Hypertension in adolescents: Difference between revisions

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==Overview==
==Overview==
Hypertension is one of the major risk factor for various cardiovascular diseases, often associated with adverse cardiac and vascular changes. Hypertension in pediatric age group often leads to development of cardiovascular event, atherosclerotic burden and renal diseases in the adulthood. So, the cautious monitoring, early diagnosis and treatment of hypertension in children is very important to prevent the progression of the disease. However, pediatric hypertension is greatly under-diagnosed due to difficulty in measurement of blood pressure in children and the need to refer to detailed tables of normative values.
[[Hypertension]] is one of the major risk factor for [[cardiovascular]] diseases. It is often associated with adverse [[cardiac]] and [[vascular]] outcomes. Hypertension in the [[pediatric]] age group often leads to the development of [[cardiovascular]] compromises for the patient, such as [[atherosclerotic]] plaques development, and [[renal]] function loss in the adulthood. To make matters worse, pediatric hypertension is greatly underdiagnosed due to the difficulty in measuring children's [[blood pressure]], and the need to refer to detailed tables of normative values. Thus, cautious monitoring, early diagnosis, and treatment of [[hypertension]] in children is critical to prevent disease progression.


==Classification==
==Classification==
Pediatric hypertension may be classified according to AAP [[(American Academic of Pediatrics)]]:
[[Pediatric]] [[hypertension]] may be classified according to the AAP [[(American Academic of Pediatrics)]]:<ref name="pmid31263043">{{cite journal| author=Weaver DJ| title=Pediatric Hypertension: Review of Updated Guidelines. | journal=Pediatr Rev | year= 2019 | volume= 40 | issue= 7 | pages= 354-358 | pmid=31263043 | doi=10.1542/pir.2018-0014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31263043  }} </ref>
{| class="wikitable"
{| class="wikitable"
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|-
|-
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Normal Blood pressure
[[Normal]] [[Blood]] [[pressure]]
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<90th percentile
<90th [[percentile]]
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<180/<90 mmhg
<180/<90 mmhg
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Elevated or High Normal Blood Pressure
Elevated or High Normal Blood Pressure
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90th to <95th percentile
90th to <95th [[percentile]]
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120-129/<80 mmHg
120-129/<80 mmHg
|-
|-
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Stage 1 Hypertension
Stage 1 [[Hypertension]]
|
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>95th percentile to <95th percentile +12 mmHg
>95th [[percentile]] to <95th [[percentile]] +12 mmHg
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130-139/80-89 mmHg
130-139/80-89 mmHg
|-
|-
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Stage 2 Hypertension
Stage 2 [[Hypertension]]
|
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>95th percentile + 12 mmHg
>95th [[percentile]] + 12 mmHg
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>140/90 mmHg
>140/90 mmHg
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==Pathophysiology==
==Pathophysiology==
It is thought that hypertension is caused by either increased resistance to blood flow, disturbance in Kidney's salt and water handling , or abnormalities of sympathetic nervous system.
*The pathophysiology of [[hypertension]] can be either [[primary]], which is multifactorial, or secondary, in which [[hypertension]] develops as a consequence of other diseases.
*Essential hypertension can be triggered by multiple factors such as: [[obesity]], [[insulin resistance]], activation of [[sympathetic nervous system]], changes in [[sodium]] homeostasis, [[renin-angiotensin-aldosterone system]] changes, disorders in the [[vascular smooth muscle]] structure or function, elevated [[uric acid]] levels, [[fetal programming]] and [[genetic]] factors.<ref name="pmid22941155">{{cite journal| author=Raj M, Krishnakumar R| title=Hypertension in children and adolescents: epidemiology and pathogenesis. | journal=Indian J Pediatr | year= 2013 | volume= 80 Suppl 1 | issue=  | pages= S71-6 | pmid=22941155 | doi=10.1007/s12098-012-0851-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22941155  }} </ref>


==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
Based on [[etiology]], hypertension in children can be classified into 2 groups:<ref>Khoury, M. and Urbina, E. M. (2021) ‘Hypertension in adolescents: diagnosis, treatment, and implications’, The Lancet Child & Adolescent Health, 5(5), pp. 357–366. doi: 10.1016/S2352-4642(20)30344-8</ref>
*1. Primary hypertension - No specific cause known
*2. Secondary hypertension - Common causes include:<ref>Friedman K, Wallis T, Maloney KW, et al. An unusual cause of pediatric hypertension. J Pediatr 2007; 151:206.</ref>


OR
*[[Renal]] diseases
*[[Renal artery stenosis]]
*[[Obstructive sleep apnea]]<ref>Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med 1998; 157:1098</ref>
*Related to [[drugs]] - [[glucocorticoids]], [[CNS]] [[stimulant]]s
*[[Congenital adrenal hyperplasia]]
*[[Pheochromocytoma]]
*[[Hyperthyroidism]]
*[[Coarctation]] of the [[aorta]]


Common causes of [disease] include [cause1], [cause2], and [cause3].
=== Common causes of pediatric hypertension by pediatric age group ===
These conditions are displayed in order of prevalence<ref name="pmid11223345">{{cite journal| author=Flynn JT| title=Evaluation and management of hypertension in childhood. | journal=Prog Pediatr Cardiol | year= 2001 | volume= 12 | issue= 2 | pages= 177-188 | pmid=11223345 | doi=10.1016/s1058-9813(00)00071-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11223345  }} </ref><ref name="pmid10218072">{{cite journal| author=Bartosh SM, Aronson AJ| title=Childhood hypertension. An update on etiology, diagnosis, and treatment. | journal=Pediatr Clin North Am | year= 1999 | volume= 46 | issue= 2 | pages= 235-52 | pmid=10218072 | doi=10.1016/s0031-3955(05)70115-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10218072  }} </ref><ref name="pmid15844381">{{cite journal| author=Flynn JT| title=Hypertension in adolescents. | journal=Adolesc Med Clin | year= 2005 | volume= 16 | issue= 1 | pages= 11-29 | pmid=15844381 | doi=10.1016/j.admecli.2004.10.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15844381  }} </ref>


OR
'''One to six years:'''
* [[Renal parenchymal disease]]; [[renal vascular disease]]; endocrine causes; [[coarctation of the aorta]]; [[essential hypertension]]
'''Six to twelve years:'''
* [[Renal parenchymal disease]]; [[essential hypertension]]; [[renal vascular disease]]; endocrine causes; [[coarctation of the aorta]]; [[iatrogenic]] illness
'''Twelve to eighteen years'''
* [[Essential hypertension]]; [[iatrogenic]] illness; [[renal parenchymal disease]]; [[renal vascular disease]]; endocrine causes; [[coarctation of the aorta]]


The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
==Differentiating Hypertension in Adolescents From Other Diseases==


OR
Hypertension in [[adolescent]]s may be a symptom of other underlying and undiagnosed conditions. Thus, these patients require a detailed medical assessment. Secondary causes were discussed above and include: [[renal]] diseases, [[drugs]], [[adrenal]] diseases and [[hyperthyroidism]].
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
 
==Differentiating ((Page name)) from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
 
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
Patients of all age groups may develop hypertension.
*According to the [[WHO]], an estimated 1.13 billion people worldwide have [[hypertension]].  
According to WHO, an estimated 1.13 billion people worldwide have hypertension. Hypertension commonly affects individuals older than 65 years of age, especially living in low or middle income countries.
*[[Hypertension]] commonly affects individuals older than 65 years of age, especially living in low or middle-income countries.
In a systemic review of the global prevalence of pediatric hypertension, pre-hypertension and elevated blood pressure had a prevalence of 9.7%(95%CI 7.3-12.4), stage 1 hypertension a prevalence of 4.0% (95% CI 2.1-6.5) and stage 2 hypertension a prevalence of 1.0%(95% 0.5-1.6). Higher prevalence noted in patient who were classified as obese or overweight.
*In a study from the University of Texas' McGovern Medical School, the [[prevalence]] of pediatric elevated [[hypertension]] from 10 to 17 years of age was 16.3%, stage 1 [[hypertension]] was 10.6% and stage 2 [[hypertension]] 2.4%.<ref name="pmid30571555">{{cite journal| author=Bell CS, Samuel JP, Samuels JA| title=Prevalence of Hypertension in Children. | journal=Hypertension | year= 2019 | volume= 73 | issue= 1 | pages= 148-152 | pmid=30571555 | doi=10.1161/HYPERTENSIONAHA.118.11673 | pmc=6291260 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30571555  }} </ref>
*Higher prevalence was noted in patients who were classified as [[obese]] or [[overweight]].<ref name="pmid30571555">{{cite journal| author=Bell CS, Samuel JP, Samuels JA| title=Prevalence of Hypertension in Children. | journal=Hypertension | year= 2019 | volume= 73 | issue= 1 | pages= 148-152 | pmid=30571555 | doi=10.1161/HYPERTENSIONAHA.118.11673 | pmc=6291260 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30571555  }} </ref>
* [[Prevalence]] of childhood hypertension has increased from 1994 to 2018.<ref name="pmid31589252">{{cite journal| author=Song P, Zhang Y, Yu J, Zha M, Zhu Y, Rahimi K | display-authors=etal| title=Global Prevalence of Hypertension in Children: A Systematic Review and Meta-analysis. | journal=JAMA Pediatr | year= 2019 | volume= 173 | issue= 12 | pages= 1154-1163 | pmid=31589252 | doi=10.1001/jamapediatrics.2019.3310 | pmc=6784751 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31589252  }} </ref>
*A [[systematic review]] estimated that in 2015, the [[prevalence]] of childhood hypertension was 4.32% among children aged 6 years. Patients aged 19 years had a [[prevalence]] of 3.28%. The peak of [[prevalence]] in [[hypertension]] occurred at age 14 years.<ref name="pmid31589252">{{cite journal| author=Song P, Zhang Y, Yu J, Zha M, Zhu Y, Rahimi K | display-authors=etal| title=Global Prevalence of Hypertension in Children: A Systematic Review and Meta-analysis. | journal=JAMA Pediatr | year= 2019 | volume= 173 | issue= 12 | pages= 1154-1163 | pmid=31589252 | doi=10.1001/jamapediatrics.2019.3310 | pmc=6784751 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31589252  }} </ref>


==Risk Factors==
==Risk Factors==
Common risk factors in the development of Hypertension include:
*The most common risk factor in the development of hypertension in adolescents is [[obesity]].
*Obesity
*Non-modifiable risk factors include [[obstructive sleep apnea]], [[diabetes]], [[low birth weight]], [[gender]], [[race]], [[genetic inheritance]], [[socioeconomic status]], [[premature birth]], use of [[umbilical artery catheter]]s and [[family history]] of [[cardiovascular disease]].<ref name="pmid27335997">{{cite journal| author=Ewald DR, Haldeman PhD LA| title=Risk Factors in Adolescent Hypertension. | journal=Glob Pediatr Health | year= 2016 | volume= 3 | issue=  | pages= 2333794X15625159 | pmid=27335997 | doi=10.1177/2333794X15625159 | pmc=4784559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27335997  }} </ref>
*Obstructive sleep apnea
*Modifiable risk factors include: [[decongestants]], use of [[nose]] or [[eye]] drops, [[oral contraceptives]], [[antidepressants]], [[bronchodilators]], [[salt]] intake, [[dietary habits]], [[excess adiposity]], [[physical level activity]], [[secondhand smoke]], [[poor sleep quality]], [[short sleep duration]].<ref name="pmid27335997">{{cite journal| author=Ewald DR, Haldeman PhD LA| title=Risk Factors in Adolescent Hypertension. | journal=Glob Pediatr Health | year= 2016 | volume= 3 | issue=  | pages= 2333794X15625159 | pmid=27335997 | doi=10.1177/2333794X15625159 | pmc=4784559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27335997  }} </ref>
*Diabetes
*Premature birth  
*Chronic kidney disease
*Congenital heart disease
*Dyslipidemia
*Family history of Hypertension


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR


According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
*According to the U.S. Preventive Services Task Force (USPSTF), [[screening]] for [[hypertension]] in asymptomatic children and adolescents is not recommended.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
*According to the 2017 American Academy of Pediatrics guidelines, [[screening]] for [[hypertension]] in asymptomatic children and adolescents is recommended annually beginning at three years of age.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
*According to the 2016 European Society of Hypertension guidelines, [[screening]] for [[hypertension]] in asymptomatic children and adolescents is recommended every two years beginning at three years of age.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, children with hypertension may progress to develop [[atherosclerotic heart disease]] in adulthood. They have also increased risk of cardiovascular disease and [[mortality]] as well as [[left ventricular hypertrophy]].
 
*Renal complications such as [[chronic kidney disease]] may develop.
OR
*Ophthalmologic compromise is also a possible with [[hypertensive retinopathy]] being a potential complication.
 
*Children and adolescents with severe hypertension are at risk of developing hypertensive encephalopathy, seizures, cerebrovascular accidents, and congestive heart failure.<ref name="pmid16719248">{{cite journal| author=Luma GB, Spiotta RT| title=Hypertension in children and adolescents. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 9 | pages= 1558-68 | pmid=16719248 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16719248  }} </ref>
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
 
OR
 
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].


OR
*The diagnostic study of choice for diagnosing hypertension in adolescents is the attainment of accurate blood pressure measurement in children and adolescents.
 
*It can be challenging due to the variance of the measurements with different cuff sizes, anxiety, patient positioning, caffeine intake, and activity levels.
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
*To choose an adequate cuff size, one must pick an inflatable bladder that is at least 40% of the arm circumference and a bladder length that is 80% to 100% of the arm circumference.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
There are no established criteria for the diagnosis of [disease name].


===History and Symptoms===
===History and Symptoms===
The majority of patients with [disease name] are asymptomatic.
*The majority of children with hypertension are asymptomatic.
 
*Common symptoms of [[hypertensive emergencies]] include [[headache]], [[altered sensorium]], [[seizures]], [[vomiting]], focal [[neurologic]] complaints and [[visual]] disturbances.<ref>Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.</ref>
OR
 
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
*Common [[physical examination]] findings of hypertension include [[retinal]] [[vascular]] changes on [[fundoscopy]], [[cardiac heave]], and laterally displaced point of maximal impulse ([[PMI]]) due to [[left ventricular hypertrophy]] (LVH). <ref>Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.</ref>


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
OR
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].


OR
*There are no [[diagnostic]] laboratory findings associated with hypertension.
 
*To evaluate for end-organ damage, hypertension causes or hypertension-associated conditions that may increase the cardiovascular risk the following exams may be useful:
[Test] is usually normal among patients with [disease name].
**[[Lipid profile]]
 
**[[Complete blood count]]
OR
**[[Fasting glucose]] or [[A1C level]]
 
**[[ALT]] and [[AST]]
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
**[[Drug screening]]
 
**Measurement of serum [[blood urea nitrogen]] (BUN)
OR
**[[Plasma]] [[renin]]
 
**[[Aldosterone]] activity
There are no diagnostic laboratory findings associated with [disease name].
**[[Creatinine]]
**[[Electrolytes]]
**[[Urinalysis]]


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].
*An ECG is not helpful in the diagnosis of [[hypertension]].  
 
*Findings on an ECG suggestive of hypertension include [[left ventricular hypertrophy]], [[ST depression]] and [[T wave inversion]].
OR
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].
*A chest [[X-ray]] is not helpful in the [[diagnosis]] of hypertension.  
 
*There are findings on an x-ray suggestive of hypertension-associated complications, which include increased [[cardiothoracic ratio]], secondary to [[left ventricular hypertrophy]].
OR
 
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
OR
Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
*There are no [[echocardiography]]/[[ultrasound]] findings diagnostic of hypertension.  
*However, an echocardiography/ultrasound may be helpful in the diagnosis of [[complications]] of hypertension, which include [[left ventricular hypertrophy]] and [[renovascular disease]].<ref>Chhadia S, Cohn RA, Vural G, Donaldson JS. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol 2013; 43:1549..</ref>


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
*There are no CT scan findings diagnostic of hypertension.
 
*It can diagnose some causes of hypertension such as [[coarctation of aorta]] or adrenal disease.
OR
 
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].
*There are no MRI scan findings diagnostic of hypertension.
 
*It can diagnose some causes of hypertension such as [[coarctation of aorta]] or adrenal disease.
OR
 
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Other Imaging Findings===
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
*There are no other imaging findings associated with hypertension.
 
OR
 
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
*There are no other diagnostic studies associated with hypertension.


OR
==Treatment==
The AAP guideline recommends keeping systolic and diastolic pressure under 90th percentile or <130/80 mmHg in patients aged 13 or older to prevent any cardiovascular events.


[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
===Medical Therapy===
 
OR


Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
====Lifestyle modifications====
 
*All children and adolescents with [[hypertension]] should change their lifestyle for the better.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
==Treatment==
*Such changes include: weight reduction if [[obese]] or [[overweight]], regular physical activity, healthy diet ([[DASH diet]]), avoidance of substance use, stress reduction, family-based interventions (involving the whole family on such lifestyle changes can dramatically increase therapeutic adherence).<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
The AAP guideline recommends keeping systolic and diastolic pressure under 90th percentile i.e <130/80 mmHg in adolescents to prevent any cardiovascular events.
===Medical Therapy===
The mainstay of treatment for hypertension in adolescents is pharmacotherapy. Pharmacological therapy is reserved for those patient who has persistent hypertension despite lifestyle modification, or has stage 2 hypertension or have hypertension secondary to chronic kidney disease or diabetes. First line medication generally include angiotensin converting enzymes inhibitors (ACEIs), Angiotensinogen receptor blockers (ARBs), long acting calcium channel blockers (CCBs) and thiazide diuretics.


====Pharmacological treatment====
*The mainstay of [[treatment]] for [[hypertension]] in adolescents is [[pharmacotherapy]]. Pharmacological therapy is reserved for those patient who have symptomatic or persistent [[hypertension]] despite [[lifestyle modification]], stage 2 [[hypertension]] without modifiable factors, or [[hypertension]] secondary to [[chronic kidney disease]] or [[diabetes]].<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
*First line medication generally include [[angiotensin converting enzyme inhibitors]] ([[ACEIs]]), [[angiotensinogen receptor blockers]] ([[ARBs]]), long acting [[calcium channel blocker]]s (CCBs) and [[thiazide]] [[diuretics]].<ref>Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2016; 34: 1887–920.</ref>
*[[Beta-blockers]] are not considered first line agents.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
*Black patients may benefit from medications other than [[angiotensin converting enzyme inhibitors]].<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
*[[Calcium channel blockers]] and [[hydrochlorothiazide]] are appropriate choices for female adolescents at risk for pregnancy.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>
*Start at the lowest dose and titrate every 2-4 weeks until blood pressure goal is reached.<ref name="pmid30277729">{{cite journal| author=Riley M, Hernandez AK, Kuznia AL| title=High Blood Pressure in Children and Adolescents. | journal=Am Fam Physician | year= 2018 | volume= 98 | issue= 8 | pages= 486-494 | pmid=30277729 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30277729  }} </ref>


==Surgery==
==Surgery==
[[Surgery]] is not the first-line [[treatment]] option for children with hypertension. [[Surgery]] is usually reserved for children with select [[adrenal]] disease or [[coarctation of aorta]].


===Primary Prevention===
==Primary prevention==
 
Effective measures for the [[primary prevention]] of primary hypertension in children include [[low sodium]] intake, adhering to the [[DASH diet]], maintaining appropriate [[body weight]], and regular physical activities.
 


===Secondary Prevention===
==Secondary prevention==
There are no established measures for the [[secondary prevention]] of hypertension in children.


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dinesh Shah, M.B.B.S, José Eduardo Riceto Loyola Junior, M.D.[2]

Synonyms and keywords:

Overview

Hypertension is one of the major risk factor for cardiovascular diseases. It is often associated with adverse cardiac and vascular outcomes. Hypertension in the pediatric age group often leads to the development of cardiovascular compromises for the patient, such as atherosclerotic plaques development, and renal function loss in the adulthood. To make matters worse, pediatric hypertension is greatly underdiagnosed due to the difficulty in measuring children's blood pressure, and the need to refer to detailed tables of normative values. Thus, cautious monitoring, early diagnosis, and treatment of hypertension in children is critical to prevent disease progression.

Classification

Pediatric hypertension may be classified according to the AAP (American Academic of Pediatrics):[1]

Age<13 years Age>=13 years

Normal Blood pressure

<90th percentile

<180/<90 mmhg

Elevated or High Normal Blood Pressure

90th to <95th percentile

120-129/<80 mmHg

Stage 1 Hypertension

>95th percentile to <95th percentile +12 mmHg

130-139/80-89 mmHg

Stage 2 Hypertension

>95th percentile + 12 mmHg

>140/90 mmHg

Pathophysiology

Causes

Based on etiology, hypertension in children can be classified into 2 groups:[3]

  • 1. Primary hypertension - No specific cause known
  • 2. Secondary hypertension - Common causes include:[4]

Common causes of pediatric hypertension by pediatric age group

These conditions are displayed in order of prevalence[6][7][8]

One to six years:

Six to twelve years:

Twelve to eighteen years

Differentiating Hypertension in Adolescents From Other Diseases

Hypertension in adolescents may be a symptom of other underlying and undiagnosed conditions. Thus, these patients require a detailed medical assessment. Secondary causes were discussed above and include: renal diseases, drugs, adrenal diseases and hyperthyroidism.

Epidemiology and Demographics

Risk Factors

Screening

  • According to the U.S. Preventive Services Task Force (USPSTF), screening for hypertension in asymptomatic children and adolescents is not recommended.[12]
  • According to the 2017 American Academy of Pediatrics guidelines, screening for hypertension in asymptomatic children and adolescents is recommended annually beginning at three years of age.[12]
  • According to the 2016 European Society of Hypertension guidelines, screening for hypertension in asymptomatic children and adolescents is recommended every two years beginning at three years of age.[12]

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

  • The diagnostic study of choice for diagnosing hypertension in adolescents is the attainment of accurate blood pressure measurement in children and adolescents.
  • It can be challenging due to the variance of the measurements with different cuff sizes, anxiety, patient positioning, caffeine intake, and activity levels.
  • To choose an adequate cuff size, one must pick an inflatable bladder that is at least 40% of the arm circumference and a bladder length that is 80% to 100% of the arm circumference.[12]

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

  • There are no CT scan findings diagnostic of hypertension.
  • It can diagnose some causes of hypertension such as coarctation of aorta or adrenal disease.

MRI

  • There are no MRI scan findings diagnostic of hypertension.
  • It can diagnose some causes of hypertension such as coarctation of aorta or adrenal disease.

Other Imaging Findings

  • There are no other imaging findings associated with hypertension.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with hypertension.

Treatment

The AAP guideline recommends keeping systolic and diastolic pressure under 90th percentile or <130/80 mmHg in patients aged 13 or older to prevent any cardiovascular events.

Medical Therapy

Lifestyle modifications

  • All children and adolescents with hypertension should change their lifestyle for the better.[12]
  • Such changes include: weight reduction if obese or overweight, regular physical activity, healthy diet (DASH diet), avoidance of substance use, stress reduction, family-based interventions (involving the whole family on such lifestyle changes can dramatically increase therapeutic adherence).[12]

Pharmacological treatment

Surgery

Surgery is not the first-line treatment option for children with hypertension. Surgery is usually reserved for children with select adrenal disease or coarctation of aorta.

Primary prevention

Effective measures for the primary prevention of primary hypertension in children include low sodium intake, adhering to the DASH diet, maintaining appropriate body weight, and regular physical activities.

Secondary prevention

There are no established measures for the secondary prevention of hypertension in children.

References

  1. ↑ Weaver DJ (2019). "Pediatric Hypertension: Review of Updated Guidelines". Pediatr Rev. 40 (7): 354–358. doi:10.1542/pir.2018-0014. PMID 31263043.
  2. ↑ Raj M, Krishnakumar R (2013). "Hypertension in children and adolescents: epidemiology and pathogenesis". Indian J Pediatr. 80 Suppl 1: S71–6. doi:10.1007/s12098-012-0851-4. PMID 22941155.
  3. ↑ Khoury, M. and Urbina, E. M. (2021) ‘Hypertension in adolescents: diagnosis, treatment, and implications’, The Lancet Child & Adolescent Health, 5(5), pp. 357–366. doi: 10.1016/S2352-4642(20)30344-8
  4. ↑ Friedman K, Wallis T, Maloney KW, et al. An unusual cause of pediatric hypertension. J Pediatr 2007; 151:206.
  5. ↑ Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med 1998; 157:1098
  6. ↑ Flynn JT (2001). "Evaluation and management of hypertension in childhood". Prog Pediatr Cardiol. 12 (2): 177–188. doi:10.1016/s1058-9813(00)00071-0. PMID 11223345.
  7. ↑ Bartosh SM, Aronson AJ (1999). "Childhood hypertension. An update on etiology, diagnosis, and treatment". Pediatr Clin North Am. 46 (2): 235–52. doi:10.1016/s0031-3955(05)70115-2. PMID 10218072.
  8. ↑ Flynn JT (2005). "Hypertension in adolescents". Adolesc Med Clin. 16 (1): 11–29. doi:10.1016/j.admecli.2004.10.002. PMID 15844381.
  9. ↑ 9.0 9.1 Bell CS, Samuel JP, Samuels JA (2019). "Prevalence of Hypertension in Children". Hypertension. 73 (1): 148–152. doi:10.1161/HYPERTENSIONAHA.118.11673. PMC 6291260. PMID 30571555.
  10. ↑ 10.0 10.1 Song P, Zhang Y, Yu J, Zha M, Zhu Y, Rahimi K; et al. (2019). "Global Prevalence of Hypertension in Children: A Systematic Review and Meta-analysis". JAMA Pediatr. 173 (12): 1154–1163. doi:10.1001/jamapediatrics.2019.3310. PMC 6784751 Check |pmc= value (help). PMID 31589252.
  11. ↑ 11.0 11.1 Ewald DR, Haldeman PhD LA (2016). "Risk Factors in Adolescent Hypertension". Glob Pediatr Health. 3: 2333794X15625159. doi:10.1177/2333794X15625159. PMC 4784559. PMID 27335997.
  12. ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 Riley M, Hernandez AK, Kuznia AL (2018). "High Blood Pressure in Children and Adolescents". Am Fam Physician. 98 (8): 486–494. PMID 30277729.
  13. ↑ Luma GB, Spiotta RT (2006). "Hypertension in children and adolescents". Am Fam Physician. 73 (9): 1558–68. PMID 16719248.
  14. ↑ Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  15. ↑ Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  16. ↑ Chhadia S, Cohn RA, Vural G, Donaldson JS. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol 2013; 43:1549..
  17. ↑ Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2016; 34: 1887–920.


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