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The Guidelines for Children with Hypertension were updated by the American Academy of Pediatrics (AAP) in 2017.1 Prior to this publication, the guidelines for hypertension (HTN) were issued by the National Heart, Lung, and Blood Institute (NHLBI). In 2013, the AAP acquired sponsorship of cardiovascular disease guidelines in children with a goal of developing evidence-based clinical practice recommendations for the practitioner. A sub-committee of experts established guidelines for the diagnosis, evaluation, and management of childhood HTN.
Prior to the 2017 revisions, data establishing diagnosis guidelines for HTN were generated from a population of healthy children, however, many were overweight or obese. Due to the likelihood of upwardly skewed normative blood pressure values from the overweight population, revised 2017 HTN guidelines were based on healthy children of normal weight.1 To supplement changes in practice, blood pressure (BP) tables and screening tools for the physician were simplified to provide only BP values that require further medical evaluation.
Recommendations for age of initial screening of BP continue to be three years of age, with new guidelines to check annually unless high-risk factors are present.1 These criteria include obesity, diabetes, renal disease, and history of aortic arch obstruction. Also considered high-risk are patients taking medications known to elevate blood pressure.
In children, BP may vary considerably. Elevated BP measurement should be repeated over time at different visits before diagnosis of HTN. Confirmed auscultatory measurements >95th percentile in children and >130/80 in adolescents thirteen or older at three separate visits indicate diagnosis for HTN. BP >90th percentile, but <95th percentile are categorized as elevated BP. The latter were previously deemed to be prehypertensive. The use of ambulatory blood pressure monitoring is recommended to confirm HTN in pediatrics.
The overall treatment goal for children and adolescents with primary or secondary hypertension is to achieve a BP level that reduces risk of organ damage as well as risk of HTN and related cardiovascular disease (CVD) in adulthood. Previous recommendations for target BP for patients without renal disease or diabetes were measurements <95th percentile, however, recent evidence has shown that organ damage can occur in children with BP >90th percentile, but <95th percentile.2 In addition, in adolescents, risk of CVD in adulthood was found to increase with BP levels exceeding 120/80 mm Hg.1 As a result, new recommendations emphasize lower target BP with optimal treatment levels for HTN at <90th percentile or <130/80 mm Hg, whichever measurement is lowest.1
Management of hypertension to achieve target BP is based on the degree of severity. Lifestyle modifications and nonpharmacologic interventions are recommended as initial treatment in conjunction with frequent auscultation in patients with elevated BP and those with Stage 1 hypertension who are asymptomatic. Clinical trials in adults demonstrate that nutritional interventions, specifically salt reduction and high intake of polyphenol oils, can lower BP – a major risk factor for cardiovascular mortality.1,3Clinical trials in hypertensive youth suggest similar benefits of dietary intervention and physical activity as in adults.1
In most cases, The Dietary Approaches to Stop Hypertension (DASH) is recommended for children and adolescents with HTN. Guidelines for following a DASH diet include high fruit and vegetable intake, whole grains, low-fat milk products, fish, poultry, nuts, legumes, and lean red meats with restrictions on sugar and salt.1The DASH diet has been found to lower BP especially with a plant-strong meal plan including high intake of fruits, vegetables, legumes and low-fat milk products.1,4 In addition to dietary management, an increase in physical activity can lower BP.1Patients with HTN should perform moderate to vigorous physical activity three to five days per week lasting 30 to 60 minutes.1 Regular physical activity and adherence to the DASH diet in children with HTN and obesity can lead to weight-loss and decrease in CV risk factors.1 Other research suggests stress reduction, meditation, and yoga may also be beneficial for HTN.1
In patients with HTN where lifestyle and nonpharmacologic interventions do not meet target BP or in patients with high-risk factors, pharmaceutical interventions are required to achieve treatment goals.1
Editor’s Note: Please see the lead article of this issue for dietary interventions that include soyfoods.
1. 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(6):e20173035
2. Urbina EM, Khoury PR, McCoy C, Daniels SR, Kimball TR, Dolan LM. Cardiac and vascular consequences of prehypertension in youth. J Clin Hypertens (Greenwich). 2011;13(5):332–342
3. Adler AJ, Taylor F, Martin N, Gottlieb S, Taylor RS, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Database Syst Rev. 2014;(12):CD009217
4. Damasceno MM, de Araújo MF, de Freitas RW, de Almeida PC, Zanetti ML. The association between blood pressure in adolescents and the consumption of fruits, vegetables and fruit juice--an exploratory study. J Clin Nurs. 2011; 20(11–12):1553–1560
Julia Driggers, RD, LDN, CNSC is a pediatric dietitian at The Children’s Hospital of Philadelphia specializing in gastrointestinal and hepatic liver disease. She is a regular contributor to the Academy of Nutrition and Dietetics Vegetarian Practice Group and a featured Stone Soup Blogger for Food & Nutrition Magazine.
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