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Accurately measure the blood pressure (BP) in all pediatric patients older than age 3 and in youngerhigh-risk patients

Author: Jennifer Maniscalco, MD

What to Do - Gather Appropriate Data

Hypertension during childhood is not rare, with an estimated prevalence ranging from 1% to 5.8%. Children with hypertension may develop early abnormalities in target organs systems, even in the absence of signs and symptoms. Furthermore, childhood hypertension is a strong risk factor for adult hypertension. An aggressive surveillance system to detect hypertension in children can lead to prompt diagnosis and management, prevention of target organ damage, and a reduced risk of adult hypertension. Recent guidelines suggest that all children older than 3 years should have their BP checked. Younger children should have their BP checked if risk factors for hypertension are present (Table 138.1 ).

Hypertension in the pediatric population is defined as an average systolic blood pressure (SBP) or diastolic blood pressure (DBP) >=95% for age, gender, and height, measured on at least three separate occasions. Appropriate technique in BP measurement is required to diagnose hypertension accurately.Auscultationusingmercurysphygmomanometryisthegoldstandard, but many oscillometric devices have been validated for use in children. Regardless of the device employed, the correct cuff size is essential for the accurate measurement of BP. The width of the cuff bladder should be approximately 40% of the arm circumference measured at the midpoint of the upper arm. The length of the cuff bladder should be 80% to 100% of the arm circumference.

Hypertension in children can be classified as primary or secondary. Primary hypertension, also called essential hypertension, does not have an identifiable cause, but rather results from a combination of genetic and environmental factors. It occurs more commonly in adolescents than younger children, and it is associated with overweight, obesity, and other cardiovascular risk factors. Individuals with primary hypertension are often asymptomatic and without evidence of target organ damage at presentation.

Secondary hypertension is more common in younger children and results from an underlying disease process. At presentation, these children are more likely to have dramatic elevations of BP, symptoms of hypertension, and evidence of target organ damage. The most common cause of secondary hypertension is renal disease. Renal parenchymal disease is more common than renovascular disease. Other causes of secondary hypertension include cardiac diseases such as coarctation of the aorta, medications, and poorly controlled pain. Primary endocrine disorders are rare and include hyperthyroidism, Cushing disease, and endocrine tumors such aspheochromocytoma and neuroblastoma. Table 138.2 provides the common causes of hypertension by age group.

Table 138.1 Conditions Under Which the Child Younger than Age 3 Should Have their Blood Pressure Checked
• History of prematurity, very low birth weight, umbilical artery catheter placement, or other neonatal condition requiring intensive care
• Congenital heart disease
• Recurrent urinary tract infections, hematuria, or proteinuria
• Known renal disease or urologic malformation
• Family history of congenital renal disease
• Solid-organ transplant
• Malignancy or bone marrow transplant
• Treatment with drugs known to raise blood pressure
• Other systemic illnesses associated with hypertension
• Evidence of elevated intracranial pressure

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Adapted from National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl):555–576.

The evaluation of a child with hypertension begins with a thorough history and physical exam. The focus should be on the signs and symptoms of diseases thatcausehypertensionaswell ascomorbidconditionsandevidence of target organ damage. For older children and adolescents, family history should focus on hypertension and its comorbid conditions. The social history should address diet, physical activity, smoking, and recreational drug use. Laboratory evaluation of children with hypertension should include complete blood count, chemistries, blood urea nitrogen, creatinine, complete urinalysis, and urine culture. A renal ultrasound should be obtained. Specialized tests such as renin, steroid and catecholamine levels, and renovascular imaging may be obtained as the clinical situation dictates. Evidence of target organ damage should be documented. Ophthalmologic consultation may reveal retinal changes, and echocardiography may reveal left ventricular hypertrophy. Comorbid conditions, such as dyslipidemia, glucose intolerance, and hyperuricemia, should be sought in children who are overweight or who have essential hypertension.

Suggested Readings

Bartosh SM, Aronson AJ. Childhood hypertension. An update on etiology, diagnosis, and treatment. Pediatr Clin North Am. 1999;46:235–252.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl):555–576.
Varda NM, Gregoric A. A diagnostic approach for the child with hypertension. Pediatr Nephrol. 2005;20:499–506.

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Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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