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HIGH BLOOD PRESSURE OVERVIEW — Blood pressure refers to the pressure that blood applies to the inner walls of blood vessels. High blood pressure is also called hypertension. Although hypertension is more common in adults, it often develops during childhood and adolescence, and can increase the risk of early heart disease and stroke during adulthood. Fortunately, high blood pressure is easy to measure and can be treated.
This topic discusses the treatment options for children and adolescents with high blood pressure. High blood pressure is divided into different stages based on the blood pressure measurement; categories include elevated blood pressure (blood pressure that is higher than normal but is not yet hypertension, formerly called "prehypertension") and stage 1 and stage 2 hypertension. In general, interventions include lifestyle changes for anyone with high blood pressure. Medications are reserved for people with stage 2 hypertension, those with persistent stage 1 hypertension despite lifestyle changes, and those with elevated blood pressure who have other chronic diseases.
The causes and diagnosis of high blood pressure (hypertension) in children are discussed separately. (See "Patient education: High blood pressure in children (Beyond the Basics)".)
DEFINITION OF HYPERTENSION — Hypertension for adolescents 13 years or older is defined as blood pressure exceeding 130/80 mmHg, and for younger children as either systolic and/or diastolic blood pressure ≥95th percentile based on sex, age, measured on three or more separate occasions.
WHY TREAT HYPERTENSION? — There are several important reasons to treat high blood pressure in children:
●To prevent/treat complications of hypertension in childhood, such as seizures or heart failure.
●Hypertension that begins in childhood and adolescence may persist into adulthood. Adult hypertension is a major risk factor contributing to early heart attack or stroke.
HYPERTENSION TREATMENT — The first step in the treatment of hypertension is to treat any underlying cause for hypertension (secondary hypertension), if present.
If treating the underlying cause does not adequately reduce blood pressure, or if there is no known underlying cause (primary, formerly called "essential", hypertension), treatments to reduce the blood pressure are recommended. (See "Patient education: High blood pressure in children (Beyond the Basics)", section on 'Types of high blood pressure'.)
Treatment includes lifestyle changes (diet changes, regular exercise, and if appropriate, weight loss) and/or medications.
LIFESTYLE CHANGES — Lifestyle changes are recommended for children with hypertension (defined as blood pressure >95th percentile) or those with elevated blood pressure (defined as blood pressure >90th to the 95th percentile or if blood pressure exceeds 120/80 mmHg in adolescents 13 years or older). (See "Patient education: High blood pressure in children (Beyond the Basics)", section on 'Normal versus high blood pressure'.)
Lifestyle changes include:
●Weight loss
●Regular exercise
●Dietary changes, including reducing salt intake and avoiding alcohol
●Although cigarette smoke does not directly affect blood pressure, exposure to cigarette smoke (including secondhand exposure) is a risk factor for cardiovascular disease and should be avoided
Weight loss — A child is said to be obese or overweight based upon the body mass index. BMI can be calculated using an online calculator for boys (calculator 1) and for girls (calculator 2).
●Children who are between the 85th and 95th percentile are said to be overweight, while children who are above the 95th percentile are said to be obese.
●In children who are obese or overweight, losing weight can help to lower blood pressure. In some cases, the child will be referred to a nutritionist, who can work with the child and parents to formulate a healthy eating plan.
Weight loss is most effective
at reducing the blood pressure when it is combined with exercise.
Exercise — Regular exercise helps lower blood pressure, even if the weight is normal. Although exercise recommendations for an individual child may vary, general recommendations include the following:
●Twenty to 30 minutes of aerobic exercise per day most days of the week. Aerobic exercise includes walking, swimming, and biking, but not weight lifting or strength training.
●Sedentary activities (watching television and/or playing video and computer games) should be limited to less than two hours per day.
Participation in sports — Children who have controlled high blood pressure are generally allowed to participate in competitive sports. Children and adolescents with high blood pressure are advised to avoid weight lifting until the blood pressure is better controlled.
Exceptions to these recommendations include children with uncontrolled severe hypertension (stage 2 hypertension, see below) or those with abnormalities due to high pressure in their echocardiogram (cardiac ultrasound) such as thickened wall of the left ventricular chamber of the heart, who are generally advised to avoid competitive sports until the blood pressure is better controlled and the cardiac abnormality has resolved.
Diet — Reducing salt intake and eating more fresh fruits and vegetables and low-fat dairy products can help to reduce blood pressure in children and adolescents with hypertension. When possible, the entire family should make these changes to encourage the child to develop healthy eating habits.
To reduce salt intake, we recommend using a no-salt added diet and avoiding or eating fewer foods with a high salt content, such as processed, junk, or fast foods. A full discussion of a low salt diet is available separately. (See "Patient education: Low-sodium diet (Beyond the Basics)".)
Smoking and alcohol — Children and adolescents who have hypertension should not smoke because it significantly increases their risk of heart disease and lung cancer. Family members of a child with hypertension are encouraged to quit smoking as well because exposure to secondhand smoke also increases the child's risk of developing heart disease. (See "Patient education: Quitting smoking (Beyond the Basics)".)
Multiple studies in adults have shown that drinking more than two alcoholic beverages per day significantly increases the risk of developing hypertension. Although studies in children are not available, children and adolescents should avoid alcohol for many other health and safety reasons.
Energy drinks — Energy drinks have a high content of sugar and/or caffeine or other stimulants and can aggravate weight, heart rhythm, and blood pressure problems, and should be avoided.
MEDICATIONS — In children and adolescents, one or more medications may be recommended to reduce high blood pressure in the following circumstances:
●Hypertension associated with symptoms that are related to elevated blood pressure, such as headaches or seizures.
●Stage 2 hypertension, defined as blood pressure level 12 mmHg greater than the 95th percentile or ≥140/90 mmHg (whichever is lower).
●Stage 1 hypertension, defined as blood pressure level between the 95th percentile and stage 2 (or between 130/80 and 139/89, whichever is lower), that persists after four to six months of nonpharmacologic therapy.
●There are physical signs of hypertension, such as a thickened wall of the left ventricular chamber of the heart.
●Any stage of hypertension or elevated blood pressure in children with chronic kidney disease.
●Any stage of hypertension in children with diabetes mellitus.
Classes of antihypertensive medications — There are several classes of antihypertensive medications commonly used to treat children. These include thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), calcium channel blockers, and beta blockers.
FOLLOW-UP — The frequency of follow-up is dependent on the initial level of blood pressure.
●Children and adolescents with elevated blood pressure or stage 1 hypertension who are treated only with nonpharmacologic therapies usually have their blood pressure monitored every three to six months.
●If medications are given to lower blood pressure, the child or adolescent is generally seen every four to six weeks for medication changes until a stable regimen is established. If no additional changes are required, the time between follow-ups is gradually increased to three to six months.
●In sexually active females who have gone through puberty, a urinary pregnancy test should be performed if ACE/ARBs medications are being considered, as they can cause birth defects.
BLOOD PRESSURE MONITORING AND GOALS — Children and adolescents with prehypertension who are treated with nonpharmacologic therapies usually have their blood pressure monitored every four to six months. Those with hypertension are generally monitored more often depending upon the severity of their hypertension.
The goal blood pressure for most children with hypertension is less than the 90th percentile. If the child is obese or has high cholesterol, diabetes, or has organ damage related to hypertension, the blood pressure goal is lower.
WHERE TO GET MORE INFORMATION — Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces 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.
Patient education: High blood pressure in children (The Basics)
Patient education: High blood pressure in adults (The Basics)
Patient education: Controlling your blood pressure through lifestyle (The Basics)
Patient education: Glomerular disease (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: High blood pressure in children (Beyond the Basics)
Patient education: Low-sodium diet (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Ambulatory blood pressure monitoring in children
Definition and diagnosis of hypertension in children and adolescents
Epidemiology, risk factors, and etiology of hypertension in children and adolescents
Evaluation of hypertension in children and adolescents
Nonemergent treatment of hypertension in children and adolescents
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
●The Nemours Foundation
(http://kidshealth.org/parent/medical/heart/hypertension.html)
●The National Kidney Foundation
(www.kidney.org/atoz/atozTopic_HighBloodPressure)
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