Key Pediatric Clinical Practice Guidelines in 2017

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

January 10, 2018

In This Article

Pediatric Hypertension

American Academy of Pediatrics

BP should be checked in all children and adolescents ≥3 yr of age at every health care encounter if they have obesity, are taking medications known to increase BP, have renal disease, have a history of aortic arch obstruction or coarctation, or have diabetes.

Trained health care professionals in the office setting should make a diagnosis of hypertension if a child or adolescent has auscultatory-confirmed BP readings ≥95th percentile at 3 different visits.

Ambulatory blood pressure monitoring (ABPM) should be performed for confirmation of hypertension in children and adolescents with office BP measurements in the elevated BP category for 1 yr or more or with stage 1 hypertension over 3 clinic visits.

Children and adolescents with suspected white coat hypertension (WCH) should undergo ABPM. Diagnosis is based on the presence of mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) <95th percentile and SBP and DBP load <25%.

Home BP monitoring should not be used to diagnose hypertension, masked hypertension, or WCH but may be a useful adjunct to office and ambulatory BP measurement after hypertension has been diagnosed.

Children and adolescents ≥6 yr of age do not require an extensive evaluation for secondary causes of hypertension if they have a positive family history of hypertension, are overweight or obese, and/or do not have history or physical examination findings suggestive of a secondary cause of hypertension.

Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for left ventricular hypertrophy (LVH).

It is recommended that echocardiography be performed to assess for cardiac target organ damage (LV mass, geometry, and function) at the time of consideration of pharmacologic treatment of hypertension.

LVH should be defined as LV mass >51 g/m (boys and girls) for children and adolescents older than age 8 yr and defined by LV mass >115 g/body surface area for boys and LV mass >95 g/BSA for girls.

Repeat echocardiography may be performed to monitor improvement or progression of target organ damage at 6- to 12-mo intervals. Indications to repeat echocardiography include persistent hypertension despite treatment, concentric LV hypertrophy, or reduced LV ejection fraction.

In patients without LV target organ injury at initial echocardiographic assessment, repeat echocardiography at yearly intervals may be considered in those with stage 2 hypertension, secondary hypertension, or chronic stage 1 hypertension incompletely treated (noncompliance or drug resistance) to assess for the development of worsening LV target organ injury.

In children and adolescents suspected of having renal artery stenosis (RAS), either CT angiography or MR angiography may be performed as noninvasive imaging studies. Nuclear renography is less useful in pediatrics and should generally be avoided.

In children and adolescents diagnosed with hypertension, the treatment goal with nonpharmacologic and pharmacologic therapy should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥13 yr old

At the time of diagnosis of elevated BP or hypertension in a child or adolescent, clinicians should provide advice on the DASH diet and recommend moderate to vigorous physical activity at least 3 to 5 days/wk (30–60 min per session) to help reduce BP.

In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy on echocardiography, symptomatic hypertension, or stage 2 hypertension without a clearly modifiable factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an angiotensin-converting enzyme (ACE) inhibitor, angiotensin-receptor blocker (ARB), long-acting calcium channel blocker, or thiazide diuretic.

Children or adolescents with both chronic kidney disease and hypertension should be treated to lower 24-hr mean arterial pressure <50th percentile by ABPM.

Children and adolescents with CKD, hypertension, and proteinuria should be treated with an ACE inhibitor or ARB.

Children and adolescents with type 1 diabetes mellitus or type 2 diabetes mellitus should be evaluated for hypertension at each medical encounter and treated if BP ≥95th percentile or >130/80 mm Hg in adolescents ≥13 yr of age.

In children and adolescents with acute severe hypertension and life-threatening symptoms, immediate treatment with short-acting antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 hr.

References

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