Hypertension in children is an increasingly prevalent health concern, especially due to the obesity epidemic. According to the Centers for Disease Control and Prevention (CDC), approximately 20% of children under 19 are considered obese.

Early diagnosis and management of hypertension in the pediatric population is necessary to prevent long-term complications, with a potential to reverse the disease.

“Primary care providers should emphasize lifestyle modifications, such as a low-sodium diet and exercise, and recheck blood pressure in three months. If blood pressure is still hypertensive or prehypertensive, the next step should be referral,” said Malavika Prasad, M.D., pediatric nephrologist with Norton Children’s Nephrology, affiliated with the UofL School of Medicine.

Risk factors, such as obesity, play a significant role in the development of primary hypertension, which makes lifestyle modification a first-line treatment for early stages of pediatric hypertension.

Stages of pediatric hypertension

Pediatric hypertension is categorized based on blood pressure and defined based on percentiles for age, height and sex for individual boys and girls (see Tables 4 and 5).

Stages of pediatric hypertension include:

Normal: Blood pressure less than 90th percentile, or less than 120/80 millimeters of mercury (mm Hg) for adolescents no matter what the 90% percentile
Prehypertension: Blood pressure between 90th to 95th percentile, or between 120/80 and 139/89 for adolescents
Stage 1 hypertension: 95th to 99th percentile, plus 5 mm Hg, or between 140/90 and 159/99 for adolescents

Stage 2 hypertension: Greater than 99th percentile, plus 5mm Hg, or greater than or equal to 160/100 for adolescents

Treatment and management strategies

Managing pediatric hypertension involves lifestyle modifications and pharmacological interventions when necessary.

Pharmacological treatment is warranted when Stage 1 hypertension has not been resolved with lifestyle modifications, if a patient has Stage 2 hypertension, and/or when symptomatic hypertension (i.e., headache, shortness of breath, chest pain, vertigo, vision change) is present.

Upon referral, initial evaluation at Norton Children’s Nephrology typically involves a complete blood count (CBC), renal function tests, urinalysis and renal ultrasound with doppler.  Further evaluation for secondary or tertiary causes of hypertension is recommended, based on the patient’s history and examination.

Identifying etiology is critical. Although primary hypertension and white coat hypertension are more prevalent among adolescents, it’s crucial to rule out secondary hypertension, depending on the age of presentation. Secondary hypertension can be caused by many conditions, such as renal artery stenosis, congenital renal malformations, renal parenchymal disease or endocrine causes, such as pheochromocytoma — in which case specialized treatments are necessary.

Lifestyle changes

Dietary changes: The American Academy of Pediatrics (AAP) recommends following the Dietary Approaches to Stop Hypertension (DASH) diet, which promotes low sodium (recommended about 2 grams of sodium intake per day), increased fruits and vegetables and high fiber intake. According to Dr. Prasad, increasing fruit and vegetables can reduce blood pressure by 11 points, while reducing sodium intake can lower it by 6 points. Cutting out sugary drinks is equally necessary as well.

Exercise: Regular physical activity must be implemented. Per AHA, moderate exercise for 20 to 30 minutes, three to four times per week, can reduce blood pressure and lower cardiovascular risks. Tracking steps (e.g., 10,000 steps daily) also can improve metabolic health in children.

Monitoring screen time: Reducing sedentary behavior also can help manage hypertension. Introduce parents to the 5-2-1-0 rule for an easy rule for lifestyle monitoring.

Children may find it difficult to adhere to daily medication routines, particularly when asymptomatic. Health care providers should focus on educating both the child and family about the importance of compliance, using tools such as phone alarms and pill boxes, and emphasizing the importance of follow-up appointments.

Pharmacological intervention

Underlying etiology is key to understanding hypertension. Preferably, a referral occurs before pharmacological treatment is initiated. Treatments will vary among patients.

“There is no one single medication drug of choice as the starting line for treatment for hypertension, because children have been shown to respond very differently to each class of medication,” Dr. Prasad said.

The first approach is typically monotherapy, with adjustments made based on side effects, compliance and blood pressure response. Step-up therapy or subsequent monotherapy may be considered. For more severe cases, adjuvant therapy is often required.

In Stage 1 hypertension, ACE inhibitors or calcium channel blockers may be initiated when lifestyle changes do not improve blood pressure upon follow-up or if symptoms are present. In Stage 2 hypertension, treatment may involve ACE inhibitors, calcium channel blockers or labetalol. In cases where rapid intervention is needed, IV medications, such as labetalol or hydralazine, may be used in hospital settings.

Long-term health implications of untreated pediatric hypertension

Pediatric hypertension, if left untreated, can lead to organ damage, including cardiovascular, renal and ocular issues. Common conditions can include left ventricular hypertrophy, microalbuminuria and retinopathy.

However, early detection, lifestyle modifications and timely interventions can help prevent long-term complications in pediatric patients. Proper patient education and support, including realistic and cost-effective tips and strategies, can improve compliance and treatment outcomes.

“When the patient sees the difference in their weight, activity, mood and blood pressure, all providers should applaud that loudly and clearly,” Dr. Prasad said. “Positive reinforcement for the family and for the child can then help make this a reversible disease.”

Collaborative care between the primary care providers, nephrologists and cardiologists is key to successful management and follow-up.