INTRODUCTION — There is increasing evidence that adult hypertension (HTN) has its antecedents during childhood, as childhood blood pressure (BP) predicts adult BP [1-3]. HTN in childhood and adolescence may contribute to premature atherosclerosis and the early development of cardiovascular disease (CVD). As a result, identifying children with HTN and successfully treating their HTN may have an important impact on long-term outcomes of CVD. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Atherosclerotic changes in childhood' and "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Hypertension' and "Nonemergent treatment of hypertension in children and adolescents", section on 'Rationale for intervention'.)
The definition and diagnosis of HTN in children will be reviewed here. The risk factors, epidemiology, etiology, evaluation, and treatment of HTN in children are discussed separately. (See "Epidemiology, risk factors, and etiology of hypertension in children and adolescents" and "Evaluation of hypertension in children and adolescents" and "Nonemergent treatment of hypertension in children and adolescents".)
DEFINITION
United States — In 2017, the American Academy of Pediatrics (AAP) published revised guidelines for screening and managing high blood pressure (BP) for children and adolescents (table 1) [4]. As was true with previous guidelines, high BP, including HTN, is defined from normative distribution of BP data in healthy children that includes children from the National Health and Nutrition Examination Survey (NHANES) and other screening studies. This is in contrast to adult HTN, which is primarily defined by clinical outcome data (ie, risk of cardiovascular disease [CVD] and mortality) from large trials of antihypertensive therapy. However, these outcome measures cannot be applied to children because cardiovascular (CV) events other than left ventricular hypertrophy do not typically occur in childhood. (See "Overview of hypertension in adults".)
Because height and sex are important determinants of pediatric BP, BP levels are interpreted based on sex, age, and height. In the 2017 AAP guidelines, normative tables (table 2 and table 3) were revised by using data only from normal-weight children. The revised tables excluded BP data from overweight and obese children (ie, children with BMI ≥85th percentile) that were previously included in normative BP databases. As a result, BP values are several mmHg lower than similar tables in previously published normative values by the National High Blood Pressure Education Program (NHBPEP) Working Group [4,5].
In children, definitions that categorize BP values were modified by the 2017 AAP guidelines (table 1) into two age groups [4]. Of note, the newly revised definitions for adolescents are aligned with adult guidelines for the detection of chronic elevated BP. With an acute elevation of BP, it is the magnitude and the rate of increase above baseline that determines the risk of serious morbidity and, at times, mortality. (See "Initial management of hypertensive emergencies and urgencies in children".)
●For children between 1 and 13 years of age:
•Normal BP – Both systolic BP (SBP) and diastolic BP (DBP) <90th percentile.
•Elevated BP (previously referred to as prehypertension) – SBP and/or DBP ≥90th percentile but <95th percentile, or 120/80 mmHg to <95th percentile (whichever is lower). Elevated BP is predictive of hypertension [6].
•Stage 1 hypertension – SBP and/or DBP ≥95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower).
•Stage 2 hypertension – SBP and/or DBP ≥95th percentile + 12 mmHg, or ≥140/90 mmHg (whichever is lower).
●For children ≥13 years of age:
•Normal BP – BP <120/80 mmHg.
•Elevated BP (previously referred to as prehypertension) – SBP between 120 and 129 with a DBP <80 mmHg.
•Stage 1 hypertension – BP between 130/80 to 139/89 mmHg.
•Stage 2 hypertension – BP ≥140/90 mmHg.
Other countries — In other countries, several studies have collected data to define normative BP for their children [7-9].
As an example, in Great Britain, reference range BP percentiles for children and young adults between 4 and 23 years of age were based upon demographic data obtained from seven national surveys that recorded three BP measurements using an oscillometric device (Dinamapp 8100) [9]. High BP for age was defined as either systolic or diastolic BP above the 98th percentile for age, and high-normal BP as BP between the 91st and 98th percentile.
National BP references based on age, sex, and height have been developed based on data from children between 7 to 17 years of age who participated in the 2010 Chinese National Survey on Students' Constitution and Health [10]. BP percentiles were established and compared with United States and previous Chinese references.
International — International BP reference values for children between 6 and 19 years of age have been developed using data from nationally represented cross-sectional surveys from seven countries [11]. However, in addition to the age restriction at or above six years, variations in population factors (eg, diet, activity, and perhaps genetic predisposition) and the lack of outcome data limit the general clinical applicability of these values [12].
As a result, the European Society of Hypertension (ESH), used the normative data from the 2004 United States NHBPEP for children up to 16 years of age [13]. For individuals 16 years or older, the ESH guidelines recommend using adult thresholds that were being used at the time when the ESH guidelines were published. However, since publication, definitions for prehypertension and hypertension for adults have also been revised (see "Overview of hypertension in adults", section on 'Hypertension'):
●Prehypertension – SBP between 130 and 139 mmHg and DBP between 85 and 89 mmHg
●Stage 1 HTN – SBP between 140 and 159 mmHg and DBP between 90 and 99 mmHg
●Stage 2 HTN – SBP between 160 and 179 mmHg and DBP between 100 and 109 mmHg
DIAGNOSIS — In the United States and Europe, the diagnosis of persistent childhood HTN is made when repeat blood pressure (BP) values on three separate visits are greater than the 95th percentile for the age, sex, and height of the patient, or it is ≥130/80 mmHg (table 2 and table 3) [4,13,14]. The diagnosis of HTN is dependent upon routine accurate measurements of BP throughout childhood using a standardized procedure and equipment. (See 'Measurement of blood pressure' below.)
SCREENING OF BP
Frequency of screening — In our practice, we follow the recommendations laid out by 2017 American Academy of Pediatrics guidelines for high blood pressure (BP) in children and adolescents, which are endorsed by the American Heart Association (AHA) and consistent with guidelines from the National Heart, Lung, and Blood Institute, and the European Society of Hypertension [4,13,15]:
●For children without risk factors or conditions associated with HTN, BP is measured beginning at three years of age during annual health supervision visits.
●For children ≥3 years of age with risk factors for HTN, BP measurement is recommended at every health care encounter (table 4).
●Children <3 years of age with risk factors for HTN should have BP measurements taken at each health supervision (table 5).
Children with systolic BP (SBP) or diastolic BP (DBP) that exceeds screening thresholds for age and sex (table 6) require further evaluation, starting with repeat BP measurement.
Tracking — Tracking refers to the pattern of repeated BP measurements over time. The clinical importance of tracking in children with annual BP over the age of three years is related to the ability to predict BP status later in childhood and adulthood. Children, especially adolescents, who are hypertensive are more likely to remain hypertensive throughout childhood and as adults, particularly in the presence of a family history of HTN, increased body weight, or increased left ventricular mass [16-23]. (See "Epidemiology, risk factors, and etiology of hypertension in children and adolescents".)
However, there are data that, in some children, hypertension or elevated BP will return to normal levels. This was illustrated in a primary care study based on data from the electronic medical records (EMRs) of almost 400,000 children that reported subsequent normalization of BP for most children who met criteria for either hypertension or elevated BP with ≥3 BP measurements recorded over 36 months [24]. Over a second concurrent 36-month period, no abnormal BP levels of the ≥3 BP measurements were recorded of 50 percent of children previously diagnosed during the first time period with hypertension (933 of 1881) or 70 percent of those diagnosed with elevated BP (1492 of 2144). Of note, a minority of patients had significant increases of BP, with 12 percent of children with elevated BP progressing to a higher BP category and 5 percent of children with stage 1 hypertension progressing to stage 2 hypertension in the second 36 months. Also, only one-half of the 7775 children with abnormally elevated BP in the first 36-month period had ≥3 BP measurements recorded during the second 36-month period. Limitations of this study included the small number of children in the entire cohort with longitudinal BP measurements necessary for study inclusion and those due to data extraction from the EMR, such as inability to determine if measurements were done appropriately and whether interventions (eg, lifestyle changes) were implemented. Nevertheless, these results highlighted normalization of BP for many children with abnormally high BP and the need to ensure these children have adequate follow-up with subsequent BP measurements. Further studies are needed to verify these results, and if findings are consistent regarding subsequent normalization of BP, this raises the possibility that criteria may need to be modified to include longer follow-up BP monitoring before diagnosing a child with hypertension.
Societal and governmental recommendations — In 2020, the United States Preventive Services Task Force (USPSTF) reaffirmed their previous conclusion based on a systematic reevaluation of the available evidence that there was inadequate evidence to support for or against BP screening in asymptomatic children and adolescents [25]. The task force recommendation is based on their assessment of inadequate evidence regarding accuracy of screening and the benefits of interventions (nonpharmacologic and pharmacologic measures) in long-term reduction of BP or effectiveness in reducing adverse health outcomes associated with high BP in adults and no direct evidence of benefit that pediatric screening reduces adverse health outcomes. In addition, there is insufficient evidence regarding whether there is harm associated with either early detection of high BP or interventions to treat high BP.
In contrast, the American Academy of Pediatrics, the American Heart Association, the National Heart, Lung, and Blood Institute, and the European Society of Hypertension recommend BP screening in children and adolescents [4,13,15,26]. These recommendations are based on the direct evidence of BP tracking from childhood to adulthood (see 'Tracking' above), indirect evidence that elevated BP in children is associated with subclinical cardiovascular disease including left ventricular mass, carotid intima-media thickening, and autopsies in adolescents and young adults demonstrating a relationship between high BP and atherosclerotic lesions (see "Nonemergent treatment of hypertension in children and adolescents", section on 'Cardiovascular disease'), and because BP screening can identify children who would be benefit from counseling that promotes health lifestyles [27,28].
MEASUREMENT OF BLOOD PRESSURE — The diagnosis of HTN is dependent on accurate blood pressure (BP) measurement. If a high BP measurement is obtained by an oscillometric device, confirmation by ausculatory measurement is required for accuracy.
The variability of BP values due to procedural differences in the BP measurement was illustrated in a comparison of normal BP readings reported by 10 different investigators in which the BP values differed by as much as 20 mmHg [29]. Confounding factors included cuff size, technique used (ie, patient position and the choice of fourth or fifth Korotkoff sound to determine diastolic BP [DBP]), the number of measurements made, and/or type of instruments used. (See 'Technique of BP measurement' below.)
Cuff size and placement — A variety of different cuff sizes are available, including adult, large adult, and thigh cuffs. The correct choice of cuff is important for accurate BP measurement.
●Correct size – The cuff size should have a bladder width that is approximately 40 percent of the circumference of the upper arm, measured midway between the olecranon and the acromion (figure 1). The clinician should measure arm circumference and use the appropriate size cuff as printed inside the device. Exact sizes may differ by manufacturer. The length of the cuff bladder should encircle 80 to 100 percent of the circumference of the upper arm midway between the olecranon and the acromion [4,30,31]. The bladder width-to-length should be at least 1:2.
●Inaccurate BP measurements – BP measurement may be inaccurate if an inappropriately large or small or large cuff is used.
•Inappropriately small cuff – If too small a cuff is used, it will overestimate the systolic pressure. This is because the pressure generated by inflating the cuff may not be fully transmitted to the brachial artery such that the pressure in the cuff may be considerably higher than the intra-arterial pressure.
•Inappropriately large cuff – Too wide a cuff may produce lower readings than the actual intra-arterial pressure.
Auscultation — The normative data was obtained by using a mercury sphygmomanometer [4], which is the gold standard for indirect blood pressure measurement. However, mercury sphygmomanometers are no longer available, because of the potential environmental risk of mercury poisoning. Aneroid sphygmomanometers are an appropriate substitute for mercury-containing devices and have been shown to be accurate if regularly calibrated [32].
Technique of BP measurement — The following steps are recommended to accurately measure BP by auscultation and compare values with normative data [4,13,30,31,33].
●Prior to BP measurement, stimulant drugs or food should be avoided.
●The BP should be measured after three to five minutes of rest in a quiet environment. The child should be seated with his/her back and feet in a supported position. In infants, BP is measured in a supine position.
●Measure BP when the heart rate is normal and steady to minimize the likelihood of obtaining falsely elevated readings. Because anxiety acutely raises both the heart rate and BP, the most reproducible readings are obtained when the pulse rate is both steady and within the normal range.
●BP is measured preferentially in the right arm for consistency and comparison with standard tables. In addition, the possibility of coarctation of the aorta would lead to falsely low BP readings in the left arm.
●The BP is measured by auscultation using the correct size and placement of the BP cuff, and by placing the bell of the stethoscope over the brachial artery pulse in the cubital fossa (figure 1 and figure 2). The BP should be taken with the patient's right arm supported at the level of the heart. Allowing the arm to hang below the heart will elevate BP levels by the added hydrostatic pressure induced by gravity (as much as 10 to 12 mmHg in adults) [34]. The sphygmomanometer should be visible but does not have to be at the level of the heart [33].
●The cuff should be inflated to 20 to 30 mmHg above the anticipated systolic BP (SBP) and then deflated slowly at a rate of 2 to 3 mmHg per heartbeat. The systolic BP is equal to the pressure at which the brachial pulse (initial tapping sound) can first be heard by auscultation (Korotkoff phase I). As the cuff is deflated below the SBP, the pulse continues to be heard until there is abrupt muffling (Korotkoff phase IV) followed by disappearance of sound (Korotkoff phase V) [35]. The DBP is the pressure at which the sound disappears. (See 'Number of measurements' below.)
●Phase V is recommended for DBP determination in children [4]. In some children, Korotkoff sounds can be heard to 0 mmHg. If this occurs, BP measurement should be repeated with less pressure on the head of the stethoscope. If phase V is still very low, phase IV (muffling) should be recorded as the DBP with the added documentation noting the use of the phase IV to determine DBP.
Number of measurements — The BP should be taken at least twice on each visit, with the measurements separated by one to two minutes to allow the release of trapped blood. If the second value is more than 5 mmHg different from the first, continued measurements should be made until a stable value is attained. The recorded value on the patient's chart should be the average of the last two measurements [36].
A new diagnosis of HTN should not be made until the SBP and/or DBP measurement is ≥95th percentile or ≥130/80 mmHg on at least three separate visits [4,30,37]. Many children have substantial reductions in BP between the first and third visits [38-40]. The fall in BP with serial measurements is primarily because of two factors: an accommodation effect resulting from reduced anxiety over time and regression to the mean. (See 'Diagnosis' above.)
Oscillometric devices — Automated office devices measure mean arterial BP based upon pressure oscillations of the brachial artery wall as the cuff is deflated. SBP and DBP measurements are calculated based on the mean BP. Manufacturers of oscillometric devices use different algorithms for these calculations.
Oscillometric devices are commonly used in practice because of their ease of use and decrease in observer bias [4,41,42]. They are particularly helpful when auscultation is difficult, as with infants and neonates; in the intensive care setting when frequent BP measurement is needed; or to screen initial BP in a busy clinical setting [30]. In systematic reviews, SBP measurements obtained by oscillometric devices were higher compared with readings obtained by auscultation, with differences ranging from one to more than 10 points higher [42-45]. As a result, we concur with the AAP recommendations that BP readings ≥90th percentile obtained with an oscillometric device be confirmed by auscultation [4].
Limitations of oscillometric devices include:
●There is a wide range of BP values when different devices are compared, with 30 percent of SBP measurements varying by more than 10 mmHg [46].
●Oscillometric devices require maintenance and repeated calibration. When routine maintenance is not followed, the accuracy of BP measurements may be affected.
Despite these limitations, the use of oscillometric devices as an initial BP screen is reasonable given how easily they can be used. However, caution should be used when interpreting BP results with these devices and ausculatory confirmation using an aneroid sphygmomanometer is required. This is especially important when oscillometric readings are high or in patients who are at risk for hypertension [4].
Our approach — In our institution, the following steps are used to screen for high BP and are in accordance with the 2017 AAP guidelines for high BP in children and adolescents [4,30] (see 'Technique of BP measurement' above):
●An appropriate cuff size to the size of the child's upper arm is required for accurate measurement. (See 'Cuff size and placement' above.)
●In order to directly compare BP values with normative data, BP measurement is performed in the right arm after the patient has been resting comfortably for at least three minutes in a seated position in a quiet environment. (See 'Technique of BP measurement' above.)
●An oscillometric device is generally used to screen initial BP measurement. However, if two to three BP measurements exceed the 90th percentile by oscillometry, it is confirmed by an auscultatory measurement. (See 'Oscillometric devices' above and 'Technique of BP measurement' above.)
●In the initial evaluation for HTN, blood pressure measurements are obtained in both upper and lower extremities to detect the possible presence of coarctation as the cause of hypertension. (See "Clinical manifestations and diagnosis of coarctation of the aorta".)
●At each visit, at least two BP measurements are obtained and spaced one or two minutes apart. The values should be less than 5 mmHg apart and continued measurements are made until a stable value is attained. The recorded value on the patient's chart is the average of the last two measurements. (See 'Number of measurements' above.)
FOLLOW-UP — The decision process for follow-up, evaluation, and treatment varies with the elevation of BP (table 1). Stage 2 HTN identifies those children who need more prompt evaluation and, depending on end-organ damage and or clinical presentation, potentially immediate pharmacologic treatment. As a result, the timing of repeat blood pressure (BP) measurements is dependent upon the initial level of increased BP, and if there are symptoms associated with HTN (table 7) [4,47].
●Elevated BP – For children with elevated BP documented by auscultatory measurements, nonpharmacologic therapy (ie, lifestyle changes) is recommended and BP should be rechecked by auscultation in six months.
•If BP remains elevated after six months, upper and lower extremity BP should be checked (right arm, left arm, and one leg) to detect coarctation of the aorta, lifestyle counseling is repeated, and auscultated BP is rechecked in six months.
•If BP continues at the elevated BP level after 12 months (eg, after three auscultatory measurements), ambulatory blood pressure monitoring (ABPM) should be considered, and diagnostic evaluation should be considered if appropriate. Consider subspecialty referral (ie, nephrology or cardiology). If ABPM is not available, home BP readings with appropriate training and blood pressure cuff may be considered to help with further management decisions. (See "Evaluation of hypertension in children and adolescents" and "Nonemergent treatment of hypertension in children and adolescents", section on 'Nonpharmacologic therapy'.)
If BP normalizes at any point, return to annual BP screening at health supervisory care visits.
●Stage 1 HTN – Provide recommendations for nonpharmacologic measures and recheck within one to two weeks (or sooner if the patient is symptomatic). If BP remains elevated, upper and lower extremity BP should be checked (right arm, left arm, and one leg) to detect coarctation of the aorta, and BP should be rechecked in three months by auscultation. If BP remains at the stage 1 level, ABPM should be ordered (if available), and diagnostic evaluation should be considered if appropriate. Consider subspecialty referral (ie, nephrology or cardiology). (See "Evaluation of hypertension in children and adolescents".)
●Stage 2 HTN
•If the patient is symptomatic, the BP is >30 mmHg above the 95th percentile, or >180/120 mmHg (whichever is lower), the child should be referred for immediate care (eg, emergency department). (See "Initial management of hypertensive emergencies and urgencies in children".)
•If the patient is not symptomatic, upper and lower extremity BP should be checked to detect coarctation of the aorta (right arm, left arm, and one leg), lifestyle recommendations given, and the BP measurement should be repeated within one week. Alternatively, the patient could be referred to subspecialist with expertise in the evaluation and management of elevated pediatric blood pressure within one week. If at the next visit the BP is still at the stage 2 level, diagnostic evaluation, including ABPM and treatment by a specialist should be considered. (See "Evaluation of hypertension in children and adolescents".)
As noted previously, these categories do not apply to an acute elevation of BP, where the magnitude and the rate of increase above baseline that determines whether there are symptoms and the risk of serious morbidity and, at times, mortality.
AMBULATORY BP MEASUREMENTS — Blood pressure (BP) changes continually in response to physiologic and environmental stimuli. In adults, 24-hour ambulatory blood pressure monitoring (ABPM) has had better reproducibility and better correlation with the risk of hypertensive cardiovascular (CV) complications and target-organ damage than office BP measurements.
Data are more limited in children, but also indicate an important role of ABPM in the evaluation of hypertension (HTN) [13,48]. In particular, ABPM provides multiple measurements during regular activities and is the only method that allows BP measurement during sleep, and therefore is felt to provide a more accurate description of the patient's BP than office BP measurements. It is especially useful (and the only recommended method) to identify white coat HTN in children who are anxious in the medical setting, as well as those with masked HTN with normal BP in the clinical setting and elevated BP by ABPM. For these reasons, the use of ABPM has been advocated for in the evaluation of children who have elevated BP or are at risk for elevated BP [4].
In an analysis of data from the SHIP AHOY study (Study of Hypertension in Pediatrics, Adult Hypertension Onset in Youth), office-based BP values >85th percentile for age, height, sex measured in adolescents at two visits using three measurements per visit were predictive of ABPM systolic hypertension [49]. These results suggest that a BP threshold >85th percentile be used to decide when to perform ABPM in the evaluation of HTN in adolescents.
ABPM Definition of hypertension — BP is higher when individuals are active and/or ambulatory versus when they are at rest. The correlation between ABPM and office measurements is poor and normative data are limited. The normative data that are used in clinical practice are based on a single study of approximately 1000 Central European children and adolescents (table 8 and table 9 and table 10 and table 11) [26,50,51]. (See "Ambulatory blood pressure monitoring in children", section on 'Normative data'.)
Despite these limitations, ABPM is used increasingly because of its ability to record numerous BP readings during a 24-hour time period while the child is engaged in his/her normal activities. Consensus recommendations for categorizing patients based on office and ambulatory BP measurements have been published and include the following [52]:
●Pre-hypertension – Office systolic BP (SBP) or diastolic BP (DBP) >90th to <95th percentile, mean ambulatory SBP or DBP <95th percentile, and ambulatory SBP or DBP load of 25 to 50 percent.
●Ambulatory hypertension – Office BP >95th percentile, mean ambulatory SBP or DBP >95th percentile and SBP or DBP load of 25 to 50.
The 2016 European Society of Hypertension (ESH) guidelines also use a threshold for HTN >95th percentile as long as the ambulatory BP values are lower than the accepted criteria for adults (24-hour mean value of 130/80 mmHg, mean daytime value of 135/85 mmHg, and mean night-time value of 125/75 mmHg). (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".)
ABPM also can give useful information regarding the BP pattern in patients with chronic kidney disease (CKD), diabetes, autonomic dysfunction, or episodic HTN, and the BP response to therapeutic intervention. These issues are discussed in detail elsewhere. (See "Ambulatory blood pressure monitoring in children".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in children".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: High blood pressure in children (The Basics)")
●Beyond the Basics topics (see "Patient education: High blood pressure in children (Beyond the Basics)" and "Patient education: High blood pressure treatment in children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition and importance – Hypertension (HTN) in childhood and adolescence contributes to premature cardiovascular disease (CVD). HTN is defined as follows (see 'Definition' above):
•In children <13 years old, HTN is defined based upon blood pressure (BP) percentiles for sex, age, and height, as summarized in the tables (table 1 and table 2 and table 3).
•In adolescents ≥13 years old, the definition is aligned with adult guidelines (table 1).
●Diagnosis – The diagnosis of chronic childhood HTN is made when the auscultated BP values on three repeated and separate visits are >95th percentile for the age, sex, and height of the patient, or is ≥130/80 mmHg even if <95th percentile. (See 'Diagnosis' above.)
●Screening – Screening BP is performed as follows (see 'Screening of BP' above):
•For children without risk factors or conditions associated with HTN, BP is measured beginning at three years of age during annual health care supervision visits.
•For children ≥3 years of age with risk factors for HTN, BP is measured at every health care encounter (table 4).
•For children <3 years of age with risk factors for HTN, BP is measured at each health supervision visit (table 5).
Children with systolic BP (SBP) or diastolic BP (DBP) that exceeds screening thresholds for age and sex (table 6) require further evaluation, starting with repeat BP measurement.
●Measuring BP – To ensure accurate measurements of BP, we suggest the following:
•Use an appropriate size cuff, defined as a bladder width of 40 percent of the circumference of the upper arm and a bladder length that encircles 80 to 100 percent of the circumference of the upper arm. (See 'Cuff size and placement' above.)
•Perform the BP measurement in the right arm after the patient has been resting comfortably for at least three minutes in a seated position in a quiet environment. (See 'Technique of BP measurement' above.)
•If the BP value exceeds the 90th percentile by oscillometry, confirm it with an auscultatory measurement. (See 'Oscillometric devices' above.)
•In the initial evaluation for HTN, perform BP measurements in both upper and lower extremities. At each visit, obtain at least two BP measurements spaced one or two minutes apart. (See 'Technique of BP measurement' above and 'Number of measurements' above.)
•When performing an auscultatory BP measurement, use the first (initial tapping sound) and fifth (disappearance) Korotkoff sounds to identify systolic and diastolic blood pressure values, respectively. (See 'Technique of BP measurement' above.)
●Ambulatory BP monitoring – Twenty four-hour ambulatory BP monitoring (ABPM) provides multiple measurements during regular activities (including sleep) and may give a more accurate description of the patient's BP. (See "Ambulatory blood pressure monitoring in children".)
