Portal de Periódicos da CAPES

Hypertension in Children and Adolescents

2019; Elsevier BV; Volume: 26; Issue: 2 Linguagem: Inglês

10.1053/j.ackd.2019.02.003

1548-5609

Joshua Samuels, Ana S. Solis Zavala, J. M. Kinney, Cynthia Bell,

Nutritional Studies and Diet

Hypertension is a growing problem in children and adolescents, with primary hypertension becoming the most common etiology. In addition to demonstrating that high blood pressure in children and young adults is likely to remain elevated into adulthood, this review (1) addresses important aspects of measuring blood pressure in children and adolescents, (2) defines elevated blood pressure and hypertension in this age group, (3) describes the initial evaluation and workup of abnormally high blood pressure, and (4) introduces treatment strategies for youth with sustained hypertension. Hypertension is a growing problem in children and adolescents, with primary hypertension becoming the most common etiology. In addition to demonstrating that high blood pressure in children and young adults is likely to remain elevated into adulthood, this review (1) addresses important aspects of measuring blood pressure in children and adolescents, (2) defines elevated blood pressure and hypertension in this age group, (3) describes the initial evaluation and workup of abnormally high blood pressure, and (4) introduces treatment strategies for youth with sustained hypertension. Clinical Summary•Evidence shows high tracking of BP in youth to adulthood hypertension and cardiovascular events.•Children ≥3 years should be screened for BP abnormalities at annual preventative visits.•New, simplified AAP guidelines define elevated BP by percentiles in children <13 years and by adult thresholds in children ≥13 years. •Evidence shows high tracking of BP in youth to adulthood hypertension and cardiovascular events.•Children ≥3 years should be screened for BP abnormalities at annual preventative visits.•New, simplified AAP guidelines define elevated BP by percentiles in children <13 years and by adult thresholds in children ≥13 years. High blood pressure (BP) is a chronic disease that affects not only adults but also children and adolescents. In the United States, prevalence estimates range between 2% and 5%.1Cheung E.L. Bell C.S. Samuel J.P. Poffenbarger T. Redwine K.M. Samuels J.A. Race and obesity in adolescent hypertension [published online April 10, 2017].Pediatrics. 2017; 139https://doi.org/10.1542/peds.2016-1433Crossref Scopus (71) Google Scholar, 2Falkner B. Hypertension in children and adolescents: epidemiology and natural history.Pediatr Nephrol. 2010; 25: 1219-1224Crossref PubMed Scopus (219) Google Scholar, 3Flynn J. The changing face of pediatric hypertension in the era of the childhood obesity epidemic.Pediatr Nephrol. 2012; 28: 1059-1066Google Scholar Although children are more likely to have a secondary cause of high BP than adults, primary hypertension is becoming the most common etiology. We will review the definitions, measurement techniques, evaluation, and management of hypertension in children and adolescents. One of the primary reasons to diagnose abnormally high BP during childhood is to identify people more at risk for cardiovascular injury and hypertension in early adulthood. Early identification of high BP may aid in the prevention of hypertension-related cardiovascular morbidity and mortality seen in adulthood.4Bao W. Threefoot S.A. Srinivasan S.R. Berenson G.S. Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study.Am J Hypertens. 1995; 8: 657-665Crossref PubMed Scopus (570) Google Scholar This tracking of pediatric elevated BP into adulthood, defined as stability of BP over time,5Lambrechtsen J. Rasmussen F. Hansen H.S. Jacobsen I.A. Tracking and factors predicting rising in ‘tracking quartile’ in blood pressure from childhood to adulthood: Odense Schoolchild Study.J Hum Hypertens. 1999; 13: 385-391Google Scholar, 6Kelly R.K. Thomson R. Smith K.J. Dwyer T. Venn A. Magnussen C.G. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study.J Pediatr. 2015; 167 (e1422): 1422-1428Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar is best examined in longitudinal cohort studies. Early evaluations by Li and colleagues7Li Z. Snieder H. Harshfield G.A. Treiber F.A. Wang X. A 15-year longitudinal study on ambulatory blood pressure tracking from childhood to early adulthood.Hypertens Res. 2009; 32: 404-410Crossref PubMed Scopus (50) Google Scholar in a 15-year longitudinal study consisting of 295 European Americans and 252 African Americans revealed the importance of pediatric BP measurement. Children with abnormally elevated BP were most likely to have elevated BP in adulthood. Although not universal, tracking correlation coefficients of BP (both office and ambulatory) from childhood into adulthood ranged from 0.30 to 0.59, indicating moderate-to-relatively high stability of tracking. Overall it was noted that 24-hour ambulatory BP monitoring (ABPM) tracked better than office reading for diastolic BP (DBP) (0.57 vs 0.46, P = 1.72 × 10−6) and pulse pressure (0.59 vs 0.51; P = 2.7 × 10−4) whereas tracking for systolic BP (SBP) was the same for office vs ABPM (0.55 vs 0.54; P = .805).7Li Z. Snieder H. Harshfield G.A. Treiber F.A. Wang X. A 15-year longitudinal study on ambulatory blood pressure tracking from childhood to early adulthood.Hypertens Res. 2009; 32: 404-410Crossref PubMed Scopus (50) Google Scholar Given its better predictiveness, ABPM should be considered in clinical settings to aid in identifying pediatric patients at risk for continued elevated BP into adulthood. The importance of tracking BP revolves around the potent cardiovascular risk factors that hypertension entails and anatomic cardiovascular and renal changes that occur. The Bogalusa Heart study found that the best predictor of future BP was baseline SBP of the study participants, whereas body mass index was also found to be highly predictive.4Bao W. Threefoot S.A. Srinivasan S.R. Berenson G.S. Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study.Am J Hypertens. 1995; 8: 657-665Crossref PubMed Scopus (570) Google Scholar Looking at the effects of differing independent variables on the presence of adult hypertension, the study found that adult onset hypertension was more prevalent in African Americans and in those who had higher BP or body mass index in childhood.4Bao W. Threefoot S.A. Srinivasan S.R. Berenson G.S. Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study.Am J Hypertens. 1995; 8: 657-665Crossref PubMed Scopus (570) Google Scholar Overall after accounting for race, sex, and age, participants in the highest BP quintile when young were 3.6 and 2.6 times more likely to develop systolic and diastolic hypertension, respectively. Moreover, the Bogalusa study found that increasing the time between evaluations to 15 years, compared with other studies looking at 3 to 8 years, did not weaken the observed tracking phenomenon of pediatric BPs.4Bao W. Threefoot S.A. Srinivasan S.R. Berenson G.S. Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study.Am J Hypertens. 1995; 8: 657-665Crossref PubMed Scopus (570) Google Scholar In addition, a longer follow-up among Bogalusa participants found that serial measurements can improve predictability of future BP measurements.8Shear C.L. Burke G.L. Freedman D.S. Berenson G.S. Value of childhood blood pressure measurements and family history in predicting future blood pressure status: results from 8 years of follow-up in the Bogalusa Heart Study.Pediatrics. 1986; 77: 862-869Google Scholar This evidence further supports the presence of pediatric hypertension as a significant risk factor for adult hypertension. More recently, a systematic meta-analysis conducted in 2008 evaluated the BP tracking from childhood to adulthood using epidemiologic data. The meta-analysis included 50 cohort studies from January 1970 to July 2006.9Chen X. Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis.Circulation. 2008; 117: 3171-3180Crossref PubMed Scopus (1074) Google Scholar The inclusion criteria included participant's baseline age 50, report of BP tracking correlation coefficients, and publication in English, Chinese, or Japanese. Of over 300 potential articles identified, investigators identified 50 cohort studies with 617 data points for SBP and 547 data points for DBP. The populations included a majority US population along with Australian, Canadian, Israeli, and New Zealanders. The meta-regression revealed a mean correlation coefficient of 0.38 for SBP (ranging from −0.12 to as high as 0.80). Although significant BP tracking from childhood into adulthood was identified, there was high between study variability in the estimates potentially due to differences in study designs, baseline age, follow-up period, measuring instruments, intrasubject variability, characteristics of study samples, and analytical methods used.9Chen X. Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis.Circulation. 2008; 117: 3171-3180Crossref PubMed Scopus (1074) Google Scholar Specifically, it was found that both SBP and DBP tracking significantly increased with baseline age. In cohorts with a baseline age 15 years. Certainly, for older teens, high BP appears to predict adult hypertension. The BP tracking from childhood to young adults appears to continue through older adulthood as well. The Coronary Artery Risk Development in Young Adult study found that younger adults with hypertension are at highest risk of future hypertensive organ damage.10Vasan R.S. High blood pressure in young adulthood and risk of premature cardiovascular disease: calibrating treatment benefits to potential harm.JAMA. 2018; 320: 1760-1763Google Scholar They evaluated approximately 5000 participants with a mean baseline age 35 years. Participants were classified into 3 groups: normal BP, Stage 1 hypertension, or Stage 2 hypertension based on the 2017 American College of Cardiology/American Heart Association (ACC/AHA) classification system. Over a median 18.8 years follow-up, there was a significant stepwise increase in cardiovascular risk among the increasing BP categories, with those having Stage 2 hypertension at baseline having a hazard ratio of 3.49 compared with normotensive subjects.10Vasan R.S. High blood pressure in young adulthood and risk of premature cardiovascular disease: calibrating treatment benefits to potential harm.JAMA. 2018; 320: 1760-1763Google Scholar Although indirect, this study provides evidence that the tracking of high BP from youth to adulthood may have long-term cardiovascular implications. Just as for adults, one of the most important aspects of BP monitoring in pediatrics is proper and accurate measurement. There are 3 types of BP measurements commonly used in pediatrics: auscultatory, oscillometric, and invasive. Invasive BP measurement is that obtained via an arterial line, which is a fluid-filled transducer attached to an arterial catheter. The catheter is attached to a fluid-filled bag of saline that is pressurized. As blood flows through the catheter, the pressurized saline pulsates and is translated into a pressure measurement, which is the mean arterial pressure. Invasive measurements, for example arterial lines, are limited to the sickest of patients and mainly used in an intensive care setting. Although these pressures may be the most accurate BP measurements in pediatrics, this method is not appropriate in the outpatient setting. Auscultatory and oscillometric measurements are the mainstays of measurement in the outpatient setting; they are frequently used in the inpatient setting as well. An auscultatory BP is obtained manually using a stethoscope and a sphygmomanometer. The examiner should place the bell of the stethoscope in the antecubital fossa of the patient's right arm and inflate the BP cuff. As the pressure is slowly released from the cuff during deflation, the first auscultated heart sound corresponds to the SBP. As the cuff further deflates, DBP is the pressure at which the heart sounds disappear entirely. Normative data, on which pediatric BP thresholds are based, were obtained using the auscultatory method.11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar Oscillometric BP measurements, on the other hand, are obtained using an automated machine.12Bell C. Bender J. Poffenbarger T. Acosta A.A. Portman R. Samuels J. Normative blood pressure limits in children by oscillometric monitoring compared to working group limits.J Am Soc Nephrol. 2008; 19: SA-PO2267Google Scholar This method has become the most common method of BP measurement used in both the clinical and inpatient setting. The automated BP cuff is placed on the patient's upper arm and the cuff automatically inflates to the point that the arm's blood flow is completely occluded. The cuff then slowly deflates, allowing initially turbulent blood to flow through the artery of the arm. The machine measures the turbulence (oscillation of blood through the artery) to determine the point of maximum oscillation. The pressure at maximum oscillation is the mean arterial pressure. Each machine then calculates the SBP and DBP using a proprietary algorithm, which manufacturers have been reluctant to share. In the outpatient setting, the most accurate BP is obtained using the auscultatory method as the normative values are based on this method. The key to obtaining a good BP measurement is ensuring the correct size BP cuff is used, that the patient has been sitting calmly for at least 5 minutes with their feet on the ground, legs not crossed, and back against a supportive surface. Choosing the proper BP cuff size involves measuring the arm circumference of the mid upper arm. The bladder length should be 80% of the mid-arm circumference and the bladder width should be at least 40%. A cuff size that is too small will overestimate the BP and a cuff size that is too large will underestimate BP. If the first reading is normal, no further measurement is required at that visit. If the BP is abnormally high, however, repeated measurements are needed to determine true office BP.13Negroni-Balasquide X. Bell C.S. Samuel J. Samuels J.A. Is one measurement enough to evaluate blood pressure among adolescents? A blood pressure screening experience in more than 9000 children with a subset comparison of auscultatory to mercury measurements.J Am Soc Hypertens. 2016; 10: 95-100Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The American Academy of Pediatrics (AAP) guidelines include an algorithm to aid in appropriate BP measurement.11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar Unlike in adults, children with high BP rarely have catastrophic cardiovascular outcomes such as heart attacks or strokes. Although fortunate, the lack of these hard outcomes in youth makes defining hypertension in this age group challenging. New guidelines have been published by the AAP11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar in 2017. For children aged <13 years, a statistical definition based on normative data collected in thousands of healthy children is used through age, height, and sex-based thresholds. Normal BP for children is classified as <90th percentile (or 120/80 mm Hg) for age, height, and sex whereas hypertension is defined as ≥95th percentile (or 130/80 mm Hg) across 3 separate office visits. As in adults, BP higher than normal but not reaching the 95% threshold for hypertension is classified as “elevated BP”. This new category, previously called prehypertension in both JNC714Chobanian A.V. Bakris G.L. Black H.R. et al.The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.JAMA. 2003; 289: 2560-2572Crossref PubMed Scopus (16577) Google Scholar and the Fourth Working Group Report,15NHBPEP The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.Pediatrics. 2004; 114: 555-576Google Scholar mimics the new ACC/AHA adult definitions and emphasizes that these pressures are already abnormally elevated.16Whelton P.K. Carey R.M. Aronow W.S. et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Hypertension. 2018; 7: 1269-1324Google Scholar Although incorporating biological sex and body size in the definition makes physiological sense, the many BP thresholds complicate diagnosis and necessitate the use of complex BP tables. Although visually like the previous table, the new BP table in the AAP Clinical Practice Guidelines have important modifications. Most importantly, the normative BP thresholds have been recalculated after removal of overweight and obese children from the normative sample. The resultant tables reveal thresholds that are a few millimeters of mercury lower than the Fourth Report tables for most age, height, and sex configurations and more accurately reflect truly normative data. BP thresholds for adolescents and young adults have been greatly simplified in the AAP guideline to match adult thresholds. The new AHA/ACC adult BP thresholds have also been adopted for all patients aged ≥13 years.11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar, 16Whelton P.K. Carey R.M. Aronow W.S. et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Hypertension. 2018; 7: 1269-1324Google Scholar These static thresholds of 120/80, 130/80, and 140/90 mm Hg form the boundaries for normal BP, elevated BP, Stage 1 hypertension, and Stage 2 hypertension for everyone aged ≥13 years, regardless of teen age, height, or sex (see Table 1). The adoption of uniform definitions for BP classification in teens and adults will greatly facilitate transition of care from pediatric-centered practices to internal medicine or adult oriented care.Table 1Definitions of Elevated Blood Pressure and HypertensionHypertension ClassificationChildren Aged 1-12 y (Percentile Based)Everyone ≥13y (mm Hg Based)Normotensive<90th Percentile<120/<80Elevated blood pressure≥90th Percentile or ≥120/80 mm Hg (lower) to <95th percentile120-129/<80Stage 1 hypertension≥95th Percentile or 130/80 mm Hg (lower) to <95th percentile + 12 mm Hg or 139/89 mm Hg130-139/80-89Stage 2 hypertension≥95th Percentile + 12 mm Hg or ≥140/90 mm Hg (lower)≥140/90 Open table in a new tab Population estimates of hypertension prevalence in children are determined in 3 primary ways: national screening programs such as the National Health and Nutrition Examination Survey (NHANES), retrospective electronic medical record (EMR) review of diagnosis codes, or study-specific regional estimates. With recent updated guidelines on hypertension diagnosis, few studies have evaluated the prevalence of hypertension based on the new criteria.11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar Sharma and colleagues17Sharma A.K. Metzger D.L. Rodd C.J. Prevalence and severity of high blood pressure among children based on the 2017 American Academy of Pediatrics Guidelines.JAMA Pediatr. 2018; 172: 557-565Crossref PubMed Scopus (105) Google Scholar were the first to update prevalence estimates based on AAP guidelines using 8 NHANES surveys from 1999 to 2015 among 5- to 18-year olds. The authors showed a slight decrease in the elevated BP prevalence (previously called prehypertension) from 10% by the Fourth Working Group Report (WG) to 9.3% by AAP. These decreases in elevated BP and normal BP resulted in a significant “upclassification” of many children with the new guidelines and hypertension prevalence increase from 2.8% by WG to 5.7% by AAP. However, these hypertensive estimates represent a wide age range and this nationally representative study did not confirm hypertensive status on 3 separate occasions as outlined in the guidelines. Conversely, study-specific estimates based on 22,224 10- to 17-year-old children screened at schools in Houston, TX, from 2000 to 2018 showed increases in elevated BP prevalence (14.7% by WG to 16.3% by AAP at initial screening) in this older pediatric population. Although the prevalence of hypertension was similar by the old and new guidelines in this school-based screening, there was substantial decrease from initial screening hypertension prevalence on confirmation: 13% at initial screening to 2.3% having confirmed Stage 1 or 2 hypertension on 3 separate occasions by AAP criteria.18Bell C.S. Samuel J.P. Samuels J.A. Prevalence of hypertension in children.Hypertension. 2019; 73: 148-152Crossref PubMed Scopus (91) Google Scholar The most recent large-scale retrospective EMR review by Hansen and colleagues of 14,187 children in a northeastern Ohio medical system determined that 3.6% of children at well-child visits had confirmed hypertension on 3 separate occasions based on WG guidelines.19Hansen M.L. Gunn P.W. Kaelber D.C. Underdiagnosis of hypertension in children and adolescents.JAMA. 2007; 298: 874-879Crossref PubMed Scopus (609) Google Scholar However, acknowledgment of this hypertensive status was low, with only 26% having documentation of elevated BP noted in the clinical record. All these studies have additionally confirmed that hypertension prevalence increases with age and is higher in male and obese children. Regardless of guidelines used or estimation technique, current prevalence estimates of pediatric hypertension range from 2% to 5% with increasing prevalence in older adolescents. However, there is evidence that the current prevalence is lower than what is has been in the past across all age groups. The most recent longitudinal analysis of NHANES data confirmed that hypertension prevalence has decreased from 7.7% in 2001 to 4.2% by AAP guidelines (3.2% to 1.5% by WG guidelines).20Jackson S.L. Zhang Z. Wiltz J.L. et al.Hypertension among youths—United States, 2001-2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 758-762Crossref PubMed Scopus (61) Google Scholar This same decrease has been seen in previous reports by NHANES going back as far as 196321Yang Q. Zhong Y. Merritt R. Cogswell M.E. Trends in high blood pressure among United States adolescents across body weight category between 1988 and 2012.J Pediatr. 2016; 169: 166-173.e3Google Scholar, 22Din-Dzietham R. Liu Y. Bielo M.V. Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002.Circulation. 2007; 116: 1488-1496Crossref PubMed Scopus (543) Google Scholar, 23Ostchega Y. Carroll M. Prineas R.J. McDowell M.A. Louis T. Tilert T. Trends of elevated blood pressure among children and adolescents: data from the National Health and Nutrition Examination Survey1988-2006.Am J Hypertens. 2009; 22: 59-67Crossref PubMed Scopus (157) Google Scholar and diverges with the obesity rate increase seen over the same period.24Skinner A.C. Ravanbakht S.N. Skelton J.A. Perrin E.M. Armstrong S.C. Prevalence of obesity and severe obesity in US children, 1999-2016.Pediatrics. 2018; 141 (e20173459)Crossref Scopus (854) Google Scholar The Bogalusa study has confirmed this decreasing trend of hypertension showing peak pediatric hypertension rate of 7.2% in boys and 10.8% in girls around 1980, which had decreased to 4.1% in boys and 5.8% in girls by 1993 despite increasing obesity in both boys and girls during the same period.25Freedman D.S. Goodman A. Contreras O.A. DasMahapatra P. Srinivasan S.R. Berenson G.S. Secular trends in BMI and blood pressure among children and adolescents: the Bogalusa Heart Study.Pediatrics. 2012; 130: e159-e166Crossref PubMed Scopus (86) Google Scholar Some have hypothesized diet as a potential mechanism, specifically reduction of daily intakes of energy, carbohydrate, total fat, and total saturated fatty acids but increase of total polyunsaturated fatty acids and dietary fiber since 1999,26Xi B. Zhang T. Zhang M. et al.Trends in elevated blood pressure among US children and adolescents: 1999-2012.Am J Hypertens. 2016; 29: 217-225Crossref PubMed Scopus (43) Google Scholar to explain this phenomenon of decreasing prevalence of hypertension in children despite increase in obesity, a well-established risk factor for hypertension at all ages. Once hypertension has been diagnosed in a child or adolescent, evaluation is also more involved than adults. Although the epidemiology is shifting more toward primary causes, secondary hypertension remains more common in younger children and adults. As such, evaluations include not only confirming diagnosis of hypertension, but also assessing for secondary causes and searching for evidence of organ damage.11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar The initial step in the evaluation of confirmed elevated office BP or sustained hypertension in a child is to perform an ABPM.11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar The 24-hour ABPM has been shown to be both safe and more predictive of target organ injury than casual office measurements.27Samuel J.P. Bell C.S. Hebert S.A. Varughese A. Samuels J.A. Tyson J.E. Office blood pressure measurement alone often misclassifies treatment status in children with primary hypertension.Blood Press Monit. 2017; 22: 328-332Google Scholar The new AAP guidelines cite ample evidence to recommend APBM as an initial step. ABPM is recommended if office pressures remain elevated for a year or after 3 office visits with BP in the hypertensive range. Although discussion of ABPM analysis is beyond the scope of this review, the AHA guidelines are an excellent place to learn more.28Flynn J.T. Daniels S.R. Hayman L.L. et al.Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association.Hypertension. 2014; 63: 1513-1518Google Scholar Once sustained out-of-office hypertension is established in any child or adolescent, evaluations should include urinalysis and measurement of chemistries, kidney function, and blood count. Additional evaluation depends on the clinical history. Although the new guidelines explicitly describe the many causes of secondary hypertension, the diagnostic workup for patients with sustained hypertension is also streamlined because of the increasing prevalence of primary hypertension. All pediatric patients with sustained hypertension still undergo a workup, including urine and blood studies, to rule out renal causes. However, recognizing the increasing epidemiology of primary hypertension, much of the evaluation for secondary hypertension is relegated to optional evaluations for high-risk patients. Renal imaging, once suggested for all patients with sustained hypertension, is now suggested only for children with abnormal urine or blood studies or aged <6 years at diagnosis. Echocardiographic evaluation should initially be reserved for those with a history or physical findings suggestive of cardiovascular disease. All patients who require pharmacologic treatment for hypertension should have an echocardiogram to evaluate for cardiac structural abnormalities, notably left ventricular hypertrophy. Although there are no data that link pediatric hypertension to long-term cardiovascular morbidity, early treatment of diagnosed hypertension can restore normal BP and reduce early markers of such injury, notably cardiovascular remodeling in the form of left ventricular hypertrophy.29Kupferman J.C. Paterno K. Mahgerefteh J. et al.Improvement of left ventricular mass with antihypertensive therapy in children with hypertension.Pediatr Nephrol. 2010; 25: 1513-1518Crossref PubMed Scopus (40) Google Scholar As such, the current AAP Clinical Practice Guidelines recommended goal of therapy is now <90th percentile in most children, and even lower in special populations such as in children with chronic kidney disease.11Flynn J.T. Kaelber D.C. Baker-Smith C.M. et al.Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published online August 21, 2017].Pediatrics. 2017; 140https://doi.org/10.1542/peds.2017-1904Crossref Scopus (1603) Google Scholar In the absence of a secondary cause of hypertension, lifestyle modification, including dietary changes and increased physical activity, remains the cornerstone of initial treatment. If these modalities fail to control BP after at least 6 months, pharmacologic treatment should be considered. First line pharmacologic agents to control BP in children and adolescents has been clarified to include renin-angiotensin-aldosterone system (RAAS) blockers such as angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers, long acting calcium channel blockers, or thiazide diuretics. No head to head comparisons have been conducted to determine a preferred initial treatment. Individualized decision making using an n-of-1 trial approach is both feasible and well tolerated.30Samuel J.P. Samuels J.A. Brooks L.E. et al.Comparative effectiveness of antihypertensive treatment for older children with primary hypertension: study protocol for a series of n-of-1 randomized trials [published online January 8, 2016].Trials. 2016; 17 (https://doi.org/10.1186/s13063-015-1142-y): 16Crossref PubMed Scopus (8) Google Scholar, 31Samuel J. Tyson J.E. Green C. et al.Treating hypertension in children with n-of-1 trials [published online March 6, 2019].Pediatrics. 2019; : e20181818Google Scholar Compared with the Fourth Report, the 2017 AAP guidelines have simpler definitions of hypertension, easier to use tables, and most importantly, static BP thresholds for teens that match the new adult guidelines. The new guidelines recommend screening for BP abnormalities in children aged ≥3 years at the annual preventative visit. Given the tracking of pediatric hypertension into adulthood, early recognition of abnormally elevated BP may be important to mitigate long-term cardiovascular risk.