Children and High Blood Pressure

M. Khurram Faizan, MD, FAAP, FASN

Over the last 30 years there has been a steady increase in the number of children who have high blood pressure (hypertension) in the United States.

The most recent data from the National Health and Nutrition Examination Survey (NHANES) shows that more than three percent of children qualify for a diagnosis of pediatric hypertension. There are racial differences, with higher rates among Hispanic and non-Hispanic African American children. Elevated blood pressure is also more common among adolescents than young children.

Body weight is also directly related to elevated blood pressure in children. Numerous studies show much higher rates in overweight and obese childeren, with some as high as nearly 25 percent. This is not surprising since the 2016 NHANES data showed rates of obesity in children approaching 20 percent, with the highest rate of obesity among Hispanic boys. Studies have also demonstrated that higher blood pressure in childhood correlates with higher blood pressure in adulthood when patients are followed long term.

The unique challenges in children

Accurate assessment and measurement of blood pressure in children presents some unique challenges to health care providers. Blood pressure measurements taken in the office are greatly affected by your child’s age, activity level, feelings of anxiety or pain, and the size of the blood pressure cuff. That is why proper technique and equipment are critical to avoid errors in measurement and diagnosis. It is also recommended that all elevated blood pressure readings in children should be confirmed on three separate visits to ensure accurate diagnosis of pediatric hypertension.

The effects of hypertension

Identifying children with high blood pressure is critical. Undiagnosed and untreated hypertension can cause serious damage to many parts of the body, including the heart, brain, kidneys and eyes.

The guidelines

In 2017, the American Academy of Pediatrics (AAP) published new guidelines to provide a standardized framework for the diagnosis of hypertension in children.

  • The guidelines recommend that blood pressure be measured annually in children starting at age three.
  • For children with obesity, diabetes, a history of kidney disease or a heart condition known as aortic coarctation, or those on medications known to increase blood pressure, it should be measured at every medical encounter.
  • Trained health care professionals in the office setting should make a diagnosis of hypertension if a child or adolescent has blood pressure readings >95th percentile for age, height and gender at 3 different visits.

Consider the White Coat Effect and the role of 24-hour ambulatory blood pressure monitoring

The AAP  guidelines also included recommendations on the proper use of 24-hour ambulatory blood pressure monitoring (ABPM). The goal of ABPM is to measure blood pressure outside of the clinic setting with the anticipation that many children have a “White Coat Effect.” When blood pressure measured at home using ABPM is normal, a high reading in the doctor's office can be attributed to anxiety. This is seen quite frequently in the office setting and it is not considered to be hypertension.

The equipment for ABPM resembles a standard blood pressure cuff that is attached to a small recording device that is about the size of a pack of cards. The child wears it around the neck for 24 hours, it is painless, and does not require any additional lab testing.

Based on numerous studies, ABPM has been shown to be a better method for monitoring blood pressure in children. It is more accurate in diagnosing hypertension than readings in the office, and it is more reliable in predicting future blood pressure.  In addition, ABPM avoids unnecessary laboratory testing and has been shown to be more cost effective. (Swartz et al, Pediatrics 2008).

The division of pediatric nephrology and hypertension at Hasbro Children’s Hospital has been using ABPM studies to make an accurate diagnosis of hypertension in children for almost 20 years. Our trained pediatric nurses place a state-of-the-art ABPM monitor on any child suspected of hypertension in the primary care office. Children and adolescents are then sent home for 24 hours while wearing the monitor and their blood pressure is continuously monitored and recorded by the equipment. The measurements are downloaded to a computer and a report is generated of the readings. All ABPM studies are reviewed and categorized by one of two board certified pediatric nephrologists at Hasbro. With proper use of this safe, effective, and painless procedure an accurate diagnosis of hypertension can be made in the children, while avoiding the anxiety and expense related to unnecessary testing in children with White Coat Effect.

In summary, the rates of obesity and hypertension continue to rise in the United States. All children should have their blood pressure measured at least annually, starting at age three. Children present unique challenges for the diagnosis of hypertension. Ambulatory blood pressure monitoring is a precise and cost-effective tool to help make an accurate diagnosis of hypertension in children.

Visit the division of pediatric nephrology and hypertension at Hasbro Children's Hospital online to learn more or call 401-444-5672. 

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