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    AAP Pediatric Hypertension Guidelines

    Diagnoses hypertension in pediatric patients; official guideline of the American Academy of Pediatrics.
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    IMPORTANT

    This tool has been developed in partnership with the American Academy of Pediatrics. The authors, editors, and contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the content of this tool. Advertising does not influence editorial decisions or content. The appearance of advertising on MDCalc sites is neither a guarantee nor an endorsement by the AAP of the product, service, or company, or the claims made for the product in such advertising.

    INSTRUCTIONS

    Use in children aged 1-17 years. Not for use in patients with low blood pressure. Recommendations are based on AAP's 2017 Clinical Practice Guideline (Table 3). Note that cutoffs reported in the calculator may vary slightly from the published tables, as the calculator accommodates for ages between whole numbers (e.g. 5.5 years), and the tables use simplified values to account for ages between whole numbers. For children ≥13 years of age, this calculator has been adjusted to meet definitions presented in the 2017 AHA/ACC hypertension guidelines for adults. 

    When to Use
    Pearls/Pitfalls
    Why Use

    Children aged 1-17 years old.

    • These values are based on auscultatory measurements, not oscillometric devices or ambulatory blood pressure measurements.
    • Blood pressure should ideally be taken by auscultatory measurement after child has been seated for 3-5 minutes with back supported and legs uncrossed. Blood pressure should be measured on the right arm for consistency. Correct cuff size should be used to ensure accuracy of measurement.
    • If the initial blood pressure is elevated, providers should take two additional measurements at the same visit and use the average value.
    • For children ≥13 years of age, this calculator has been adjusted to meet definitions presented in the 2017 AHA/ACC adult hypertension guidelines in order to facilitate the management of older adolescents with high blood pressure.
    • Classifies blood pressure in pediatric patients, which varies based on age and gender.
    • Measuring BP at routine well-child visits enables early detection of primary hypertension as well as detection of asymptomatic hypertension secondary to another underlying disorder. Hypertension is a known major contributor to cardiovascular disease.
    • Can guide timing of:
      • Blood pressure recheck.
      • Diagnostic evaluation.
      • Treatment initiation.
    years
    Male
    Female
    in
    mm Hg
    mm Hg

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Screening for hypertension is recommended in children beginning at age 3 years.
    • There are many etiologies for falsely elevated BP, such as anxiety or caffeine intake, and therefore the diagnosis of hypertension is made by checking multiple measurements over time.
    • Hypertension is diagnosed if a child has auscultatory-confirmed BP readings ≥95th percentile on 3 different visits.

    Management

    AAP recommendations for management (from Flynn 2017):

    Normal BP

    • No additional action is needed.
    • BP should be rechecked at the next routine well-child care visit.

    Elevated BP

    • Lifestyle interventions (nutrition, sleep, physical activity) should be initiated.
    • BP should be rechecked by auscultatory measurement in 6 months.
      • If it remains elevated at 6 months, upper and lower extremity BP should be checked and lifestyle measures should be repeated.
      • If BP is still elevated after 12 months from initial measurement, ambulatory blood pressure monitoring (ABPM) should be ordered along with diagnostic evaluation, and subspecialty referral should be considered.

    Stage 1 hypertension

    • If asymptomatic, lifestyle interventions should be initiated.
    • BP should be rechecked by auscultatory measurement in 1-2 weeks.
      • If it remains classified as Stage 1 HTN at 1-2 weeks, upper and lower extremity BP should be checked, and BP should be checked in 3 months by auscultation with consideration for nutrition/weight management referral.
      • If BP continues to be classified as Stage 1 HTN after 3 visits, ABPM should be ordered along with diagnostic evaluation, and treatment should be initiated with consideration for subspecialty referral.

    Stage 2 hypertension

    • If asymptomatic, lifestyle interventions should be initiated.
    • BP should be rechecked by auscultatory measurement in 1 week OR the patient can be directly referred to a subspecialist within 1 week.
      • If it remains classified as Stage 2 HTN at 1 week, ABPM should be ordered along with diagnostic evaluation, and treatment should be initiated OR the patient should be referred to subspecialty care within 1 week.

    Additional note: any patient with evidence of LVH may not participate in sports until BP is normalized with therapy. Athletes with Stage 2 HTN (even without evidence of target organ injury) should not participate in sports until HTN is controlled by lifestyle modification or pharmacologic therapy.

    Critical Actions

    If the patient is symptomatic (encephalopathy, acute kidney injury, congestive heart failure) with Stage 2 HTN level, OR the BP is >30 mmHg above the 95th percentile (or >180/120 mmHg in an adolescent), refer to emergency department immediately for evaluation and treatment of acute severe HTN.

    Formula

    Individual regression equations for boys/girls and SBP/DBP percentiles for children aged 1-12 years are published in Rosner 2008.

    Facts & Figures

    Interpretation:

    1-12 years old

    ≥13 years old

    Normal BP

    SBP <90th percentile, and

    DBP <90th percentile 

    SBP <120

    DBP <80

    Elevated BP

    SBP ≥90th percentile but <95th percentile, or

    DBP ≥90th percentile but <95th percentile, or

    120/80 to <95th percentile (whichever is lower)

    SBP 120-129

    DBP <80

    Stage 1 HTN

    SBP ≥95th percentile but <12 mm Hg above 95th percentile, or

    SBP ≥95th percentile but <12 mm Hg above 95th percentile, or

    130-139/80-89 (whichever is lower)

    SBP 130-139

    DBP 80-89

    Stage 2 HTN

    SBP or DBP ≥12 mm Hg above 95th percentile, or

    ≥140/90 (whichever is lower)

    SBP ≥140

    DBP ≥90

    Use the higher of the two values; e.g. if a 14 year old has BP 135/90, diagnosis is Stage 2 HTN.

    From Flynn 2017.

    Evidence Appraisal

    Multiple models were used to evaluate pediatric blood pressure data, and this data is based off of a quantile regression model.

    These percentiles are based on normal weight children (BMI <85th percentile), as including overweight and obese children was thought to increase bias, knowing that these patients have a higher prevalence of high blood pressure. Therefore, the BP values in the new pediatric guidelines are several mmHg lower than previous youth hypertension guidelines.

    Dr. Bernard Rosner

    About the Creator

    Bernard Rosner, PhD, is a professor of biostatistics at the Harvard T.H. Chan School of Public Health, Harvard Medical School, and Brigham and Women's Hospital. His work has had cardiovascular, pulmonary, ophthalmologic, oncologic, and nutritional applications. Dr. Rosner's primary research interests involve statistical modeling of longitudinal data, analysis of clustered continuous, binary, and ordinal data, and methods for the adjustment of regression models to address measurement error.

    To view Dr. Bernard Rosner's publications, visit PubMed

    Dr. Joseph T. Flynn

    About the Creator

    Joseph T. Flynn, MD, MS, is a professor of pediatrics at the University of Washington School of Medicine, where he holds the Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology. He is also chief of the division of nephrology at Seattle Children’s Hospital, and has served as president of the American Society of Pediatric Nephrology, on the Working Group of the National High Blood Pressure Education Program, and as co-chair of an American Academy of Pediatrics committee focused on childhood hypertension. Dr. Flynn’s research interests involve the epidemiology and treatment of childhood hypertension, as well as cardiovascular complications of pediatric chronic kidney disease.

    To view Dr. Joseph T. Flynn's publications, visit PubMed

    Content Contributors
    • Sneha Daya, MD
    Content Contributors
    • Sneha Daya, MD