exp date isn't null, but text field is
The following guideline has been developed and is regularly reviewed by clinicians within the Renal Unit at the Royal Hospital for Children. These guidelines are based on current evidence and best practice relating to the investigation and management of hypertension in infants, children and adolescents (aged 1-17 years). A separate West of Scotland guideline exists for ‘Hypertension in neonatal patients’ and this should be referred to if necessary. These guidelines are intended for use by clinicians and nursing staff. For further discussion of this guideline, please contact a member of the nephrology team based within the Renal Unit (On call Consultant through switchboard, Renal Registrar on page 18282 or 84563 or via Renal Hotdesk 0141 452 4563).
Blood pressure rises throughout childhood relative to age and height. As with height and weight there are specific percentiles for blood pressure measurement available for both sexes. Published values for blood pressure for both sexes are included in the appendices 1 & 2.
Definitions are as follows:
2016 European Society for Hypertension Guideline Classification of hypertension in children and adolescents2.
Category |
0-15 years |
16 years and older |
Normal |
<90th |
<130/85 |
High-normal |
>90th to <95th |
130-139/85-89 |
Hypertension |
>95th |
>140/90 |
Stage 1 hypertension |
95th to 99th and 5mmHg |
140-159/90-99 |
Stage 2 hypertension |
>99th plus 5mmHg |
160-179/100-109 |
Stage 2 hypertension may be associated with systemic features due to target-organ damage (e.g. left ventricular hypertrophy, renal impairment, retinopathy).
The European Society for Hypertension proposes a flow chart (see below) for hypertension based on percentile distribution of age sex and height for those age <16 years old. A consensus in the present guidelines is now presented for adolescent males and females aged 16 or older, where the definition of hypertension should no longer be based on the 95th percentile but on the absolute cut off used for adults2.
From the 2016 European Society for Hypertension guidelines for the management of high blood pressure in children and adolescents2.
Previously the “gold standard” for blood pressure measurement was mercury sphygmomanometry, now banned due to the environmental toxicity of mercury. Blood pressure is most commonly measured using automated oscillometric devices. While convenient and widely used, if a raised blood pressure is suspected following use of an automated device auscultation using a validated manual device must be performed to confirm a suspected raised blood pressure. https://bihsoc.org/bp-monitors/for-specialist-use details devices validated by the British and Irish Hypertension Society.
An appropriate sized cuff must be used. The width of the cuff should cover at least 75% of the upper arm from the acromion to the olecranon, leaving sufficient space at the antecubital fossa to allow application of the bell of the stethoscope. The diastolic blood pressure is recorded when the sounds disappear (5th Korotkoff sound) for all ages. In some children Korotkoff sounds can be heard down to 0mmHg, which excludes diastolic hypertension.
Measure the blood pressure with the child in a seated position and their arm gently supported, ideally after the child has been sitting quietly for 5 minutes (or lying supine for an infant). Confirm hypertension with an average of measurements on three separate days/visits. Measure height and plot on an appropriate gender-specific growth chart to establish the height percentile then refer to the blood pressure centile chart for the appropriate gender.
24 hour ambulatory blood pressure monitoring (ABPM) is increasingly recognized as useful in the diagnosis and management of hypertension. To confirm a diagnosis of hypertension in children > 6 years old consider performing 24 hour ABPM.
Indications for the use of ABPM in the diagnosis of hypertension include2:
Infants and younger children may require admission to hospital for blood pressure monitoring in order to confirm the diagnosis as reliable blood pressure recordings can be difficult to obtain in this age group.
It is important to ask about the following:
Most significant hypertension in children below age 10 years is secondary to an underlying cause. Primary (essential) hypertension is a diagnosis increasingly recognized in older children, aged over 10 years, associated with a family history of hypertension and/or being overweight.
Primary (essential) hypertension |
Obesity |
Family history of hypertension or cardiovascular disease |
|
Secondary hypertension in
|
Renal causes
|
Cardiovascular causes
|
|
Respiratory
|
|
Neurological
|
|
Iatrogenic
|
|
Secondary hypertension in children and adolescents
|
Renal causes
|
Cardiac causes
|
|
Endocrine causes
|
|
Neurological causes
|
|
Drug-related causes including immunosuppressants, NSAID’s, sympathomimetics and antidepressants |
The extent to which hypertension is investigated depends on its severity and the information obtained from a careful history and examination. A family history of hypertension, renal disease or endocrine causes may help guide you in a particular direction. Clinical features of any of the aforementioned causes may be detected on examination thus helping focus your investigations.
Initial investigations to consider:
Secondary investigations
Secondary investigations are guided by the findings from the above preliminary investigations along with the clinical findings and include:
N.B. Investigations should be undertaken prior to the commencement of treatment unless severity dictates immediate management.
From the 2016 European Society for Hypertension guidelines for the management of high blood pressure in children and adolescents2.
Therapeutic lifestyle changes
Most patients will benefit from lifestyle changes irrespective of the aetiology of their hypertension. These include exercise, weight loss, low-salt or no-added-salt diets, and increased intake of fruit, vegetables, fibre and low-fat dairy products.
Short-term treatment of acute hypertension
The most common indication in this category would be the treatment of hypertension secondary to acute nephritis leading to salt and water retention causing volume overload. A well-tolerated combination would be a loop diuretic (e.g. furosemide) plus a vasodilating Ca2+ channel blocker (e.g. nifedipine).
Long-term treatment of chronic hypertension
Pharmacological therapy is considered in patients who do not respond to lifestyle modifications or who have secondary hypertension, symptomatic hypertension or established target-organ damage. The aim is to use a single agent if possible and to select a long-acting once-daily agent to aid compliance. The choice of antihypertensive is dependent on the underlying aetiology. See Appendix III for a detailed list of potential pharmacological agents, including dosing regimens.
European guideline targets for treatment2:
Hypertension without comorbidities
BP goal < 16 years: < 95th percentile
BP goal ≥ 16 years: < 140/90
HTN + diabetes mellitus type 1 or 2
BP goal < 16 years: < 90th percentile
BP goal ≥ 16 years: < 130/80
HTN + CKD
-Without proteinuria
BP goal < 16 years: < 75th percentile
BP goal ≥ 16 years: < 130/80
-With proteinuria
BP goal < 16 years: < 50th percentile
BP goal ≥ 16 years: < 125/75
Treatment of severe, symptomatic hypertension
Symptomatic hypertensive emergencies should be treated without delay to avoid further damage to vital organs. The aim is to lower blood pressure promptly but in a controlled manner. A sudden drop in blood pressure is associated with an increased risk of intracranial bleeding. Short-acting antihypertensives such as nifedipine should be avoided for this reason. The initial aim of therapy is to reduce the mean arterial pressure by approximately 25% over the first 24 hours. This is best done with intravenous antihypertensives. If blood pressure drops more rapidly on initiation of treatment then volume expansion with isotonic 0.9% sodium chloride must be considered. Any serious complications must be managed before, or as, hypertension is being treated (e.g. anticonvulsants should be administered to a seizing patient along with antihypertensive medications).
Drugs used in hypertensive emergencies include:
Class |
Drug |
Dose |
Dosing Interval |
Comments |
Angiotensin |
|
Child 1-11 years Child 12-17 years |
three times daily |
|
|
Child 1-11 years Child 12-17 years (50kg) Child 12-17 years (> 50kg) |
once -twice daily |
||
|
Child 6-11 years Child 12-17 years |
once daily |
|
||||
Class |
Drug |
Dose |
Dosing Interval |
Comments |
Angiotensinreceptor blocker (ARB) |
Child 6-17 years (20-49kg) Child 6-17 years (>50kg) |
once daily |
|
|
|
||||
Alpha and Beta Blocker |
Child 1-11 years Child 12-17 years |
three to four times a day Twice daily but can be given up to 3-4 times daily |
|
|
|
||||
Beta-Blocker |
Child 1-11 years Child 12-17 years |
once daily-twice daily |
|
|
|
Child 1-11 years Initially 1 mg/kg twice daily, increased if necessary up to 8 mg/kg daily in 2–4 divided doses (max. per dose 400 mg).
Child 12-17 years Initially 50–100 mg daily, increased if necessary to 200 mg daily in 1–2 divided doses, high doses are rarely necessary; maximum 400 mg per day. |
twice daily |
|
Child 1-11 years Child 12-17 years
|
twice daily-three times daily |
|
|
|
||||
Calcium channel blocker |
Child 1-11 years Child 12-17 years |
once daily |
|
|
|
*Child 1-17 years |
once -twice daily |
||
|
||||
Central αagonist |
Child 2-17 years |
three times daily |
|
|
|||||
Diuretic |
Child 1-11 years Child 12-17 years |
2–3 times a day |
|
||
|
Child 1-11 years Child 12-17 years |
once daily-twice daily |
|||
|
Child 1-11 years Child 12-17 years |
twice daily |
|||
|
|||||
Peripheral αantagonist |
*Child 1-5 years Child 6-11 years Child 12-17 years
|
once daily |
May cause hypotension and syncope, especially after first dose.
|
||
|
Child 1-11 years Child 12-17 years |
two to four times daily |
|||
|
|||||
Vasodilator |
Child 1-11 years Child 12-17 years |
four times daily |
|
||
Child 1-11 years Child 12-17 years |
once -twice daily |
||||
All doses correct at time of completion of the Guideline from online August 2019 BNFc except Doxazosin (1-5years) & Nifedipine MR |
|||||
* Frank Shann Drug Doses 2017 |
Class |
Drug |
Dosing Interval |
ACE inhibitor (ACEi)
|
Fosinopril |
once daily |
Quinapril |
once daily |
|
|
||
Angiotensin-receptor blocker (ARB) |
Irbesartan |
once daily |
|
||
Calcium channel blocker
|
Felodipine |
once daily |
Isradipine |
three -four times daily |
|
|
||
Diuretic
|
Hydro-chlorothiazide |
once daily |
Chlorthalidone |
once daily |
|
Triamterene |
twice daily |
|
|
||
Peripheral α-antagonist |
Terazosin |
once daily |
Last reviewed: 31 July 2019
Next review: 30 September 2021
Author(s): Dr Douglas Stewart, Paediatric Senior Trainee; Revised by Dr David Hughes, Consultant Paediatric Nephrologist, RHC
Version: 2
Co-Author(s): Other professionals consulted: Dr Ian Ramage – Consultant Paediatric Nephrologist, RHC
Approved By: Paediatric & Neonatal Clinical Risk & Effectiveness Committee