- Open Access
Pediatric hypertension: an updated review
Clinical Hypertension volume 26, Article number: 22 (2020)
Globally hypertension in adults is among the leading preventable cause of premature death, where a graded association from the childhood hypertension is well recognised. With the concurrent rise in obesity and pediatric hypertension (HTN) during the past decade in developed countries, a parallel trend is emerging in developing countries that has a potential for exponential rise in cardiovascular, cerebrovascular and renal tragedies. A cumulative incidence of pediatric HTN in China and India is 50–70 and 23% respectively, is quite disturbing. New guidelines for the detection, evaluation and management of hypertension in children and adolescents published in 2017, where a jump in prevalence of pediatric HTN is observed, rings a call to address this under-attended burning problem; for which a review in pediatric hypertension and its management is warranted.
Blood pressure (BP), is the pressure of the blood exerted on the arterial walls, produced by the contraction of the left ventricle against the resistance offered by arteries and arterioles that is required for the optimal body functioning, however, persistent high blood pressure (hypertension) is a global health issue. Globally, hypertension (HTN) is found to be major risk factor accounting for 10.2 million deaths and 208 million disability adjusted life years . Evidence based exiting data published for both pediatrics and adults, has projected a graded association between increased blood pressure (BP) and risk of cardiovascular disease, end-stage renal disease, along with mortality [2,3,4].
Meta-analysis of more than 61 prospective studies from 1 million adults, showed that the risk of cardiovascular disease increased beginning at systolic BP levels less than 115 mmHg and diastolic BP levels less than 75 mmHg . Considering 115/75 mmHg a normal BP for an adolescent corresponding to his/her age, height and sex; nevertheless, a consistent linear upward trend of this BP level forms the basis of adult HTN a leading cause of high cardiovascular, nervous system and kidney related morbidity and mortality.
Globally the prevalence of hypertension is increasing and more than 1 billion people are hypertensive, and the increasing trends are witnessed more in low-income and middle-income countries [6, 7]. In our country (India), there is a steady increase in HTN prevalence from > 1% in 1960’s , 5–7% in 1990’s , and in 2013 it was 29.8% . During last 10 years in USA, HTN has risen to 5% in adolescents; elevated BP (combination of prehypertension and HTN) increased up to 12.6% in girls and 19.2% in boys ; while using the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents, a multicentre study in India showed the prevalence of 23% in systolic and/or diastolic hypertension among healthy school going 5–15 years old children . In one of the landmark study in China, the overall prevalence of elevated blood pressure (≥95th percentile) among school age children (6–13 years) was 18.4%; 20.2% for boys and 16.3% for girls, with children aged 10–11 years having the highest prevalence . In a cross- sectional study from Brazil involving 794 children, aged 6–13 years a prevalence of 7% of pediatric hypertension was reported , while in Japan, a prevalence 15.9% in 4th-grade boys and 15.8% in 4th-grade girls was observed .
According to the Fourth Report  the diagnosis of pediatric HTN was based on the distribution of BP values obtained from both normal and obese children, where as in new clinical practice guidelines (CPG) which is an update on 4th report, data was generated from healthy normal weight pediatric population and updated definitions , are detailed in Table 1, as under.
White coat hypertension (WCH)
BP ≥95th percentile in the office or clinical setting but <95th percentile outside of the office or clinical setting is considered as WCH which is more significant in pediatric population. It is confirmed by using Ambulatory Blood Pressure Monitoring (ABPM) where mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) are <95th percentile, in addition to SBP and DBP load are < 25%; for age, sex, and height [18, 19].
Masked hypertension (MH)
Again with aid of ABPM, it is the presence of hypertension despite normal office BP . Obese and those with secondary forms of HTN especially chronic kidney disease (CKD) patients are at risk of MH .
Primary hypertension (PH)
Also known as essential hypertension is defined as a blood pressure (BP) ≥95th percentile without an identifiable cause. Children with primary HTN are usually ≥6 years, overweight/obese, have positive family history and usually have systolic HTN .
It is the HTN with an identifiable cause, mostly seen in younger preschool children, where renal and urological disorders are the common causes and these children have usually diastolic HTN . Common causes of pediatric HTN are shown in Table 2.
Methods of BP measurement
Accurate BP recording is must to address the problem at hand and parental concerns. It has been observed that anxiety and recent caffeine intake are causes of isolated BP elevation, reiterating the report from a study where only 56% of sample population had same stage HTN on 3 different occasions . BP should be measured in the right arm by using standard measurement practices unless the child has atypical aortic arch anatomy, such as right aortic arch and coarctation of aorta or any similar anomaly. Various methods like auscultatory, aneroid, and oscillatory can be used for BP recording in children. However, for labelling a patient hypertensive is based on repeated auscultatory and ABPM measurement. It is prudent to use oscillatory method as a screening tool, where if BP is elevated, further evaluation is warranted.
BP measuring devices
Auscultatory mercury sphygmomanometer
Normative values for blood pressure are based on auscultatory sphygmomanometry, which continues to be the preferred method for blood pressure estimation. After resting for 5-min, in relaxed environment, seated with back supported, feet on the floor, with no history of stimulant intake; a stethoscope is placed on brachial artery, proximal and medial to the antecubital fossa, below the bottom edge of the cuff, BP measurement is recorded. Age related proper sized cuff should be used for precise BP measurements in children. An estimated 80–100% length and 45–55% width of bladder to that of patients midarm circumference, while upper arm is held in neutral position with elbow flexed to 90° [25, 26] has been recommended.
Traditionally, blood pressure is assessed using the auscultatory technique (Korotkoff sounds) with the pressure in the cuff measured by mercury sphygmomanometer, which is recognised as, the ‘gold standard’. However, due to adverse environmental concerns like the maintenance and disposal problems, mercury as a component in BP measuring devices, has led to the imposition of bans in some European countries and its restricted use in health care, for which appropriate health and safety procedures should be followed including the availability of mercury spillage kits. Disposal of mercury should be performed in compliance with the appropriate environmental regulations in place.
Oscillometric devices are increasingly being used as they are user friendly, automatic with no digit preference. Although these devices measure the oscillations transmitted from disrupted arterial flow by using the cuff as a transducer to determine mean arterial pressure (MAP), and interpret the relation to proprietary algorithm for the MAP calculation . These devices are very helpful in pre-schoolers and non-cooperative kids, and can well be used for screening purpose.
Ambulatory blood pressure monitoring (ABPM)
ABPM devices measure BP outside the office setting and provides multiple readings over a period. It provides the mean, daytime, night-time ambulatory BP and detects the hidden variations of HTN. Based on existing data, ABPM is more accurate for the diagnosis of HTN than office/clinic-measured BP and is more predictive of future BP . ABPM devices consist of BP cuff, a tubing that connects to a small wallet sized monitor, and circadian BP is recorded periodically (usually every 20–30 min) and then data is later downloaded to a computer for analysis, interpretation of which is done according to American Heart Association guidelines . Here the patient is instructed to record wake-up time, sleep time and medication if any. Following classification has been suggested based on ABPM recordings in children [29, 30].
1.Normal BP: <90th percentile in office BP with <95th percentile mean ABPM and < 25% ambulatory BP load
WCH: Office BP with ≥95th percentile with <95th percentile mean ABPM and < 25% ambulatory BP load
MH: < 95th percentile in office with ≥95th percentile mean ABPM and ≥ 25% ambulatory BP load
Prehypertension: Office BP ≥90th percentile, with <95th percentile mean ABPM and ≥ 25% ambulatory BP load
Ambulatory HTN: Office BP ≥95th percentile, with ≥95th percentile mean ABPM and 25–50% ambulatory BP load
Severe Ambulatory HTN: Office BP ≥95th percentile, with ≥95th percentile mean ABPM and ≥ 50% ambulatory BP load
Diagnosis of pediatric hypertension
As with other clinical entities, a thoughtful history and thorough clinical examination must be the first step for the evaluation of pediatric HTN. A detailed history starting from the conception, gestational events, foetal growth patterns, birth weight, maternal hypertension,  perinatal infection, and neonatal hospitalization must be noted followed by the information regarding nutritional history including early breast feeding , weaning, daily intake of amount of salt , fat, fast foods preferences, vegetable, fruit, and legumes. Like-wise history about the physical activity , screen time, and sleep-disordered breathing (SDB) should be sought . Family history of hypertension , and renal diseases must be recorded. Similarly, psychosocial history regarding stressful childhood, early onset anxiety and depression , or obesity associated school bullying  must be noted.
To confirm various clues obtained from the history, physical examination starts with the assessment of general appearance like syndromic facies like (Willium’s, Cushing’s, Turner’s), along with weight, height, BMI, waist hip ratio, head circumference, and general growth. This is followed by vital sign measurements like pulse rate, radio femoral delay, difference in blood pressure in upper and lower limbs. Presence of pallor, proptosis, adenoids, thyromegaly, hirsutism, acne, café-au-lait spots, butterfly rash, lymphadenopathy, localised chest bulge, dyspnoea, murmur, apical heave, abdominal mass, palpable kidneys, ambiguous genitalia, hematuria, joint swellings, and muscle weakness must be looked for.
Screening of blood pressure should be carried if there is history of oligohydramnios, foetal USG documented renal/urological anomaly, prematurity, low birth weight, umbilical artery/vein catheterization, congenital heart disease, neurofibromatosis, tuberous sclerosis, ambiguous genitalia, recurrent urinary tract infections, features suggestive of renal disease, malignancy, organ transplant. Further action is warranted if the BP of the child or adolescent is above the values as depicted in Table 3.
However, applying this data which is extracted from the 4th report wherein overweight and obese children are excluded, will continue to serve as basic source, till quality indigenous data becomes available with us. While using the new Clinical Practice Guidelines 2017, the prevalence of confirmed hypertension among shorter children < 13 years old and taller 13+ years old children are more likely to be diagnosed with hypertension . Concentrating around the impact of height on the pediatric HTN, it seems prudent to have indigenous reference normative data to draw the precision line between normotensive and hypertensive children among the Asian children.
In general, basic work up like estimation of haemoglobin, renal functions, serum electrolytes, serum lipids, blood glucose, urinalysis routine and/or culture, spot protein to creatinine ratio and chest X-ray might be considered. In patients with BMI >95th percentile, HbA1c, ALT, AST, TSH, drug screen, and sleep study in SDB will be helpful . In addition to above investigations echocardiography, [40, 41] renal ultrasonography,  CT/MR angiography are helpful for proper management of the pediatric hypertension [43, 44].
Goals for the pediatric hypertension must include prevention of target organ damage and occurrence of adult hypertension along with optimal BP maintenance among hypertensive children and adolescents. It has consistently been proven that Dietary Approach to Stop Hypertension (DASH) diet , and good physical activity of 40 min a day for 3 to 5 days a week , be initiated and continued before embarking on pharmacological treatment. The DASH diet includes multiple servings of fresh vegetables and fruits, whole grains, nuts and legumes; limiting foods high in sodium, sugars, and fats, with fair amount of lean protein products. Next step in regulating the HTN is pharmacologic treatment to those who fail lifestyle modifications, who have chronic kidney disease/ and/or diabetes mellitus with hypertension, symptomatic hypertension, and stage 2 hypertension. The current practice guidelines recommend that single antihypertensive drug with lowest dose must be initiated and upward titration or addition of second agent be sought after 2–4 weeks until BP reaches to <90th percentile or < 50th percentile in CKD patients. Hypertensive children with chronic kidney disease, proteinuria, or diabetes mellitus, an initial therapy of choice is angiotensin converting enzyme inhibitor or angiotensin receptor blockers, unless contraindicated. Otherwise, an angiotensin-converting enzyme inhibitor, angiotensin receptor blockers, long acting calcium channel blockers, and thiazide diuretics are appropriate initial agents.
The goal of the treating physician is to optimise the BP while the child is on pharmacotherapy and/or DASH approach. A 4–6 weekly follow up is recommended for the dose adjustments and drug modification in patients on pharmacotherapy. Once the BP is stabilized the frequency of visits can be extended to every 3 to 4 months. However, in DASH approach a 3–6 monthly follow up is required. It has been suggested that home BP measurement and repeat ABPM  is also required to assess current BP, compliance, drug adherence, and emergence of any complication.
Rising prevalence of pediatric HTN carrying global health dimensions, needs early identification and appropriate management, a goal-oriented step wise progress with heightened awareness of this entity shall be envisioned, where primary prevention could stand tall before all measures.
Availability of data and materials
Published medical data mostly of last 5 years.
GBD 2016 Risk factors collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the global burden of disease study 2016. Lancet. 2017;390:1345–422.
Sun SS, Grave GD, Siervogel RM, Pickoff AA, Arslanian SS, Daniels SR. Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics. 2007;119:237–46.
Lubrano R, Travasso E, Raggi C, Guido G, Masciangelo R, Elli M. Blood pressure load, proteinuria and renal function in pre-hypertensive children. Pediatr Nephrol. 2009;24:823–31.
Theodore RF, Broadbent J, Nagin D, Ambler A, Hogan S, Ramrakha S, et al. Childhood to early-midlife systolic blood pressure trajectories: early-life predictors, effect modifiers, and adult cardiovascular outcomes. Hypertension. 2015;66:1108–15.
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective studies collaboration: age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–13.
Zhou B, Bentham J, DiCesare M, Bixby H, Danaei G, Cowan MJ, et al. NCD risk factor collaboration (NCD-RisC). World wide trends in blood pressure from 1975to2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet. 2017;389(10064):37–55.
Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control clinical perspective: a systematic analysis of population-based studies from 90 countries. Circulation. 2016;134:441–50.
Gupta R, Al-Odat NA, Gupta VP. Hypertension epidemiology in India: meta-analysis of fifty-year prevalence rates and blood pressure trends. J Hum Hypertens. 1996;10:465–72.
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens. 2004;18:73–8.
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Angelantonio E, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32:1170–7.
Rosner B, Cook NR, Daniels S, Falkner B. Childhood blood pressure trends and risk factors for high blood pressure: the NHANES experience 1988–2008. Hypertension. 2013;62:247–54.
Narang R, Saxena A, Desai A, Ramakrishnan S, Thangjam RS, Kulkarni S, et al. Prevalence and determinants of hypertension in apparently healthy schoolchildren in India: a multi-center study. Eur J Prev Cardiol. 2018;25:1775–84.
Zhai Y, Li WR, Shen C, Qian F, Shi XM. Prevalence and correlates of elevated blood pressure in chinese children aged 6-13 years: a Nationwide School-based survey. Biomed Environ Sci. 2015;28:401–9.
Fuly JT, Giovaninni NP, Marcato DG, Alves ER, Sampaio JD, Moraes LI, et al. Evidence of underdiagnosis and markers of high blood pressure risk in children aged 6 to 13 years. J Pediatr. 2014;90:65–70.
Shirasawa T, Shimada N, Ochiai H, Ohtsu T, Hoshino H, Nishimura R, et al. High blood pressure in obese and nonobese Japanese children: blood pressure measurement is necessary even in nonobese Japanese children. J Epidemiol. 2010;20:408–12.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555–76.
Flynn JT, Kaelber DC, Baker-Smith CM, Blowy D, Carrole AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140:e20171904.
Flynn JT, Daniels SR, Hayman LL, Maahs DM, McCrindle BW, Mitsnefes M, et al. American Heart Association atherosclerosis, hypertension and obesity in youth Committee of the Council on cardiovascular disease in the young. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63:1116–35.
Siu AL, U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2015;163:778–86.
Stabouli S, Kotsis V, Toumanidis S, Papamichael C, Constantopoulos A, Zakopoulos N. White-coat and masked hypertension in children: association with target-organ damage. Pediatr Nephrol. 2005;20:1151–5.
Shatat IF, Flynn JT. Hypertension in children with chronic kidney disease. Adv Chronic Kidney Dis. 2005;12:378–84.
Flynn J, Zhang Y, Solar-Yohay S, Shi V. Clinical and demographic characteristics of children with hypertension. Hypertension. 2012;60(4):1047–54.
Brewer ED, Swartz SJ. Evaluation of hypertension in childhood diseases. In: Avner ED, Harmon WE, Niaudet P, Yoshikawa N, Emma F, Goldstein SI, editors. Pediatric nephrology. 7th ed. Berlin Heidelberg: Springer-Verlag; 2016. p. 1998.
McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and prehypertension among adolescents. J Pediatr. 2007;150:640–4.
Burke MJ, Towers HM, O’Malley K, Fitzgerald DJ, O’Brien ET. Sphygmomanometers in hospital and family practice: problems and recommendations. Br Med J (Clin Res Ed). 1982;285(6340):469–71.
Falkner B. Hypertension in children and adolescents: epidemiology and natural history. Pediatr Nephrol. 2010;25:1219–24.
Alpert BS, Quinn D, Gallick D. Oscillometric blood pressure: a review for clinicians. J Am Soc Hypertens. 2014;8:930–8.
Li Z, Snieder H, Harshfield GA, Treiber FA, Wang X. A 15-year longitudinal study on ambulatory blood pressure tracking from childhood to early adulthood. Hypertens Res. 2009;32:404–41.
Flynn JT, Daniels SR, Hayman LL, Maahs DM, McCrindle BW, Mitsnefes M, et al. Update: ambulatory blood pressure monitoring in children and adolescents. Hypertension. 2014;63:1116–35.
Flynn JT, Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertens (Greenwich). 2012;14:372–82.
Staley JR, Bradley J, Silverwood RJ, Howe LD, Tilling K, Lawlor DA, et al. Associations of blood pressure in pregnancy with offspring blood pressure trajectories during childhood and adolescence: findings from a prospective study. J Am Heart Assoc. 2015;4:e001422.
Martin RM, Gunnell D, Smith GD. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. Am J Epidemiol. 2005;161(1):15–26.
Rebholz CM, Gu D, Chen J, Huang JF, Cao J, Chen JC, et al. Gen salt collaborative research group. Physical activity reduces salt sensitivity of blood pressure: the genetic epidemiology network of salt sensitivity study. Am J Epidemiol. 2012;176(suppl 7):S106–13.
Enright PL, Goodwin JL, Sherril DL, Quan JR, Quan SF. Blood pressure elevation associated with sleeprelated breathing disorder in a community sample of white and Hispanic children: the Tucson Children’s assessment of sleep apnea study. Arch Pediatr Adolesc Med. 2003;157:901–4.
Benson L, Baer HJ, Greco PJ, Kaelber DC. When is family history obtained? - lack of timely documentation of family history among overweight and hypertensive paediatric patients. J Paediatr Child Health. 2010;46(10):600–5.
Stein DJ, Scott K, Haro Abad JM, et al. Early childhood adversity and later hypertension: data from the world mental health survey. Ann Clin Psychiatry. 2010;22:19–28.
Maggio AB, Martin XE, Saunders Gasser C, Aguilar-Gaxiola S, Alonso J, Angermeyer M, et al. Medical and nonmedical complications among children and adolescents with excessive body weight. BMC Pediatr. 2014;14:232.
Bell CS, Samuel JP, Samuels JA. Prevalence of hypertension in children: applying the new American Academy of Pediatrics clinical practice guideline. Hypertension. 2019;73:148–52.
Wiesen J, Adkins M, Fortune S, Horowitz J, Pincus N, Frank R, et al. Evaluation of pediatric patients with mild-to-moderate hypertension: yield of diagnostic testing. Pediatrics. 2008;122(5):1 Available at: www.pediatrics.org/cgi/content/full/122/5/e988.
Urbina EM, Gidding SS, Bao W, Pickoff AS, Berdusis K, Berenson GS. Effect of body size, ponderosity, and blood pressure on left ventricular growth in children and young adults in the Bogalusa heart study. Circulation. 1995;91:2400–6.
Hanevold C, Waller J, Daniels S, Portman R, Sorof J, International Pediatric Hypertension Association. The effects of obesity, gender, and ethnic group on left ventricular hypertrophy and geometry in hypertensive children: a collaborative study of the international pediatric hypertension association. Pediatrics. 2004;113:328–33.
Castelli PK, Dillman JR, Kershaw DB, Khalatbari S, Stanley JC, Smith EA. Renal sonography with Doppler for detecting suspected pediatric renin-mediated hypertension - is it adequate? Pediatr Radiol. 2014;44:42–4.
Rountas C, Vlychou M, Vassiou K, Liakopoulos V, Kapsalaki E, Koukoulis G, et al. Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography. Ren Fail. 2007;29:295–02.
Marks SD, Tullus K. Update on imaging for suspected renovascular hypertension in children and adolescents. Curr Hypertens Rep. 2012;14:591–5.
Damasceno MM, de Araújo MF, de Freitas RW, de Almeida PC, Zanetti ML. The association between blood pressure in adolescents and the consumption of fruits, vegetables and fruit juice--an exploratory study. J Clin Nurs. 2011;20:1553–60.
Torrance B, McGuire KA, Lewanczuk R, McGavock J. Overweight, physical activity and high blood pressure in children: a review of the literature. Vasc Health Risk Manag. 2007;3(1):139–49.
Barnes VA, Kapuku GK, Treiber FA. Impact of transcendental meditation on left ventricular mass in African American adolescents. Evid Based Complement Alternat Med. 2012;2012:923153.
Dr. Vaseem Yousuf, Ph D; Ainul-Saba Khattab, Buruj Khattab, and Jalees Khattab for their support during the prepration of this review.
Ethics approval and consent to participate
Consent for publication
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Ashraf, M., Irshad, M. & Parry, N.A. Pediatric hypertension: an updated review. Clin Hypertens 26, 22 (2020). https://doi.org/10.1186/s40885-020-00156-w
- Blood pressure