Pediatric Hypertension

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Hypertension in children and adolescents remains a significant health care concern. Historically, pediatric hypertension was considered a secondary phenomenon until proven otherwise.

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However, more recent evidence describes primary hypertension as being more likely than secondary hypertension among children referred to subspecialty care for evaluation of elevated BP in communities where obesity is prevalent. In this special pediatric hypertension series, we have assembled contributions from global experts in childhood hypertension to provide the reader with a comprehensive and current update on the varied aspects of hypertension diagnosis, secondary etiologies, and cardiovascular co-morbidities.

We were fortunate to enlist a prominent group of 22 authors to contribute a wide range of articles. In total, 10 papers have been included Lewis et al. We introduced the topic of Pediatric Hypertension with a review article highlighting current methodologies and recommendations for hypertension screening in children and adolescents Lewis et al. The article by Michaela Lewis, Ibrahim Shatat, and Shannon Phillips walks readers through key issues contributing to both the inaccurate measurement of blood pressure and the misclassification of HTN among children and presents strategies to address these issues.

As the authors point out, although national guidelines for the diagnosis and management of pediatric HTN have been available for nearly 40 years, knowledge and recognition of the problem by clinicians remains poor due to a host of influencing factors.

They bring to the reader's attention a host of potential exposures known to affect BP, such as recent use of tobacco products, e-cigarettes, consumption of a sodium-rich or high caffeine diet, as well as multiple over-the-counter, herbal, and prescription medications. The authors provided the readers with a comparison between different available measurement devices [Table 1 in Lewis et al.

Last year and after this review Lewis et al. The new guidelines expanded the role for ambulatory BP monitoring ABPM in the diagnosis and management of pediatric hypertension. Caitlin Peterson and Yosuke Miyashita contributed an article Peterson and Miyashita to this collection emphasizing that h ABPM should be considered standard of care in pediatric patients. In two of the best written reviews in the field, Sun-Young Ahn and Charu Gupta reviewed for the readers the topic of genetic programming of hypertension Ahn and Gupta.

Table 1 in this review elegantly summarizes monogenic forms of hypertension, while the text discusses methodologies employed in genetic studies of essential HTN, mechanisms for epigenetic modulation of essential HTN, pharmacogenomics and HTN, and recent advances in genetic studies of essential HTN in the pediatric population. Complementing this review, Shari Gurusinghe, Anita Tambay, and Christine Sethna reviewed the developmental origins of hypertension and the role of nephron endowment Gurusinghe et al. The authors guide the readers through one of the most intriguing concepts in pediatric nephrology, that is, how the in utero environment may increase the risk of both hypertension and chronic kidney disease.

In Figure 2 of their manuscript, the authors propose a flow chart linking low nephron number to hypertension.


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Furthermore, the authors discuss the impact of ethnicity and postnatal modifiers on nephron numbers. Tammy Brady contributed a review that focused on the unique aspects of hypertension evaluation and management in the child with comorbid obesity Brady. Charnaya and Moudgil reviewed the etiology of post-transplant hypertension Charnaya and Moudgil ; they pointed out that HTN is both a risk factor for graft loss and a consequence of multiple transplant related factors including: donor characteristics, recipient factors, medications, and lifestyle attributes similar to those associated with hypertension in the general population.

The authors further discuss other useful techniques to assess CVD in this at risk population. In figure 1 of their review, the authors reproduced with permission from Lenders et al. They also outline the pre-, intra- and postoperative management of these challenging tumors as well as follow up. We found that using two different HBP definitions, preterm delivery, cesarean delivery, and family hypertension history were risk factors for HBP in children, which was consistent with previous studies [33,34].

In the previous review, the relationship between high birth weight and HBP in children and adolescents was inconsistent, with studies reporting positive, inverse, or no associations [35]. The present study found that high birth weight was negatively associated with HBP in children and adolescents with similar odds ratios using THE two definitions after adjusting for current BMI. These findings were inline with Steinthorsdottir's study [36] , and current weight could be a potential causal pathway between high birth weight and HBP.

Association between high birth weight and hypertension in children and adolescents: a cross-sectional study in China. J Hum Hypertens ; — We also assessed the association of HBP with behavioral factors i. The updated CPG guideline suggests that the recommendation of diet and physical activity in childhood is similar to that in adults [9]. Although the literature indicates a high intake of fruits and vegetables is associated with lower BP [9] , we observed no significant association between fruits, vegetables, and breakfast with HBP risk in the current study applying either HBP definitions.

Yet, we found significant associations between HBP and other behavioral factors, such as consumption of fried food, western fast food, meat products and eating speed, screen time, and, for boys only, engagement in regular physical activity. The findings support the influence of lifestyle factors on HBP in children and the need for behavioral interventions. Our study has several potential implications. First, as the updated CPG definition has lower HBP reference values , more youth will be identified as hypertensive and the threshold for HBP intervention in early life will be lowered, which may lead to a declined risk of target organ damage in childhood [37] , and reduced risk of HBP and CVD in adulthood [38—41].

Second, with more youth likely to be identified with HBP, the transition to the new CPG offers an opportunity for improving HBP awareness among healthcare providers of children. Few large surveys have studied HBP awareness in children and adolescents. Further, a recent survey revealed that only An even lower HBP awareness is speculated in Chinese young people without comorbid health conditions. Hence, increasing pediatric awareness would be a primary task for regular BP measurement and HBP screening to motivate subsequent intervention and treatment in those with pediatric hypertension [44].

Third, although the updated CPG definition will increase the HBP prevalence, highly consistent associations between HBP and obesity, early life factors, and behavioral factors were detected for both definitions, even after adjusting for several confounding factors. The strong and consistent associations point to relevant targets for prevention and treatment of pediatric hypertension.

That more children and adolescents will be identified as hypertensive will result in increased use of pharmacological treatments and costs, especially in children with resistant HBP. However, lifestyle modifications in diet, physical activity, weight, and stress should remain the key approaches according to CPG recommendations.

Study limitations are noted. Firstly, BP levels in our study were obtained at a single visit, which may overestimate the HBP prevalence [45]. Secondly, the reference values of both the Fourth Report and the CPG were based on American children, which may influence its use in the Chinese population. However, the Fourth Report was widely used in previous studies conducted in China, and it is expected that the updated CPG definition will be widely used in Chinese children as well. Data were obtained from seven Chinese provinces geographically located in the north, northeast, central, south, east, northwest, and southwest of China.

The participants were recruited to be largely representative of Chinese children and adolescents. The prevalence of overweight and obesity in children Thirdly, indicators of target organ damage, which were not collected here, warrant investigation in future studies. Finally, measures of early life factors and dietary behavioral factors were self-reported. Additionally, the strength of association between HBP and obesity, height, early life factors, and behavioral factors using the CPG definition did not change significantly compared with the results using the Fourth Report.


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Researchers and clinical practitioners should understand the differences between the two pediatric guidelines for HBP classification and refresh their routine practice. Consistent and strong associations between HBP with BMI, hip and waist circumference, and behavioral factors support the importance of these features as prevention and intervention targets for pediatric hypertension.

Future study is warranted to understand the rationality of the updated HBP definition, especially its association with target organ damage and other health consequences in adulthood. The authors acknowledge the efforts of the research team members and the participating students, teachers, parents, and local education and health staff. Information about previous presentations: Neither whole nor part of the work presented in this manuscript was presented in previous articles.

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Some error has occurred while processing your request. Please try after some time. Back to Top Article Outline. TABLE 1.

2018 Quality and Safety in Children's Health Conference

TABLE 2. Reduction of risk for cardiovascular disease in children and adolescents. Circulation ; — Cited Here Ingelfinger JR. The child or adolescent with elevated blood pressure. N Engl J Med ; — Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Progression of normotensive adolescents to hypertensive adults: a study of 26, teenagers. Hypertension ; — The fourth report on the diagnosis , evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics ; — PubMed CrossRef.

Hypertension Canada's guidelines for the diagnosis , assessment, prevention, and treatment of pediatric hypertension. Can J Cardiol ; — J Hypertens ; — National blood pressure reference for Chinese Han children and adolescents aged 7 to 17 years.

Editorial ARTICLE

Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics ; e Determination of blood pressure percentiles in normal-weight children: some methodological issues. Am J Epidemiol ; — Components of height and blood pressure in childhood. Int J Epidemiol ; — Body mass index cut offs to define thinness in children and adolescents: international survey. BMJ ; Establishing a standard definition for child overweight and obesity worldwide: international survey.

BMJ ; — Vital Health Stat 11 ; — Percentiles of waist-hip ratio and the relationship with blood pressure among children and adolescents in Shandong, China. Ann Hum Biol ; — A systematic review of waist-to-height ratio as a screening tool for the prediction of cardiovascular disease and diabetes: 0. Nutr Res Rev ; — Anthropometric reference data for children and adults: United States, — Vital Health Stat ; — Chinese Society of Nutrition. The dietary guidelines of Chinese school-age children. House PsMP, editor. Beijing: People's Medical Publishing House; American Academy of Pediatrics. Committee on Public Education.

American Academy of Pediatrics: Children, adolescents, and television.

Frontiers | Editorial: Pediatric Hypertension: Update | Pediatrics

Chinese guidelines for data processing and analysis concerning the International Physical Activity Questionnaire. Cardiometabolic risks and severity of obesity in children and young adults. The relationship of body mass index and blood pressure in primary care pediatric patients. J Pediatr ; — The impact of the degree of obesity on the discrepancies between office and ambulatory blood pressure values in youth.

Change in weight status and development of hypertension. Use of national and international growth charts for studying height in European children: development of up-to-date European height-for-age charts. PLoS One ; 7:e Zong XN, Li H. Physical growth of children and adolescents in China over the past 35 years.

Bull World Health Organ ; — Potential misclassification of blood pressure status in children and adolescents with short or tall stature. Birth weight and birth weight for gestational age in relation to risk of hospitalization with primary hypertension in children and young adults. Matern Child Health J ; — Cesarean delivery, overweight throughout childhood, and blood pressure in adolescence. J Pediatr ; The role of size at birth and postnatal catch-up growth in determining systolic blood pressure: a systematic review of the literature.


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