FIGURE 1

Abstract

These pediatric hypertension guidelines are an update to the 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” Significant changes in these guidelines include (1) the replacement of the term “prehypertension” with the term “elevated blood pressure,” (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

  • Abbreviations:
    AAP
    American Academy of Pediatrics
    ABPM
    ambulatory blood pressure monitoring
    ACC
    American College of Cardiology
    ACE
    angiotensin-converting enzyme
    AHA
    American Heart Association
    ARB
    angiotensin receptor blocker
    ARR
    aldosterone to renin ratio
    BP
    blood pressure
    BSA
    body surface area
    cIMT
    carotid intimamedia thickness
    CKD
    chronic kidney disease
    CTA
    computed tomographic angiography
    CV
    cardiovascular
    CVD
    cardiovascular disease
    DASH
    Dietary Approaches to Stop Hypertension
    DBP
    diastolic blood pressure
    ED
    emergency department
    EHR
    electronic health record
    FMD
    flow-mediated dilation
    HTN
    hypertension
    LVH
    left ventricular hypertrophy
    LVMI
    left ventricular mass index
    MA
    microalbuminuria
    MAP
    mean arterial pressure
    MH
    masked hypertension
    MI
    motivational interviewing
    MRA
    magnetic resonance angiography
    NF-1
    neurofibromatosis type 1
    OSAS
    obstructive sleep apnea syndrome
    PCC
    pheochromocytoma
    PICOT
    Patient, Intervention/Indicator, Comparison, Outcome, and Time
    PRA
    plasma renin activity
    PWV
    pulse wave velocity
    QALY
    quality-adjusted life-year
    RAAS
    renin-angiotensin-aldosterone system
    RAS
    renal artery stenosis
    SBP
    systolic blood pressure
    SDB
    sleep-disordered breathing
    T1DM
    type 1 diabetes mellitus
    T2DM
    type 2 diabetes mellitus
    UA
    uric acid
    WCH
    white coat hypertension
  • 1. Introduction

    1. Scope of the Clinical Practice Guideline

    Interest in childhood hypertension (HTN) has increased since the 2004 publication of the “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents” (Fourth Report).1 Recognizing ongoing evidence gaps and the need for an updated, thorough review of the relevant literature, the American Academy of Pediatrics (AAP) and its Council on Quality Improvement and Patient Safety developed this practice guideline to provide an update on topics relevant to the diagnosis, evaluation, and management of pediatric HTN. It is primarily directed at clinicians caring for children and adolescents in the outpatient setting. This guideline is endorsed by the American Heart Association.

    When it was not possible to identify sufficient evidence, recommendations are based on the consensus opinion of the expert members of the Screening and Management of High Blood Pressure in Children Clinical Practice Guideline Subcommittee (henceforth, “the subcommittee”). The subcommittee intends to regularly update this guideline as new evidence becomes available. Implementation tools for this guideline are available on the AAP Web site (https://www.aap.org/en-us/professional-resources/quality-improvement/quality-improvement-resources-and-tools/Pages/hypertension.aspx).

    1.1 Methodology

    The subcommittee was co-chaired by a pediatric nephrologist and a general pediatrician and consisted of 17 members, including a parent representative. All subcommittee members were asked to disclose relevant financial or proprietary conflicts of interest for members or their family members at the start of and throughout the guideline preparation process. Potential conflicts of interest were addressed and resolved by the AAP. A detailed list of subcommittee members and affiliations can be found in the Consortium section at the end of this article. A listing of subcommittee members with conflicts of interest will be included in the forthcoming technical report.

    The subcommittee epidemiologist created a detailed content outline, which was reviewed and approved by the subcommittee. The outline contained a list of primary and secondary topics generated to guide a thorough literature search and meet the goal of providing an up-to-date systemic review of the literature pertaining to the diagnosis, management, and treatment of pediatric HTN as well as the prevalence of pediatric HTN and its associated comorbidities.

    Of the topics covered in the outline, ∼80% were researched by using a Patient, Intervention/Indicator, Comparison, Outcome, and Time (PICOT) format to address the following key questions:

    1. How should systemic HTN (eg, primary HTN, renovascular HTN, white coat hypertension [WCH], and masked hypertension [MH]) in children be diagnosed, and what is the optimal approach to diagnosing HTN in children and adolescents?

    2. What is the recommended workup for pediatric HTN? How do we best identify the underlying etiologies of secondary HTN in children?

    3. What is the optimal goal systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) for children and adolescents?

    4. In children 0 to 18 years of age, how does treatment with lifestyle versus antihypertensive agents influence indirect measures of cardiovascular disease (CVD) risk, such as carotid intimamedia thickness (cIMT), flow-mediated dilation (FMD), left ventricular hypertrophy (LVH), and other markers of vascular dysfunction?

    To address these key questions, a systematic search and review of literature was performed. The initial search included articles published between the publication of the Fourth Report (January 2004) and August 2015. The process used to conduct the systematic review was consistent with the recommendations of the Institute of Medicine for systematic reviews.2

    For the topics not researched by using the PICOT format, separate searches were conducted. Not all topics (eg, economic aspects of pediatric HTN) were appropriate for the PICOT format. A third and final search was conducted at the time the Key Action Statements (KASs) were generated to identify any additional relevant articles published between August 2015 and July 2016. (See Table 1 for a complete list of KASs.)

    TABLE 1

    Summary of KASs for Screening and Management of High BP in Children and Adolescents

    A detailed description of the methodology used to conduct the literature search and systematic review for this clinical practice guideline will be included in the forthcoming technical report. In brief, reference selection involved a multistep process. First, 2 subcommittee members reviewed the titles and abstracts of references identified for each key question. The epidemiologist provided a deciding vote when required. Next, 2 subcommittee members and the epidemiologist conducted full-text reviews of the selected articles. Although many subcommittee members have extensively published articles on topics covered in this guideline, articles were not preferentially selected on the basis of authorship.

    Articles selected at this stage were mapped back to the relevant main topic in the outline. Subcommittee members were then assigned to writing teams that evaluated the evidence quality for selected topics and generated appropriate KASs in accordance with an AAP grading matrix (see Fig 1 and the detailed discussion in the forthcoming technical report).3 Special working groups were created to address 2 specific topics for which evidence was lacking and expert opinion was required to generate KASs, “Definition of HTN” and “Definition of LVH.” References for any topics not covered by the key questions were selected on the basis of additional literature searches and reviewed by the epidemiologist and subcommittee members assigned to the topic. When applicable, searches were conducted by using the PICOT format .

    AAP grading matrix.

    ” data-icon-position=”” data-hide-link-title=”0″>FIGURE 1

    FIGURE 1

    AAP grading matrix.

    In addition to the 30 KASs listed above, this guideline also contains 27 additional recommendations that are based on the consensus expert opinion of the subcommittee members. These recommendations, along with their locations in the document, are listed in Table 2.

    TABLE 2

    Additional Consensus Opinion Recommendations and Text Locations

    2. Epidemiology and Clinical Significance

    2.1 Prevalence of HTN in Children

    Information on the prevalence of high blood pressure (BP) in children is largely derived from data from the NHANES and typically is based on a single BP measurement session. These surveys, conducted since 1988, indicate that there has been an increase in the prevalence of childhood high BP, including both HTN and elevated BP.4,5 High BP is consistently greater in boys (15%–19%) than in girls (7%–12%). The prevalence of high BP is higher among Hispanic and non-Hispanic African American children compared with non-Hispanic white children, with higher rates among adolescents than among younger children.6

    However, in a clinical setting and with repeated BP measurements, the prevalence of confirmed HTN is lower in part because of inherent BP variability as well as an adjustment to the experience of having BP measured (also known as the accommodation effect). Therefore, the actual prevalence of clinical HTN in children and adolescents is ∼3.5%.7,8 The prevalence of persistently elevated BP (formerly termed “prehypertension,” including BP values from the 90th to 94th percentiles or between 120/80 and 130/80 mm Hg in adolescents) is also ∼2.2% to 3.5%, with higher rates among children and adolescents who have overweight and obesity.7,9

    Data on BP tracking from childhood to adulthood demonstrate that higher BP in childhood correlates with higher BP in adulthood and the onset of HTN in young adulthood. The strength of the tracking relationship is stronger in older children and adolescents.10 Trajectory data on BP (including repeat measurements from early childhood into midadulthood) confirm the association of elevated BP in adolescence with HTN in early adulthood11 and that normal BP in childhood is associated with a lack of HTN in midadulthood.11

    2.2 Awareness, Treatment, and Control of HTN in Children

    Of the 32.6% of US adults who have HTN, almost half (17.2%) are not aware they have HTN; even among those who are aware of their condition, only approximately half (54.1%) have controlled BP.12 Unfortunately, there are no large studies in which researchers have systematically studied BP awareness or control in youth, although an analysis of prescribing patterns from a nationwide prescription drug provider found an increase in the number of prescriptions written for high BP in youth from 2004 to 2007.13

    The SEARCH for Diabetes in Youth study found that only 7.4% of youth with type 1 diabetes mellitus (T1DM) and 31.9% of youth with type 2 diabetes mellitus (T2DM) demonstrated knowledge of their BP status.14 Even after becoming aware of the diagnosis, only 57.1% of patients with T1DM and 40.6% of patients with T2DM achieved good BP control.14 The HEALTHY Primary Prevention Trial of Risk Factors for Type 2 Diabetes in Middle-School Youth, which examined a school-based intervention designed to reduce cardiovascular (CV) risk among middle school students, found the prevalence of stage 1 or 2 HTN to be ∼9.5%.15 There was no significant reduction in HTN in the control group after the intervention; the intervention group saw a reduction in the prevalence of HTN of ∼1%, leaving 8.5% with BP still above the ideal range.

    Researchers in a number of small, single-center studies have evaluated BP control in children and adolescents with HTN. One study found that lifestyle change and medications produced adequate BP control in 46 of 65 youth (70%) with HTN.16 Another study in which researchers used ambulatory blood pressure monitoring (ABPM) to assess BP control among a group of 38 children (of whom 84% had chronic kidney disease [CKD]) found that only 13 children (34%) achieved adequate BP control even among those who received more than 1 drug.17 A similar study found that additional drugs did increase rates of BP control in children with CKD, however.18

    2.3 Prevalence of HTN Among Children With Various Chronic Conditions

    It is well recognized that HTN rates are higher in children with certain chronic conditions, including children with obesity, sleep-disordered breathing (SDB), CKD, and those born preterm. These are described below.

    2.3a Children With Obesity

    HTN prevalence ranges from 3.8% to 24.8% in youth with overweight and obesity. Rates of HTN increase in a graded fashion with increasing adiposity.1924 Similar relationships are seen between HTN and increasing waist circumference.4,25,26 Systematic reviews of 63 studies on BMI27 and 61 studies on various measures of abdominal adiposity28 have shown associations between these conditions and HTN. Obesity is also associated with a lack of circadian variability of BP,29,30 with up to 50% of children who have obesity not experiencing the expected nocturnal BP dip.3133

    Studies have shown that childhood obesity is also related to the development of future HTN.22 Elevated BMI as early as infancy is associated with higher future BP.34 This risk appears to increase with obesity severity; there is a fourfold increase in BP among those with severe obesity (BMI >99th percentile) versus a twofold increase in those with obesity (BMI 95th–98th percentiles) compared with normal-weight children and adolescents.35

    Collectively, the results of these cross-sectional and longitudinal studies firmly establish an increasing prevalence of HTN with increasing BMI percentile. The study results also underscore the importance of monitoring BP in all children with overweight and/or obesity at every clinical encounter.

    Obesity in children with HTN may be accompanied by additional cardiometabolic risk factors (eg, dyslipidemia and disordered glucose metabolism)36,37 that may have their own effects on BP or may represent comorbid conditions arising from the same adverse lifestyle behaviors.25,38 Some argue that the presence of multiple risk factors, including obesity and HTN, leads to far greater increases in CV risk than is explained by the individual risk factors alone. Although this phenomenon has been hard to demonstrate definitively, the Strong Heart Study did show that American Indian adolescents with multiple cardiometabolic risk factors had a higher prevalence of LVH (43.2% vs 11.7%), left atrial dilation (63.1% vs 21.9%; P < .001), and reduced LV systolic and diastolic function compared with those without multiple cardiometabolic risk factors.39 Notably, both obesity and HTN were drivers of these CV abnormalities, with obesity being a stronger determinant of cardiac abnormalities than HTN (odds ratio, 4.17 vs 1.03).

    2.3b Children With SDB

    SDB occurs on a spectrum that includes (1) primary snoring, (2) sleep fragmentation, and (3) obstructive sleep apnea syndrome (OSAS). Researchers in numerous studies have identified an association between SDB and HTN in the pediatric population.4042 Studies suggest that children who sleep 7 hours or less per night are at increased risk for HTN.43 Small studies of youth with sleep disorders have found the prevalence of high BP to range between 3.6% and 14%.40,41 The more severe the OSAS, the more likely a child is to have HTN.45,46 Even inadequate duration of sleep and poor-quality sleep have been associated with elevated BP.43

    2.3c Children With CKD

    There are well-established pathophysiologic links between childhood HTN and CKD. Certain forms of CKD can lead to HTN, and untreated HTN can lead to CKD in adults, although evidence for the latter in pediatric patients is lacking. Among children and adolescents with CKD, ∼50% are known to be hypertensive.4648 In children and adolescents with end-stage renal disease (either those on dialysis or after transplant), ∼48% to 79% are hypertensive, with 20% to 70% having uncontrolled HTN.4953 Almost 20% of pediatric HTN may be attributable to CKD.54

    2.3d Children With History of Prematurity

    Abnormal birth history—including preterm birth and low birth weight—has been identified as a risk factor for HTN and other CVD in adults55; only low birth weight has been associated with elevated BP in the pediatric age range.56 One retrospective cohort study showed a prevalence of HTN of 7.3% among 3 year olds who were born preterm.57 Researchers in another retrospective case series noted a high prevalence of HTN in older children with a history of preterm birth.58 It also appears that preterm birth may result in abnormal circadian BP patterns in childhood.59 These data are intriguing but limited. Further study is needed to determine how often preterm birth results in childhood HTN.

    2.4 Importance of Diagnosing HTN in Children and Adolescents

    Numerous studies have shown that elevated BP in childhood increases the risk for adult HTN and metabolic syndrome.10,6062 Youth with higher BP levels in childhood are also more likely to have persistent HTN as adults.60,63 One recent study found that adolescents with elevated BP progressed to HTN at a rate of 7% per year, and elevated BMI predicted sustained BP elevations.64 In addition, young patients with HTN are likely to experience accelerated vascular aging. Both autopsy65 and imaging studies66 have demonstrated BP-related CV damage in youth. These intermediate markers of CVD (eg, increased LV mass,67 cIMT,68 and pulse wave velocity [PWV]69) are known to predict CV events in adults, making it crucial to diagnose and treat HTN early.

    Eighty million US adults (1 in 3) have HTN, which is a major contributor to CVD.12 Key contributors to CV health have been identified by the American Heart Association (AHA) as “Life’s Simple 7,” including 4 ideal health behaviors (not smoking, normal BMI, physical activity at goal levels, and a healthy diet) and 3 ideal health factors (untreated, normal total cholesterol; normal fasting blood glucose; and normal untreated BP, defined in childhood as ≤90th percentile or <120/80 mm Hg). Notably, elevated BP is the least common abnormal health factor in children and adolescents70; 89% of youth (ages 12–19 years) are in the ideal BP category.6

    Given the prevalence of known key contributors in youth (ie, tobacco exposure, obesity, inactivity, and nonideal diet12,71), adult CVD likely has its origins in childhood. One-third of US adolescents report having tried a cigarette in the past 30 days.72 Almost half (40%–48%) of teenagers have elevated BMI, and the rates of severe obesity (BMI >99th percentile) continue to climb, particularly in girls and adolescents.7375 Physical activity measured by accelerometry shows less than half of school-aged boys and only one-third of school-aged girls meet the goal for ideal physical activity levels.72 More than 80% of youth 12 to 19 years of age have a poor diet (as defined by AHA metrics for ideal CV health); only ∼10% eat adequate fruits and vegetables, and only ∼15% consume <1500 mg per day of sodium, both of which are key dietary determinants of HTN.76

    Finally, measuring BP at routine well-child visits enables the early detection of primary HTN as well as the detection of asymptomatic HTN secondary to another underlying disorder. Early detection of HTN is vital given the greater relative prevalence of secondary causes of HTN in children compared with adults.

    3. Definition of HTN

    3.1 Definition of HTN (1–18 Years of Age)

    Given the lack of outcome data, the current definition of HTN in children and adolescents is based on the normative distribution of BP in healthy children.1 Because it is a major determinant of BP in growing children, height has been incorporated into the normative data since the publication of the 1996 Working Group Report.1 BP levels should be interpreted on the basis of sex, age, and height to avoid misclassification of children who are either extremely tall or extremely short. It should be noted that the normative data were collected by using an auscultatory technique,1 which may provide different values than measurement obtained by using oscillometric devices or from ABPM.

    In the Fourth Report, “normal blood pressure” was defined as SBP and DBP values <90th percentile (on the basis of age, sex, and height percentiles). For the preadolescent, “prehypertension” was defined as SBP and/or DBP ≥90th percentile and <95th percentile (on the basis of age, sex, and height tables). For adolescents, “prehypertension” was defined as BP ≥120/80 mm Hg to <95th percentile, or ≥90th and <95th percentile, whichever was lower. HTN was defined as average clinic measured SBP and/or DBP ≥95th percentile (on the basis of age, sex, and height percentiles) and was further classified as stage 1 or stage 2 HTN.

    There are still no data to identify a specific level of BP in childhood that leads to adverse CV outcomes in adulthood. Therefore, the subcommittee decided to maintain a statistical definition for childhood HTN. The staging criteria have been revised for stage 1 and stage 2 HTN for ease of implementation compared with the Fourth Report. For children ≥13 years of age, this staging scheme will seamlessly interface with the 2017 AHA and American College of Cardiology (ACC) adult HTN guideline.* Additionally, the term “prehypertension” has been replaced by the term “elevated blood pressure,” to be consistent with the AHA and ACC guideline and convey the importance of lifestyle measures to prevent the development of HTN (see Table 3).

    TABLE 3

    Updated Definitions of BP Categories and Stages

    3.2 New BP Tables

    New normative BP tables based on normal-weight children are included with these guidelines (see Tables 4 and 5). Similar to the tables in the Fourth Report,1 they include SBP and DBP values arranged by age, sex, and height (and height percentile). These values are based on auscultatory measurements obtained from ∼50 000 children and adolescents. A new feature in these tables is that the BP values are categorized according to the scheme presented in Table 3 as normal (50th percentile), elevated BP (>90th percentile), stage 1 HTN (≥95th percentile), and stage 2 HTN (≥95th percentile + 12 mm Hg). Additionally, actual heights in centimeters and inches are provided.

    TABLE 4

    BP Levels for Boys by Age and Height Percentile

    TABLE 5

    BP Levels for Girls by Age and Height Percentile

    Unlike the tables in the Fourth Report,1 the BP values in these tables do not include children and adolescents with overweight and obesity (ie, those with a BMI ≥85th percentile); therefore, they represent normative BP values for normal-weight youth. The decision to create these new tables was based on evidence of the strong association of both overweight and obesity with elevated BP and HTN. Including patients with overweight and obesity in normative BP tables was thought to create bias. The practical effect of this change is that the BP values in Tables 4 and 5 are several millimeters of mercury lower than in the similar tables in the Fourth Report.1 These tables are based on the same population data excluding participants with overweight and obesity, and the same methods used in the Fourth Report.1 The methods and results have been published elsewhere.77 For researchers and others interested in the equations used to calculate the tables’ BP values, detailed methodology and the Statistical Analysis System (SAS) code can be found at: http://sites.google.com/a/channing.harvard.edu/bernardrosner/pediatric-blood-press/childhood-blood-pressure.

    There are slight differences between the actual percentile-based values in these tables and the cut-points in Table 3, particularly for teenagers ≥13 years of age. Clinicians should understand that the scheme in Table 3 was chosen to align with the new adult guideline and facilitate the management of older adolescents with high BP. The percentile-based values in Tables 4 and 5 are provided to aid researchers and others interested in a more precise classification of BP.

    3.2a. Simplified BP Table

    This guideline includes a new, simplified table for initial BP screening (see Table 6) based on the 90th percentile BP for age and sex for children at the 5th percentile of height, which gives the values in the table a negative predictive value of >99%.78 This simplified table is designed as a screening tool only for the identification of children and adolescents who need further evaluation of their BP starting with repeat BP measurements. It should not be used to diagnose elevated BP or HTN by itself. To diagnose elevated BP or HTN, it is important to locate the actual cutoffs in the complete BP tables because the SBP and DBP cutoffs may be as much as 9 mm Hg higher depending on a child’s age and length or height. A typical-use case for this simplified table is for nursing staff to quickly identify BP that may need further evaluation by a clinician. For adolescents ≥13 years of age, a threshold of 120/80 mm Hg is used in the simplified table regardless of sex to align with adult guidelines for the detection of elevated BP.

    TABLE 6

    Screening BP Values Requiring Further Evaluation

    3.3 Definition of HTN in the Neonate and Infant (0–1 Year of Age)

    Although a reasonably strict definition of HTN has been developed for older children, it is more difficult to define HTN in neonates given the well-known changes in BP that occur during the first few weeks of life.79 These BP changes can be significant in preterm infants, in whom BP depends on a variety of factors, including postmenstrual age, birth weight, and maternal conditions.80

    In an attempt to develop a more standardized approach to the HTN definition in preterm and term neonates, Dionne et al79 compiled available data on neonatal BP and generated a summary table of BP values, including values for the 95th and 99th percentiles for infants from 26 to 44 weeks’ postmenstrual age. The authors proposed that by using these values, a similar approach to that used to identify older children with elevated BP can be followed in neonates, even in those who are born preterm.

    At present, no alternative data have been developed, and no outcome data are available on the consequences of high BP in this population; thus, it is reasonable to use these compiled BP values in the assessment of elevated BP in newborn infants. Of note, the 1987 “Report of the Second Task Force on Blood Pressure Control in Children” published curves of normative BP values in older infants up to 1 year of age.81 These normative values should continue to be used given the lack of more contemporary data for this age group.

    4. Measurement of BP

    4.1 BP Measurement Technique

    BP in childhood may vary considerably between visits and even during the same visit. There are many potential etiologies for isolated elevated BP in children and adolescents, including such factors as anxiety and recent caffeine intake.82 BP generally decreases with repeated measurements during a single visit,83 although the variability may not be large enough to affect BP classification.84 BP measurements can also vary across visits64,85; one study in adolescents found that only 56% of the sample had the same HTN stage on 3 different occasions.8 Therefore, it is important to obtain multiple measurements over time before diagnosing HTN.

    The initial BP measurement may be oscillometric (on a calibrated machine that has been validated for use in the pediatric population) or auscultatory (by using a mercury or aneroid sphygmomanometer86,87). (Validation status for oscillometric BP devices, including whether they are validated in the pediatric age group, can be checked at www.dableducational.org.) 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 aortic coarctation or left aortic arch with aberrant right subclavian artery (see Table 7). Other important aspects of proper BP measurement are illustrated in an AAP video available at http://youtu.be/JLzkNBpqwi0. Care should be taken that providers follow an accurate and consistent measurement technique.88,89

    TABLE 7

    Best BP Measurement Practices

    An appropriately sized cuff should be used for accurate BP measurement.83 Researchers in 3 studies in the United Kingdom and 1 in Brazil documented the lack of availability of an appropriately sized cuff in both the inpatient and outpatient settings.9194 Pediatric offices should have access to a wide range of cuff sizes, including a thigh cuff for use in children and adolescents with severe obesity. For children in whom the appropriate cuff size is difficult to determine, the midarm circumference (measured as the midpoint between the acromion of the scapula and olecranon of the elbow, with the shoulder in a neutral position and the elbow flexed to 90°86,95,96) should be obtained for an accurate determination of the correct cuff size (see Fig 2 and Table 7).95

    Determination of proper BP cuff size.95 A, Marking spine extending from acromion process. B, Correct tape placement for upper arm length. C, Incorrect tape placement for upper arm length. D, Marking upper arm length midpoint.

    ” data-icon-position=”” data-hide-link-title=”0″>FIGURE 2

    FIGURE 2

    Determination of proper BP cuff size.95 A, Marking spine extending from acromion process. B, Correct tape placement for upper arm length. C, Incorrect tape placement for upper arm length. D, Marking upper arm length midpoint.

    If the initial BP is elevated (≥90th percentile), providers should perform 2 additional oscillometric or auscultatory BP measurements at the same visit and average them. If using auscultation, this averaged measurement is used to determine the child’s BP category (ie, normal, elevated BP, stage 1 HTN, or stage 2 HTN). If the averaged oscillometric reading is ≥90th percentile, 2 auscultatory measurements should be taken and averaged to define the BP category (see Fig 3).

    Modified BP measurement algorithm.

    ” data-icon-position=”” data-hide-link-title=”0″>FIGURE 3

    FIGURE 3

    Modified BP measurement algorithm.

    4.1a Measurement of BP in the Neonate

    Multiple methods are available for the measurement of BP in hospitalized neonates, including direct intra-arterial measurements using indwelling catheters as well as indirect measurements using the oscillometric technique. 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 outpatient 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 diabetes,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 patient 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 patient 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); and

    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 patient 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; and

    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 patient 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 patient should be referred to subspecialty care within 1 week (see Table 11); and

    3. If the BP reading is at the stage 2 HTN level and the patient 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 patient 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 patients 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 patient 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 patients 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 patient 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 patients 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 patient. 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 patient preferences Some patients 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 patient. Some insurance plans may not reimburse for the test. The risk of diagnosing and labeling a patient 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 patient preferences Some patients 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 patient. 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 patient preferences Some patients may prefer repeat office or home measurements to ABPM
    Exclusions None
    Strength Moderate recommendation
    Key references 155

    4.7a Masked Hypertension

    MH occurs when patients 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 patients have significant risk for end organ hypertensive damage.200,203 Patients who are at risk of MH include patients with obesity and secondary forms of HTN, such as CKD or repaired aortic coarctation. MH is particularly prevalent in patients 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 patients
    Benefit–harm assessment Benefit exceeds risk
    Intentional vagueness None
    Role of patient preferences Important; some patients 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 patient 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.