use of ARBs and ACE inhibitors in adults. Lowering the degree of MA in adults has been associated with decreased CVD risk.

    In contrast, data to support a clear relationship between HTN and MA in pediatric signe d’hypertension artérielle pulmonaires with primary HTN are limited.408410 A single, retrospective study of children with primary HTN and WCH found that 20% of the former had MA versus 0% of the latter.411 MA appears to be a nonspecific finding in children that can occur in the absence of HTN; it can occur in children who have obesity, insulin resistance, diabetes, dyslipidemia, and even in those who have recently participated in vigorous physical activity.412 The previously mentioned study by Seeman et al411 did not control for these potential confounders.

    Limited, single-center data suggest that a reduction in the degree of MA, more than a reduction in BMI or SBP, is associated with a decrease in LVMI. In particular, researchers in this single-center, nonrandomized, prospective study of 64 hypertensive children without kidney disease who were 11 to 19 years of age evaluated the children at baseline and after 12 months of combination ACE and hydrochlorothiazide (N = 59) or ACE, hydrochlorothiazide, and ARB therapy (N = 5). Results found that lowering MA in children is associated with a regression of LVH.413 Given the single-center design and lack of a control group, however, the applicability of these findings to the general population of children with primary HTN is unknown.

    Key Action Statement 18

    Routine testing for MA is not recommended for children and adolescents with primary HTN (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Avoid improper detection of MA in children with HTN. Detection of MA is strongly influenced by other factors, such as recent participation in rigorous physical activity, obesity, insulin resistance and diabetes. Hence, there is no clear benefit for testing for MA in the absence of other known comorbidities
    Risks, harm, cost No known risks given a lack of clear association between MA and primary HTN in children
    Benefit–harm assessment Limited data to support any real benefit for screening children for MA
    Intentional vagueness Screening of children with primary HTN versus screening of children with single kidney or CKD and HTN
    Role of signe d’hypertension artérielle pulmonaire preferences Unknown
    Exclusions None
    Strength Moderate recommendation
    Key references 408,410,411,413

    7. Treatment

    7.1 Overall Goals

    The overall goals for the treatment of HTN in children and adolescents, including both primary and secondary HTN, include achieving a BP level that not only reduces the risk for target organ damage in childhood but also reduces the risk for HTN and related CVD in adulthood. Several studies have shown that currently available treatment options can even reverse target organ damage in hypertensive youth.105,414,415

    The previous recommendations for HTN treatment target in children without CKD or diabetes were SBP and DBP <95th percentile. Since that recommendation was made, evidence has emerged that markers of target organ damage, such as increased LVMI, can be detected among some children with BP >90th percentile (or >120/80 mm Hg) but <95th percentile.66,416,417 Longitudinal studies on BP from childhood to adulthood that include indirect measures of CV injury indicate that the risk for subsequent CVD in early adulthood increases as the BP level in adolescence exceeds 120/80 mm Hg.11,103,418 In addition, there is some evidence that targeting a BP <90th percentile results in reductions in LVMI and prevalence of LVH.104 Therefore, an optimal BP level to be achieved with treatment of childhood HTN is <90th percentile or <130/80 mm Hg, whichever is lower.

    Treatment and management options are discussed below, including lifestyle modifications and pharmacologic therapy to achieve optimal BP levels in children and adolescents with HTN.

    Key Action Statement 19

    In children and adolescents diagnosed with HTN, the treatment goal with nonpharmacologic and pharmacologic therapy should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥ 13 years old (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Lower risk of childhood target organ damage, lower risk of adulthood HTN and CVD
    Risk, harm, cost Risk of drug adverse effects and polypharmacy
    Benefit–harm assessment Preponderance of benefit
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Patient may have preference for nonpharmacologic or pharmacologic treatment
    Exclusions None
    Strength Moderate recommendation
    Key references 11,66,103,104,416–418

    7.2 Lifestyle and Nonpharmacologic Interventions

    Lifestyle interventions are recommended to lower BP. There is good evidence from studies in adults showing that nutritional interventions lower BP,419 including clinical trials demonstrating that reducing dietary sodium results in lower BP and CV mortality,338 and a diet high in olive oil polyphenols lowers BP.420 Studies of hypertensive youth suggest that the relationship between diet, physical activity, and BP in childhood is similar to that observed in adults.

    7.2a Diet

    The Dietary Approaches to Stop Hypertension (DASH) approach and specific elements of that diet have been the primary dietary strategy tested in the literature. These elements include a diet that is high in fruits, vegetables, low-fat milk products, whole grains, fish, poultry, nuts, and lean red meats; it also includes a limited intake of sugar and sweets along with lower sodium intake (see Table 16). Cross-sectional studies demonstrate associations between elements of the DASH diet and BP. For example, population-based data from NHANES show correlations between dietary sodium and BP in childhood and elevated BP and HTN, particularly in people with excess weight.332

    TABLE 16

    DASH Diet Recommendations

    A high intake of fruits, vegetables, and legumes (ie, a plant-strong diet) is associated with lower BP.421 A lack of fruit consumption in childhood has been linked to increases in cIMT in young adulthood in the Young Finns study.422 Higher intake of low-fat dairy products has been associated with lower BP in childhood.423

    Longitudinal, observational, and interventional data also support relationships between diet and BP in youth. The National Heart Lung and Blood Institute’s Growth and Health Study, which followed 2185 girls over 10 years, demonstrated that consuming ≥2 servings of dairy and ≥3 servings of fruits and vegetables daily was associated with lower BP in childhood and a 36% lower risk of high BP by young adulthood.424 Similar associations have been demonstrated in children and adolescents with diabetes.425 Moreover, an improvement in diet led to lower BP in some studies of adolescents with elevated BP,426 youth with overweight,427 girls with metabolic syndrome,428 and youth with T2DM.429 However, consuming a healthier diet may increase costs.430

    7.2b Physical Activity

    Observational data support a relationship between physical activity and lower BP, although the data are scant.339 Interventional data demonstrate increasing physical activity leads to lower BP. A review of 9 studies of physical activity interventions in children and adolescents with obesity suggested that 40 minutes of moderate to vigorous, aerobic physical activity at least 3 to 5 days per week improved SBP by an average of 6.6 mm Hg and prevented vascular dysfunction.340 A number of subsequent, additional studies with small sample sizes support a benefit of physical activity on BP.341 A more recent analysis of 12 randomized controlled trials including 1266 subjects found reductions of 1% and 3% for resting SBP and DBP, respectively. These results did not reach statistical significance, however, and the authors suggested that longer studies with larger sample sizes are needed.344 Any type of exercise, whether it’s aerobic training, resistance training, or combined training, appears to be beneficial342 (see “HTN and the Athlete”).

    Programs that combine diet and physical activity can have a beneficial effect on SBP, as is shown in several studies designed to prevent childhood obesity and address cardiometabolic risk.431

    Key Action Statement 20

    At the time of diagnosis of elevated BP or HTN in a child or adolescent, clinicians should provide advice on the DASH diet and recommend moderate to vigorous physical activity at least 3 to 5 days per week (30–60 minutes per session) to help reduce BP (grade C, weak recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Potential to reduce BP
    Risk, harm, cost No or low potential for harm. Following a healthier diet may increase costs to signe d’hypertension artérielle pulmonaires and families
    Benefit–harm assessment Potential benefit outweighs lack of harm and minimal cost
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Level of caregiver and signe d’hypertension artérielle pulmonaire concern may influence adoption of the DASH diet and physical activity. Patients may also have preferences around the use of a medication. These factors may influence the efficacy of lifestyle change
    Exclusions None
    Strength Weak recommendation
    Key references 332,339–342,424–431

    7.2c Weight Loss and Related CV Risk Factors

    As is true for children and adolescents with isolated HTN, a DASH diet426,432 and vigorous physical activity431 are recommended in pediatric signe d’hypertension artérielle pulmonaires with multiple obesity-related risk factors as part of intensive weight-loss therapy.433,434 Motivational interviewing (MI) is a tool recommended for pediatricians’ use by the AAP Expert Committee Statement on Obesity.435 MI may be a useful counseling tool to use in combination with other behavioral techniques to address overweight and obesity in children.436 Studies in hypertensive adults support the use of MI to improve adherence to antihypertensive medications437 and decrease SBP.436 Although there are no trials investigating the use of MI in the care of hypertensive youth, a number of studies have shown that MI can be used successfully to address or prevent childhood obesity by promoting physical activity and dietary changes.438441 However, other studies have been less promising.442,443 In addition to the standard lifestyle approaches, intensive weight-loss therapy involving regular signe d’hypertension artérielle pulmonaire and/or family contact and at least 1 hour of moderate to vigorous physical activity on a daily basis should be offered to children and adolescents with obesity and HTN.444

    7.2d Stress Reduction

    Complimentary medicine interventions have shown some promise in studies in normotensive children and adolescents and in those with elevated BP. Breathing-awareness meditation, a component of the Mindfulness-Based Stress Reduction Program at the University of Massachusetts Memorial Medical Center,445 led to a reduction in daytime, nighttime, and 24-hour SBP (3–4 mm Hg) and DPB (1 mm Hg) in normotensive African American adolescents and African American adolescents with elevated BP.446 Another study of transcendental meditation showed no significant BP effect but did lead to a decrease in LVM in African American adolescents with elevated BP.447 Scant data suggest yoga may also be helpful.448

    7.3 Pharmacologic Treatment

    Children who remain hypertensive despite a trial of lifestyle modifications or who have symptomatic HTN, stage 2 HTN without a clearly modifiable factor (eg, obesity), or any stage of HTN associated with CKD or diabetes mellitus therapy should be initiated with a single medication at the low end of the dosing range (see Table 17). Depending on repeated BP measurements, the dose of the initial medication can be increased every 2 to 4 weeks until BP is controlled (eg, <90th percentile), the maximal dose is reached, or adverse effects occur. Although the dose can be titrated every 2 to 4 weeks using home BP measurements, the signe d’hypertension artérielle pulmonaire should be seen every 4 to 6 weeks until BP has normalized. If BP is not controlled with a single agent, a second agent can be added to the regimen and titrated as with the initial drug. Because of the salt and water retention that occurs with many antihypertensive medications, a thiazide diuretic is often the preferred second agent.

    TABLE 17

    Dosing Recommendations for the Initial Prescription of Antihypertensive Drugs for Outsigne d’hypertension artérielle pulmonaire Management of Chronic HTN

    Lifestyle modifications should be continued in children requiring pharmacologic therapy. An ongoing emphasis on a healthy, plant-strong diet rich in fruits and vegetables; reduced sodium intake; and increased exercise can improve the effectiveness of antihypertensive medications. The use of a combination product as initial treatment has been studied only for bisoprolol and hydrochlorothiazide,449 so the routine use of combination products to initiate treatment in children cannot be recommended. Once BP control has been achieved, a combination product can be considered as a means to improve adherence and reduce cost if the dose and formulation are appropriate.

    7.3a Pharmacologic Treatment and Pediatric Exclusivity Studies

    Studies completed in hypertensive children show that antihypertensive drugs decrease BP with few adverse effects.173,202,242244,450467 There are few studies in children in which researchers compare different antihypertensive agents.453 These studies do not show clinically significant differences in the degree of BP lowering between agents. There are no clinical trials in children that have CV end points as outcomes. Long-term studies on the safety of antihypertensive medications in children and their impact on future CVD are limited.455

    Because of legislative acts that provide incentives and mandates for drug manufacturers to complete pediatric assessments,468 most of the newer antihypertensive medications have undergone some degree of efficacy and safety evaluation. Antihypertensive drugs without patent protection have not been, and are unlikely to be, studied in children despite their continued widespread use.238

    7.3b Pharmacologic Treatment: Choice of Agent

    Pharmacologic treatment of HTN in children and adolescents should be initiated with an ACE inhibitor, ARB,469 long-acting calcium channel blocker, or a thiazide diuretic. Because African American children may not have as robust a response to ACE inhibitors,470,471 a higher initial dose for the ACE inhibitor may be considered; alternatively, therapy may be initiated with a thiazide diuretic or long-acting calcium channel blocker. In view of the expanded adverse effect profile and lack of association in adults with improved outcomes compared with other agents, β-blockers are not recommended as initial treatment in children. ACE inhibitors and ARBs are contraindicated in pregnancy because these agents can cause injury and death to the developing fetus. Adolescents of childbearing potential should be informed of the potential risks of these agents on the developing fetus; alternative medications (eg, calcium channel blocker, β-blocker) can be considered when appropriate.

    In children with HTN and CKD, proteinuria, or diabetes mellitus, an ACE inhibitor or ARB is recommended as the initial antihypertensive agent unless there is an absolute contraindication. Other antihypertensive medications (eg, α-blockers, β-blockers, combination α- and β-blockers, centrally acting agents, potassium-sparing diuretics, and direct vasodilators) should be reserved for children who are not responsive to 2 or more of the preferred agents (see “Treatment in CKD”).

    Key Action Statement 21

    In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy on echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor (eg, obesity)), clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic (grade B, moderate recommendation).

    Aggregate Evidence Quality Grade B
    Benefits Potential prevention of progressive CVD; regression or avoidance of target organ damage; resolution of hypertensive symptoms; improved cognition; avoidance of worsening HTN; potential avoidance of stroke, heart failure, coronary artery disease, kidney failure
    Risks, harm, cost Potential for hypotension, financial cost, chronic medication treatment, adverse medication effects, impact on insurability (health and life)
    Benefit–harm assessment Preponderance of benefits over harms
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences The choice of which antihypertensive medication to use should be made in close discussion with the signe d’hypertension artérielle pulmonaire and parent regarding risk, benefits, and adverse effects
    Exclusions None
    Strength Moderate recommendation
    Key references 452,455,467

    7.3c Treatment: Follow-Up and Monitoring

    Treatment of a child or adolescent with HTN requires ongoing monitoring because goal BP can be difficult to achieve.472 If the decision has been made to initiate treatment with medication, the signe d’hypertension artérielle pulmonaire should be seen frequently (every 4–6 weeks) for dose adjustments and/or addition of a second or third agent until goal BP has been achieved (see the preceding section). After that, the frequency of visits can be extended to every 3 to 4 months.

    If the decision has been made to proceed with lifestyle changes only, then follow-up visits can occur at longer intervals (every 3–6 months) so that adherence to lifestyle change can be reinforced and the need for initiation of medication can be reassessed.

    In signe d’hypertension artérielle pulmonaires treated with antihypertensive medications, home BP measurement is frequently used to get a better assessment of BP control (see “At-Home Measurement”). Repeat ABPM may also be used to assess BP control and is especially important in signe d’hypertension artérielle pulmonaires with CKD (see “Treatment: Use of ABPM and Assessment”).

    At each follow-up visit, the signe d’hypertension artérielle pulmonaire should be assessed for adherence to prescribed therapy and for any adverse effects of the prescribed medication; such assessment may include laboratory testing depending on the medication (for example, electrolyte monitoring if the signe d’hypertension artérielle pulmonaire is on a diuretic). It is also important to continually reinforce adherence to lifestyle changes because effective treatment will depend on the combination of effects from both medication and lifestyle measures. Finally, known hypertensive target organ damage (such as LVH) should be reassessed according to the recommendations in “Imaging Evaluation, Echocardiography: Coarctation of the Aorta and Detection of Target Organ Damage.”

    7.3d Treatment: Use of ABPM to Assess Treatment

    ABPM can be an objective method to evaluate treatment effect during antihypertensive drug therapy. Data obtained in a multicenter, single-blind, crossover study in which hypertensive children received a placebo or no treatment demonstrated no change in ABPM after receiving the placebo.473 A report from a single center found that among hypertensive children receiving antihypertensive drugs, BP data from ABPM resulted in medication changes in 63% of signe d’hypertension artérielle pulmonaires.474 Another study of 38 hypertensive children used ABPM to evaluate the effectiveness of antihypertensive therapy (nonpharmacologic and pharmacologic). After 1 year of treatment, ABPM results indicated that treatment-goal BP was achieved in only one-third of children with HTN.17

    Key Action Statement 22

    ABPM may be used to assess treatment effectiveness in children and adolescents with HTN, especially when clinic and/or home BP measurements indicate insufficient BP response to treatment (grade B, moderate recommendation).

    Aggregate Evidence Quality Grade B
    Benefits ABPM results can guide adjustment in medication. ABPM can facilitate achieving treatment-goal BP levels
    Risks, harm, cost Inconvenience and signe d’hypertension artérielle pulmonaire annoyance in wearing an ABPM monitor. Cost of ABPM monitors
    Benefit–harm assessment Overall benefit
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Patients may choose not to wear the ambulatory BP monitor repeatedly, which may necessitate alternative approaches to evaluate treatment efficacy
    Exclusions Uncomplicated HTN with satisfactory BP control
    Strength Moderate recommendation
    Key references 17,474,475

    7.4 Treatment-Resistant HTN

    Resistant HTN in adults is defined as persistently elevated BP despite treatment with 3 or more antihypertensive agents of different classes. All of these drugs should be prescribed at maximally effective doses, and at least 1 should be a diuretic. Key to the identification of signe d’hypertension artérielle pulmonaires with true resistant HTN is correct office BP measurement, confirmation of adherence to current therapy, and confirmation of treatment resistance by ABPM.

    The treatment of signe d’hypertension artérielle pulmonaires with resistant HTN includes dietary sodium restriction, the elimination of substances known to elevate BP, the identification of previously undiagnosed secondary causes of HTN, the optimization of current therapy, and the addition of additional agents as needed.475 Recent clinical trial data suggest that an aldosterone receptor antagonist (such as spironolactone) is the optimal additional agent in adults with resistant HTN; it helps address volume excess as well as untreated hyperaldosteronism, which is common in adult signe d’hypertension artérielle pulmonaires with true resistant HTN.476,477

    At present, there are no data on whether true treatment-resistant HTN exists in pediatric signe d’hypertension artérielle pulmonaires. Evaluation and management strategies similar to those proven effective in adults with resistant HTN would be reasonable in children and adolescents who present with apparent treatment resistance.

    8. Treatment in Special Populations

    8.1 Treatment in Patients With CKD and Proteinuria

    8.1a CKD

    Children and adolescents with CKD often present with or develop HTN.478 HTN is a known risk factor for the progression of kidney disease in adults and children.173,479,480 Evidence suggests that the treatment of HTN in children with CKD might slow the progression of or reverse end organ damage.173,415 When evaluated by 24-hour ABPM, children and adolescents with CKD often have poor BP control even if BP measured in the clinic appears to be normal.48 MH is associated with end organ damage, such as LVH.203,481 Threshold values that define HTN are not different in children with CKD, although there is some evidence that lower treatment goals might improve outcomes.

    In the European Effect of Strict Blood Pressure Control and ACE-Inhibition on Progression of Chronic Renal Failure in Pediatric Patients study, researchers randomly assigned children with CKD to standard antihypertensive therapy (with a treatment goal of 24-hour MAP <90th percentile by ABPM) or to intensive BP control (24-hour MAP <50th percentile by ABPM). The study demonstrated fewer composite CKD outcomes in children with the lower BP target.173 Recent adult data from the Systolic Blood Pressure Intervention Trial suggest lower BP targets may be beneficial in preventing other, adverse CV outcomes as well.482

    Key Action Statement 23

    Children and adolescents with CKD should be evaluated for HTN at each medical encounter;

    Children or adolescents with both CKD and HTN should be treated to lower 24-hour MAP to <50th percentile by ABPM; et

    Regardless of apparent control of BP with office measures, children and adolescents with CKD and a history of HTN should have BP assessed by ABPM at least yearly to screen for MH (grade B; strong recommendation).

    Aggregate Evidence Quality Grade B
    Benefits Control of BP in children and adolescents with CKD has been shown to decrease CKD progression and lead to resolution of LVH
    Risks, harm, cost Cost of ABPM and BP control, both financial and nonfinancial
    Benefit–harm assessment Benefits of BP control in signe d’hypertension artérielle pulmonaires with CKD outweigh treatment risks
    Intentional vagueness Threshold
    Role of signe d’hypertension artérielle pulmonaire preferences Patients may not want to wear the ambulatory BP monitor repeatedly, which should lead to detailed counseling regarding the benefits of this procedure in CKD
    Exclusions None
    Strength Strong recommendation
    Key references 47,173,203,415,480–483

    8.1b Proteinuria

    Proteinuric renal disease is often associated with HTN and a rapid decline in glomerular filtration.483 Studies in both adults and children have indicated that both BP control and a reduction in proteinuria are beneficial for preserving renal function. Researchers in multiple studies have evaluated the utility of RAAS blockade therapy in signe d’hypertension artérielle pulmonaires with CKD and HTN.452,464,465,484487 These medications have been shown to benefit both BP and proteinuria.

    The benefit of such therapies may not be sustained, however.173,488 The Effect of Strict Blood Pressure Control and ACE-Inhibition on Progression of Chronic Renal Failure in Pediatric Patients study demonstrated an initial 50% reduction in proteinuria in children with CKD after treatment with ramipril but with a rebound effect after 36 months.450,464,488 This study also showed that BP reduction with a ramipril-based antihypertensive regimen improved renal outcomes. In children with HTN related to underlying CKD, the assessment of proteinuria and institution of RAAS blockade therapy appears to have important prognostic implications.

    Key Action Statement 24

    Children and adolescents with CKD and HTN should be evaluated for proteinuria (grade B, strong recommendation).

    Aggregate Evidence Quality Grade B
    Benefits Detection of proteinuria among children with CKD and HTN may foster early detection and treatment of children at risk for more advanced renal disease
    Risks, harm, cost Additional testing
    Benefit–harm assessment Benefit of detection of a higher-risk group exceeds the risk of testing
    Intentional vagueness Whether to screen children with HTN without CKD for proteinuria
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions Children without CKD
    Strength Strong recommendation
    Key references 47,484

    Key Action Statement 25

    Children and adolescents with CKD, HTN, and proteinuria should be treated with an ACE inhibitor or ARB (grade B, strong recommendation).

    Aggregate Evidence Quality Grade B
    Benefits ACE inhibitor and ARB therapy has been shown in the short-term to be effective in reducing urine proteinuria
    Risks, harm, cost Positive effect on urine protein concentrations after the receipt of an ACE inhibitor may not be sustained over time
    Benefit–harm assessment Treatment with an ACE inhibitor or ARB may lower the rate of progression of renal disease even if the effect is not sustained in the long-term
    Intentional vagueness Whether to aggressively treat the BP so that it is <90th percentile
    Role of signe d’hypertension artérielle pulmonaire preferences Patients may have concerns about the choice of medication, which should be addressed
    Exclusions Children without CKD
    Strength Strong recommendation
    Key references 173,464,465,485,487,488

    8.2. Treatment in Patients With Diabetes

    Based on the Fourth Report criteria for the diagnosis of HTN,1 between 4% and 16% of children and adolescents with T1DM are found to have HTN.14,489491 In the SEARCH study of 3691 youth between the ages of 3 and 17 years, elevated BP was documented in 6% of children with T1DM, with the highest prevalence in Asian Pacific Islander and American Indian children followed by African American and Hispanic children and those with higher glycosylated hemoglobin A1c levels.14 An office-based study in Australia found much higher rates (16%) and a positive correlation with BMI.490 BP >130/90 mm Hg has been associated with a more-than-fourfold increase in the relative risk of coronary artery disease and mortality at 10-year follow-up of individuals with T1DM.492

    The prevalence of HTN is higher in youth with T2DM compared with T1DM, ranging from 12% at baseline (N = 699) in the Treatment Options for Type 2 Diabetes in Adolescents and Youth study493 to 31% (N = 598) in the Pediatric Diabetes Consortium Type 2 Diabetes Clinic Registry.494 BP and arterial stiffness in cohort studies have correlated with BMI, male sex, African American race, and age of onset of diabetes.14,494,495 Unlike T1DM, HTN in T2DM is not correlated with glycosylated hemoglobin A1c levels or glycemic failure, and it develops early in the course of the disease.496 It is also associated with rapid onset of adverse cardiac changes111,497 and may not respond to diet changes.425 The concurrence of obesity and T2DM compounds the risks for target end organ damage.111,498

    Empirical evidence shows a poor awareness of HTN in youth with T1DM and T2DM.14 Additionally, only a fraction of children with HTN and diabetes were found to be on pharmacologic therapy14,490,498,499 despite treatment recommendations from the American Diabetes Association,499 the International Society for Pediatric and Adolescent Diabetes,500 AHA,110 and the National Heart, Lung, and Blood Institute.501

    Key Action Statement 26

    Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP is ≥95th percentile or >130/80 mm Hg in adolescents ≥13 years of age (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Early detection and treatment of HTN in children with T1DM and T2DM may reduce future CV and kidney disease
    Risks, harm, cost Risk of drug adverse effects and polypharmacy
    Benefit–harm assessment Preponderance of benefit
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Family concerns about additional testing and/or medication may need to be addressed
    Exclusions None
    Strength Weak to moderate recommendation
    Key references 14,110,111,494

    9. Comorbidities

    9.1 Comorbidities: Dyslipidemia

    Children and adolescents with HTN are at increased risk for lipid disorders attributable to the “common soil” phenomenon,502 in which poor diet, inactivity, and obesity contribute to both disorders. Some observational pediatric data confirm this association.503506 Furthermore, both HTN and dyslipidemias are associated with subclinical atherosclerosis206 and are risk factors for future CVD.503 Screening is recommended to identify those at increased risk for early atherosclerosis.503 Treatment of lipid disorders identified in the setting of HTN should follow existing pediatric lipid guidelines with lifestyle advice, including weight loss and pharmacotherapy, as necessary.503

    9.2 Comorbidities: OSAS

    Children with snoring, daytime sleepiness (in adolescents), or hyperactivity (in younger children) may have OSAS and consequent HTN.507 The more severe the OSAS, the more likely a child is to have elevated BP44,45 (see Table 18). Children with moderate to severe OSAS are at increased risk for HTN. However, it is not known whether OSAS treatment with continuous positive airway pressure results in improved BP in all children.44 Furthermore, adenotonsillectomy may not result in BP improvement in all children with OSAS. In particular, children who have obesity and OSAS may be less likely to experience a lowering of BP after an adenotonsillectomy.508

    TABLE 18

    OSAS Symptoms and Signs

    Therefore, children with signs of OSAS (eg, daytime fatigue, snoring, hyperactivity, etc) should undergo evaluation for elevated BP regardless of treatment status. Given that both nighttime and daytime BP is affected by OSAS, the use of ABPM is the recommended method for assessing the BP of children with suspected OSAS.

    9.3 Comorbidities: Cognitive Impairment

    Data from studies conducted in adults suggest that the central nervous system is a target organ that can be affected by HTN.419 Preliminary studies suggest that this is true in children as well. Hypertensive children score lower on tests of neurocognition and on parental reports of executive function compared with normotensive controls.509,510 Adams et al511 found an increased prevalence of learning disabilities in children with primary HTN compared with normotensive controls. The postulated mechanism for these findings is impaired cerebrovascular reactivity.512515 At the present time, these findings do not have specific clinical implications with respect to the diagnostic evaluation of childhood HTN, although they underscore the importance of early detection and treatment.

    10. Sex, Racial, and Ethnic Differences in BP and Medication Choice

    BP differences between various ethnic groups are well described in the adult population.216,516 Large, cross-sectional studies have demonstrated that, per capita, minority ethnic groups have both a higher prevalence of HTN and more significant end organ damage and outcomes.517,518 Although a growing body of evidence indicates that racial and ethnic differences in BP appear during adolescence,519521 the cause of these differences and when they develop in childhood are yet to be fully determined. The risk of HTN correlates more with obesity status than with ethnicity or race, although there may be some interaction.216 At this time, although limited data suggest that there may be a racial difference in response to ACE inhibitors in the pediatric age group,471 the strength of available evidence is insufficient to recommend using racial, sex, or ethnic factors to inform the evaluation or management of HTN in children.

    11. Special Populations and Situations

    11.1 Acute Severe HTN

    There is a lack of robust evidence to guide the evaluation and management of children and adolescents with acute presentations of severe HTN. Thus, much of what is known is derived from studies conducted in adults, including medication choice.522 The evidence base has been enhanced somewhat over the past decade by the publication of several pediatric clinical trials and case series of antihypertensive agents that can be used to treat such signe d’hypertension artérielle pulmonaires.465,523530

    Although children and adolescents can become symptomatic from HTN at lesser degrees of BP elevation, in general, signe d’hypertension artérielle pulmonaires who present with acute severe HTN will have BP elevation well above the stage 2 HTN threshold. In a study of 55 children presenting to a pediatric ED in Taiwan with hypertensive crisis, 96% had SBP greater than that of stage 2 HTN, and 76% had DBP greater than that of stage 2 HTN.531 The major clinical issue in such children is that this level of BP elevation may produce acute target organ effects, including encephalopathy, acute kidney injury, and congestive heart failure. Clinicians should be concerned about the development of these complications when a child’s BP increases 30 mm Hg or more above the 95th percentile.

    Although a few children with primary HTN may present with features of acute severe HTN,532 the vast majority will have an underlying secondary cause of HTN.532,533 Thus, for signe d’hypertension artérielle pulmonaires who present with acute severe HTN, an evaluation for secondary causes is appropriate and should be conducted expediently. Additionally, target organ effects should be assessed with renal function, echocardiography, and central nervous system imaging, among others.

    Given the potential for the development of potentially life-threatening complications, expert opinion holds that children and adolescents who present with acute severe HTN require immediate treatment with short-acting antihypertensive medications that may abort such sequelae.533,534 Treatment may be initiated with oral agents if the signe d’hypertension artérielle pulmonaire is able to tolerate oral therapy and if life-threatening complications have not yet developed. Intravenous agents are indicated when oral therapy is not possible because of the signe d’hypertension artérielle pulmonaire’s clinical status or when a severe complication has developed (such as congestive heart failure) that warrants a more controlled BP reduction. In such situations, the BP should be reduced by no more than 25% of the planned reduction over the first 8 hours, with the remainder of the planned reduction over the next 12 to 24 hours.533,534 The ultimate short-term BP goal in such signe d’hypertension artérielle pulmonaires should generally be around the 95th percentile. Table 19 lists suggested doses for oral and intravenous antihypertensive medications that may be used to treat signe d’hypertension artérielle pulmonaires with acute severe HTN.

    TABLE 19

    Oral and Intravenous Antihypertensive Medications for Acute Severe HTN

    Key Action Statement 27

    In children and adolescents with acute severe HTN and life-threatening symptoms, immediate treatment with short-acting antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 hours (grade expert opinion D, weak recommendation).

    Aggregate Evidence Quality Expert Opinion, D
    Benefits Avoidance of complications caused by rapid BP reduction
    Risks, harm, cost Severe BP elevation may persist
    Benefit–harm assessment Benefit outweighs harm
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions Patients without acute severe HTN and life-threatening symptoms
    Strength Weak recommendation because of expert opinion
    Key references 240,533,535

    11.2 HTN and the Athlete

    Sports participation and increased physical activity should be encouraged in children with HTN. In adults, physical fitness is associated with lower all-cause mortality.536 Although meta-analyses and randomized controlled trials consistently show lower BP after exercise training in adults,535 the results are less robust in children.340 On the basis of this evidence, sports participation should improve BP over time. Additionally, there is evidence that exercise itself has a beneficial effect on cardiac structure in adolescents.537

    The athlete interested in participating in competitive sports and/or intense training presents a special circumstance. Existing guidelines present conflicting recommendations.1,538 Although increased LV wall dimension may be a consequence of athletic training,360 recommendations from AHA and ACC include the following: (1) limiting competitive athletic participation among athletes with LVH beyond that seen with athlete’s heart until BP is normalized by appropriate antihypertensive drug therapy, and (2) restricting athletes with stage 2 HTN (even among those without evidence of target organ injury) from participating in high-static sports (eg, weight lifting, boxing, and wrestling) until HTN is controlled with either lifestyle modification or drug therapy.539

    The AAP policy statement “Athletic Participation by Children and Adolescents Who Have Systemic Hypertension” recommends that children with stage 2 HTN be restricted from high-static sports (classes IIIA to IIIC) in the absence of end organ damage, including LVH or concomitant heart disease, until their BP is in the normal range after lifestyle modification and/or drug therapy.538 It is further recommended that athletes be promptly referred and evaluated by a qualified pediatric medical subspecialist within 1 week if they are asymptomatic or immediately if they are symptomatic. The subcommittee agrees with these recommendations.

    It should be acknowledged that there are no data linking the presence of HTN to sudden death related to sports participation in children, although many cases of sudden death are of unknown etiology. That said, athletes identified as hypertensive (eg, during preparticipation sports screening) should undergo appropriate evaluation as outlined above. For athletes with more severe HTN (stage 2 or greater), treatment should be initiated before sports participation.

    Key Action Statement 28

    Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and risk have been assessed (grade C, moderate recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Aerobic exercise improves CVD risk factors in children and adolescents with HTN
    Risks, harm, cost Unknown, but theoretical risk related to a rise in BP with strenuous exercise may exist
    Benefit–harm assessment The benefits of exercise likely outweigh the potential risk in the vast majority of children and adolescents with HTN
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Families may have different opinions about sports participation in children with HTN
    Exclusions None
    Strength Moderate recommendation
    Key references 341,360,538,540,541

    Key Action Statement 29

    Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participating in competitive sports (grade C, weak recommendation).

    Aggregate Evidence Quality Grade C
    Benefits Aerobic exercise improves CVD risk factors in children and adolescents with HTN
    Risks, harm, cost Unknown, but theoretical risk related to a rise in BP with strenuous exercise may exist
    Benefit–harm assessment The benefits of exercise likely outweigh the potential risk in the vast majority of children and adolescents with HTN
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences None
    Exclusions None
    Strength Weak recommendation
    Key references 341,360,538,540,541

    11.3 HTN and the Posttransplant Patient

    HTN is common in children after solid-organ transplants, with prevalence rates ranging from 50% to 90%.179,180,540,541 Contributing factors include the use of steroids, calcineurin inhibitors, and mTOR (mammalian target of rapamycin) inhibitors. In signe d’hypertension artérielle pulmonaires with renal transplants, the presence of native kidneys, CKD, and transplant glomerulopathy are additional risk factors for HTN. HTN rates are higher by 24-hour ABPM compared with clinic BP measurements because these populations commonly have MH and nocturnal HTN.179183,542 Control of HTN in renal-transplant signe d’hypertension artérielle pulmonaires has been improved with the use of annual ABPM.184,185 Therefore, ABPM should be used to identify and monitor nocturnal BP abnormalities and MH in pediatric kidney and heart-transplant recipients. The use of home BP assessment may provide a comparable alternative to ABPM for BP assessment after transplant as well.186

    The management of identified HTN in the pediatric transplant signe d’hypertension artérielle pulmonaire can be challenging. Rates of control of HTN in renal-transplant signe d’hypertension artérielle pulmonaires generally range from 33% to 55%.180,187 In studies by Seeman et al,188 intensified antihypertensive treatment in pediatric renal-transplant recipients improved nocturnal SBP and significantly reduced proteinuria.543 Children in these studies who achieved normotension had stable graft function, whereas those who remained hypertensive at 2 years had a progression of renal disease.544

    Antihypertensive medications have rarely been systematically studied in this population. There is limited evidence that ACE inhibitors and ARBs may be superior to other agents in achieving BP control and improving long-term graft survival in renal-transplant signe d’hypertension artérielle pulmonaires.185,543,544 However, the combination of ACE inhibitors and ARBs in renal-transplant signe d’hypertension artérielle pulmonaires has been associated with acidosis and hyperkalemia and is not recommended.545

    12. Lifetime HTN Treatment and Transition to Adulthood

    For adolescents with HTN requiring ongoing treatment, the transition from pediatric care to an adult provider is essential.546 HTN definition and treatment recommendations in this guideline are generally consistent with the forthcoming adult HTN treatment guideline, so diagnosis and treatment should not typically change with transition.

    Key Action Statement 30

    Adolescents with elevated BP or HTN (whether they are receiving antihypertensive treatment) should typically have their care transitioned to an appropriate adult care provider by 22 years of age (recognizing that there may be individual cases in which this upper age limit is exceeded, particularly in the case of youth with special health care needs). There should be a transfer of information regarding HTN etiology and past manifestations and complications of the signe d’hypertension artérielle pulmonaire’s HTN (grade X, strong recommendation).

    Aggregate Evidence Quality Grade X
    Benefits Provides continuity of care for signe d’hypertension artérielle pulmonaires
    Risks, harm, cost None
    Benefit–harm assessment No risk
    Intentional vagueness None
    Role of signe d’hypertension artérielle pulmonaire preferences Patient can pick adult care provider
    Exclusions None
    Strength Strong recommendation
    Key references 547

    13. Prevention of HTN

    13.1 Importance of Preventing HTN

    BP levels tend to increase with time even after adult height is reached. The rate of progression to frank HTN in a study of more than 12 000 Japanese adults (20–35 years of age at baseline, followed for 9 years) was 36.5% and was greater with higher baseline BP category.548 The rate of progression may also be accelerated in African American individuals. Similarly, both the Bogalusa Heart63 and Fels Longitudinal60 studies have clearly demonstrated that the risk of HTN in early adulthood is dependent on childhood BP, with greater numbers of elevated BP measurements in childhood conferring an increased risk of adult HTN.

    Because the tracking of BP levels in children has also been well documented,10 it is not surprising that analyses of the National Childhood BP database found 7% of adolescents with elevated BP per year progressed to true hypertensive BP levels. Of note, initial BMI and change in BMI were major determinants of the development of HTN.22 Therefore, in both children and adults, efforts (discussed below) should be made to prevent progression to sustained HTN and to avoid the development of hypertensive CV diseases.

    13.2 Strategies for Prevention

    One of the largest trials of preventing progression to HTN in adults, the Trial of Preventing Hypertension study, proved that 2 years of treatment with candesartan reduced the number of subjects with elevated BP from developing stage 1 HTN even after the drug was withdrawn.547 However, no similar study has been conducted in youth; for this reason, prevention efforts to date have focused on lifestyle modification, especially dietary intervention,426 exercise,549 and treatment of obesity.550 The best evidence for the potential of such prevention strategies comes from epidemiologic evidence for risk factors for the development of HTN or from studies focused on the treatment of established HTN. These risk factors include positive family history, obesity, a high-sodium diet, the absence of a DASH-type diet, larger amounts of sedentary time, and possibly other dietary factors.551553

    Because family history is immutable, it is difficult to build a preventive strategy around it. However, a positive family history of HTN should suggest the need for closer BP monitoring to detect HTN if it occurs.

    Appropriate energy balance with calories eaten balanced by calories expended in physical activity is important. This is the best strategy to maintain an appropriate BMI percentile for age and sex and to avoid the development of obesity.554 From a broader dietary perspective, a DASH-type diet (ie, high in fruits, vegetables, whole grains, and low-fat dairy, with decreased intake of foods high in saturated fat or sugar) may be beneficial (see Table 16).423,427 Avoiding high-sodium foods may prove helpful in preventing HTN, particularly for individuals who are more sensitive to dietary sodium intake.555

    Adhering to recommendations for 60 minutes a day of moderate to vigorous physical activity can be important to maintaining an appropriate weight and may be independently helpful to maintaining a lower BP.344 The achievement of normal sleep habits and avoidance of tobacco products are also reasonable strategies to reduce CV risk.

    These preventive strategies can be implemented as part of routine primary health care for children and adolescents.

    14. Challenges in the Implementation of Pediatric HTN Guidelines

    Many studies have shown that physicians fail to meet benchmarks with respect to screening, especially universal screening for high BP in children.7,115 Although the reasons for this failure likely vary from practice to practice, a number of common challenges can be identified.

    The first challenge is determining how to identify every child in a clinic who merits a BP measurement. This could be accomplished through flags in an EHR, documentation rules for specific signe d’hypertension artérielle pulmonaires, and/or clinic protocols.

    The second challenge is establishing a local clinic protocol for measuring BP correctly on the basis of the algorithms in this guideline. It is important to determine the optimal approach on the basis of the available equipment, the skills of clinic personnel, and the clinic’s throughput needs.

    The third challenge is for clinic personnel to be aware of what to do with high BP measurements when they occur. Knowing when to counsel signe d’hypertension artérielle pulmonaires, order tests or laboratory work, and reach out for help is essential. Making this part of standard practice so every child follows the prescribed pathway may be challenging.

    The final diagnosis of HTN also relies on a number of sequential visits. Ensuring that signe d’hypertension artérielle pulmonaires return for all of these visits and are not lost to follow-up may require new clinic processes or mechanisms. Information technology may help remind providers to schedule these visits and remind signe d’hypertension artérielle pulmonaires to attend these visits; even with that assistance, however, completing all the visits may be difficult for some signe d’hypertension artérielle pulmonaires.

    In addition, family medicine physicians and general pediatricians may face challenges in having normative pediatric BP values available for use at all times. Although adult BP cutoffs are easy to memorize, pediatric BP percentile cutoffs are greatly dependent on age and height. The BP tables in this guideline provide cutoffs to use for the proper diagnosis of HTN; their availability will simplify the recognition of abnormal BP values.

    The AAP Education in Quality Improvement for Pediatric Practice module on HTN identification and management556 and its accompanying implementation guide557 should be of assistance to practitioners who wish to improve their approach to identifying and managing childhood HTN. This module is currently being updated to incorporate the new recommendations in this guideline.

    15. Other Topics

    15.1 Economic Impact of BP Management

    Researchers in a small number of studies have examined the potential economic impacts related to pediatric BP management.208,558,559 Wang et al558 estimated both the effectiveness and cost-effectiveness of 3 screening strategies and interventions to normalize pediatric BP based on the literature and through a simulation of children (n = 4 017 821). The 3 screening strategies included the following: (1) no screening; (2) selected screening and treatment, as well as “treating everyone” (ie, with population-wide interventions, such as targeted programs for overweight adolescents (eg, weight-loss programs, exercise programs, and salt-reduction programs)); and (3) nontargeted programs for exercise and salt reduction.

    The simulation suggested that these various strategies could reduce mortality, with a modest expected survival benefit of 0.5 to 8.6 days. The researchers also examined quality-adjusted life-years (QALYs) and the cost per QALY. Only 1 intervention, a nontargeted salt-reduction campaign, had a negative cost per QALY. This intervention and the other 2 described in that article support the concept that population-wide interventions may be the most cost-effective way to improve CV health. The article has serious limitations, however, including the fact that population-wide interventions for exercise and the reduction of sodium intake have not, thus far, been effective.

    The accurate determination of those who actually have HTN (as opposed to WCH) is fundamental to providing sound care to signe d’hypertension artérielle pulmonaires. Researchers in two studies examined the effects of using ABPM in the diagnosis of HTN.208,559 Davis et al559 compared 3 HTN screening strategies; these options are summarized in the following value-analysis framework (see Table 20).560 It appears that the implementation of ABPM for all signe d’hypertension artérielle pulmonaires is not ensured. The next best option, screening clinic BP with ABPM, is most likely to be implementable and has significant clinical benefit given the high prevalence of WCH.

    TABLE 20

    Comparison of HTN Screening Strategies

    Swartz et al208 conducted a retrospective review of 267 children with elevated clinic BP measurements referred for ABPM. Of the 126 signe d’hypertension artérielle pulmonaires who received ABPM, 46% had WCH, 49% had stage 1 HTN, and 5% had stage 2 HTN. This is consistent with the concept that screening with clinic BP alone results in high numbers of false-positive results for HTN. The diagnosis of HTN in this study resulted in an additional $3420 for evaluation (includes clinic visit, facility fee, laboratory testing, renal ultrasound, and echocardiography) vs $1265 (includes clinic visit, facility fee, and ABPM). This suggests that ABPM is cost-effective because of the reduction of unnecessary testing in signe d’hypertension artérielle pulmonaires with WCH.

    When examining these costs, the availability of ABPM, and the availability of practitioners who are skilled in pediatric interpretation, the most cost-effective and implementable screening solution is to measure clinic BP and confirm elevated readings by ABPM.

    15.2 Patient Perspective and Pediatric HTN

    Children and adolescents are not just signe d’hypertension artérielle pulmonaires; they are active participants in their health management. If children and adolescents lack a clear understanding of what is happening inside their bodies, they will not be able to make informed choices in their daily activities. Better choices lead to better decisions executed in self-care. For clear judgments to be made, there needs to be open communication between physicians and families, a provision of appropriate education on optimal HTN management, and a strong partnership assembled within a multidisciplinary health care team including physicians, advanced practice providers, dietitians, nurses, and medical and clinical assistants.

    It is important for physicians to be mindful that children and adolescents want, and need, to be involved in their medical care. Pediatric HTN signe d’hypertension artérielle pulmonaires are likely to feel excluded when clinicians or other providers speak to their parents instead of including them in the conversation. When signe d’hypertension artérielle pulmonaires are neither included in the discussion nor encouraged to ask questions, their anxiety can increase, thus worsening their HTN. Keeping an open line of communication is important and is best done by using a team approach consisting of the signe d’hypertension artérielle pulmonaire, the family, health care support staff, and physicians. With practical education on HTN management provided in easily understandable terms, the signe d’hypertension artérielle pulmonaires will be more likely to apply the concepts presented to them. Education is important and should be given in a way that is appropriate for young children and their families to understand. Education should consist of suitable medication dosing, a proper diet and level of activity, the identification of symptoms, and appropriate BP monitoring (including cuff size).

    Patient Perspective, by Matthew Goodwin

    “I am not just a 13 year old, I am a teenager who has lived with hypertension, renal disease, and midaortic syndrome since I was 4 years old. I have experienced surgeries, extended hospitalizations, daily medications, procedures, tests, continued blood pressure monitoring, lifestyle changes, and dietary restrictions. Hypertension is a part of my everyday life. It will always be a component of me. I had to learn the effects of hypertension at a young age. I knew what would happen to me if I ate too much salt or did not fully hydrate, thus I became watchful. I did this so I could efficiently communicate with my physicians any changes I physically felt or any symptoms that were new or different regarding my illness. This has allowed me, my family, and my doctors to work effectively as one unit. I am grateful for my doctors listening to me as a person and not as a kid.”

    15.3 Parental Perspective and Pediatric HTN

    Parents play a key role in the management and care of their children’s health. Parents and physicians should act as a cohesive unit to foster the best results. It is vital for physicians to provide concise information in plain language and do so using a team approach. This will facilitate parents having a clear understanding of the required tests, medications, follow-ups, and outcomes.

    Parents of children with hypertensive issues can encounter 1 or more specialists in addition to their pediatric clinician. This can prove to be overwhelming, frightening, and may fill the parent with anxiety. Taking these things into account and creating unified partners, built with the physician and family, will encourage the family to be more involved in the signe d’hypertension artérielle pulmonaire’s health management. Plain language in a team approach will yield the most positive outcomes for the signe d’hypertension artérielle pulmonaire.

    Understanding the family and signe d’hypertension artérielle pulmonaire’s perception of HTN and any underlying disease that may be contributing to it is important to resolve any misconceptions and encourage adherence to the physician’s recommendations. To attain therapeutic goals, proper education must be provided to the family as a whole. This education should include proper medication dosages, recommended sodium intake, any dietary changes, exercise expectations, and any other behavioral changes. It is equally important to stress to the family the short- and long-term effects of HTN if it is not properly managed. Parents with younger children will carry the ultimate burden of daily decisions as it applies to medications, food choices, and activity. Parents of older adolescents will partner with the children to encourage the right choices. Education as a family unit is important for everyone involved to understand the consequences.

    A family-based approach is important for all pediatric diseases but plays a particular role in conditions that are substantially influenced by lifestyle behaviors. This has been shown in several pediatric populations, including those with T2DM and obesity.561565

    16. Evidence Gaps and Proposed Future Directions

    In general, the pediatric HTN literature is not as robust as the adult HTN literature. The reasons for this are many, but the 2 most important are as follows: (1) the lower prevalence of HTN in childhood compared with adults, and (2) the lack of adverse CV events (myocardial infarction, stroke, and death) attributable to HTN in young signe d’hypertension artérielle pulmonaires. These factors make it difficult to conduct the types of clinical trials that are needed to produce high-quality evidence. For example, no large pediatric cohort has ever been assembled to answer the question of whether routine BP measurement in childhood is useful to prevent adult CVD.566 Given this, other types of evidence, such as from cross-sectional and observational cohort studies, must be examined to guide practice.567

    From the standpoint of the primary care provider, the most significant evidence gaps relate to whether diagnosing elevated BP and HTN in children and adolescents truly has long-term health consequences, whether antihypertensive medications should be used in a child or adolescent with elevated BP, and what medications should be preferentially used. These evidence gaps have been alluded to previously in this document.

    Other important evidence gaps should be highlighted, including the following:

    • Is there a specific BP level in childhood that predicts adverse outcomes, and can a single number (or numbers) be used to define HTN, as in adults?

    • Can and should ABPM ever replace auscultation in the diagnosis of childhood HTN?

    • Are the currently used, normative standards for ABPM appropriate, or are new normative data needed?568

    • What is the best diagnostic evaluation to confidently exclude secondary causes of HTN?

    • Are other assessments of hypertensive target organ damage (such as urine MA or vascular studies) better than echocardiography?

    • How confident can we be that a child or teenager with elevated BP will have HTN and/or CVD disease as an adult?

    Some of these questions may eventually be answered by research that is currently in progress, such as further analysis of the International Childhood Cardiovascular Cohort Consortium569 and the promising Adult Hypertension Onset in Youth study, which seeks to better define the level of BP in childhood that predicts the development of hypertensive target organ damage.570 Other studies will need to be performed in children and adolescents to fill in the remaining gaps, including more rigorous validation studies of automated BP devices in the pediatric population, expanded trials of lifestyle interventions, further comparative trials of antihypertensive medications, and studies of the clinical applicability of hypertensive target organ assessments.

    Furthermore, and perhaps more crucially, there needs to be prospective assessment of the recommendations made in this document with regular updates based on new evidence as it is generated (generally, per AAP policy, these occur approximately every 5 years). With such ongoing reassessment and revision, it is hoped that this document and its future revisions will come to be viewed as an effective guide to practice and will improve the care of the young signe d’hypertension artérielle pulmonaires who are entrusted to us.

    Implementation tools for this guideline are available on the AAP Web site (https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/coqips/Pages/Implementation-Guide.aspx).

    Authors

    Joseph T. Flynn, MD, MS, FAAP

    David C. Kaelber, MD, PhD, MPH, FAAP, FACP, FACMI

    Carissa M. Baker-Smith, MD, MS, MPH, FAAP, FAHA

    Douglas Blowey, MD

    Aaron E. Carroll, MD, MS, FAAP

    Stephen R. Daniels, MD, PhD, FAAP

    Sarah D. de Ferranti, MD, MPH, FAAP

    Janis M. Dionne, MD, FRCPC

    Susan K. Flinn, MA

    Bonita Falkner, MD

    Samuel S. Gidding, MD

    Celeste Goodwin

    Michael G. Leu, MD, MS, MHS, FAAP

    Makia E. Powers, MD, MPH, FAAP

    Corinna Rea, MD, MPH, FAAP

    Joshua Samuels, MD, MPH, FAAP

    Madeline Simasek, MD, MSCP, FAAP

    Vidhu V. Thaker, MD, FAAP

    Elaine M. Urbina, MD, MS, FAAP

    Subcommittee on Screening and Management of High Blood Pressure in Children (Oversight by the Council on Quality Improvement and Patient Safety)

    Joseph T. Flynn, MD, MS, FAAP, Co-chair, Section on Nephrology

    David Kaelber, MD, MPH, PhD, FAAP, Co-chair, Section on Medicine-Pediatrcs, Council on Clinical Information Technology

    Carissa M. Baker-Smith, MD, MS, MPH, Epidemiologist and Methodologist

    Aaron Carroll, MD, MS, FAAP, Partnership for Policy Implementation

    Stephen R. Daniels, MD, PhD, FAAP, Committee on Nutrition

    Sarah D. de Ferranti, MD, MPH, FAAP, Committee on Cardiology and Cardiac Surgery

    Michael G. Leu, MD, MS, MHS, FAAP, Council on Quality Improvement and Patient Safety

    Makia Powers, MD, MPH, FAAP, Committee on Adolescence

    Corinna Rea, MD, MPH, FAAP, Section on Early Career Physicians

    Joshua Samuels, MD, MPH, FAAP, Section on Nephrology

    Madeline Simasek, MD, FAAP, Quality Improvement Innovation Networks

    Vidhu Thaker, MD, FAAP, Section on Obesity

    Liaisons

    Douglas Blowey, MD, American Society of Pediatric Nephrology

    Janis Dionne, MD, FRCPC, Canadian Association of Paediatric Nephrologists

    Bonita Falkner, MD, International Pediatric Hypertension Association

    Samuel Gidding, MD, American College of Cardiology, American Heart Association

    Celeste Goodwin, National Pediatric Blood Pressure Awareness Foundation

    Elaine Urbina, MD, FAAP, American Heart Association AHOY Committee

    Medical Writer

    Susan K. Flinn, MA

    Staff

    Kymika Okechukwu, MPA, Manager, Evidence-Based Practice Initiatives

    Footnotes

    • Address correspondence to Joseph T Flynn. E-post: joseph.flynnatseattlechildrens.org
    • FINANCIAL DISCLOSURE: The authors have indicated that they have no financial relationships relevant to this article to disclose.

    • FUNDING: The American Academy of Pediatrics provided funding to cover travel costs for subcommittee members to attend subcommittee meetings, to pay for the epidemiologist (Dr Baker-Smith) and consultant (Susan Flynn), and to produce the revised normative blood pressure tables.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated that they have no potential conflicts of interest to disclose.

    • The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    • Endorsed by the American Heart Association.

    • * Whelton PK, Carey RM, Aranow WS, et al. ACC/AHA/APPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and managament of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017, In press.

    • Members of the subcommittee are listed followed by their AAP section and council affiliation or other organization that they represented.

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    Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents | From the American Academy of Pediatrics sur hypertension causes
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