Evaluation and management of hypertension in childhood

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Abstract

Hypertension, a relatively uncommon problem in childhood except in certain groups of children, is an important cardiovascular risk factor that can have significant health implications, especially the tendency for an elevated blood pressure in childhood to predict the development of adult hypertension. Common causes of childhood hypertension include renal and cardiac disease, as well as essential hypertension in adolescents. Given these factors, it is usually possible to evaluate the hypertensive child in a focused manner that should reveal not only the underlying cause of hypertension, but also its severity. Treatment should incorporate non-pharmacologic approaches as well as antihypertensive medications, and should take into account other cardiovascular risk factors such as hyperlipidemia. This review highlights these and other important issues in the evaluation and management of hypertensive children, and provides practical guidance to the practitioner involved in caring for such patients.

Introduction

Although hypertension is a relatively uncommon problem in childhood, the awareness of it among both the medical community and general public has increased in recent years, leading to greater numbers of hypertensive children coming to medical attention. As will be discussed below, the causes of hypertension in children are diverse, with a significantly greater percentage of hypertensive children having secondary forms of hypertension compared to adults. Therefore, it is important for the physician or other practitioner who cares for hypertensive children to have a thorough understanding of the different types of hypertension seen in childhood, as well as to have an organized approach to the diagnostic evaluation and treatment of such patients. The objective of this review is to provide the reader with the necessary background information, diagnostic strategies and treatment recommendations required to effectively care for children with hypertension.

Section snippets

Defining normal blood pressure in children

Amongst pediatricians and pediatric specialists, the major impetus for the increased emphasis on detecting and treating hypertensive children came from the First and Second Task Force Reports (published in 1977 [1] and 1987 [2], respectively), as well as the more recent Working Group Report [3]. These consensus bodies produced clear guidelines for the proper detection and management of hypertension in childhood, including recommendations for proper methods of blood pressure determination and

Importance of identifying hypertensive children — blood pressure tracking

From the preventative cardiology standpoint, one of the more interesting consequences of the development of the definitions of normal and abnormal blood pressure in childhood has been the identification of a group of children who have intermittently elevated blood pressures, or blood pressures that fall into the ‘high-normal’ range (between the 90th and 95th percentiles). Typically these children are otherwise healthy and have no underlying renal, cardiac or other organ system disease causing

Etiology of hypertension in children

Overall, most childhood hypertension is secondary; that is, caused by another underlying disorder, which in most cases will be renal disease ([14], [15], [16], [17], [18] Table 3). Essential or primary hypertension becomes more prevalent with increasing age, to the point that most older adolescents will have essential hypertension. The distribution of causes of childhood hypertension seen at a specific center or by a given practitioner will vary according to the practice setting (primary vs.

Evaluation of the child with suspected hypertension

As emphasized in the Second Task Force Report, one of the most important steps in the evaluation of children with suspected hypertension is to ensure that the blood pressure is being measured correctly [2]. A conventional mercury column or aneroid sphygmomanometer should be used in school-aged children and teenagers. Although less accurate, an automated, oscillometric device such as the Dynamap® (Critikon Inc., Tampa, FL, USA), can be used in infants and toddlers who will not cooperate with

Treatment of childhood hypertension

As in hypertensive adults, effective treatment of hypertensive children requires a comprehensive approach incorporating patient/family education, non-pharmacologic measures, and antihypertensive medications, as well as monitoring for medication side effects and treatment response. This can be a time-consuming endeavor but it is essential to include all components, as hypertension can be a lifelong problem for many children and adolescents, particularly those with secondary forms of hypertension.

Conclusions

Blood pressure elevation in childhood may be the first clue to underlying renal or other organ system pathology, or simply a warning sign of future cardiovascular risk. Careful measurement of blood pressure and thorough evaluation of children with sustained blood pressure elevation should allow identification of those who require treatment. While few data exist regarding the optimal agents for treatment of hypertensive children, usually a combination of pharmacologic and non-pharmacologic

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