Definition and epidemiology
This monograph covers the diagnostic evaluation of elevated blood pressure in children — distinct from the AAP BP percentile calculator that classifies a single reading. The 2017 AAP guideline replaced “prehypertension” with elevated BP and provides normative tables indexed to age, sex and height. For children 1 to <13 years, categories use percentiles: normal <90th; elevated BP ≥90th to <95th (or ≥120/80); stage 1 hypertension ≥95th to <95th + 12 mmHg; stage 2 ≥95th + 12 mmHg. For adolescents ≥13 years, fixed adult-style thresholds apply (e.g. stage 1 ≥130/80, stage 2 ≥140/90). Hypertension requires elevated readings on three separate occasions.
Prevalence is rising with childhood obesity, estimated at roughly 3–4%. The clinical pivot in children is that secondary hypertension is common — more so the younger the child and the higher the BP — in sharp contrast to adults, where primary hypertension dominates.
Clinical features
Most hypertensive children are asymptomatic and detected on routine screening, which the AAP recommends annually from age 3 (and at every encounter in children with obesity, renal or cardiac disease, diabetes, or on hypertensive drugs). Symptomatic presentations — headache, visual change, epistaxis, or a hypertensive emergency with encephalopathy — warrant urgent action. History should probe for renal disease, umbilical lines (neonatal renovascular injury), drug/supplement/stimulant use, sleep-disordered breathing, and a family history of early hypertension or cardiovascular disease.
Diagnosis and workup
Confirm the BP technique first: correct cuff size, auscultatory confirmation of oscillometric readings, and ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis and unmask white-coat or masked hypertension. Examination looks for secondary clues — growth/dysmorphology, four-limb BP and femoral pulses (coarctation), abdominal bruit (renovascular), Cushingoid or thyroid features, and signs of renal disease.
Recommended evaluation in confirmed hypertension includes urinalysis, electrolytes, urea and creatinine, fasting lipids and glucose, and renal ultrasound; in younger children, those with stage 2 or with clinical clues, extend to renin/aldosterone, plasma/urine metanephrines, and further renovascular or endocrine imaging. Echocardiography assesses for left ventricular hypertrophy as target-organ damage, generally before starting drug therapy.
See the full criteria: Hypertension
Red flags
- Stage 2 hypertension, or any hypertension in an infant or young child — secondary cause until proven otherwise
- BP with neurological signs, seizures or visual change — hypertensive emergency
- Discrepant upper/lower limb BP or absent femoral pulses — coarctation
- Hypokalaemia, paroxysmal symptoms, or a flank/abdominal bruit
- Haematuria, proteinuria, oedema or impaired renal function
- Growth failure with hypertension — chronic kidney disease
Management overview
Management is staged after the workup defines primary versus secondary disease. Lifestyle modification — weight management, the DASH-style diet, sodium reduction, regular activity and sleep — is first-line for elevated BP and primary stage 1. Pharmacotherapy is indicated for symptomatic hypertension, stage 2, secondary hypertension, hypertension with diabetes or chronic kidney disease, or target-organ damage, or when lifestyle measures fail. First-line drug classes include ACE inhibitors or angiotensin-receptor blockers (favoured in proteinuric/diabetic renal disease), calcium-channel blockers, and thiazide diuretics; beta-blockers are not first-line. Treat the underlying cause where one is found, and refer to pediatric nephrology, cardiology or endocrinology accordingly. A hypertensive emergency with encephalopathy requires controlled BP reduction with parenteral agents in a monitored setting, lowering pressure gradually to avoid ischaemic injury.
References
- Flynn JT, et al. AAP Clinical Practice Guideline. Pediatrics. 2017;140:e20171904.
- Lurbe E, et al. ESH guidelines. J Hypertens. 2016;34:1887–1920.
- Flynn JT, et al. ABPM 2022 Update. Hypertension. 2022;79:e114–e124.
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.