OFFICIAL ABP TOPIC: 

Plan the evaluation of a child with hypertension

• BACKGROUND
• IDENTIFYING HYPERTENSION
• EVALUATION OF HYPERTENSION

Hypertension affects 3.5% of children, with increasing prevalence due to the childhood obesity epidemic. It’s essential to distinguish between primary HTN, more common in older children and associated with obesity and family history, and secondary HTN, more prevalent in younger children and caused by underlying conditions.

IDENTIFYING HYPERTENSION

BP should be measured annually in all children ≥3 years old. Accurate BP measurement is essential for diagnosing HTN. Key steps include:

• Using an appropriate cuff size (bladder length should be 80-100% of arm circumference)
• Ensuring the patient is seated with back supported, feet on the floor, and arm at heart level
• Obtaining at least two more readings at the same visit and averaging them if the initial BP is elevated

Classification of HTN

Children should be diagnosed with hypertension once they have BP readings ≥95th percentile on three different visits.

• For children <13 years:
  • Elevated BP: Between 90th and 95th percentile for age, sex, and height.  Measure the BP and then check a table to determine if the BP is normal, elevated, or considered HTN.
    • TABLE: www.pbrlinks.com/BPGUIDE
  • Stage 1 Hypertension: 95th percentile to 95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower).
  • Stage 2 Hypertension: 95th percentile + 12 mmHg or higher, or ≥140/90 mmHg (whichever is lower).
• For adolescents ≥13 years:
  • Elevated BP: 120/<80 to 129/<80 mmHg.
  • Stage 1 Hypertension: 130/80 to 139/89 mmHg.
  • Stage 2 Hypertension: 140/90 mmHg or higher.

Symptoms of Hypertension vary by age:

• Infants: Irritability, poor feeding, failure to thrive.
• Young children: Headache, vomiting, seizures.
• Older children: Headache, fatigue, visual changes.

EVALUATION OF HYPERTENSION

If a child presents with an elevated BP, the BP should be remeasured at least twice at the same visit and averaged to confirm the diagnosis. A thorough history and physical examination should assess for secondary hypertension caused by underlying conditions.

Red flags for secondary HTN include a history of congenital anomalies, renal disease, umbilical catheterization, renal bruits, edema, tachycardia, or symptoms of an endocrine disorder. See the table below for examples of primary and secondary hypertension and their distinguishing features.

Assess for comorbidities such as obesity, dyslipidemia, diabetes, sleep apnea, or chronic kidney disease. Also evaluate for target organ damage, including left ventricular hypertrophy (LVH) and retinal changes.

Initial Evaluation for Elevated BP

1. Repeat BP measurements to confirm the diagnosis and classify based on age, sex, and height.
2. Consider 24-hour ambulatory blood pressure monitoring for suspected white coat hypertension or children with secondary hypertension, diabetes, or obesity.
3. Order baseline labs:
   • BUN, creatinine: Assess kidney function.
   • Urinalysis: Screen for blood or protein.
   • Lipid panel: Evaluate for dyslipidemia.
   • HbA1c and liver function tests (LFTs): Screen for diabetes and fatty liver disease in obese children.
4. Perform an echocardiogram to assess for LVH if pharmacologic treatment is being considered.
5. Obtain a renal ultrasound if the child is <6 years old or has abnormal renal labs/urinalysis.

Additional Testing Based on Clinical Suspicion

• CBC: For growth delays, abnormal renal function, or other concerns.
• Drug screen: For potential illicit drug use.
• Plasma renin/aldosterone: If renovascular hypertension or mineralocorticoid excess is suspected.
• 24-hour urine metanephrines: For episodic symptoms (e.g., headache, sweating, tachycardia) suggesting pheochromocytoma.
• TFTs if signs of hyperthyroidism (tachycardia, weight loss, goiter).
• Sleep study: For suspected obstructive sleep apnea (e.g., snoring, daytime sleepiness).
• Doppler renal ultrasound: For children ≥8 years old with suspected renal artery stenosis.

REFERENCES

https://publications.aap.org/pediatrics/article/140/3/e20171904/38358/Clinical-Practice-Guideline-for-Screening-and

https://www.uptodate.com/contents/hypertension-in-children-and-adolescents-evaluation