Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents Joseph T

CLINICAL PRACTICE GUIDELINE Guidance for the Clinician in Rendering Pediatric Care

Clinical Practice Guideline for Screening and Management Joseph T. Flynn, MD, MS, FAAP,a David C. Kaelber, MD, PhD, MPH, FAAP, FACP, FACMI,b Carissa M. Baker-Smith, MD, MS, MPH,of FAAP, High FAHA,c Douglas Blood Blowey, MD,d Aaron Pressure E. Carroll, MD, MS, FAAP,e Stephenin R. Daniels, MD, PhD, FAAP,f Sarah D. de Ferranti, MD, MPH, FAAP,g Janis M. Dionne, MD, FRCPC,h Bonita Falkner, MD,i Susan K. Flinn, MA,j Samuel S. Gidding, MD,k Celeste Goodwin,l Michael G. Leu, MD, MS, MHS, FAAP,m Makia E. Powers, MD, MPH, FAAP,n Corinna Rea, MD, MPH, FAChildren AP,o Joshua Samuels, MD, MPH,and FAAP,p MadelineAdolescents Simasek, MD, MSCP, FAAP,q Vidhu V. Thaker, MD, FAAP,r Elaine M. Urbina, MD, MS, FAAP,s SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN

These pediatric hypertension guidelines are an update to the 2004 “Fourth abstract Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” Significant changes in these guidelines include (1) the replacement of the term “prehypertension” with the term elevated blood pressure, (2) new normative pediatric blood pressure (BP) aDr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, “ ” Division of Nephrology, Department of Pediatrics, University of tables based on normal-weight children, (3) a simplified screening table for Washington and Seattle Children's Hospital, Seattle, Washington; bDepartments of Pediatrics, Internal Medicine, Population and identifying BPs needing further evaluation, (4) a simplified BP classification Quantitative Health Sciences, Center for Clinical Informatics Research in adolescents ≥13 years of age that aligns with the forthcoming American and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio; cDivision of Pediatric Cardiology, School of Heart Association and American College of Cardiology adult BP guidelines, Medicine, University of Maryland, Baltimore, Maryland; dChildren’s (5) a more limited recommendation to perform screening BP measurements Mercy Hospital, University of Missouri-Kansas City and Children’s Mercy Integrated Care Solutions, Kansas City, Missouri; eDepartment only at preventive care visits, (6) streamlined recommendations on the of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana; fDepartment of Pediatrics, School of Medicine, University initial evaluation and management of abnormal BPs, (7) an expanded role of Colorado-Denver and Pediatrician in Chief, Children’s Hospital for ambulatory BP monitoring in the diagnosis and management of pediatric Colorado, Aurora, Colorado; gDirector, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical hypertension, and (8) revised recommendations on when to perform School, Boston, Massachusetts; hDivision of Nephrology, Department echocardiography in the evaluation of newly diagnosed hypertensive of Pediatrics, University of British Columbia and British Columbia Children’s Hospital, Vancouver, British Columbia, Canada; Departments pediatric patients (generally only before medication initiation), along with a of iMedicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; jConsultant, American revised definition of left ventricular hypertrophy. These guidelines include Academy of Pediatrics, Washington, District of Columbia; kCardiology 30 Key Action Statements and 27 additional recommendations derived Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware; lNational Pediatric Blood Pressure from a comprehensive review of almost 15 000 published articles between Awareness Foundation, Prairieville, Louisiana; Departments of mPediatrics and Biomedical Informatics and Medical Education, January 2004 and July 2016. Each Key Action Statement includes level of University of Washington, University of Washington Medicine and evidence, benefit-harm relationship, and strength of recommendation. This Information Technology Services, and Seattle Children's Hospital, clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce To cite: Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical unnecessary and costly medical interventions, improve patient diagnoses Practice Guideline for Screening and Management of High and outcomes, support implementation, and provide direction for future Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904 research.

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1. Scope of the Clinical Practice preparation process. Potential thickness (cIMT), flow-mediated Guideline conflicts of interest were addressed dilation (FMD), left ventricular and resolved by the AAP. A detailed hypertrophy (LVH), and other list of subcommittee members markers of vascular dysfunction? and affiliations can be found in the Interest in childhood hypertension To address these key questions, a “ Consortium section at the end of this (HTN) has increased since the 2004 systematic search and review of article. A listing of subcommittee publication of the Fourth Report literature was performed. The initial members with conflicts of interest on the Diagnosis, Evaluation, and search included articles published ” will be included in the forthcoming Treatment of High Blood Pressure in between the publication of the Fourth technical report. Children1 and Adolescents (Fourth Report (January 2004) and August Report). Recognizing ongoing The subcommittee epidemiologist 2015. The process used to conduct evidence gaps and the need for an created a detailed content outline, the systematic review was consistent updated, thorough review of the which was reviewed and approved with the recommendations of the relevant literature, the American by the subcommittee. The outline Institute2 of Medicine for systematic Academy of Pediatrics (AAP) and its contained a list of primary and reviews. Council on Quality Improvement and secondary topics generated to Patient Safety developed this practice guide a thorough literature search For the topics not researched by guideline to provide an update on and meet the goal of providing an using the PICOT format, separate topics relevant to the diagnosis, up-to-date systemic review of the searches were conducted. Not all evaluation, and management of literature pertaining to the diagnosis, topics (eg, economic aspects of pediatric HTN. It is primarily directed management, and treatment pediatric HTN) were appropriate for at clinicians caring for children and of pediatric HTN as well as the the PICOT format. A third and final adolescents in the outpatient setting. prevalence of pediatric HTN and its search was conducted at the time the This guideline is endorsed by the associated comorbidities. Key Action Statements (KASs) were American Heart Association. ∼ generated to identify any additional Of the topics covered in the outline, relevant articles published between When it was not possible to 80% were researched by using August 2015 and July 2016. (See identify sufficient evidence, a Patient, Intervention/Indicator, ‍Table 1 for a complete list of KASs.) recommendations are based on the Comparison, Outcome, and Time consensus opinion of the expert (PICOT) format to address the A detailed description of the members of the Screening and following key questions: methodology used to conduct the Management of High Blood Pressure literature search and systematic “ 1. How should systemic HTN (eg, in Children Clinical Practice Guideline review for this clinical practice ” primary HTN, renovascular HTN, guideline will be included in the Subcommittee (henceforth, the white coat hypertension [WCH], forthcoming technical report. In subcommittee ). The subcommittee and masked hypertension [MH]) brief, reference selection involved intends to regularly update this in children be diagnosed, and a multistep process. First, 2 guideline as new evidence becomes what is the optimal approach to subcommittee members reviewed available. Implementation tools for diagnosing HTN in children and the titles and abstracts of references this guideline are available on the adolescents? AAP Web site (https://www.aap.org/ identified for each key question. en-us/about-the-aap/Committees- 2. What is the recommended workup The epidemiologist provided a Councils-Sections/coqips/Pages/ for pediatric HTN? How do we deciding vote when required. Next, best identify the underlying Implementation-1.1 MethodologyGuide.aspx). 2 subcommittee members and the etiologies of secondary HTN in epidemiologist conducted full-text children? reviews of the selected articles. Although many subcommittee The subcommittee was co-chaired 3. What is the optimal goal systolic members have extensively published by a pediatric nephrologist and a blood pressure (SBP) and/or articles on topics covered in general pediatrician and consisted diastolic blood pressure (DBP) for this guideline, articles were not of 17 members, including a parent children and adolescents? preferentially selected on the basis of representative. All subcommittee 4. In children 0 to 18 years of age, authorship. members were asked to disclose how does treatment with lifestyle relevant financial or proprietary versus antihypertensive agents Articles selected at this stage were conflicts of interest for members or influence indirect measures of mapped back to the relevant main their family members at the start cardiovascular disease (CVD) topic in the outline. 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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 1 Summary of KASs for Screening and Management of High BP in Children and Adolescents KAS Evidence Quality, Strength of Recommendation 1. BP should be measured annually in children and adolescents ≥3 y of age. C, moderate 2. BP should be checked in all children and adolescents ≥3 y of age at every health care encounter if they have obesity, are taking C, moderate medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes. 3. Trained health care professionals in the office setting should make a diagnosis of HTN if a child or adolescent has auscultatory- C, moderate confirmed BP readings≥ 95th percentile at 3 different visits. 4. Organizations with EHRs used in an office setting should consider including flags for abnormal BP values, both when the values C, weak are being entered and when they are being viewed. 5. Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a B, strong device that has been validated in the pediatric age group. If elevated BP is suspected on the basis of oscillometric readings, confirmatory measurements should be obtained by auscultation. 6. ABPM should be performed for confirmation of HTN in children and adolescents with office BP measurements in the elevated C, moderate BP category for 1 year or more or with stage 1 HTN over 3 clinic visits. 7. Routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions (see Table B, moderate 12) to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage. 8. ABPM should be performed by using a standardized approach (see Table 13) with monitors that have been validated in a C, moderate pediatric population, and studies should be interpreted by using pediatric normative data. 9. Children and adolescents with suspected WCH should undergo ABPM. Diagnosis is based on the presence of mean SBP and DBP B, strong <95th percentile and SBP and DBP load <25%. 10. Home BP monitoring should not be used to diagnose HTN, MH, or WCH but may be a useful adjunct to office and ambulatory BP C, moderate measurement after HTN has been diagnosed. 11. Children and adolescents ≥6 y of age do not require an extensive evaluation for secondary causes of HTN if they have a C, moderate positive family history of HTN, are overweight or obese, and/or do not have history or physical examination findings (Table 14) suggestive of a secondary cause of HTN. 12. Children and adolescents who have undergone coarctation repair should undergo ABPM for the detection of HTN (including B, strong MH). 13. In children and adolescents being evaluated for high BP, the provider should obtain a perinatal history, appropriate B, strong nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination to identify findings suggestive of secondary causes of HTN. 14. Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for LVH. B, strong 15-1. It is recommended that echocardiography be performed to assess for cardiac target organ damage (LV mass, geometry, C, moderate and function) at the time of consideration of pharmacologic treatment of HTN. 15-2. LVH should be defined as LV mass >51 g/m2.7 (boys and girls) for children and adolescents older than age 8 y and defined by LV mass >115 g/BSA for boys and LV mass >95 g/BSA for girls. 15-3. 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 HTN despite treatment, concentric LV hypertrophy, or reduced LV ejection fraction. 15-4. In patients without LV target organ injury at initial echocardiographic assessment, repeat echocardiography at yearly intervals may be considered in those with stage 2 HTN, secondary HTN, or chronic stage 1 HTN incompletely treated (noncompliance or drug resistance) to assess for the development of worsening LV target organ injury. 16. Doppler renal ultrasonography may be used as a noninvasive screening study for the evaluation of possible RAS in normal- C, moderate wt children and adolescents ≥8 y of age who are suspected of having renovascular HTN and who will cooperate with the procedure. 17. In children and adolescents suspected of having RAS, either CTA or MRA may be performed as noninvasive imaging studies. D, weak Nuclear renography is less useful in pediatrics and should generally be avoided. 18. Routine testing for MA is not recommended for children and adolescents with primary HTN. C, moderate 19. In children and adolescents diagnosed with HTN, the treatment goal with nonpharmacologic and pharmacologic therapy C, moderate should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥ 13 years old. 20. At the time of diagnosis of elevated BP or HTN in a child or adolescent, clinicians should provide advice on the DASH diet and C, weak recommend moderate to vigorous physical activity at least 3 to 5 d per week (30–60 min per session) to help reduce BP. 21. In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy B, moderate on echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic. 22. ABPM may be used to assess treatment effectiveness in children and adolescents with HTN, especially when clinic and/or B, moderate home BP measurements indicate insufficient BP response to treatment. 23-1. Children and adolescents with CKD should be evaluated for HTN at each medical encounter. B, strong 23-2. Children or adolescents with both CKD and HTN should be treated to lower 24-hr MAP <50th percentile by ABPM. 23-3. Regardless of apparent control of BP with office measures, children and adolescents with CKD and a history of HTN should have BP assessed by ABPM at least yearly to screen for MH. 24. Children and adolescents with CKD and HTN should be evaluated for proteinuria. B, strong 25. Children and adolescents with CKD, HTN, and proteinuria should be treated with an ACE inhibitor or ARB. B, strong

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 1 Continued KAS Evidence Quality, Strength of Recommendation 26. Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP ≥95th C, moderate percentile or >130/80 mm Hg in adolescents ≥13 y of age. 27. In children and adolescents with acute severe HTN and life-threatening symptoms, immediate treatment with short-acting Expert opinion, D, weak antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 h. 28. Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and C, moderate cardiovascular risk have been assessed. 29. Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participation in C, moderate competitive sports. 30. Adolescents with elevated BP or HTN (whether they are receiving antihypertensive treatment) should typically have their care X, strong transitioned to an appropriate adult care provider by 22 y of age (recognizing that there may be individual cases in which this upper age limit is exceeded, particularly in the case of youth with special health care needs). There should be a transfer of information regarding HTN etiology and past manifestations and complications of the patient’s HTN.

writing teams that evaluated the since 1988, indicate that there has Trajectory data on BP (including evidence quality for selected topics been an increase in the prevalence repeat measurements from early

and generated appropriate KASs of childhood high BP, including4,5 childhood into midadulthood) in accordance with an AAP grading both HTN and elevated BP. High confirm the association of elevated – – matrix (see Fig 1 and the detailed BP is consistently greater in boys BP in adolescence11 with HTN in early discussion in the forthcoming3 (15% 19%) than in girls (7% 12%). adulthood and that normal BP in technical report). Special working The prevalence of high BP is higher childhood is associated11 with a lack of groups were created to address 2 among Hispanic and non-Hispanic 2.2HTN Awareness, in midadulthood Treatment,. and specific topics for which evidence African American children compared Control of HTN in Children was lacking and expert opinion with non-Hispanic white children, “ ” “ was required to generate KASs, with higher rates among adolescents ” 6 Definition of HTN and Definition than among younger children. Of the 32.6% of US adults who of LVH. References for any topics not However, in a clinical setting and have HTN, almost half (17.2%) are covered by the key questions were with repeated BP measurements, not aware they have HTN; even selected on the basis of additional the prevalence of confirmed HTN is among those who are aware of literature searches and reviewed by lower in part because of inherent BP their condition, only approximately the epidemiologist and subcommittee 12 variability as well as an adjustment half (54.1%) have controlled BP. members assigned to the topic. When to the experience of having BP Unfortunately, there are no large applicable, searches were conducted measured (also known as the studies in which researchers have by using the PICOT format . accommodation effect). Therefore, systematically studied BP awareness In addition to the 30 KASs listed the actual prevalence of clinical or control in youth, although an ∼ above, this guideline also contains HTN in children7,8 and adolescents analysis of prescribing patterns 27 additional recommendations is 3.5%. The prevalence of from a nationwide prescription drug “ ” that are based on the consensus persistently elevated BP (formerly provider found an increase in the expert opinion of the subcommittee termed prehypertension, including number of prescriptions written members. These recommendations, BP values from the 90th to 94th for high BP in youth from 2004 to 13 along with their locations in the percentiles or between 120/80 and 2007. ∼ document, are listed in Table 2. 130/80 mmHg in adolescents) is also The SEARCH for Diabetes in Youth 2. Epidemiology and Clinical 2.2% to 3.5%, with higher rates study found that only 7.4% of Significance among children and adolescents who 7,9 youth with type 1 diabetes mellitus have overweight and obesity. 2.1 Prevalence of HTN in Children (T1DM) and 31.9% of youth with Data on BP tracking from childhood type 2 diabetes mellitus (T2DM)

to adulthood demonstrate that demonstrated14 knowledge of their Information on the prevalence higher BP in childhood correlates BP status. Even after becoming of high blood pressure (BP) in with higher BP in adulthood aware of the diagnosis, only 57.1% children is largely derived from data and the onset of HTN in young of patients with T1DM and 40.6% of

from the NHANES and typically is adulthood. The strength of the patients with14 T2DM achieved good based on a single BP measurement tracking relationship is stronger10 in BP control. The HEALTHY Primary session. These surveys, conducted older children and adolescents. Prevention Trial of Risk Factors for Downloaded from www.aappublications.org/news by guest on September 25, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 2 Additional Consensus Opinion Recommendations and Text Locations Recommendation CPG Section(s) Type 2 Diabetes in Middle-School Youth, which examined a school- 1. Follow the revised classification scheme in Table 3 for childhood BP levels, including 3.1 based intervention designed to the use of the term “elevated BP,” the new definition of stage 2 HTN, and the use of similar BP levels as adults for adolescents ≥13 y of age. reduce cardiovascular (CV) risk 2. Use simplified BP tables (Table 4) to screen for BP values that may require further 3.2a among middle school students, found evaluation by a clinician. ∼ the prevalence15 of stage 1 or 2 HTN to 3. Use reference data on neonatal BP from ref 80 to identify elevated BP values in 3.3 be 9.5%. There was no significant neonates up to 44 wk postmenstrual age and BP curves from the 1987 Second Task reduction in HTN in the control Force report to identify elevated BP values in infants 1–12 mo of age. group after the intervention; the 4. Use the standardized technique for measuring BP by auscultation described in Table 4.1 ∼ 7 and Fig 2 (including appropriate cuff size, extremity, and patient positioning) to intervention group saw a reduction obtain accurate BP values. in the prevalence of HTN of 1%, 5. If the initial BP at an office visit is elevated, as described in Fig 3, obtain 2 4.1 leaving 8.5% with BP still above the additional BP measurements at the same visit and average them; use the averaged ideal range. auscultatory BP measurement to determine the patient’s BP category. 6. Oscillometric devices are used to measure BP in infants and toddlers until they are 4.1a Researchers in a number of able to cooperate with auscultatory BP. Follow the same rules for BP measurement technique and cuff size as for older children. small, single-center studies have 7. Measure BP at every health care encounter in children <3 y of age if they have an 4.2 evaluated BP control in children underlying condition listed in Table 9 that increases their risk for HTN. and adolescents with HTN. One 8. After a patient’s BP has been categorized, follow Table 11 for when to obtain repeat 4.3 study found that lifestyle change BP readings, institute lifestyle changes, or proceed to a workup for HTN. and medications produced adequate 9. When an oscillometric BP reading is elevated, obtain repeat readings, discard the 4.5 first reading, and average subsequent readings to approximate auscultatory BP. BP control16 in 46 of 65 youth (70%) 10. Wrist and forearm BP measurements should not be used in children and 4.6 with HTN. Another study in which adolescents for the diagnosis or management of HTN. researchers used ambulatory blood 11. Use ABPM to evaluate high-risk patients (those with obesity, CKD, or repaired aortic 4.7a, 4.8 pressure monitoring (ABPM) to coarctation) for potential MH. assess BP control among a group 12. Routine use of BP readings obtained in the school setting is not recommended for 4.10 diagnosis of HTN in children and adolescents. of 38 children (of whom 84% had 13. Use the history and physical examination to identify possible underlying causes of 5.2–5.4, 5.7, chronic kidney disease [CKD]) found HTN, such as heart disease, kidney disease, renovascular disease, endocrine HTN 9.2 that only 13 children (34%) achieved (Table 15), drug-induced HTN (Table 8), and OSAS-associated HTN (Table 18). adequate BP control even among 14. Suspect monogenic HTN in patients with a family history of early-onset HTN, 5.8 those who received more than 1 hypokalemia, suppressed plasma renin, or an elevated ARR. 17 15. Obtain laboratory studies listed in Table 10 to evaluate for underlying secondary 6.4 drug. A similar study found that causes of HTN when indicated. additional drugs did increase rates 16. Routine use of vascular imaging, such as carotid intimal-media measurements or 6.7 of BP control18 in children with CKD, PWV measurements, is not recommended in the evaluation of HTN in children and however2.3 Prevalence. of HTN Among adolescents. 17. Suspect renovascular HTN in selected children and adolescents with stage 2 HTN, 6.8a Children With Various Chronic significant diastolic HTN, discrepant kidney sizes on ultrasound, hypokalemia on Conditions screening laboratories, or an epigastric and/or upper abdominal bruit on physical examination. 18. Routine measurement of serum UA is not recommended for children and 6.9 adolescents with elevated BP. It is well recognized that HTN rates 19. Offer intensive weight-loss programs to hypertensive children and adolescents with 7.2c are higher in children with certain obesity; consider using MI as an adjunct to the treatment of obesity. chronic conditions, including children 20. Follow-up children and adolescents treated with antihypertensive medications 7.3c with obesity, sleep-disordered every 4–6 wk until BP is controlled, then extend the interval. Follow-up every 3–6 mo breathing (SDB), CKD, and those born is appropriate for patients treated with lifestyle modification only. 21. Evaluate and treat children and adolescents with apparent treatment-resistant HTN 7.4 2.3apreterm. Children These With are Obesity described below. in a similar manner to that recommended for adults with resistant HTN. 22. Treat hypertensive children and adolescents with dyslipidemia according to 9.1 current, existing pediatric lipid guidelines. 23. Use ABPM to evaluate for potential HTN in children and adolescents with known or 9.2 HTN prevalence ranges from 3.8% suspected OSAS. to 24.8% in youth with overweight 24. Racial, ethnic, and sex differences need not be considered in the evaluation and 10 and obesity.– Rates of HTN increase management of children and adolescents with HTN. in a graded19 fashion24 with increasing 25. Use ABPM to evaluate BP in pediatric heart- and kidney-transplant recipients. 11.3 adiposity. ‍ ‍ Similar relationships

are seen between HTN4,25,26 and increasing waist circumference. Systematic27 reviews of 63 studies on BMI and 61 studies on various measures Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 5

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 2 Continued Recommendation CPG latter in pediatric patients is lacking. Section(s) ∼ 26. Reasonable strategies for HTN prevention include the maintenance of a normal 13.2 Among children– and adolescents BMI, consuming a DASH-type diet, avoidance of excessive sodium consumption, and with CKD, 50%46 48 are known to be regular vigorous physical activity. hypertensive. ‍ ‍ In children and 27. Provide education about HTN to patients and their parents to improve patient 15.2, 15.3 adolescents with end-stage renal involvement in their care and better achieve therapeutic goals. ∼ disease (either those on dialysis Based on the expert opinion of the subcommittee members (level of evidence = D; strength of recommendations = weak). CPG, clinical practice guideline. or after transplant), 48% to– 79%

are hypertensive, with 20%49 to53 70% having uncontrolled HTN. ‍ ‍

28 Almost 20% of pediatric54 HTN may be of abdominal adiposity have hard to demonstrate definitively, 2.3dattributable Children toWith CKD History. of shown associations between these the Strong Heart Study did show Prematurity conditions and HTN. Obesity is also that American Indian adolescents — associated with a lack of circadian with multiple cardiometabolic risk 29,30 — variability of BP, with up to 50% factors had a higher prevalenceP of Abnormal birth history including of children– who have obesity not LVH (43.2% vs 11.7%), left atrial preterm birth and low birth weight

experiencing31 33 the expected nocturnal dilation (63.1% vs 21.9%; < .001), has been identified as a risk factor55 for BP dip. ‍ and reduced LV systolic and diastolic HTN and other CVD in adults ; only Studies have shown that childhood function compared with those low birth weight has been associated without multiple39 cardiometabolic with elevated56 BP in the pediatric age obesity is also related to the22 development of future HTN. risk factors. Notably, both obesity range. One retrospective cohort Elevated BMI as early as infancy and HTN were drivers of these CV study showed a prevalence of HTN abnormalities, with obesity being of 7.3% among 3 year57 olds who is associated34 with higher future BP. This risk appears to increase a stronger determinant of cardiac were born preterm. Researchers with obesity severity; there is a abnormalities than HTN (odds ratio, in another retrospective case series 2.3b Children With SDB fourfold increase in BP among those 4.17 vs 1.03). noted a high prevalence of HTN with severe obesity (BMI >99th in older children58 with a history of – percentile) versus a twofold increase preterm birth. It also appears that in those with obesity (BMI 95th 98th SDB occurs on a spectrum that preterm birth may result in abnormal59 includes (1) primary snoring, circadian BP patterns in childhood. percentiles) compared with normal-35 weight children and adolescents. (2) sleep fragmentation, and (3) These data are intriguing but limited. obstructive sleep apnea syndrome Further study is needed to determine Collectively, the results of these (OSAS). Researchers in numerous how often preterm birth results in cross-sectional and longitudinal studies have identified –an association childhood2.4 Importance HTN. of Diagnosing HTN in studies firmly establish an increasing between SDB and HTN40 in42 the Children and Adolescents prevalence of HTN with increasing pediatric population. ‍ ‍ Studies BMI percentile. The study results suggest that children who sleep also underscore the importance of 7 hours or less per night43 are at Numerous studies have shown that monitoring BP in all children with increased risk for HTN. Small elevated BP in –childhood increases overweight and/or obesity at every studies of youth with sleep disorders the risk for adult HTN and metabolic clinical encounter. 10,60 62 have found the prevalence of high40,41 BP syndrome. ‍ ‍ ‍ Youth with higher Obesity in children with HTN may to range between 3.6% and 14%. BP levels in childhood are also more

be accompanied by additional The more severe the OSAS, the44,45 more likely to60,63 have persistent HTN as cardiometabolic risk factors (eg, likely a child is to have HTN. adults. One recent study found

dyslipidemia36,37 and disordered glucose Even inadequate duration of sleep that adolescents with elevated metabolism) that may have their and poor-quality sleep have 43been BP progressed to HTN at a rate 2.3c Children With CKD own effects on BP or may represent associated with elevated BP. of 7% per year, and elevated BMI 64 comorbid conditions arising from25,38 the predicted sustained BP elevations. same adverse lifestyle behaviors. In addition, young patients with HTN

Some argue that the presence of There are well-established are likely to experience accelerated65 multiple risk factors, including pathophysiologic links between vascular aging. Both66 autopsy and obesity and HTN, leads to far greater childhood HTN and CKD. Certain imaging studies have demonstrated increases in CV risk than is explained forms of CKD can lead to HTN, and BP-related CV damage in youth.

by the individual risk factors alone. untreated HTN can lead to CKD in These intermediate markers67 of 68CVD Although this phenomenon has been adults, although evidence for the (eg, increased LV mass, cIMT, and Downloaded from www.aappublications.org/news by guest on September 25, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 3 Updated Definitions of BP Categories and Stages 69 For Children Aged 1–13 y For Children Aged ≥13 y pulse wave velocity [PWV] ) are known to predict CV events in adults, Normal BP: <90th percentile Normal BP: <120/<80 mm Hg Elevated BP: ≥90th percentile to <95th percentile or 120/80 Elevated BP: 120/<80 to 129/<80 mm Hg making it crucial to diagnose and mm Hg to <95th percentile (whichever is lower) treat HTN early. Stage 1 HTN: ≥95th percentile to <95th percentile + 12 mmHg, Stage 1 HTN: 130/80 to 139/89 mm Hg Eighty million US adults (1 in 3) have or 130/80 to 139/89 mm Hg (whichever is lower) Stage 2 HTN: ≥95th percentile + 12 mm Hg, or ≥140/90 mm Hg Stage 2 HTN: ≥140/90 mm Hg HTN, which12 is a major contributor (whichever is lower) to CVD. Key contributors to CV health have been identified by the “ ’ ” American Heart Association (AHA) as Life s Simple 7, including 4 disorder. Early detection of HTN lower. HTN was defined as average ideal health behaviors (not smoking, ≥ is vital given the greater relative clinic measured SBP and/or DBP normal BMI, physical activity at goal prevalence of secondary causes of 95th percentile (on the basis of levels, and a healthy diet) and 3 ideal HTN in children compared with age, sex, and height percentiles) health factors (untreated, normal adults. and was further classified as stage 1 total cholesterol; normal fasting ≤ 3. Definition of HTN or stage 2 HTN. blood glucose; and normal untreated

There are still no data to identify BP, defined in childhood as 90th 3.1 Definition of HTN (1–18 Years of percentile or <120/80 mmHg). Age) a specific level of BP in childhood Notably, elevated BP is the least that leads to adverse CV outcomes common abnormal health factor in in adulthood. Therefore, the – 70 subcommittee decided to children and adolescents ; 89% of Given the lack of outcome data, maintain a statistical definition youth (ages 12 196 years) are in the the current definition of HTN in for childhood HTN. The staging ideal BP category. children and adolescents is based criteria have been revised for Given the prevalence of known key on the normative distribution of 1 stage 1 and stage 2 HTN for ease contributors in youth (ie, tobacco BP in healthy children. Because of implementation compared with exposure, obesity, inactivity, and it is a major determinant of BP in ≥ 12,71 the Fourth Report. For children nonideal diet ), adult CVD likely growing children, height has been 13 years of age, this staging has its origins in childhood. One- incorporated into the normative scheme will seamlessly interface third of US adolescents report data since the publication of the – 1 with the 2017 AHA and American having tried a cigarette in the past 1996 Working Group Report. BP 72 College of Cardiology (ACC) adult 30 days. Almost half (40% 48%) levels should be interpreted on “ ” HTN guideline.* Additionally, the of teenagers have elevated BMI, the basis of sex, age, and height to “ term prehypertension has been and the rates of severe obesity avoid misclassification of children ” replaced by the term elevated (BMI >99th percentile) continue who are either extremely tall or – blood pressure, to be consistent to climb, particularly in girls and extremely short. It should be noted 73 75 with the AHA and ACC guideline adolescents. ‍ Physical activity that the normative data were and convey the importance of measured by accelerometry shows collected by using an auscultatory 1 lifestyle measures to prevent the less than half of school-aged boys technique, which may provide 3.2development New BP Tables of HTN (see Table 3). and only one-third of school-aged different values than measurement

girls meet the 72goal for ideal physical obtained by using oscillometric activity levels. More than 80% devices or from ABPM.“ New normative BP tables based on of youth 12 to 19 years of age ” In the Fourth Report, normal blood normal-weight children are included have a poor diet (as defined by ∼ pressure was defined as SBP and with these guidelines (see Tables 4 AHA metrics for ideal CV health); ∼ DBP values <90th percentile (on and 5). Similar to the tables in the only 10% eat adequate fruits the basis of age, sex, and height “ ” and vegetables, and only 15% percentiles). For the preadolescent, ≥ *Whelton PK, Carey RM, Aranow WS, et al. ACC/ consume <1500 mg per day of prehypertension was defined as sodium, both of which are key AHA/APPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/ 76 SBP and/or DBP 90th percentile PCNA Guideline for the prevention, detection, dietary determinants of HTN. and <95th percentile (on the basis evaluation and managament of high blood “ ” Finally, measuring BP at routine of age, sex, and height tables). For pressure in adults: A report of the American ≥ well-child visits enables the early adolescents, prehypertension College of Cardiology/American Heart Association ≥ Task Force on Clinical Practice Guidelines. detection of primary HTN as well as was defined as BP 120/80 mm Hg Hypertension. 2017, In press. the detection of asymptomatic HTN to <95th percentile, or 90th and secondary to another underlying <95th percentile, whichever was Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 7

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics 1 Fourth Report, they include SBP and understand that the scheme in Table In an attempt to develop a more DBP values arranged by age, sex, and 3 was chosen to align with the new standardized approach to the HTN

height (and height percentile). These adult guideline and facilitate the definition in preterm and79 term values are based on auscultatory management of older adolescents neonates, Dionne et al compiled ∼ measurements obtained from with high BP. The percentile- available data on neonatal BP and 50000 children and adolescents. A based values in Tables 4 and 5 are generated a summary table of BP new feature in these tables is that the provided to aid researchers and values, including values for the 95th ’ BP values are categorized according others interested in a more precise and 99th percentiles for infants from to the scheme presented in Table 3 classification3.2a. Simplified of BP.BP Table 26 to 44 weeks postmenstrual age. as normal (50th percentile), elevated The authors proposed that by using ≥ BP (>90th percentile), stage 1 HTN these values, a similar approach to ≥ ( 95th percentile), and stage 2 HTN This guideline includes a new, that used to identify older children ( 95th percentile + 12 mmHg). simplified table for initial BP with elevated BP can be followed in Additionally, actual heights in screening (see Table 6) based on neonates, even in those who are born centimeters and inches are provided. the 90th percentile BP for age and preterm. sex for children at the 5th percentile Unlike the tables in the Fourth At present, no alternative data have 1 of height, which gives the values in Report, the BP values in these been developed, and no outcome data the table a negative predictive value tables do not include children and 78 are available on the consequences of ≥ of >99%. This simplified table is adolescents with overweight and high BP in this population; thus, it is designed as a screening tool only obesity (ie, those with a BMI 85th reasonable to use these compiled BP for the identification of children percentile); therefore, they represent values in the assessment of elevated and adolescents who need further “ normative BP values for normal- BP in newborn infants. Of note, the evaluation of their BP starting with weight youth. The decision to create 1987 Report of the Second Task repeat BP measurements. It should ” these new tables was based on Force on Blood Pressure Control not be used to diagnose elevated evidence of the strong association in Children published curves BP or HTN by itself. To diagnose of both overweight and obesity with of normative BP values in older elevated BP or HTN, it is important 81 elevated BP and HTN. Including infants up to 1 year of age. These to locate the actual cutoffs in the patients with overweight and normative values should continue complete BP tables because the SBP obesity in normative BP tables was ’ to be used given the lack of more and DBP cutoffs may be as much as 9 thought to create bias. The practical contemporary data for this age group. mmHg higher depending on a child s effect of this change is that the BP age and length or height. A typical- 4. Measurement of BP values in Tables 4 and 5 are several use case for this simplified table is millimeters of mercury lower than for nursing staff to quickly identify 4.1 BP Measurement Technique in the similar tables in the Fourth ≥ 1 BP that may need further evaluation Report. These tables are based on by a clinician. For adolescents 13 the same population data excluding years of age, a threshold of 120/80 BP in childhood may vary participants with overweight and mmHg is used in the simplified considerably between visits and obesity, and the same methods used 1 table regardless of sex to align with even during the same visit. There in the Fourth Report. The methods adult guidelines for the detection of are many potential etiologies for and results have been published 77 elevated3.3 Definition BP. of HTN in the Neonate isolated elevated BP in children and elsewhere. For researchers and ’ and Infant (0–1 Year of Age) adolescents, including such factors as others interested in the equations 82 anxiety and recent caffeine intake. used to calculate the tables BP BP generally decreases with repeated values, detailed methodology and 83 Although a reasonably strict measurements during a single visit, the Statistical Analysis System (SAS) definition of HTN has been developed although the variability may code can be found at: http://sites. for older children, it is more difficult not be large enough to affect BP google.com/a/channing.harvard. 84 to define HTN in neonates given the classification. BP measurements edu/bernardrosner/pediatric- blood- 64,85 well-known changes in BP that occur can also vary across visits ; one press/childhood- blood- pressure. 79 during the first few weeks of life. study in adolescents found that only

There are slight differences between These BP changes can be significant 56% of the sample had the same 8 the actual percentile-based values in preterm infants, in whom BP HTN stage on 3 different occasions. in these tables and the cut-points in depends on a variety of factors, Therefore, it is important to obtain ≥ ‍Table 3, particularly for teenagers including postmenstrual age, birth80 multiple measurements over time 13 years of age. Clinicians should weight, and maternal conditions. before diagnosing HTN. Downloaded from www.aappublications.org/news by guest on September 25, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS

DBP (mm Height Percentile or Measured Hg)

SBP (mm 43.0 44.3 45.5 46.7 47.4 41.1 41.8 43.0 44.3 45.5 46.7 47.4 Height Percentile or Measured 91 92 93 94 95 96 96 51 51 52 53 54 55 55 85 85 86 86 87 88 88 40 40 40 41 41 42 42 98 99 99 100 100 101 101 52 52 53 53 54 54 54 93 93 94 95 96 97 98 54 54 55 56 57 57 58 87 87 88 89 89 90 91 43 43 44 44 45 46 46 94 94 95 97 98 98 99 56 56 57 58 58 59 59 88 89 89 90 91 92 92 45 46 46 47 48 49 49 5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95% 90 90 91 92 93 94 94 48 49 49 50 51 52 52 119 120 121 121 122 123 124 78 79 80 81 82 82 83 114 114 115 115 116 117 117 66 66 67 67 68 69 69 120 121 122 123 124 125 126 81 82 82 83 84 84 85 116 117 117 118 119 119 120 69 70 70 71 72 73 73 122 122 123 124 126 127 128 83 83 84 85 85 86 86 118 118 119 119 120 121 121 72 73 73 74 75 76 76 119 119 120 120 121 122 122 75 76 77 78 79 79 80 Hg Hg Hg Hg Hg Hg Hg

50th 50th 90th 103 104 105 106 107 108 108 63 64 65 65 66 67 67 90th 95th 107 108 109 109 110 111 112 66 67 68 69 70 70 71 95th 102 102 103 103 104 105 105 54 54 55 55 56 57 57 50th 50th 90th 105 105 106 107 109 110 110 66 66 67 68 68 69 69 90th 100 100 101 102 103 103 104 55 55 56 56 57 58 58 95th 108 109 110 111 112 113 114 69 70 70 71 72 72 73 95th 104 105 105 106 107 107 108 57 58 58 59 60 61 61 50th 50th 90th 106 107 108 109 110 111 111 68 68 69 70 70 71 71 90th 101 102 102 103 104 105 105 58 58 59 59 60 61 61 95th 110 110 111 112 114 115 116 71 71 72 73 73 74 74 95th 106 106 107 107 108 109 109 60 61 61 62 63 64 64 50th 90th 102 103 104 105 105 106 107 60 61 62 62 63 64 64 95th 107 107 108 108 109 110 110 63 64 65 66 67 67 68 Height (in) 30.4 30.8 31.6 32.4 33.3 34.1 34.6 30.4 30.8 31.6 32.4 33.3 34.1 34.6 Height (in) 43.4 44.2 45.4 46.8 48.2 49.4 50.2 43.4 44.2 45.4 46.8 48.2 49.4 50.2 Height (in) 33.9 34.4 35.3 36.3 37.3 38.2 38.8 33.9 34.4 35.3 36.3 37.3 38.2 38.8 Height (in) 45.7 46.5 47.8 49.3 50.8 52.1 52.9 45.7 46.5 47.8 49.3 50.8 52.1 52.9 Height (in) 36.4 37 37.9 39 40.1 41.1 41.7 36.4 37 37.9 39 40.1 41.1 41.7 Height (in) 38.8 39.4 40.5 41.7 42.9 43.9 44.5 38.8 39.4 40.5 41.7 42.9 43.9 44.5 Height (in) 41.1 41.8 Height (cm) 104.4 106.2 109.1 112.4 115.7 118.6 120.3 104.4 106.2 109.1 112.4 115.7 118.6 120.3 Height (cm) 77.2 78.3 80.2 82.4 84.6 86.7 87.9 77.2 78.3 80.2 82.4 84.6 86.7 87.9 Height (cm) 110.3 112.2 115.3 118.9 122.4 125.6 127.5 110.3 112.2 115.3 118.9 122.4 125.6 127.5 Height (cm) 86.1 87.4 89.6 92.1 94.7 97.1 98.5 86.1 87.4 89.6 92.1 94.7 97.1 98.5 Height (cm) 116.1 118 121.4 125.1 128.9 132.4 134.5 116.1 118 121.4 125.1 128.9 132.4 134.5 Height (cm) 92.5 93.9 96.3 99 101.8 104.3 105.8 92.5 93.9 96.3 99 101.8 104.3 105.8 Height (cm) 98.5 100.2 102.9 105.9 108.9 111.5 113.2 98.5 100.2 102.9 105.9 108.9 111.5 113.2 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm BP Levels for Boys by Age and Height Percentile

1 Age (y) BP Percentile 6 2 7 3 4 5 TABLE 4

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DBP (mm Height Percentile or Measured Hg)

SBP (mm 58.1 60.1 62.2 64 65.2 55.2 56.3 58.1 60.1 62.2 64 65.2 Height Percentile or Measured 95 96 97 98 99 99 100 57 57 58 59 59 60 60 96 97 98 99 100 101 101 57 58 59 60 61 62 62 97 98 99 100 101 102 103 59 60 61 62 63 63 64 5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95% 99 99 101 102 103 104 106 61 61 62 63 63 63 63 128 129 130 133 136 138 140 90 90 90 90 90 91 91 123 124 124 126 127 128 129 84 85 85 86 87 87 87 131 132 134 137 140 142 143 90 90 90 90 92 93 93 124 124 125 127 128 130 131 86 86 87 88 88 89 89 135 137 139 142 144 145 146 89 90 91 93 94 95 96 124 125 126 128 130 132 133 88 88 89 89 90 90 90 126 126 128 130 132 135 136 89 90 90 90 90 90 90 Hg Hg Hg Hg Hg Hg Hg

50th 101 101 102 104 106 108 109 61 62 62 62 62 63 63 50th 90th 113 114 115 117 119 121 122 75 75 75 75 75 76 76 90th 107 108 109 110 111 112 112 69 70 70 71 72 72 73 95th 116 117 118 121 124 126 128 78 78 78 78 78 79 79 95th 111 112 112 114 115 116 117 72 73 73 74 75 75 75 50th 103 104 105 108 110 111 112 61 60 61 62 63 64 65 50th 90th 115 116 118 121 124 126 126 74 74 74 75 76 77 77 90th 107 108 109 110 112 113 114 70 71 72 73 74 74 74 95th 119 120 122 125 128 130 131 78 78 78 78 80 81 81 95th 112 112 113 115 116 118 119 74 74 75 76 76 77 77 50th 105 106 109 111 112 113 113 60 60 62 64 65 66 67 50th 90th 119 120 123 126 127 128 129 74 74 75 77 78 79 80 90th 108 109 111 112 113 115 116 72 73 74 74 75 75 76 95th 123 125 127 130 132 133 134 77 78 79 81 82 83 84 95th 112 113 114 116 118 120 121 76 76 77 77 78 78 78 50th 90th 110 111 112 114 116 117 118 74 74 75 75 75 76 76 95th 114 114 116 118 120 123 124 77 78 78 78 78 78 78 Height (in) 47.8 48.6 50 51.6 53.2 54.6 55.5 47.8 48.6 50 51.6 53.2 54.6 55.5 Height (in) 57.9 59.1 61 63.1 65.2 67.1 68.3 57.9 59.1 61 63.1 65.2 67.1 68.3 Height (in) 49.6 50.5 52 53.7 55.4 56.9 57.9 49.6 50.5 52 53.7 55.4 56.9 57.9 Height (in) 60.6 61.8 63.8 65.9 68.0 69.8 70.9 60.6 61.8 63.8 65.9 68.0 69.8 70.9 Height (in) 51.3 52.2 53.8 55.6 57.4 59.1 60.1 51.3 52.2 53.8 55.6 57.4 59.1 60.1 Height (in) 53 54 55.7 57.6 59.6 61.3 62.4 53 54 55.7 57.6 59.6 61.3 62.4 Height (in) 55.2 56.3 Height (cm) 140.3 143 147.5 152.7 157.9 162.6 165.5 140.3 143 147.5 152.7 157.9 162.6 165.5 Height (cm) 121.4 123.5 127 131 135.1 138.8 141 121.4 123.5 127 131 135.1 138.8 141 Height (cm) 147 150 154.9 160.3 165.7 170.5 173.4 147 150 154.9 160.3 165.7 170.5 173.4 Height (cm) 126 128.3 132.1 136.3 140.7 144.7 147.1 126 128.3 132.1 136.3 140.7 144.7 147.1 Height (cm) 153.8 156.9 162 167.5 172.7 177.4 180.1 153.8 156.9 162 167.5 172.7 177.4 180.1 Height (cm) 130.2 132.7 136.7 141.3 145.9 150.1 152.7 130.2 132.7 136.7 141.3 145.9 150.1 152.7 Height (cm) 134.7 137.3 141.5 146.4 151.3 155.8 158.6 134.7 137.3 141.5 146.4 151.3 155.8 158.6 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm Continued

8 Age (y) BP Percentile 13 9 14 10 11 12 TABLE 4

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DBP (mm Hg). The 50th, 90th, and 95th percentiles were derived by using

Height Percentile or Measured Hg)

SBP (mm 77 . Table 3 (elevated BP: ≥ 90th percentile; stage 1 HTN: 95th and 2 percentile + 12 mm

Height Percentile or Measured 5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95% 139 141 143 144 146 147 147 90 91 93 95 96 97 97 142 143 145 146 147 148 149 92 93 95 96 97 98 98 144 145 146 147 149 150 150 93 94 96 97 98 98 99 Hg Hg Hg

50th 108 110 112 113 114 114 114 61 62 64 65 66 67 68 90th 123 124 126 128 129 130 130 75 76 78 79 80 81 81 95th 127 129 131 132 134 135 135 78 79 81 83 84 85 85 50th 111 112 114 115 115 116 116 63 64 66 67 68 69 69 90th 126 127 128 129 131 131 132 77 78 79 80 81 82 82 95th 130 131 133 134 135 136 137 80 81 83 84 85 86 86 50th 114 115 116 117 117 118 118 65 66 67 68 69 70 70 90th 128 129 130 131 132 133 134 78 79 80 81 82 82 83 95th 132 133 134 135 137 138 138 81 82 84 85 86 86 87 Height (in) 62.6 63.8 65.7 67.8 69.8 71.5 72.5 62.6 63.8 65.7 67.8 69.8 71.5 72.5 Height (in) 63.8 64.9 66.8 68.8 70.7 72.4 73.4 63.8 64.9 66.8 68.8 70.7 72.4 73.4 Height (in) 64.5 65.5 67.3 69.2 71.1 72.8 73.8 64.5 65.5 67.3 69.2 71.1 72.8 73.8 Height (cm) 159 162 166.9 172.2 177.2 181.6 184.2 159 162 166.9 172.2 177.2 181.6 184.2 Height (cm) 162.1 165 169.6 174.6 179.5 183.8 186.4 162.1 165 169.6 174.6 179.5 183.8 186.4 Height (cm) 163.8 166.5 170.9 175.8 180.7 184.9 187.5 163.8 166.5 170.9 175.8 180.7 184.9 187.5 95th + 12 mm 95th + 12 mm 95th + 12 mm Continued

Age (y) BP Percentile 15 16 17 TABLE 4 Use percentile values to stage BP readings according the scheme in quantile regression on the basis of normal-weight children (BMI <85th percentile)

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DBP (mm Height Percentile or Measured Hg)

SBP (mm 42.6 43.9 45.2 46.5 47.3 40.8 41.5 42.6 43.9 45.2 46.5 47.3 Height Percentile or Measured 89 90 91 92 93 94 94 50 51 51 53 54 55 55 92 93 94 95 97 98 99 55 55 56 57 58 59 60 88 89 89 90 91 92 93 48 48 49 50 51 53 53 92 92 93 94 96 97 97 54 54 55 56 57 58 59 87 87 88 89 90 91 91 45 46 47 48 49 50 51 90 91 92 93 94 95 96 52 52 53 55 56 57 57 98 99 99 100 101 102 102 54 55 56 56 57 58 58 84 85 86 86 87 88 88 41 42 42 43 44 45 46 5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95% 119 120 121 121 122 123 124 78 79 80 81 82 82 83 107 108 109 109 110 111 112 66 67 68 69 70 70 71 103 104 105 106 107 108 108 62 63 64 65 66 67 67 121 122 123 124 125 126 127 84 84 85 85 86 86 87 109 110 111 112 113 114 115 72 72 73 73 74 74 75 106 106 107 109 110 111 112 68 68 69 70 71 72 72 118 118 119 120 121 122 122 76 77 77 78 79 80 81 106 106 107 108 109 110 110 64 65 65 66 67 68 69 102 103 104 104 105 106 107 60 61 61 62 63 64 65 121 121 122 123 124 125 126 82 83 84 84 85 86 86 109 109 110 111 112 113 114 70 71 72 72 73 74 74 105 106 107 108 109 110 111 67 67 68 69 70 71 71 116 117 118 118 119 120 121 74 75 75 76 77 78 78 104 105 106 106 107 108 109 62 63 63 64 65 66 66 101 101 102 103 104 105 106 58 58 59 60 61 62 62 108 109 109 110 111 112 113 68 69 70 71 72 73 73 120 121 121 122 123 124 125 80 81 82 83 84 85 85 104 105 106 107 108 109 110 64 65 66 67 68 69 70 101113 102 114 102 114 103 115 104 116 105 117 105 117 59 71 59 71 60 72 60 72 61 73 62 74 62 74 Hg Hg Hg Hg Hg Hg Hg

95th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 50th Height (in) 40.8 41.5 Height (in) 38.3 38.9 39.9 41.1 42.4 43.5 44.2 38.3 38.9 39.9 41.1 42.4 43.5 44.2 Height (in) 45.6 46.4 47.7 49.2 50.7 52.1 53 45.6 46.4 47.7 49.2 50.7 52.1 53 Height (in) 35.8 36.4 37.3 38.4 39.6 40.6 41.2 35.8 36.4 37.3 38.4 39.6 40.6 41.2 Height (in) 43.3 44 45.2 46.6 48.1 49.4 50.3 43.3 44 45.2 46.6 48.1 49.4 50.3 Height (in) 33.4 34 34.9 35.9 36.9 37.8 38.4 33.4 34 34.9 35.9 36.9 37.8 38.4 Height (in) 29.7 30.2 30.9 31.8 32.7 33.4 33.9 29.7 30.2 30.9 31.8 32.7 33.4 33.9 Height (cm) 97.2 98.8 101.4 104.5 107.6 110.5 112.2 97.2 98.8 101.4 104.5 107.6 110.5 112.2 Height (cm) 115.9 117.8 121.1 124.9 128.8 132.5 134.7 115.9 117.8 121.1 124.9 128.8 132.5 134.7 Height (cm) 91 92.4 94.9 97.6 100.5 103.1 104.6 91 92.4 94.9 97.6 100.5 103.1 104.6 Height (cm) 110 111.8 114.9 118.4 122.1 125.6 127.7 110 111.8 114.9 118.4 122.1 125.6 127.7 Height (cm) 84.9 86.3 88.6 91.1 93.7 96 97.4 84.9 86.3 88.6 91.1 93.7 96 97.4 Height (cm) 103.6 105.3 108.2 111.5 114.9 118.1 120 103.6 105.3 108.2 111.5 114.9 118.1 120 Height (cm) 75.4 76.6 78.6 80.8 83 84.9 86.1 75.4 76.6 78.6 80.8 83 84.9 86.1 BP Percentile 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm BP Levels for Girls by Age and Height Percentile

5 4 7 3 6 2 Age (y) 1 TABLE 5

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DBP (mm Height Percentile or Measured Hg)

SBP (mm 59 60.9 62.8 64.5 65.5 56.2 57.3 59 60.9 62.8 64.5 65.5 Height Percentile or Measured 98 99 101 102 104 105 106 60 60 60 61 62 63 64 96 97 98 99 101 102 103 58 59 59 60 61 61 62 95 95 97 98 99 100 101 57 58 59 60 60 61 61 93 94 95 97 98 99 100 56 56 57 59 60 61 61 5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75% 90% 95% 127 128 129 130 132 135 136 88 89 89 89 89 89 89 115 116 117 118 120 123 124 76 77 77 77 77 77 77 111 112 113 114 116 118 120 74 74 74 74 74 75 75 135 135 136 137 138 139 139 92 92 92 92 93 93 94 123 123 124 125 126 127 127 80 80 80 80 81 81 82 118 118 120 122 123 123 123 76 76 76 76 77 77 77 125 126 126 128 129 131 132 87 87 88 88 88 88 88 113 114 114 116 117 119 120 75 75 76 76 76 76 76 105 106 107 108 109 109 109 63 63 64 65 66 66 66 109 110 111 112 113 115 116 72 73 73 73 73 73 73 133 134 135 136 138 138 139 91 91 91 91 92 92 93 121 122 123 124 126 126 127 79 79 79 79 80 80 81 116 117 119 121 122 123 123 75 75 75 76 76 76 76 124 124 125 126 128 129 130 86 86 87 87 87 87 87 112 112 113 114 116 117 118 74 74 75 75 75 75 75 104 105 106 107 108 108 109 62 62 63 64 65 65 66 108 108 109 111 112 113 114 71 71 72 73 73 73 73 118 119 120 122 124 125 126 78 78 78 78 79 79 79 130 131 132 134 136 137 138 90 90 90 90 91 91 91 114 115 116 118 120 122 122 75 75 75 75 76 76 76 110122 111 123 112 124 113 125 115 127 116 128 117 129 72 84 73 85 74 86 74 86 75 87 75 87 75 87 102 102 104 105 107 108 108 61 61 61 62 64 65 65 107 107 108 110 111 112 113 69 70 71 72 72 73 73 Hg Hg Hg Hg Hg Hg Hg

95th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 95th 50th 90th 50th Height (in) 56.2 57.3 Height (in) 53.4 54.5 56.2 58.2 60.2 61.9 63 53.4 54.5 56.2 58.2 60.2 61.9 63 Height (in) 59.3 60.2 61.8 63.5 65.2 66.8 67.7 59.3 60.2 61.8 63.5 65.2 66.8 67.7 Height (in) 51.1 52 53.7 55.5 57.4 59.1 60.2 51.1 52 53.7 55.5 57.4 59.1 60.2 Height (in) 58.3 59.3 60.9 62.7 64.5 66.1 67 58.3 59.3 60.9 62.7 64.5 66.1 67 Height (in) 49.3 50.2 51.7 53.4 55.1 56.7 57.7 49.3 50.2 51.7 53.4 55.1 56.7 57.7 Height (in) 47.6 48.4 49.8 51.4 53 54.5 55.5 47.6 48.4 49.8 51.4 53 54.5 55.5 Height (cm) 135.6 138.3 142.8 147.8 152.8 157.3 160 135.6 138.3 142.8 147.8 152.8 157.3 160 Height (cm) 150.6 153 156.9 161.3 165.7 169.7 172.1 150.6 153 156.9 161.3 165.7 169.7 172.1 Height (cm) 129.7 132.2 136.3 141 145.8 150.2 152.8 129.7 132.2 136.3 141 145.8 150.2 152.8 Height (cm) 148.1 150.6 154.7 159.2 163.7 167.8 170.2 148.1 150.6 154.7 159.2 163.7 167.8 170.2 Height (cm) 125.3 127.6 131.3 135.6 140.1 144.1 146.6 125.3 127.6 131.3 135.6 140.1 144.1 146.6 Height (cm) 142.8 145.5 149.9 154.8 159.6 163.8 166.4 142.8 145.5 149.9 154.8 159.6 163.8 166.4 Height (cm) 121 123 126.5 130.6 134.7 138.5 140.9 121 123 126.5 130.6 134.7 138.5 140.9 BP Percentile 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm 95th + 12 mm Continued

12 11 14 10 13 9 Age (y) 8 TABLE 5

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics The initial BP measurement may be oscillometric (on a calibrated machine that has been validated for use in the pediatric population) or

auscultatory (by using a mercury86,87 or aneroid sphygmomanometer ‍ ). (Validation status for oscillometric BP devices, including whether they Hg) are validated in the pediatric age group, can be checked at www. dableducational.org.) BP should be DBP (mm measured in the right arm by using Hg). The 50th, 90th, and 95th percentiles were derived by using standard measurement practices unless the child has atypical aortic Height Percentile or Measured arch anatomy, such as right aortic arch and aortic coarctation or left aortic arch with aberrant right subclavian artery (see Table 7). Other important aspects of proper BP measurement are illustrated in an AAP video available at http:// youtu.be/JLzkNBpqwi0. Care should be taken that providers

follow an accurate and consistent88,89 measurement technique.

An appropriately sized cuff should be83 used for accurate BP measurement. Researchers in 3 studies in the United Kingdom and 1 in Brazil documented the lack of availability of an – Hg)

appropriately sized cuff in both the91 94 inpatient and outpatient settings. ‍

SBP (mm Pediatric offices should have access to a wide range of cuff sizes, including 77 . a thigh cuff for use in children and

Height Percentile or Measured adolescents with severe obesity. For

Table 3 (elevated BP: ≥ 90th percentile; stage 1 HTN: 95th and 2 percentile + 12 mm children in whom the appropriate

cuff size is difficult to determine, the midarm circumference (measured as the midpoint between the acromion

5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50% 75%of the 90% scapula 95% and olecranon of the 137 137 138 139 140 140 140 92 92 92 93 94 94 94 125 125 126 127 128 128 128 80 80 80 81 82 82 82 120 121 123 124 124 125 125 76 76 77 77 78 78 78 107 108 109 110 110 110 111 64 64 65 66 66 66 67 136 137 137 139 139 140 140 92 92 92 93 94 94 94 124 125 125 127 127 128 128 80 80 80 81 82 82 82 119 120 122 123 124 124 124 76 76 76 77 78 78 78 106 107 108 109 109 110 110 64 64 65 66 66 67 67 124136 124 136 125 137 126 138 127 139 127 139 128 140 80 92 80 92 80 92 81 93 82 94 82 94 82 94 118 119 121 122 123 123 124 76 76 76 77 77 78 78 105 106 107 108 109 109 109 64 64 64 65 66 67 67 elbow, with the shoulder in a neutral ° position86,95, 96 and the elbow flexed to Hg Hg Hg

90 ‍ ‍ ‍ ) should be obtained for an

accurate determination of the correct95 95th 90th 50th 95th 90th 50th 95th 90th 50th cuff size (see Fig 2 and Table≥ 7). Height (in) 60.0 60.9 62.5 64.2 65.9 67.4 68.4 60.0 60.9 62.5 64.2 65.9 67.4 68.4 Height (in) 59.9 60.8 62.4 64.1 65.8 67.3 68.3 59.9 60.8 62.4 64.1 65.8 67.3 68.3 Height (in) 59.7 60.6 62.2 63.9 65.6 67.2 68.1 59.7 60.6 62.2 63.9 65.6 67.2 68.1 Height (cm) 152.4 154.7 158.7 163.0 167.4 171.3 173.7 152.4 154.7 158.7 163.0 167.4 171.3 173.7 Height (cm) 152.1 154.5 158.4 162.8 167.1 171.1 173.4 152.1 154.5 158.4 162.8 167.1 171.1 173.4 Height (cm) 151.7 154 157.9 162.3 166.7 170.6 173 151.7 154 157.9 162.3 166.7 170.6 173 BP Percentile 95th + 12 mm 95th + 12 mm 95th + 12 mm If the initial BP is elevated ( 90th percentile), providers should perform 2 additional oscillometric Continued

or auscultatory BP measurements at the same visit and average them. 17 16 Age (y) 15 If using auscultation, this averaged Use percentile values to stage BP readings according the scheme in quantile regression on the basis of normal-weight children (BMI <85th percentile) TABLE 5 ’ measurement is used to determine the child s BP category (ie, normal, Downloaded from www.aappublications.org/news by guest on September 25, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 6 Screening BP Values Requiring Further Evaluation Age, y BP, mm Hg Boys Girls Systolic DBP Systolic DBP 1 98 52 98 54 2 100 55 101 58 3 101 58 102 60 4 102 60 103 62 5 103 63 104 64 6 105 66 105 67 7 106 68 106 68 8 107 69 107 69 9 107 70 108 71 10 108 72 109 72 11 110 74 111 74 12 113 75 114 75 ≥13 120 80 120 80

elevated BP, stage 1 HTN, or stage 2 ≥ HTN). If the averaged oscillometric reading is 90th percentile, 2 FIGURE 1 AAP grading matrix. auscultatory measurements should be taken and averaged to define the BP4.1a category Measurement (see Fig of BP3). in the Neonate

and toddlers). Normative values for Offices that will be obtaining BP Multiple methods are available neonatal and infant BP have generally measurements in neonates need to for the measurement of BP in been determined in the right upper have a variety of cuff sizes available. hospitalized neonates, including arm with the infant supine, and a In addition, the oscillometric device direct intra-arterial measurements similar approach should be followed used should be validated in neonates in the outpatient setting. and programmed to have an initial using indwelling catheters as well ≤ as indirect measurements using inflation value appropriate for As with older children, proper infants (generally 120 mmHg). the oscillometric technique. In the ’ office, however, the oscillometric cuff size is important in obtaining Auscultation becomes technically technique typically is used at least accurate BP readings in neonates. feasible once the infant s upper arm until the infant is able to cooperate The cuff bladder length should is large enough for the smallest cuff with manual BP determination encircle 80% to 100% of the arm available for auscultatory devices. (which also depends on the ability circumference; a cuff bladder with a Measurements are best taken when

of the individual measuring the BP width-to-arm circumference ratio79,97, 98of the infant is in a calm state; multiple 0.45 to 0.55 is recommended. ‍ ‍ readings may be needed if the first TABLEto obtain 7 Best auscultatory BP Measurement BP Practicesin infants 1. The child should be seated in a quiet room for 3–5 min before measurement, with the back supported and feet uncrossed on the floor. 2. BP should be measured in the right arm for consistency, for comparison with standard tables, and to avoid a falsely low reading from the left arm in the case of coarctation of the aorta. The arm should be at heart level,90 supported, and uncovered above the cuff. The patient and observer should not speak while the measurement is being taken. 3. The correct cuff size should be used. The bladder length should be 80%–100% of the circumference of the arm, and the width should be at least 40%. 4. For an auscultatory BP, the bell of the stethoscope should be placed over the brachial artery in the antecubital fossa, and the lower end of the cuff should be 2–3 cm above the antecubital fossa. The cuff should be inflated to 20–30 mm Hg above the point at which the radial pulse disappears. Overinflation should be avoided. The cuff should be deflated at a rate of –2 3 mm Hg per second. The first (phase I Korotkoff) and last (phase V Korotkoff) audible sounds should be taken as SBP and DBP. If the Korotkoff sounds are heard to 0 mm Hg, the point at which the sound is muffled (phase IV Korotkoff) should be taken as the DBP, or the measurement repeated with less pressure applied over the brachial artery. The measurement should be read to the nearest 2 mm Hg. 5. To measure BP in the legs, the patient should be in the prone position, if possible. An appropriately sized cuff should be placed midthigh and the stethoscope placed over the popliteal artery. The SBP in the legs is usually 10%–20% higher than the brachial artery pressure. Adapted from Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005;111(5):697–716.

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics “ to increase BP (see Table 8 and the ” Secondary Causes: Medication- 112,113 related section of this guideline). ‍ Children younger than 3 years should have BP measurements taken at well-child care visits if they are at

increased risk1 for developing HTN (seeKey Action Table Statement 9). 1

≥ BP should be measured annually in children and adolescents 3 years of age (grade C, moderate recommendation).Key Action Statement 2

≥ BP should be checked in all children and adolescents 3 years of age at every health care encounter if they have obesity, are taking medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes (see Table 9) (grade C, moderate recommendation). 4.3 Patient Management on the Basis of Office BP 4.3a Normal BP

If BP is normal or normalizes after repeat readings (ie, BP <90th percentile), then no additional action is needed. Practitioners should measure the BP at the next routine FIGURE 2 Determination of proper BP cuff size.95 A, Marking spine extending from acromion process. B, Correct well-child4.3b Elevated care BP visit. tape placement for upper arm length. C, Incorrect tape placement for upper arm length. D, Marking upper arm length midpoint. 1. If the BP reading is at the elevated BP level (Table 3), lifestyle interventions should be reading is elevated, similar to the the ambulatory setting beginning recommended (ie, healthy diet, technique99, recommended100 for older at 3 years of1 age should remain sleep, and physical activity); the 4.2children BP Measurement. Frequency unchanged. For otherwise healthy measurement should be repeated children, however, BP need only in 6 months by auscultation. be measured annually rather than Nutrition and/or weight during every health care encounter. It remains unclear what age management referral should be is optimal to begin routine BP Some children should have BP considered as appropriate; measurement in children, although measured at every health encounter, 2. If BP remains at the elevated BP ≥ – available data suggest that prevention– specifically those5,27, with107 obesity109 (BMI level after 6 months, upper and and intervention efforts10,60, should101 106 95 percentile),46 110,‍ 111‍ renal lower extremity BP should be begin at a young age. ‍ ‍‍ disease, diabetes, ‍ aortic arch checked (right arm, left arm, and The subcommittee believes that the obstruction or coarctation, or those 1 leg), lifestyle counseling should recommendation to measure BP in who are taking medications known be repeated, and BP should be Downloaded from www.aappublications.org/news by guest on September 25, 2021 16 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 1. BP should be measured annually in children and adolescents ≥3 years of age (grade C, moderate recommendation). the patient is asymptomatic, Aggregate Evidence Quality Grade C Benefits Early detection of asymptomatic HTN; prevention of short- and long- provide lifestyle counseling and term HTN-related morbidity recheck the BP in 1 to 2 weeks by Risks, harm, cost Overtesting, misclassification, unnecessary treatment, discomfort auscultation; from BP measurement procedure, time involved in measuring BP Benefit–harm assessment Benefit of annual BP measurement exceeds potential harm 2. If the BP reading is still at the Intentional vagueness None stage 1 level, upper and lower Role of patient preferences Increased visit time, discomfort of cuff extremity BP should be checked Exclusions None Strength Moderate recommendation (right arm, left arm, and 1 leg), Key references 10,60,102,103 and BP should be rechecked in 3 months by auscultation. Nutrition Key Action Statement 2. BP should be checked in all children and adolescents and/or weight management ≥3 years of age at every health care encounter if they have obesity, are taking referral should be considered as medications known to increase BP, have renal disease, a history of aortic appropriate; and arch obstruction or coarctation, or diabetes (see Table 9) (grade C, moderate recommendation). 3. If BP continues to be at the stage Aggregate Evidence Quality Grade C 1 HTN level after 3 visits, ABPM Benefits Early detection of HTN and prevention of CV morbidity in predisposed should be ordered (if available), children and adolescents diagnostic evaluation should be Risks, harm, cost Time for and difficulty of conducting measurements Benefit–harm assessment Benefits exceed harm conducted, and treatment should Intentional vagueness Frequency of evaluation be initiated. Subspecialty referral Role of patient preferences Increased visit time, discomfort of cuff should be considered (see Table Exclusions Children and adolescents who are not at increased risk for HTN 4.3d11). Stage 2 HTN Strength Moderate recommendation Key references 27,46,107,110–112 1. If the BP reading is at the stage 2 HTN level (Table 3), upper and rechecked in 6 months (ie, at (see Table 10 for a list of screening lower extremity BP should be the next well-child care visit) by tests and the populations in checked (right arm, left arm, and auscultation; which they should be performed). 1 leg), lifestyle recommendations given, and the BP measurement 3. If BP continues at the elevated BP Consider subspecialty referral (ie, should be repeated within 1 week. level after 12 months (eg, after cardiology or nephrology) (see Alternatively, the patient could 3 auscultatory measurements), ‍Table 11); and be referred to subspecialty care ABPM should be ordered (if 4. If BP normalizes at any point, within 1 week; available), and diagnostic return to annual BP screening at evaluation should be conducted well-child care visits. 2. If the BP reading is still at the 4.3c Stage 1 HTN TABLE 8 Common Pharmacologic Agents stage 2 HTN level when repeated, Associated With Elevated BP in then diagnostic evaluation, Children including ABPM, should be Over-the-counter Decongestants 1. If the BP reading is at the stage conducted and treatment should drugs Caffeine 1 HTN level (Table 3) and be initiated, or the patient should TABLE 9 Conditions Under Which Children Younger Than 3 Years Should Have BP Measured Nonsteroidal anti- inflammatory drugs History of prematurity <32 week’s gestation or small for gestational age, very low birth weight, other Alternative therapies, neonatal complications requiring intensive care, umbilical artery line herbal and nutritional Congenital heart disease (repaired or unrepaired) supplements Recurrent urinary tract infections, hematuria, or proteinuria Prescription Stimulants for attention- Known renal disease or urologic malformations drugs deficit/hyperactivity Family history of congenital renal disease disorder Solid-organ transplant Hormonal contraception Malignancy or bone marrow transplant Steroids Treatment with drugs known to raise BP Tricyclic antidepressants Other systemic illnesses associated with HTN (neurofibromatosis, tuberous sclerosis, sickle cell Illicit drugs Amphetamines disease,114 etc) Cocaine Evidence of elevated intracranial pressure Adapted from the Fourth Report.1 Adapted from Table 3 in the Fourth Report.1

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 3. Trained health care professionals in the office setting should make a diagnosis of HTN if a child or adolescent has auscultatory- confirmed BP readings ≥95th percentile on 3 different visits (grade C, moderate decision support in conjunction with recommendation). an EHR in adult populations has also Aggregate Evidence Quality Grade C been associated with improved BP Benefits Early detection of HTN; prevention of CV morbidity in predisposed screening, recognition, medication– children and adolescents; identification of secondary causes of HTN prescribing, and control; pediatric122 125 Risks, harm, cost Overtesting, misclassification, unnecessary treatment, discomfort from data are limited, however. ‍ ‍ BP measurement, time involved in taking BP Some studies failed to show Benefit–harm assessment Benefits of repeated BP measurement exceeds potential harm improvement in BP screening or Intentional vagueness None 122,126 Role of patient preferences Families may have varying levels of concern about elevated BP readings control, but given the inherent and may request evaluation on a different time line complexity in the interpretation Exclusions None of pediatric BP measurements, Strength Moderate recommendation EHRs should be designed to flag Key references 8,84,85 abnormal values both at the time of measurement and on entry into the KeyEHR. Action Statement 4 be referred to subspecialty care One analysis using nationally within 1 week (see Table 11); and representative survey data found that providers measured BP at only Organizations with EHRs used in 3. If the BP reading is at the stage 67% of preventive visits for children an office setting should consider 2 HTN level and the patient is 3 to 18 years of age. Older children including flags for abnormal BP symptomatic, or the BP is >30 and children with overweight or values both when the values are mmHg above the 95th percentile obesity were more likely to be being entered and when they (or >180/120 mmHg in an 117 screened. In a large cohort study are being viewed (grade C, weak adolescent), refer to an immediate of 14187 children, 507 patients met recommendation). source of care, such as an 4.5 Oscillometric Versus the criteria for HTN, but only 131 Keyemergency Action Statement department 3 (ED). Auscultatory (Manual) BP (26%) had the diagnosis documented Measurement in their electronic health records (EHRs). Elevated BP was only Trained health care professionals 7 recognized in 11% of cases. in the office setting should make Although pediatric normative BP data are based on auscultatory a diagnosis of HTN if a child or It is likely that the low rates of ≥ measurements, oscillometric BP adolescent has auscultatory- screening and diagnosis of pediatric devices have become commonplace confirmed BP readings 95th HTN are related, at least in part, to 127 in health care settings. Ease of percentile on 3 different visits (grade the need to use detailed reference use, a lack of digit preference, and 4.4C, moderate Use of Electronic recommendation). Health Records tables incorporating age, sex, and 118 automation are all perceived benefits height to classify BP levels. of using oscillometric devices. Unlike Studies have shown that using auscultatory measurement, however, Studies have demonstrated that health information technology oscillometric devices measure primary care providers frequently can increase adherence to clinical – the oscillations transmitted from fail to measure BP and often guidelines and improve practitioner 85,115, 116 119 121 disrupted arterial flow by using the underdiagnose HTN. ‍ ‍ performance. ‍ ‍ In fact, applying cuff as a transducer to determine Key Action Statement 4. Organizations with EHRs used in an office setting should mean arterial pressure (MAP). Rather consider including flags for abnormal BP values both when the values are being than directly measuring any pressure entered and when they are being viewed (grade C, weak recommendation). that correlates to SBP or DBP, the Aggregate Evidence Quality Grade C device uses a proprietary algorithm Benefits Improved rate of screening and recognition of elevated BP to calculate these values from the Risks, harm, cost Cost of EHR development, alert fatigue 127 Benefit–harm assessment Benefit of EHR flagging of elevated BP outweighs harm from directly measured MAP. Because development cost and potential for alert fatigue the algorithms vary for different Intentional vagueness None brands of oscillometric devices, 128there Role of patient preferences None is no standard oscillometric BP. Exclusions None Strength Weak recommendation (because of a lack of pediatric data) Researchers in several studies– Key references 7,117,120,125 have evaluated the accuracy127,129 134 of oscillometric devices ‍ ‍ ‍ and compared auscultatory and Downloaded from www.aappublications.org/news by guest on September 25, 2021 18 FROM THE AMERICAN ACADEMY OF PEDIATRICS

TABLE 10 Screening Tests and Relevant Populations ’ Patient Population Screening Tests

oscillometric readings ability135 to All patients Urinalysis predict target organ damage. Chemistry panel, including electrolytes, blood urea nitrogen, and These studies demonstrated that creatinine Lipid profile (fasting or nonfasting to include high-density lipoproteina oscillometric devices systematically and total cholesterol) overestimate SBP and DBP Renal ultrasonography in those <6 y of age or those with abnormal compared with values129,133 obtained urinalysis or renal function by auscultation. BP status In the obese (BMI >95th Hemoglobin A1c (accepted screen for diabetes) potentially can be misclassified percentile) child or Aspartate transaminase and alanine transaminase (screen for fatty adolescent, in addition to liver) because of the different values the above Fasting lipid panel (screen for dyslipidemia) obtained by these 2 methods, which Optional tests to be obtained Fasting serum glucose for those at high risk for diabetes mellitus may be 86,magnified88, 129 in the office on the basis of history, Thyroid-stimulating hormone setting. ‍ ‍ Target organ damage physical examination, and Drug screen (such as increased LV mass and initial studies Sleep study (if loud snoring, daytime sleepiness, or reported history of apnea) elevated PWV) was best predicted by 135 Complete blood count, especially in those with growth delay or BPs obtained by auscultation. abnormal renal function Adapted from Wiesen J, Adkins M, Fortune S, et al. Evaluation of pediatric patients with mild-to-moderate hypertension: A major issue with oscillometric yield of diagnostic testing. Pediatrics. 2008;122(5). Available at: www.pediatrics.org/cgi/content/full/122/5/e988. devices is that there appears to be great within-visit variation Key Action Statement 5 with inaccurately high readings 136 obtained on initial measurement. repeat measures averaged to An elevated initial oscillometric approximate values obtained by Oscillometric devices may be reading should be ignored and auscultation. used for BP screening in children Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 19

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 11 Patient Evaluation and Management According to BP Level BP Category BP Screening Lifestyle Check ABPMa Diagnostic Initiate Consider (See Table Schedule Counseling Upper Evaluationb Treatmentc Subspecialty ventricular mass index138,139 (LVMI) than 3) (Weight and and Referral systolic office BP. ‍ Nutrition) Lower – Extremity Although many wrist devices140 142 have BP been validated in adults, ‍ ‍ some studies have shown greater variation Normal Annual X ————— – Elevated BP Initial X ————— and decreased accuracy in143 the146 measurement resulting measurements. ‍ ‍ These Second XX ———— negative outcomes may possibly measurement: result from differences in the number repeat in 6 mo 139 of measurements taken, the Third X — XX — X measurement: position of147 the wrist in relation to repeat in 6 mo the heart, flexion or extension148 of Stage 1 HTN Initial X ————— the wrist during measurement, 149 measurement or differences in pulse pressure. Second XX ———— measurement: Technologies are being developed150, to151 repeat in 1–2 help standardize wrist position. ‍ wk Third X — XXXX Few studies using wrist monitors measurement: have been conducted in children. repeat in 3 mo One study in adolescents compared Stage 2 HTNd Initial XX ———— measurement a wrist digital monitor with a Second X — XXXX mercury sphygmomanometer and measurement: found high agreement between repeat, refer systolic measurements but to specialty lower agreement for diastolic care within 1 wk measurements,152 which was clinically relevant. Researchers in 2 X, recommended intervention; —, not applicable. a ABPM is done to confirm HTN before initiating a diagnostic evaluation. small studies conducted in PICUs b See Table 15 for recommended studies. compared wrist monitors with c Treatment may be initiated by a primary care provider or subspecialist. indwelling arterial lines and found d If the patient is symptomatic or BP is >30 mm Hg above the 95th percentile (or >180/120 mm Hg in an adolescent), send to an ED. good agreement between 153,the154 2 measurement modalities. ‍ No large comparative studies or formal validation studies of wrist monitors and adolescents. When doing so, BP measurements, equivalence have been conducted in children, providers should use a device that to readings obtained by mercury however. Because of limited data, the has been validated in the pediatric sphygmomanometers or ABPM, use of wrist and forearm monitors is age group. If elevated BP is suspected andKey betterAction correlationStatement 5. with Oscillometric left devicesnot may recommended be used for BP in screening the diagnosis in or on the basis of oscillometric readings, children and adolescents. When doing so, providers should use a device that has confirmatory measurements should been validated in the pediatric age group. If elevated BP is suspected on the basis be obtained by auscultation (grade B, of oscillometric readings, confirmatory measurements should be obtained by strong recommendation). auscultation (grade B, strong recommendation). 4.6 Forearm and/or Wrist BP Measurement Aggregate Evidence Quality Grade B Benefits Use of auscultatory readings prevents potential misclassification of patients as hypertensive because of inaccuracy of oscillometric devices Wrist monitors have several potential Risks, harm, cost Auscultation requires more training and experience and has flaws such advantages when compared with arm as digit preference devices. They are smaller; they can Benefit–harm assessment Benefit exceeds harm be placed more easily; and, because Intentional vagueness None Role of patient preferences Patients may prefer the convenience of oscillometric monitors wrist diameter is less affected by Exclusions None BMI, they do not need to be83,137 modified Strength Strong recommendation for patients with obesity. ‍ Key references 86,88,128–136 Several studies in adults have found excellent reproducibility of wrist Downloaded from www.aappublications.org/news by guest on September 25, 2021 20 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 12 High-Risk Conditions for Which ABPM May Be Useful Condition Rationale Secondary HTN Severe ambulatory HTN or nocturnal HTN indicates higher likelihood of secondary HTN161,‍167 CKD or structural renal abnormalities Evaluate for MH or nocturnal HTN,168 ‍–172 better control delays progression of renal disease173 T1DM and T2DM Evaluate for abnormal ABPM patterns,174, ‍175 better BP control delays the development of MA176‍–178 Solid-organ transplant Evaluate for MH or nocturnal HTN, better control BP179‍–188 Obesity Evaluate for WCH and MH23,‍189 ‍–192 OSAS Evaluate for nondipping and accentuated morning BP surge43,‍46, ‍193, ‍194 Aortic coarctation (repaired) Evaluate for sustained HTN and MH58,‍112, ‍113 Genetic syndromes associated with HTN (neurofibromatosis, Turner HTN associated with increased arterial stiffness may only be manifest with activity syndrome, Williams syndrome, coarctation of the aorta) during ABPM58,‍195 Treated hypertensive patients Confirm 24-h BP control155 Patient born prematurely Evaluate for nondipping196 Research, clinical trials To reduce sample size197

TABLE 13 Recommended Procedures for the Application of ABPM Procedure Recommendation Device Should be validated by the Association for the Advancement of Medical Instrumentation or the British Hypertension Society for use in children May be oscillometric or auscultatory Application Trained personnel should apply the monitor Correct cuff size should be selected Right and left arm and a lower extremity BP should be obtained to rule out coarctation of the aorta Use nondominant arm unless there is large difference in size between the left arm and right arm, then apply to the arm with the higher BP Take readings every 15–20 min during the day and every 20–30 min at night Compare (calibrate) the device to resting BP measured by the same technique (oscillometric or auscultatory) Record time of medications, activity, and sleep Assessment A physician who is familiar with pediatric ABPM should interpret the results Interpret only recordings of adequate quality. Minimum of 1 reading per hour, 40–50 for a full day, 65%–75% of all possible recordings Edit outliers by inspecting for biologic plausibility, edit out calibration measures Calculate mean BP, BP load (% of readings above threshold), and dipping (% decline in BP from wake to sleep) Interpret with pediatric ABPM normal data by sex and height Use AHA staging schema155 Consider interpretation of 24-h, daytime, and nighttime MAP, especially in patients with CKD173,‍198 Adapted from Flynn JT, Daniels SR, Hayman LL, et al; American Heart Association Atherosclerosis, Hypertension and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63(5):1116–1135.

158,159 management of HTN in children and pediatric providers have access to BP, ‍ is160 more predictive of 4.7adolescents ABPM at this time. ABPM, there are still gaps in access future BP, and can assist in161 the and knowledge regarding the optimal detection of secondary HTN. ’ application of ABPM155,157 to the evaluation Furthermore, increased LVMI and of children s BP. ‍ For example, LVH correlate more strongly with An ambulatory BP monitor consists – there are currently no reference data ABPM parameters than casual of a BP cuff attached to a box slightly 162 166 for children whose height is <120 cm. BP. ‍ ‍ In addition, ABPM is more larger than a cell phone, which – Because no outcome data exist reproducible than casual or home BP records BP periodically (usually 159 linking ABPM data from childhood measurements. For these reasons, every 20 30 minutes) throughout to hard CV events in adulthood, the routine application of ABPM is the day and night; these data are recommendations either rely largely recommended, when available, as later downloaded to a computer for 155 on surrogate outcome markers or are indicated below (see also Tables analysis. extrapolated from adult studies. 12 and 13). Obtaining ABPM may ABPM has been recommended by Keyrequire Action referral Statement to a specialist.6 the US Preventive Services Task However, sufficient data exist

Force for the confirmation of HTN156 in to demonstrate that ABPM is adults before starting treatment. more accurate for the diagnosis ABPM should be performed for the Although a growing number of of HTN than clinic-measured confirmation of HTN in children Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 21

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics 209 and adolescents with office BP that compared with those with with established HTN. Most (but measurements in the elevated BP normal 24-hour BP, these patients not all) studies suggest that WCH

category for 1 year or more or with have significant risk for200, end203 organ is not associated200,207, 210 with increased stage 1 HTN over 3 clinic visits (grade hypertensive damage. ‍ Patients LV mass. ‍ ‍ Although the C, moderate recommendation). who are at risk of MH include distinction between WCH and true ≥ For technical reasons, ABPM may patients with obesity and secondary HTN is important, abnormal BP need to be limited to children 5 forms of HTN, such as CKD or response to exercise and increased repaired aortic coarctation. MH is LVM has been found to occur in years of age who can tolerate the 207 particularly prevalent in patients children with WCH. Furthermore, procedure and those for whom 48 with CKD and is associated with the identification of WCH may reduce referenceKey Action dataStatement are available. 7 203 target organ damage. Children costs by reducing the number of with CKD should be periodically additional tests performed and evaluated using ABPM for MH as decreasing the number of children The routine performance of ABPM – part of routine CKD who are exposed to antihypertensive should be strongly considered 201,204 206 208 management. ‍ ‍ ‍ medications. Children and in children and adolescents with 4.7b White Coat Hypertension adolescents with WCH should high-risk conditions (see Table have screening BP measured at 12) to assess HTN severity and ≥ regular well-child care visits with determine if abnormal circadian BP WCH is defined as BP 95th consideration of a repeat ABPM in 1 patterns are present, which may percentile in the office or clinical to 2 years. indicate increased risk for target Key Action Statement 9 setting but <95th percentile outside organ damage (grade B, moderate of the office or clinical setting. Keyrecommendation). Action Statement 8 WCH is diagnosed by ABPM when Children and adolescents with the mean SBP and DBP are <95th suspected WCH should undergo percentile and SBP and DBP load ABPM should be performed by using ABPM. Diagnosis is based on the are <25%; load is defined as the a standardized approach (see Table presence of mean SBP and DBP percentage of valid ambulatory BP 13) with monitors that have been <95th percentile and SBP and measurements above a set threshold validated in a pediatric population, DBP load <25% (grade B, strong value (eg, 95th percentile) for and studies should be interpreted by 155,156, 206 recommendation). age, sex, and height. ‍ ‍ It is 4.8 Measurement in Children With using pediatric normative data (grade estimated that up to half of children Obesity C,4.7a moderate Masked Hypertensionrecommendation). who are evaluated207,208 for elevated office BP have WCH. Accurate BP measurement can be MH occurs when patients have In adults, compared with challenging in individuals with normal office BP but elevated BP on normotension, WCH is associated 23,211, 212 obesity. ‍ ‍ Elevated BMI ABPM, and it has been found in 5.8% with only a slightly increased risk in children and adolescents is of unselected children studied by of adverse outcomes but at a much 199 associated with an increase in the ABPM. There is growing evidence lower risk compared with those 96 Key Action Statement 6. ABPM should be performed for the confirmation of HTN midarm circumference, requiring in children and adolescents with office BP measurements in the elevated BP the use of a larger cuff to obtain – 83 category for 1 year or more or with stage 1 HTN over 3 clinic visits (grade C, accurate BP measurements. During moderate recommendation). NHANES 2007 2010, among children Aggregate Evidence Quality Grade C 9 to 11 years of age with obesity, Benefits Avoids unnecessarily exposing youth with WCH to extensive diagnostic one-third of boys and one-quarter of testing or medication girls required an adult BP cuff, and Risks, harm, cost Risk of discomfort to patient. Some insurance plans may not reimburse for the test a fraction required a large adult cuff Benefit–harm assessment The risk of ABPM is lower than the risk of unnecessary treatment. The or an adult thigh cuff213 for an accurate use of ABPM has also been shown to be more cost-effective than other measurement of BP. Researchers approaches to diagnosing HTN in studies of adults have also noted Intentional vagueness None the influence of the conical upper Role of patient preferences Some patients may prefer repeat office or home measurements to ABPM Exclusions None arm shape on BP measurements214,215 in Strength Moderate recommendation people with obesity. ‍ ABPM is a Key references 23,155,158,159 valuable tool in the diagnosis of HTN in children with obesity because of the discrepancies between casual and Downloaded from www.aappublications.org/news by guest on September 25, 2021 22 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 7. The routine performance of ABPM should be strongly – considered in children and adolescents with high-risk conditions (see Table 12) 222,225 227 to assess HTN severity and determine if abnormal circadian BP patterns are in children. ‍ ‍ Home BP present, which may indicate increased risk for target organ damage (grade B, measurements show– no consistent

moderate recommendation). pattern when compared228 230 with office Aggregate Evidence Quality Grade B measurements. ‍ ‍ Benefits Improved 24-h control of BP improves outcomes. Recognition of MH or There are several practical nocturnal HTN might lead to therapeutic changes that will limit end organ damage concerns with the use of home BP Risks, harm, cost Risk of discomfort to patient. Some insurance plans may not measurement, however. The only reimburse for the test. The risk of diagnosing and labeling a patient normative data available are from as having MH or nocturnal HTN might lead to increased anxiety and the relatively small Arsakeion cost of evaluation 231 School study. In addition, only a Benefit–harm assessment The risk of ABPM is much lower than the risk of inadequate treatment Intentional vagueness Frequency at which normal or abnormal ABPM should be repeated is few automated devices have been not known validated for use in the pediatric Role of patient preferences Some patients may prefer repeat office or home measurements to population, and available cuff sizes ABPM for them are limited. Furthermore, Exclusions None Strength Moderate recommendation there is no consensus regarding how Key references 47,155,199–202 many home measurements across what period of time are needed to evaluateKey Action BP. Statement 10 Key Action Statement 8. ABPM should be performed by using a standardized approach (see Table 13) with monitors that have been validated in a pediatric population, and studies should be interpreted by using pediatric normative data Home BP monitoring should not be (grade C, moderate recommendation). used to diagnose HTN, MH, or WCH Aggregate Evidence Quality Grade C but may be a useful adjunct to office Benefits Validated monitors applied and interpreted correctly will provide the and ambulatory BP measurement most accurate results after HTN has been diagnosed (grade Risks, harm, cost Risk of discomfort to patient. Some insurance plans may not reimburse C, moderate recommendation). for the test. Monitors validated in the pediatric population and 4.10 School Measurement and expertise in reading pediatric ABPM may not be universally available the Role of School-Based Health Benefit–harm assessment There is substantial evidence showing incorrect application or Professionals interpretation reduces the accuracy of results Intentional vagueness None Role of patient preferences Some patients may prefer repeat office or home measurements to ABPM Exclusions None There is limited evidence to support ’ Strength Moderate recommendation school-based measurement8,232 of Key references 155 children s BP. ‍ Observational

studies demonstrate that school233 measurements can be reliable

23,33 and that8, longitudinal232, 234 follow-up is ambulatory BP 26,29, and155, the216, higher217 Numerous studies have shown feasible. ‍ Available data do not prevalence4.9. At-Home of Measurement MH. ‍ ‍ that it is feasible– for families to distinguish between the efficacy of

conduct221 repeated223 measurements at school-based screening programs in home. ‍‍ Home BP measurements which measurements are obtained Home measurement (or self- appear to be more reproducible than by trained clinical personnel (not a monitoring) of BP has advantages those conducted in the office, likely school nurse) versus measurements over both office and ambulatory because of the familiarity of the home obtained by the school nurse.

monitoring, including convenience environment and greater comfort159,223, 224 Because of insufficient evidence and the ability to obtain repeated83,218 with repeated measurements. ‍ and a lack of established protocols, measurements over time. ‍ Inaccuracies occur when the routine use of school-based Furthermore, automated devices with measurements obtained at home are measurements to diagnose HTN

memory capacity are straightforward either excluded219 or inappropriately cannot be recommended. However, to use and avoid potential problems, recorded. Inconsistencies in school-based BP measurement can be such as observer bias, inaccurate home, office, and ambulatory a useful tool to identify children who reporting, and terminal digit BP measurements seem to be require formal evaluation as well as preference (ie, overreporting of influenced by both age and HTN a helpful adjunct in the monitoring of

certain digits, like 0, as219, the220 terminal status, with ABPM tending to be diagnosed HTN. Note: School-based digit in recording BP). ‍ higher than home BP measurements health clinics are considered part of Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 23

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 9. Children and adolescents with suspected WCH should undergo ABPM. Diagnosis is based on the presence of mean SBP and DBP <95th percentile and SBP and DBP load <25% (grade B, strong recommendation). evaluation for secondary causes of Aggregate Evidence Quality Grade B (Evidence Level A in Adults) HTN if they have a positive family Benefits Improved diagnosis of WCH and the benefit of fewer additional history of HTN, are overweight or laboratory tests and/or treatment of primary HTN. Costs might be obese, and/or do not have history reduced if the treatment of those misdiagnosed as hypertensive is or physical examination findings prevented (Table 14) suggestive of a secondary Risks, harm, cost Additional costs; costs may not be covered by insurance companies. The ambulatory BP monitor is uncomfortable for some patients cause of HTN (grade C, moderate recommendation). Benefit–harm assessment Benefit exceeds risk 5.2 Secondary Causes: Renal and/or Intentional vagueness None Role of patient preferences Important; some patients may not want to undergo ABPM. Benefits Renovascular of the procedure should be reviewed with families to assist in decision-making Exclusions None Renal disease and renovascular Strength Strong recommendation disease are among the most common Key references 206 secondary causes of HTN in children. Renal parenchymal disease and Key Action Statement 10. Home BP monitoring should not be used to diagnose renal structural abnormalities HTN, MH, or WCH but may be a useful adjunct to office and ambulatory BP measurement after HTN has been diagnosed (grade C, moderate accounted for 34% to 79% of recommendation). patients with secondary HTN in 3 retrospective, single-center case Aggregate Evidence Quality Grade C Benefits Convenient, cost-effective, widely available, can be used over time series, and renovascular101, disease240, 241 was Risks, harm, cost Risk of inaccurate diagnosis. Unclear what norms or schedule should present in 12% to 13%. ‍ ‍ be used. Few validated devices in children, and cuff sizes are limited The literature suggests that renal Benefit–harm assessment Benefits outweigh harm when used as an adjunctive measurement disease is a more common cause239 technique of HTN in younger children. Intentional vagueness None Role of patient preferences Patients may find home BP more convenient and accessible than office Renal disorders (including vascular or ambulatory BP problems) accounted for 63% to 74% Exclusions None of children <6 years of age who were Strength Moderate recommendation enrolled in 3 recent– clinical trials Key references 159,221–225,227,230 of angiotensin239,242 244receptor blockers (ARBs). ‍ ‍ ‍ No increased frequency was seen in younger

patients in a recent101 single-center case series, however. It is appropriate systems of pediatric primary care, more common than secondary238 HTN to have a high index of suspicion and these comments would not apply among American youth. for renal and renovascular disease to them. in hypertensive pediatric patients, General characteristics of children ≥ particularly in those <6 years of age. 5. Primary and Secondary Causes with primary HTN include older 5.3 Secondary Causes: Cardiac, of HTN 239,240 age ( 6 years), ‍ positive Including Aortic Coarctation family history (in a parent and/or 5.1 Primary HTN 236,237, 240 grandparent) of HTN, ‍ 16,236, and237, 239 overweight and/or obesity. ‍ ‍ ‍ Coarctation of the aorta is a congenital Severity of BP elevation has not abnormality of the aortic arch Primary HTN is now the predominant differed significantly between characterized by discrete narrowing diagnosis for hypertensive children children with primary235, and237 secondary of the aortic arch, generally at the and adolescents seen in referral HTN in some studies, ‍ but level of the aortic isthmus. It is usually 235,236 centers in the United States, ‍ DBP elevation appears to be more239,240 associated with HTN and right arm although single-center studies from predictive of secondary HTN, ‍ BP that is 20 mmHg (or more)

outside the United States still find237 whereas systolic HTN appears to be greater than the lower extremity BP. primary HTN to be uncommon. more236, predictive239 of primary Repair in infants is often surgical; Although prospective, multicenter HTNKey Action. Statement 11 adolescents may be treated with studies are generally lacking, at least angioplasty or stenting. Long-segment ≥ one large study in which researchers narrowing of the abdominal aorta used insurance claims data confirmed Children and adolescents 6 years can also cause HTN and should be that primary HTN is significantly of age do not require an extensive considered in children with refractory Downloaded from www.aappublications.org/news by guest on September 25, 2021 24 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 11. Children and adolescents ≥6 years of age do not require an extensive evaluation for secondary causes of HTN if they have a positive family history of HTN, are overweight or obese, and/or do not have history or physical surgical cure or achieve a dramatic examination findings (Table 14) suggestive of a secondary cause of HTN (grade C, response248 with pharmacologic moderate recommendation). therapy. Known endocrine causes Aggregate Evidence Quality Grade C with associated molecular defects Benefits Avoidance of unnecessary diagnostic evaluation (when known) are summarized in Risks, harm, cost Potential to miss some children with secondary HTN ‍Table5.5 Secondary 15. Causes: Benefit–harm assessment Benefit equals harm Environmental Exposures Intentional vagueness Not applicable Role of patient preferences Some families may want further testing performed Exclusions Hypertensive children <6 y of age Strength Moderate recommendation Several environmental exposures Key references 16,129,235–240 have been associated with higher childhood BP, although most studies – are limited to small case series. Among 58,245 247 the most prominent are lead, cadmium, HTN and a gradient between the more useful than casual BP. ‍ ‍ ‍ •mercury,• and phthalates. upper and lower extremities in Screening is recommended as a part which the upper extremity SBP of usual care on an annual basis Lead: Long-term exposure to lead

in adults has been associated with295, 296 exceeds the245 lower extremity SBP by beginning, at most, 12 years after 20 mmHg. Of note, children with coarctation repair. Earlier screening higher BP in population studies ‍ and in studies of industrial workers abdominal aortic obstruction may may be considered on the basis of 297 with high lead exposure, although have neurofibromatosis, Williams Keyrisk Action factors Statement and clinician 12 discretion. 298 syndrome, Alagille syndrome, or findings have not been consistent. Takayasu arteritis. At least 1 cross-sectional study of 122 children demonstrated that Children and adolescents who have Patients with coarctation can remain children with higher blood lead undergone coarctation repair should hypertensive or develop HTN even concentrations had higher BP; undergo ABPM for the detection of after early and successful repair, lower socioeconomic status was with reported prevalence varying HTN (including MH) (grade B, strong 112 also seen in this group, which may299 from 17% to 77%. HTN can be 5.4recommendation). Secondary Causes: Endocrine HTN have confounded the BP results. a manifestation of recoarctation. Furthermore, in a randomized study Recoarctation in repaired patients of lead-exposed children, those who should be assessed for by using 4 received chelation with succimer did HTN resulting from hormonal extremity BP measurements and not have lower BP than in those who excess accounts for a relatively 300 echocardiography. HTN can also246 •• received a placebo. occur without recoarctation. The small proportion of children with secondary HTN. Although rare (with Cadmium: Environmental cadmium prevalence of HTN increases over time112 after successful coarctation repair. a prevalence ranging101,237, from239, 2400.05% exposure has been linked to higher to 6% in children ‍ ‍ ‍ ), an BP levels and the development Routine office BP measurement alone – accurate diagnosis of endocrine HTN of HTN in adults, particularly is often insufficient for diagnosing 296,301 303 113,246 provides the clinician with a unique among women. ‍ ‍‍ Although HTN after coarctation repair. ‍ treatment opportunity to render a cross-sectional studies have Children who have undergone Key Action Statement 12. Children and adolescents who have undergone coarctation repair may have normal coarctation repair should undergo ABPM for the detection of HTN (including MH) in-office BP but high BP out of the (grade B, strong recommendation). office, which is consistent with 58,112 ∼ Aggregate Evidence Quality Grade B (Aggregate Level of Evidence Equals B, Given 3 Studies MH. ‍ Of children with a history With Similar Findings) ∼ of aortic coarctation, 45% have MH Benefits Early detection of HTN at 1 to 14 years after coarctation Risks, harm, cost Additional costs related to the placement of ABPM 58,113 Benefit–harm assessment Benefits exceed harms repair. ‍ Children with a history Intentional vagueness Frequency of measurement. Because the development of HTN after of repaired aortic coarctation and coarctation repair is influenced by many factors, the ideal onset of screening for HTN (including MH) is unknown normal58 in-office BP are58, 112at risk for LVH, HTN, and MH. ‍ Role of patient preferences None Exclusions Individuals with a history of residual aortic arch obstruction ABPM has emerged as the gold Strength Strong recommendation standard for diagnosing HTN among Key references 58,112,113 individuals who have undergone coarctation repair, and it is likely Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 25

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 14 Examples of Physical Examination Findings and History Suggestive of Secondary HTN or Related to End Organ Damage Secondary to HTN Body System Finding, History Possible Etiology confirmed potential nephrotoxicity304 of cadmium in children, no Vital signs Tachycardia Hyperthyroidism PCC definite effect on304, BP305 has been Neuroblastoma •• demonstrated. ‍ Decreased lower extremity pulses; drop Coarctation of the aorta in BP from upper to lower extremities Mercury: Mercury is a known Eyes Proptosis Hyperthyroidism nephrotoxin, particularly306,307 in its Retinal changesa Severe HTN, more likely to be associated elemental form. ‍ Severe with secondary HTN mercury intoxication has been ’ Ear, nose, throat Adenotonsillar hypertrophy SDB linked to acute HTN in children History of snoring Sleep apnea Height, weight Growth retardation Chronic renal failure in several case reports; patients Obesity (high BMI) Cushing syndrome symptoms may resemble – Truncal obesity Insulin resistance syndrome those seen in patients with 308 310 Head, neck Elfin facies Williams syndrome •• pheochromocytoma (PCC). ‍ Moon facies Cushing syndrome Thyromegaly, goiter Hyperthyroidism Phthalates: Antenatal and Webbed neck Turner syndrome childhood exposure to phthalates– Skin Pallor, flushing, diaphoresis PCC has recently been associated Acne, hirsutism, striae Cushing syndrome 311 313 Anabolic steroid abuse with higher childhood BP ‍ ‍ Café-au-lait spots Neurofibromatosis but not with the development of Adenoma sebaceum Tuberous sclerosis overt HTN. Specific metabolites of Malar rash Systemic lupus these ubiquitous chemicals may Acanthosis nigricans T2DM 313 Hematologic Pallor Renal disease have differential effects on BP, Sickle cell anemia indicating that much more detailed Chest, cardiac Chest pain Heart disease study is needed to completely Palpitations understand the effect of such Exertional dyspnea exposure. Widely spaced nipples Turner syndrome 5.6 Secondary Causes: Heart murmur Coarctation of the aorta Neurofibromatosis Friction rub Systemic lupus (pericarditis) Collagen vascular disease Apical heavea LVH Abdomen Abdominal mass Wilms tumor Neurofibromatosis type 1 (NF-1) Neuroblastoma (also known as Von Recklinghausen PCC disease) is a rare autosomal Epigastric, flank bruit RAS dominant disorder characterized by Palpable kidneys Polycystic kidney disease distinct clinical examination findings. Hydronephrosis Multicystic dysplastic kidney These include the following: cafe- Genitourinary Ambiguous or virilized genitalia Congenital adrenal hyperplasia au-lait macules, neurofibromas, Urinary tract infection Renal disease Lisch nodules of the iris, axillary Vesicoureteral reflux freckling, optic nerve gliomas, and Hematuria, edema, fatigue distinctive bone lesions. Patients Abdominal trauma Extremities Joint swelling Systemic lupus with NF-1 have several unique and Collagen vascular disease potential secondary causes of HTN, Muscle weakness Hyperaldosteronism most commonly renal artery stenosis Liddle syndrome (RAS); coarctation of the– aorta, Neurologic, Hypokalemia, headache, dizziness, Reninoma middle aortic syndrome, and PCC are metabolic polyuria, nocturia 314 319 Muscle weakness, hypokalemia Monogenic HTN (Liddle syndrome, GRA, also well described. ‍ ‍ AME) Additionally, an increased incidence AME, apparent mineralocorticoid excess; GRA, glucocorticoid-remediable aldosteronism. Adapted from Flynn JT. Evaluation of idiopathic HTN has been and management of hypertension in childhood. Prog Pediatr Cardiol. 2001;12(2):177–188; National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. The fourth report on the documented in patients with NF-1, diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2):555–576. as high as 6.1% in a recent pediatric a Findings that may be indicative of end organ damage related to HTN. case series, which is a much greater

incidence than320 in the general population. PCC has also been well described in patients with NF-1, although exact incidences are difficult Downloaded from www.aappublications.org/news by guest on September 25, 2021 26 FROM THE AMERICAN ACADEMY OF PEDIATRICS

++ and/or urine a channel sensitivity causing increased ++ Biochemical Mechanism and Notes am androstenedione, testosterone, and DHEAS metanephrines and normetanephrines aldosterone synthesis channels, leading to aldosterone synthesis blocker, or potassium supplementation blocker, causing sodium+ influx that activates Ca Elevated DOC and corticosterone Excessive, ACTH-regulated aldosterone production Elevated levels of DOC, 11-deoxycortisol, Higher prevalence in Moroccan Jews Decreased androstenedione, testosterone and DHEAS Prominent in Dutch Mennonites Increased Ca May add low-dose spironolactone, calcium channel Excessive autonomous aldosterone production Mutation leads to loss of potassium+ sensitivity Diagnostic test: fractionated plasma Clinical Feature(s) girls hyperplasia in girls hyperplasia first-degree relative family described bilateral adrenal hyperplasia HTN and hypokalemia Young subjects with PA Hypokalemia Low aldosterone and renin HTN Acne, hirsutism, and virilization in Pseudoprecocious puberty in boys 11% of congenital adrenal Undervirilized boys, sexual infantilism <1% of congenital adrenal Palpitations, headache, sweating Abdominal mass Incidental radiographic finding Family screening PA and HTN age <10 y Milder phenotypes also seen Family history of young strokes Prescription with low-dose dexamethasone PA in the patient with an affected Early onset severe HTN in the first Variable developmental abnormalities Unresponsive to dexamethasone May have adrenal adenoma or HTN from 1.2% to 6%) AD Screening test: ARR: PAC, PRA preferably obtained between 8:00 and 10:00 AD AD De novo, AD Genetic Mutation Mode of Inheritance β -hydroxylase – (11 aldosterone synthase, gain of function) channel (gain of function) channel (loss of function) CYP17 (loss of function) AR Hybrid CYP11B1 and CYP11B2 CYP11B1 (loss of function) AR SDHB (15%) SDHD (10%) RET CACNA1D coding for calcium Unknown, possibly 7p22 AD (prevalence varies KCNJ5 G-protein potassium VHL (49%) Endocrine Causes of HTN

α hydroxylase deficiency Early onset HTN Potassium level abnormalities Family history of primary aldosteronism Resistant HTN β– hydroxylase deficiency Consider if: 11 17- Type 1 Specific etiologies addressed below Type 4 Type 2 Type 3 PCC, paraganglioma

Congenital adrenal hyperplasia Familial hyperaldosteronism

Mineralocorticoid excess

Name of Disorder Other genetic causes

Catecholamine excess TABLE 15

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics 279 ‍ 287 290 ‍ ‍ ‍ 274 ‍ 276 ‍ 281 ‍ 283 ‍ 292 ‍ 294 – – – ‍ 284 7 5 8 275, ‍ ‍ 280, 282, ‍ ‍ 293, ‍ 273, ‍ 291, ‍ 27 ‍ ‍ 28 28 Ref No(s). Biochemical Mechanism and Notes testicles may be present gains access to MR channel causing salt retention and volume expansion of hyperparathyroidism causing salt retention and volume expansion vasoconstriction, cardiac output, activation of RAS and decreased peripheral resistance Tumors in the breast, thyroid, pituitary gland, or Reduced or absent activity of 11 β -HSD2: cortisol Mimicked by licorice toxicity Constitutive activation of the epithelial sodium Constitutive activation of MR Initial prescription with β blockers Mechanism unknown, may not remit after treatment Loss of function glucocorticoid receptor Rare familial cause Also activated by progesterone Increased activity of sodium chloride cotransporter Likely attributable to increased DOC, sensitivity Mechanism increased cardiac output, stroke volume, Clinical Feature(s) t stature abnormalities or infertility in women metabolic acidosis Pituitary and other tumors Cutaneous pigmentation Fibrous dysplasia HTN Hypokalemia Low birth weight Failure to thrive Polyuria, polydipsia Severe HTN Hypokalemia Metabolic alkalosis Muscle weakness Onset of HTN <20 y HTN Tremors Other signs of hyperthyroidism Hypercalcemia Other signs of hyperparathyroidism Ambiguous genitalia Precocious puberty Androgen excess, menstrual HTN Skin pigmentation Exacerbated by pregnancy Hyperkalemic and hyperchloremic Borderline HTN Other signs of Cushing syndrome Shor HTN Tachycardia Somatic — AD AD AD AD — — ticoid-d β -subunit – SCNN1G Genetic Mutation Mode of Inheritance α -subunit 4; KLHL3; CUL3; SPAK γ -subunit (activating mutation) activating receptor, mutation) glucocorticoid receptor) (activating mutation) SCNN1B MCR (mineralocor — HSD11B2 (loss of function) AR NR3C1 (loss of function PRKAR1A WNK1, To be discovered To be discovered ticoid ticoid tical Continued

thyroidism excess resistance (Chrousos syndrome) type 2 (Gordon syndrome) adrenocor carcinoma, iatrogenic excess McCune Albright syndrome GNAS, Primary glucocor Apparent mineralocor Liddle syndrome Geller syndrome Hyperparathyroidism Carney complex Pseudohypo-aldosteronism Cushing syndrome, Hyper Name of Disorder

Glucocorticoid excess Other endocrine abnormalities

influenced by posture, specialized center preferred. TABLE 15 ACTH, adrenocorticotropic hormone; AD, autosomal dominant; AR, recessive; DHEAS, dehydroepiandrosterone sulfate; DOC, deoxycortisol; MR, magnetic resonance; PA, primary hyperaldosteronism; PAC, plasma aldosterone concentration; RAS, renin angiotensin system; — , not applicable. a

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics to determine, and patients may321, not322 HTN include stimulants (eg, cocaine is a critical component in the have classic symptoms of PCC. ‍ and amphetamine derivatives) and evaluation of a patient with anabolic5.8 Monogenic steroids. HTN suspected HTN. Evaluation focuses Vascular causes of HTN and PCC on determining possible causes of all require specific treatment and/or comorbidities associated and follow-up, so maintaining a with HTN. Evaluation, as is detailed Monogenic forms of HTN are high index of suspicion for these in the following sections, should uncommon, although the exact disorders is important in evaluating include appropriate patient history, incidence is unknown. In a study of hypertensive children and family history, physical examination, adolescents with NF-1. select hypertensive children without 5.7 Secondary Causes: Medication 6.2laboratory History evaluation, and imaging. Related a known etiology, genetic testing for familial hyperaldosteronism type I (FH-I), or glucocorticoid- remediable aldosteronism, confirmed The first step in the evaluation of the Many over-the-counter drugs, responsible genetic263 mutations in 3% child or adolescent with elevated BP prescription medications, alternative of the population. is to obtain a history. The various therapies (ie, herbal and nutritional components of the history include the Other monogenic forms of HTN in supplements), dietary products, and perinatal history, past medical history, children include Liddle syndrome, recreational drugs can increase BP. nutritional history, activity history, pseudohypoaldosteronism type Common prescription –medications and psychosocial history. Each is II (Gordon syndrome), apparent associated with a rise323 in325 BP include 6.2adiscussed Perinatal in the History following sections. mineralocorticoid excess, familial oral contraceptives, ‍‍ central326 glucocorticoid resistance, nervous system1, stimulants,327 and corticosteroids. ‍ When a child mineralocorticoid receptor activating “ As discussed, perinatal factors such has elevated BP measurements, the mutation, and congenital adrenal as maternal HTN and low birth practitioner should inquire about the hyperplasia (see Secondary ” weight have been shown to influence intake of pharmacologic agents (see Causes: Endocrine328 Causes of 56,330 later BP, even in childhood. ‍ Table‍ 8). Hypertension ). All manifest as HTN with suppressed plasma renin Additionally, a high incidence of Usually, the BP elevation is mild activity (PRA) and increased sodium preterm birth among hypertensive and reversible on discontinuation absorption in the distal tubule. children has recently 101been reported of the medication, but a significant Other features may include serum in 1 large case series. Thus, it increase in BP can occasionally potassium abnormalities, metabolic is appropriate to obtain a history occur with higher doses or as an acid-base disturbances, and abnormal of pertinent prenatal information, idiosyncratic response. Over-the- plasma aldosterone concentrations, including maternal pregnancy counter cold medications that contain complications; gestational age; although the clinical presentations263,328, 329 decongestants (eg, pseudoephedrine can be highly variable. ‍ ‍ In the birth weight; and, if pertinent, and phenylpropanolamine) may study of FH-I, all affected children had complications occurring in the cause a mild increase in BP with the suppressed PRA and an aldosterone neonatal nursery and/or ICU. It recommended dosing, but severe HTN to renin ratio (ARR) (ng/dL and ng/ is also appropriate to document has been observed as an idiosyncratic M1 per hour, respectively) of >10; the pertinent procedures, such as response with appropriate dosing as authors suggest that an ARR >10 is an umbilical6.2b Nutritional catheter History placement. well as with excessive doses. indication to perform genetic263 testing Nonsteroidal anti-inflammatory in a hypertensive child. Monogenic drugs may antagonize forms of HTN should be suspected High sodium intake has been linked the BP-lowering effect of in hypertensive children with a to childhood HTN and increased LVMI suppressed PRA or elevated ARR, and is the focus of several population antihypertensive medications – 4,331 (specifically, angiotensin-converting especially if there is a family history of health campaignsn. ‍ In NHANES enzyme [ACE] inhibitors) but do not early-onset HTN. 2003 2008, among children 8 to appear to have an impact on BP in 6. Diagnostic Evaluation 18 years of age ( = 6235), higher those without HTN. The commonly sodium intake (as assessed by dietary used supplement ephedra (ma 6.1 Patient Evaluation recall) was associated with a twofold haung) likely contains some amount increase in the combined outcome of ephedrine and caffeine that can of elevated BP or HTN. The effect

cause an unpredictable rise in BP. As with any medical condition, was threefold332 among participants Recreational drugs associated with appropriate diagnostic evaluation with obesity. Limited data suggest Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 29

the same333 effect is seen in younger physical examination findings. The children. One study found that high physical examination in hypertensive Taking and updating the family intake of total fat and saturated fat, as children is frequently normal except – history is a quick and easy way well as adiposity and central obesity, for the BP elevation. 334 336 to risk-stratify pediatric patients Key Action Statement 13 were also predictors of SBP. ‍‍ with an increased risk for HTN. It Nutrition history is an important is important to update the family ’ part of the patient assessment history for HTN over the course of – In children and adolescents being because it may identify dietary the pediatric patient s lifetime in the evaluated for high BP, the provider contributors to HTN and detect practice (typically until 18 21 years should obtain a perinatal history, areas in which lifestyle modification of age) because first- and second- appropriate nutritional history, may be appropriate. The important degree relatives may develop HTN physical activity history, psychosocial components to discuss include salt during this time. All too often, the history, and family history and intake (including salt added in the diagnosis of HTN in the pediatric perform a physical examination kitchen and at the table and sodium patient stimulates the collection of to identify findings suggestive of hidden in processed and fast food), a detailed family history of HTN, secondary causes of HTN (grade B, consumption of high-fat foods, and sometimes even years after the 337,338 6.4strong Laboratory recommendation). Evaluation consumption of sugary beverages. ‍ pediatric patient has had elevated352 BP, Infrequent consumption of fruits, 6.3instead Physical of the Examination other way around. vegetables, and low-fat dairy products6.2c Physical should Activity also History be identified. The purpose of the laboratory A complete physical examination may evaluation is to identify underlying provide clues to potential secondary secondary causes of HTN (eg, renal A detailed history of physical causes of HTN and assess possible or endocrine disease) that would ’ activity and inactivity is an integral hypertensive end organ damage. The require specific treatment guided by a part of the patient assessment, not child s height, weight, calculated BMI, subspecialist. In general, such testing only to understand contributors and percentiles for age should be includes a basic set of screening tests to the development of HTN but determined at the start of the physical and additional, specific tests; the also to direct lifestyle– modification examination. Poor growth may latter are selected on the basis of clues counseling as 339an important344 part of indicate an underlying chronic illness. obtained from the history and physical management. ‍‍ 6.2d Psychosocial History examination and/or the354 results of the At the second visit with confirmed initial screening tests. Table 10 elevated BP or stage 1 HTN or the provides a list of screening tests and first visit with confirmed stage 2 the populations in which they should Providers should obtain a HTN, BP should be measured in both be6.5 performed. Electrocardiography psychosocial history in children arms and in a leg. Normally, BP is and adolescents with suspected or 10 to 20 mmHg higher in the legs confirmed HTN.345 Adverse experiences than the arms. If the leg BP is lower Approximately one-half of both prenatally and during than the arm BP, or if femoral pulses adolescents with HTN have childhood (including maltreatment, are weak or absent, coarctation of undergone electrocardiography early onset depression, and anxiety) the aorta may be present. Obesity at least once as an assessment for are associated346,347 with adult-onset alone is an insufficient explanation 355 LVH. Unlike echocardiography, HTN. ‍ The identification of stress for diminished femoral pulses in the electrocardiography takes little may suggest a diagnosis of WCH. presence of high BP. The psychosocial history should time and is a relatively low-cost include questions about feelings of The remainder of the physical test. Electrocardiography has high depression and anxiety, bullying, examination should pursue clues specificity but poor sensitivity– and body perceptions. The latter is found in the history and should focus for identifying children356 and358 particularly important for patients on body systems and findings that adolescents with LVH. ‍ ‍ ∼ with overweight or obesity because may indicate secondary HTN and/ The positive predictive value of 70% of these children report or end organ damage related to HTN. electrocardiography359 to identify LVH is extremely low. having bullying348 and body perception ‍Table 14 lists important physical Key Action Statement 14 concerns. Starting at 11 years of examination353 findings in hypertensive age, the psychosocial history should349,350 children. These are examples of include questions about smoking,351 ‍ history and physical findings and do Clinicians should not perform alcohol, and other drug use. not represent all possible history and electrocardiography in hypertensive Downloaded from www.aappublications.org/news by guest on September 25, 2021 30 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 13. In children and adolescents being evaluated for high BP, the provider should obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history and perform a The American Society of physical examination to identify findings suggestive of secondary causes of HTN Echocardiography recommendations (grade B, strong recommendation). should be followed with regard to Aggregate Evidence Quality Grade B image acquisition and LV measurement Benefits Identify personal risk factors for HTN for calculating LV ejection fraction,369, 371 Risks, harm, cost None mass, and relative wall thickness. ‍ Benefit–harm assessment Identification of personal risk factors is useful in LV ejection fraction may be the assessment of childhood HTN Intentional vagueness None significantly decreased in severe or Role of patient preferences None acute onset HTN with associated1 Exclusions Children with normal BP congestive heart failure. Rarely, Strength Strong recommendation LV ejection fraction may be mildly Key references 56,330 depressed in chronic HTN. Because the heart increases in size

in relation to body size,361 indexing LV mass is required. Indexing LV children and adolescents being regression of LVH independently368 evaluated for LVH (grade B, strong predicts outcomes in adults. mass is particularly important in 6.6recommendation). Imaging Evaluation, infants and younger children372,373 because Echocardiography: Detection of The best-studied measures of LV of their rapid growth. ‍ Physical Target Organ Damage target organ injury are measures training increases LV mass in a of LV structure (LV mass and the healthful manner. Lean body mass relationship of LV wall thickness is more strongly associated370 with Echocardiography was identified or mass to LV cavity volume) and LV mass than fat mass. Because in the Fourth Report as a tool systolic function (LV ejection body composition is not routinely to measure left ventricular (LV) fraction). LV structure is usually measured clinically, surrogate formulae for indexing are required. target organ1 injury related to HTN stratified into 4 groups on the in children. The basis for this basis of LV mass (normal or It is unclear whether expected values for LV mass should be derived from assessment is as follows: (1) the361 hypertrophied) and relative LV wall relationship of LV mass to BP, thickness (normal or increased). reference populations of normal (2) the independent and– strong These 4 are as follows: (1) normal weight and normotensive children or should include normotensive relationship of LVH362 to adverse364 CVD geometry with normal LV mass outcomes in adults, ‍ and (3) and wall thickness, (2) concentric children who have overweight or that a significant percentage of geometry with normal LV mass and obesity. The best method for indexing children and adolescents with HTN increased LV wall thickness, (3) LV mass in children is an area of demonstrate– the degree of LVH eccentric LVH with increased LV active investigation.

associated365 with367 adverse outcomes mass and normal LV wall thickness, in adults. ‍‍ Antihypertensive and (4) concentric LVH with both For this document, the following definitions for LV target organ treatment reduces LVH. increased LV mass and 369,increased370 Observational data suggest that the relative wall thickness. ‍ injury have been chosen regarding Key Action Statement 14. Clinicians should not perform electrocardiography in hypertrophy, relative wall thickness, hypertensive children and adolescents being evaluated for LVH (grade B, strong and ejection fraction. These definitions recommendation). are based on published guidelines Aggregate Evidence Quality Grade B (Aggregate of Level of Evidence Equals B Because of from the American Society of Multiple Level of Evidence C References With Similar Findings) Echocardiography and associations of Benefits Electrocardiography is less expensive than echocardiography or thresholds for indexed LV mass with other imaging modalities for identifying LVH 362,363, 369 adverse outcomes in adults ‍ ‍ : Risks, harm, cost Electrocardiography has a low sensitivity for detecting LVH •• Benefit–harm assessment The risk of concluding that a child with HTN does not have LVH on 2.7 the basis of a normal electrocardiogram means that a diagnosis LVH is defined as LV mass >51 g/m of end organ injury is potentially missed or LV mass >115 g per body Intentional vagueness None surface area (BSA) for boys and Role of patient preferences Patients and families may prefer electrocardiography because of LV mass >95 g/BSA for girls. (Note cost and convenience, but the sensitivity of the test is poor Exclusions None that the values for LVH are well Strength Strong recommendation above the 95th percentile for Key references 1,355–360 distributions of LV369 mass in children and adolescents. The clinical significance of values between the Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 31

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 16 DASH Diet Recommendations Food Servings per Day 95th percentile of a population- based distribution and these Fruits and vegetables 4–5 372 Low-fat milk products ≥2 •• thresholds is uncertain ); Whole grains 6 Fish, poultry, and lean red meats ≤2 An LV relative wall thickness >0.42 Legumes and nuts 1 cm indicates concentric geometry. Oils and fats 2–3 LV wall thickness373 >1.4 cm is Added sugar and sweets (including sweetened beverages) ≤1 •• abnormal ; and Dietary sodium <2300 mg per d Adapted from Barnes TL, Crandell JL, Bell RA, Mayer-Davis EJ, Dabelea D, Liese AD. Change in DASH diet score and Decreased LV ejection fraction is a cardiovascular risk factors in youth with type 1 and type 2 diabetes mellitus: the SEARCH for Diabetes in Youth study. value <53%. Nutr Diabetes. 2013;3:e91; US Department of Health and Human Services, US Department of Agriculture. Appendix 7. Nutritional goals for age-sex groups based on dietary reference intakes and dietary guidelines recommendations. In: 2015- 2020 Dietary Guidelines for Americans. Washington, DC: US Department of Health and Human Services, US Department of There are a number of additional Agriculture; 2015; and Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and evidence gaps related to the Adolescents; National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics. 2011;128 (suppl 5): S213 S256. echocardiographic assessment of – LV target organ injury. The value of LV mass assessment in risk reclassification independent of 4. In patients without target organ injury (grade C, conventional risk assessment364 has not LV target organ injury at 6.7moderate Vascular recommendation).Structure and Function been established in adults. The initial echocardiographic costs and benefits of incorporation assessment, repeat of echocardiography into HTN echocardiography at yearly Emerging data demonstrate an care has not been assessed. Quality intervals may be considered association of higher levels of BP control regarding reproducibility of in those with stage 2 HTN, in youth with adverse changes in measurements374 across laboratories may secondary HTN, or chronic measures of vascular structure and be suboptimal. The most accurate stage 1 HTN incompletely function, including ultrasonography method to measure LV mass (M-mode; treated (noncompliance or drug of the cIMT, PWV, a robust66 measure two-dimensional; or, in the near resistance) to assess for the of central arterial stiffness that is future, three-dimensional techniques) development of worsening LV related to hard CV events in adults requires further research. Key Action Statement 15 Key Action Statement 15. 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 HTN; LVH should be defined as LV mass >51 g/m2.7 (boys and girls) for children and 1. It is recommended that adolescents older than 8 years and defined by LV mass >115 g/BSA for boys and echocardiography be performed LV mass >95 g/BSA for girls; to assess for cardiac target organ Repeat echocardiography may be performed to monitor improvement or damage (LV mass, geometry, progression of target organ damage at 6- to 12-month intervals. Indications to and function) at the time of repeat echocardiography include persistent HTN despite treatment, concentric LV consideration of pharmacologic hypertrophy, or reduced LV ejection fraction; and treatment of HTN; In patients without LV target organ injury at initial echocardiographic 2. LVH should2.7 be defined as LV mass assessment, repeat echocardiography at yearly intervals may be considered >51 g/m (boys and girls) for in those with stage 2 HTN, secondary HTN, or chronic stage 1 HTN incompletely children and adolescents older treated (noncompliance or drug resistance) to assess for the development of than 8 years and defined by LV worsening LV target organ injury (grade C, moderate recommendation). mass >115 g/BSA for boys and LV Aggregate Evidence Quality Grade C mass >95 g/BSA for girls; Benefits Severe LV target organ damage can only be identified with LV imaging. May improve risk stratification 3. Repeat echocardiography Risks, harm, cost Adds cost; improvement in outcomes from incorporating may be performed to monitor echocardiography into clinical care is not established improvement or progression Benefit–harm assessment Benefits exceed harms of target organ damage at 6- to Intentional vagueness None Role of patient preferences Patients may elect to not to have the study 12-month intervals. Indications to Exclusions None repeat echocardiography include Strength Moderate recommendation persistent HTN despite treatment, Key references 361,363,364,367–369 concentric LV hypertrophy, or reduced LV ejection fraction; and Downloaded from www.aappublications.org/news by guest on September 25, 2021 32 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics (eg, stroke,69 myocardial infarction, vascular parameters. The routine of renal artery stenoses389 was 75% etc), and FMD, which assesses measurement of vascular structure and 89%, respectively. Factors endothelial function and describes the and function to stratify risk in that may affect the accuracy of ’ ability of the endothelium to release375 hypertensive youth cannot be Doppler ultrasonography include nitric oxide in response to stress. recommended at this time. patient cooperation, the technician s 6.8 Imaging for Renovascular ’ – Disease experience, the age of the child, Although there are multiple large ≥ 376 381 and the child s BMI. Best results studies of PWV in youth, ‍ ‍ they ≤ 388 are obtained in older ( 8 years), all suffer from notable limitations, There are no evidence-based criteria nonobese (BMI 85th percentile), primarily the lack of racial and for the identification of children and cooperative children and adolescents ethnic diversity and differences in adolescents who may be more likely who are examined in a facility with measurement devices and protocols. N to have RAS. Some experts will do a extensive pediatric vascular imaging Researchers in the largest study of more extensive evaluation for RAS experience. Doppler ultrasonography PWV in youth to date ( = 6576) in children and adolescents with should probably not be obtained only evaluated 10 and 11 year olds stage 2 HTN, those with significant in patients who do not meet these and measured only carotid-radial diastolic HTN (especially on ABPM), criteria or in facilities that lack PWV across the arm; this measure those with HTN and hypokalemia on appropriate pediatric experience. has not been linked to CV events in Key Action Statement 16 382 screening laboratories, and those with adults. Researchers in one large N a notable size discrepancy between study of FMD performed in youth the kidneys on standard ultrasound ( = 5809) only included 10- to Doppler renal ultrasonography may 382 imaging. Bruits over the renal arteries 11-year-old children in England. be used as a noninvasive screening are also suggestive of RAS but are not The largest set of data for cIMT study for the evaluation of possible always present. Consultation with a ≥ included 1155 European youth RAS in normal-weight children and 383 subspecialist is recommended to help who were 6 to 18 years of age. adolescents 8 years of age who are decide which patients warrant further No racial and ethnic breakdown suspected of having renovascular investigation and to aid in the selection was provided for this study. The HTN and who will cooperate with of6.8a the Renal appropriate Ultrasonography imaging modality. wide heterogeneity in the methods the procedure (grade C, moderate for cIMT measurement hinders recommendation). 6.8b Computed Tomographic the pooling of data. For instance, The utility of Doppler renal Angiography, Magnetic Resonance researchers in the aforementioned ultrasonography as a noninvasive Angiography, and Renography article only measured common 383 screening study for the identification carotid, although the bulb and of RAS in children and adolescents internal carotid are the sites of 384 has been examined in at least 2 Other noninvasive imaging studies earliest atherosclerotic disease. recent case series; sensitivity has that have been assessed for their Many studies have had significant been reported to be 64% to 90%,387, 388 ability to identify RAS include issues related to methodology. For with a specificity of 68% to 70%. ‍ computed tomographic angiography example, carotid-femoral PWV is not In another study that included both (CTA), magnetic resonance measured identically with different children and adults, sensitivity angiography (MRA), and nuclear devices and is not equivalent to andKey specificityAction Statement for the 16. detection Doppler renal ultrasonographymedicine studies. may be Each used of as these a other measures of PWV,385, such386 as noninvasive screening study for the evaluation of possible RAS in normal- brachial-femoral PWV. ‍ No weight children and adolescents ≥8 years of age who are suspected of having direct comparisons have been made renovascular HTN and who will cooperate with the procedure (grade C, moderate between carotid-femoral and brachial- recommendation). ankle PWV, methods in which Aggregate Evidence Quality Grade C brachial-ankle PWV provide values Benefits Avoidance of complications of invasive procedure (angiography) or considerably higher than carotid- radiation from traditional or computed tomography angiography 378 Risks, harm, cost Potential false-positive or false-negative results femoral PWV. The brachial-ankle Benefit–harm assessment Potential for avoidance of an invasive procedure outweighs risk of PWV measures stiffness along both a false-negative or false-positive results central elastic artery (aorta) and the Intentional vagueness None medium muscular arteries of the leg. Role of patient preferences None Exclusions Children and adolescents without suspected renovascular HTN Therefore, insufficient normative Strength Moderate recommendation data are available to define clinically Key references 387–390 actionable cut-points between normal and abnormal for these Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 33

Capsule: 1.25, 2.5, 5 10 mg (generic) Tablet: 5, 10, 20, 40 mg (generic) Extemporaneous liquid: 1 mg/mL Tablet: 5, 10, 20, 40 mg (generic) Extemporaneous liquid: 2 mg/mL Solution: 1 mg/mL Tablet: 10, 20, 40 mg (generic) Tablet: 2.5, 5, 10, 20, 30, 40 mg (generic) Solution: 1 mg/mL Tablet: 25, 50 Extemporaneous liquid: 2.5 mg/mL Tablet: 5, 20, 40 mg Extemporaneous liquid: 2 mg/mL Tablet: 40, 80, 160, 320 mg (generic) Extemporaneous liquid: 4 mg/mL Suspension: 250/5 mL Extemporaneous liquid: 1 mg/mL Tablet: 75, 150, 300 mg (generic) Tablet: 25, 50, 100 mg (generic) Extemporaneous liquid: 1 mg/mL Dosing Interval Daily Daily Daily Daily to twice a dayDaily Tablet: 2.5, 5, 10, 20 mg (generic) Daily Daily to twice a day Tablet: 4, 8, 16, 32 mg Daily Daily to twice a dayDaily to twice a day Tablet: 250, 500 mg (generic) Tablet: 12.5, 25, 50 mg Daily Daily to 4 times a day Tablet: 12.5, 25, 50, 100 mg (generic) Three times a day Maximal Dose per d 2 per d) per d) per d) per d) per d) per d) 6 mg/m 80 mg per d 16 mg per d 32 mg per d 40 mg per d 40 mg per d 1.4 mg/kg (up to 100 mg)— Daily 20 mg 2.7 mg/kg (up to 160 mg) Daily 20 mg/kg per d (up to 375 mg 2 mg/kg per d (up to 37.5 mg 300 mg per d 150 mg per d 6 mg/kg per d 40 mg 2 mg/k per d (50 mg) Daily 6 mg/kg per d tensive Drugs for Outpatient Management of Chronic HTN Initial Dose per d 2 5 mg per d 8 mg per d 0.2 mg/kg per d (up to 10 mg d) 0.6 mg/kg per d (up to 40 mg 0.08 mg/kg per d (up to 5 mg d)0.1 mg/kg per d (up to 5 mg d) 0.6 mg/kg per d (up to 40 mg 5 mg per d 0.07 mg/kg per d (up to 5 mg d)1.6 mg/m 0.6 mg/kg per d (up to 40 mg 0.02 mg/kg per d (up to 4 mg d) 0.4 mg/kg per d (up to 16 mg 0.7 mg/kg (up to 50 mg) — 1.3 mg/kg (up to 40 mg) 10 mg/kg per d 1 mg/kg per d 150 mg per d 75 mg per d 20 mg a a a a a a a a a a a 6 y Age ≥ 13 ≥ 6 y Child 0.3 mg/kg ≥ ≥ 6 y ≥ 6 y ≥ 6 y ≥ 6 y ≥ 6 y Child Child 1 – 5 y 6 – 12 y <50 kg 4 mg per d <50 kg <35 kg 10 mg Infants 0.05 mg/kg per dose ≥ 50 kg ≥ 35 kg ≥ 1 mo ≥ 50 kg Children 0.5 mg/kg per dose — — Dosing Recommendations for the Initial Prescription of Antihyper tan

tan thalidone Bs E inhibitors Contraindications: pregnancy Common adverse effects: headache, dizziness Severe adverse effects: hyperkalemia, acute kidney injury, fetal toxicity Contraindications: pregnancy, angioedema Common adverse effects: cough, headache, dizziness, asthenia Severe adverse effects: hyperkalemia, acute kidney injury, angioedema, fetal toxicity Contraindications: anuria Common adverse effects: dizziness, hypokalemia Severe adverse effects: cardiac dysrhythmias, cholestatic jaundice, new onset diabetes mellitus, pancreatitis R C Candesar Quinapril A Irbesartan A Drug Benazepril Captopril Fosinopril Lisinopril Ramipril Olmesar Thiazide diuretics Chlor Hydrochlorothiazide Losartan Chlorothiazide Valsartan Enalapril TABLE 17

Downloaded from www.aappublications.org/news by guest on September 25, 2021 34 FROM THE AMERICAN ACADEMY OF PEDIATRICS

5, and MRA have generally been found to be acceptable as noninvasive imaging modalities for the identification of hemodynamically Formulations

10 mg significant vascular stenosis. One study that included both pediatric and adult patients showed that the (generic) (generic) sensitivity and specificity for the Tablet: 2.5, 5, Extemporaneous liquid: 1 mg/mL Tablet (extended release): 2.5, Capsule: 2.5, 5 mg Extended-release tablet: 5, 10 mg detection of RAS was 94% and 93%

for CTA and 90%389 and 94% for MRA, respectively. Unfortunately, studies of either technique that include only pediatric patients are limited at best for Dosing Interval CTA and are nonexistent for MRA. times a day; extended- release tablet: daily Daily Daily to twice a day Tablet (extended-release): 30, 60, 90 mg Despite this, expert opinion holds that either modality may be used for noninvasive screening for suspected

RAS, but neither 390is a substitute for angiography. CTA typically involves significant radiation exposure, and MRA generally Maximal Dose requires sedation or anesthesia in

per d) young children, which are factors that 0.6 mg/kg (up to 5 mg per d) Daily 10 mg 10 mg 0.6 mg/kg (up to 10 mg per d) Capsule: twice daily to 3 3 mg/kg/d (up to 120 mg must be considered when deciding to use one of these modalities.

Nuclear renography is based on the principle that after the administration of an agent affecting the renin-angiotensin- aldosterone system (RAAS), there

Initial Dose will be reduced blood flow to a kidney or kidney segment affected by hemodynamically significant

– 0.1 mg/kg RAS. Such reduced blood flow 0.1 mg/kg 2.5 mg 2.5 mg 0.05 0.2 – 0.5 mg/kg per d can be detected by a comparison of perfusion before and after the administration of the RAAS a

6 y agent. Limited pediatric nuclear – 5 y Age ≥ 6 y Child Child 1 ≥ renography studies exist that show variable sensitivity and specificity,–

ranging from 48% to 85.7% 391and393 73% to 92.3%, respectively. ‍ ‍ The utility of nuclear renography may be less in children then adults because children with RAS often have more complicated vascular Continued 394 abnormalities than adults. Given these issues, nuclear renography Contraindications: hypersensitivity to CCBs Common adverse effects: flushing, peripheral edema, dizziness Severe adverse effects: angioedema alcium channel blockers Drug C Amlodipine Isradipine Felodipine Nifedipine extended release

FDA pediatric labeling. has generally been abandoned as a TABLE 17 — , not applicable. a screening test390 for RAS in children and adolescents. Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 35

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 17 411 also shown that lowering UA can Seeman et al did not control for decrease BP levels, and increased UA these potential confounders. In children and adolescents – levels blunt the efficacy of lifestyle suspected of having RAS, either 400 404 Limited, single-center data suggest modifications on BP control. ‍ ‍ CTA or MRA may be performed as a that a reduction in the degree of MA, No large-scale, multicenter study has noninvasive imaging study. Nuclear more than a reduction in BMI or yet been conducted to confirm these renography is less useful in pediatrics SBP, is associated with a decrease in preliminary findings. Hence, there is and should generally be avoided LVMI. In particular, researchers in currently not sufficient evidence to 6.9(grade Uric D, Acid weak recommendation). this single-center, nonrandomized, support the routine measurement prospective study of 64 hypertensive of serum UA in the evaluation children without kidney disease who and management of children with Cross-sectional data have suggested were 11 to 19 years of age evaluated 6.10elevated Microalbuminuria BP. a relationship between elevated the children at baselineN and after serum uric acid (UA) levels and HTN. 12 months of combination ACE and – Two recent studies of adolescents hydrochlorothiazideN ( = 59) or included in NHANES 1999 2000 Microalbuminuria (MA), which ACE, hydrochlorothiazide, and ARB should be differentiated from and a small study conducted in– Italy therapy ( = 5). Results found that proteinuria in CKD, has been shown lowering MA in children is associated found that elevated UA levels395 were397 413 associated with higher BP. ‍ ‍ to be a marker– of HTN-related kidney with a regression of LVH. Given In the Italian study and in another injury and405 408 a predictor of CVD in the single-center design and lack adults. ‍ ‍ MA has been shown to of a control group, however, the US study397,398 of youth with obesity and HTN, elevated UA was also be effectively reduced via the use of applicability of these findings to the associated with other markers of CV ARBs and ACE inhibitors in adults. general population of children with risk. These findings suggest that the Lowering the degree of MA in adults Keyprimary Action HTN Statement is unknown. 18 measurement of UA levels may best has been associated with decreased be viewed as 1 component of CV risk CVD risk. assessment, especially in those with In contrast, data to support a clear Routine testing for MA is not obesity. relationship between– HTN and MA recommended for children and

in pediatric patients408 410 with primary adolescents with primary HTN (grade A causative role for elevated UA in HTN are limited. ‍‍ A single, C, moderate recommendation). the development of childhood HTN retrospective study of children with 7. Treatment has not been definitively established, primary HTN and WCH found that 7.1 Overall Goals although recent studies suggest that 20% of the former411 had MA versus it may be on the causal pathway. 0% of the latter. MA appears to A longitudinal study in which be a nonspecific finding in children researchers followed a group of that can occur in the absence of HTN; The overall goals for the treatment children for an average of 12 years it can occur in children who have of HTN in children and adolescents, demonstrated that childhood UA obesity, insulin resistance, diabetes, including both primary and levels were associated with adult dyslipidemia, and even in those secondary HTN, include achieving a

BP levels even after399 controlling who have recently participated412 in BP level that not only reduces the risk for baseline BP. A few small, vigorous physical activity. The for target organ damage in childhood single-centerKey Action Statement clinical trials17. In havechildren and adolescentspreviously suspected mentioned of having study byRAS, but also reduces the risk for HTN and either CTA or MRA may be performed as a noninvasive imaging study. Nuclear related CVD in adulthood. Several renography is less useful in pediatrics and should generally be avoided (grade D, studies have shown that currently weak recommendation). available treatment options can Aggregate Evidence Quality Grade D even reverse target organ105,414, 415damage in Benefits Avoidance of complications of an invasive procedure (angiography) hypertensive youth. ‍ ‍ Risks, harm, cost Potential false-positive or false-negative results Benefit–harm assessment Potential for avoidance of an invasive procedure outweighs risk of The previous recommendations for false-negative or false-positive results HTN treatment target in children Intentional vagueness None without CKD or diabetes were SBP Role of patient preferences None Exclusions Children and adolescents without suspected RAS and DBP <95th percentile. Since that Strength Weak recommendation; pediatric data are limited recommendation was made, evidence Key references 389,390 has emerged that markers of target organ damage, such as increased LVMI, can be detected among some Downloaded from www.aappublications.org/news by guest on September 25, 2021 36 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 18. Routine testing for MA is not recommended for children and adolescents with primary HTN (grade C, moderate recommendation). that the relationship between Aggregate Evidence Quality Grade C Benefits Avoid improper detection of MA in children with HTN. Detection of MA diet, physical activity, and BP is strongly influenced by other factors, such as recent participation in childhood is similar to that in rigorous physical activity, obesity, insulin resistance and 7.2aobserved Diet in adults. diabetes. Hence, there is no clear benefit for testing for MA in the absence of other known comorbidities Risks, harm, cost No known risks given a lack of clear association between MA and primary HTN in children The Dietary Approaches to Stop Benefit–harm assessment Limited data to support any real benefit for screening children for MA Hypertension (DASH) approach Intentional vagueness Screening of children with primary HTN versus screening of children with single kidney or CKD and HTN and specific elements of that diet Role of patient preferences Unknown have been the primary dietary Exclusions None strategy tested in the literature. Strength Moderate recommendation These elements include a diet that Key references 408,410,411,413 is high in fruits, vegetables, low- fat milk products, whole grains, Key Action Statement 19 fish, poultry, nuts, and lean red meats; it also includes a limited children with BP >90th percentile intake of sugar and sweets along (or >120/80 mmHg) but <95th 66,416, 417 In children and adolescents with lower sodium intake (see percentile. ‍ ‍ Longitudinal diagnosed with HTN, the treatment ‍Table 16). Cross-sectional studies studies on BP from childhood to goal with nonpharmacologic and demonstrate associations between adulthood that include indirect pharmacologic therapy should be a elements of the DASH diet and BP. measures of CV injury indicate that reduction in SBP and DBP to <90th For example, population-based data the risk for subsequent CVD in early ≥ percentile and <130/80 mmHg in from NHANES show correlations adulthood increases as the BP level adolescents 13 years old (grade C, between dietary sodium and BP in adolescence exceeds 120/80 in childhood and elevated BP and 11,103, 418 7.2moderate Lifestyle recommendation). and Nonpharmacologic mmHg. ‍ In addition, there is HTN, particularly in people with Interventions 332 some evidence that targeting a BP excess weight. <90th percentile results in reductions104 in LVMI and prevalence of LVH. A high intake of fruits, vegetables, Therefore, an optimal BP level to be Lifestyle interventions are and legumes (ie, a plant-strong achieved with treatment of childhood recommended to lower BP. There diet) is associated with lower 421 HTN is <90th percentile or <130/80 is good evidence from studies in BP. A lack of fruit consumption mmHg, whichever is lower. adults showing that nutritional419 in childhood has been linked interventions lower BP, including to increases in cIMT in young Treatment and management clinical trials demonstrating that adulthood422 in the Young Finns options are discussed below, reducing dietary sodium results338 in study. Higher intake of low-fat including lifestyle modifications and lower BP and CV mortality, dairy products has been associated423 pharmacologic therapy to achieve and a diet high in olive oil420 with lower BP in childhood. optimal BP levels in children and polyphenols lowers BP. Studies adolescents with HTN. of hypertensive youth suggest Longitudinal, observational, and Key Action Statement 19. In children and adolescents diagnosed with HTN, the interventional data also support treatment goal with nonpharmacologic and pharmacologic therapy should be a relationships between diet and BP reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ’ ≥ 13 years old (grade C, moderate recommendation). in youth. The National Heart Lung and Blood Institute s Growth and Aggregate Evidence Quality Grade C Health Study, which followed 2185 Benefits Lower risk of childhood target organ damage, lower risk of ≥ girls over 10 years, demonstrated adulthood HTN and CVD ≥ Risk, harm, cost Risk of drug adverse effects and polypharmacy that consuming 2 servings of Benefit–harm assessment Preponderance of benefit dairy and 3 servings of fruits and Intentional vagueness None vegetables daily was associated Role of patient preferences Patient may have preference for nonpharmacologic or with lower BP in childhood and a pharmacologic treatment Exclusions None 36% lower424 risk of high BP by young Strength Moderate recommendation adulthood. Similar associations Key references 11,66,103,104,416–418 have been demonstrated in children425 and adolescents with diabetes. Moreover, an improvement in diet Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 37

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics TABLE 18 OSAS Symptoms and Signs History of frequent snoring (≥3 nights per week) led to lower BP in some studies426 of Labored breathing during sleep adolescents with elevated427 BP, Gasps, snorting noises, observed episodes of apnea Sleep enuresis (especially secondary enuresis) youth with overweight,428 girls with metabolic syndrome, and youth Sleeping in a seated position or with the neck hyperextended 429 Cyanosis with T2DM. However, consuming Headaches on awakening a healthier430 diet may increase Daytime sleepiness 7.2bcosts Physical. Activity Attention-deficit/hyperactivity disorder Learning problems Physical examination Underweight or overweight Observational data support a Tonsillar hypertrophy relationship between physical Adenoidal facies activity and lower BP, although the Micrognathia, retrognathia 339 High-arched palate data are scant. Interventional Failure to thrive data demonstrate increasing HTN physical activity leads to lower BP. Adapted from Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of A review of 9 studies of physical childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3). Available at: www.pediatrics.org/cgi/content/full/ activity interventions in children and 130/3/e714. adolescents with obesity suggested that 40 minutes of moderate to – vigorous, aerobic physical activity at week (30 60 minutes per session) combination with other behavioral least 3 to 5 days per week improved to help reduce BP (grade C, weak techniques to address overweight SBP by an average of 6.6 mmHg and 436 340 recommendation).7.2c Weight Loss and Related CV Risk and obesity in children. Studies prevented vascular dysfunction. Factors in hypertensive adults support the A number of subsequent, additional use of MI to improve adherence to studies with small sample sizes 437 antihypertensive medications and support a benefit of physical activity 436 341 As is true for children and decrease SBP. Although there are on BP. A more recent analysis adolescents with isolated HTN, no trials investigating the use of MI of 12 randomized controlled trials 426,432 a DASH diet ‍ and vigorous in the care of hypertensive youth, including 1266 subjects found 431 physical activity are recommended a number of studies have shown reductions of 1% and 3% for resting in pediatric patients with multiple that MI can be used successfully SBP and DBP, respectively. These obesity-related risk factors as part of to address or prevent childhood results did not reach statistical 433,434 – intensive weight-loss therapy. obesity by promoting physical significance, however, and the ’ 438 441 activity and dietary changes. ‍‍ authors suggested that longer Motivational interviewing (MI) is a tool recommended for pediatricians However, other studies have been studies with larger sample sizes 442,443 ’ 344 use by the AAP Expert Committee less promising. In addition to are needed. Any type of exercise, 435 Statement on Obesity. MI may the standard lifestyle approaches, whether it s aerobic training, be a useful counseling tool to use in intensive weight-loss therapy resistance training, or combined “ ” 342 Key Action Statement 20. At the time of diagnosis of elevated BP or HTN in a child training, appears to be beneficial or adolescent, clinicians should provide advice on the DASH diet and recommend (see HTN and the Athlete ). moderate to vigorous physical activity at least 3 to 5 days per week (30–60 Programs that combine diet and minutes per session) to help reduce BP (grade C, weak recommendation). physical activity can have a beneficial Aggregate Evidence Quality Grade C effect on SBP, as is shown in Benefits Potential to reduce BP several studies designed to prevent Risk, harm, cost No or low potential for harm. Following a healthier diet may increase childhood obesity and address costs to patients and families 431 Benefit–harm assessment Potential benefit outweighs lack of harm and minimal cost Keycardiometabolic Action Statement risk 20. Intentional vagueness None Role of patient preferences Level of caregiver and patient concern may influence adoption of the DASH diet and physical activity. Patients may also have preferences around the use of a medication. These factors may influence the At the time of diagnosis of elevated efficacy of lifestyle change BP or HTN in a child or adolescent, Exclusions None clinicians should provide advice Strength Weak recommendation on the DASH diet and recommend Key references 332,339–342,424–431 moderate to vigorous physical activity at least 3 to 5 days per Downloaded from www.aappublications.org/news by guest on September 25, 2021 38 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics involving regular patient and/or initial drug. Because of the salt and despite238 their continued widespread family contact and at least 1 hour water retention that occurs with use. of moderate to vigorous physical many antihypertensive medications, 7.3b Pharmacologic Treatment: Choice activity on a daily basis should be a thiazide diuretic is often the of Agent

offered to children and444 adolescents preferred second agent. with7.2d Stress obesity Reduction and HTN. Lifestyle modifications should be continued in children requiring Pharmacologic treatment of HTN pharmacologic therapy. An ongoing Complimentary medicine in children and adolescents should emphasis on a healthy, plant-strong interventions have shown some be initiated with an ACE inhibitor, diet rich in fruits and vegetables; 469 promise in studies in normotensive ARB, long-acting calcium channel reduced sodium intake; and children and adolescents and in blocker, or a thiazide diuretic. increased exercise can improve the those with elevated BP. Breathing- Because African American children effectiveness of antihypertensive awareness meditation, a component may not have as robust a response medications. The use of a 470,471 of the Mindfulness-Based Stress to ACE inhibitors, ‍ a higher combination product as initial Reduction Program at the University initial dose for the ACE inhibitor treatment has been studied only for of Massachusetts Memorial Medical 449 may be considered; alternatively, 445 bisoprolol and hydrochlorothiazide, Center, led to a reduction in therapy may be initiated with a – so the routine use of combination daytime, nighttime, and 24-hour SBP thiazide diuretic or long-acting products to initiate treatment in (3 4 mmHg) and DPB (1 mmHg) calcium channel blocker. In view of children cannot be recommended. in normotensive African American the expanded adverse effect profile Once BP control has been achieved, adolescents and African American and lack of association in adults 446 a combination product can be β adolescents with elevated BP. with improved outcomes compared considered as a means to improve Another study of transcendental with other agents, -blockers are not adherence and reduce cost if the dose meditation showed no significant BP recommended as initial treatment and7.3a formulationPharmacologic are Treatment appropriate. and in children. ACE inhibitors and ARBs effect but did lead to a decrease in Pediatric Exclusivity Studies LVM in African American447 adolescents are contraindicated in pregnancy with elevated BP. Scant data 448 because these agents can cause injury suggest7.3 Pharmacologic yoga may also Treatment be helpful. and death to the developing fetus. Studies completed in hypertensive Adolescents of childbearing potential children show that– antihypertensive– should be informed of the potential drugs decrease BP with few adverse Children who remain hypertensive 173,202, 242 244,450 467 risks of these agents on the developing effects. ‍ ‍ ‍ ‍ ‍ ‍ There β despite a trial of lifestyle fetus; alternative medications (eg, are few studies in children in which modifications or who have calcium channel blocker, -blocker) researchers compare different symptomatic HTN, stage 2 HTN 453 can be considered when appropriate. antihypertensive agents. These without a clearly modifiable factor studies do not show clinically (eg, obesity), or any stage of HTN In children with HTN and CKD, significant differences in the degree associated with CKD or diabetes proteinuria, or diabetes mellitus, of BP lowering between agents. mellitus therapy should be initiated an ACE inhibitor or ARB is There are no clinical trials in children with a single medication at the low recommended as the initial that have CV end points as outcomes. end of the dosing range (see Table antihypertensive agent unless there Long-term studies on the safety of 17). Depending on repeated BP is an absolute contraindication. Other antihypertensive medications in α β α measurements, the dose of the initial antihypertensive medications (eg, children and their impact on future β medication can be increased every 455 -blockers, -blockers, combination - CVD are limited. 2 to 4 weeks until BP is controlled and -blockers, centrally acting agents, (eg, <90th percentile), the maximal Because of legislative acts that potassium-sparing diuretics, and direct dose is reached, or adverse effects provide incentives and mandates vasodilators) should be reserved for for drug manufacturers to complete children who are not responsive to 2 occur. Although the dose can be 468 “ ” titrated every 2 to 4 weeks using pediatric assessments, most of the or more of the preferred agents (see home BP measurements, the patient newer antihypertensive medications KeyTreatment Action Statement in CKD ). 21 should be seen every 4 to 6 weeks have undergone some degree of until BP has normalized. If BP is efficacy and safety evaluation. not controlled with a single agent, Antihypertensive drugs without In hypertensive children and a second agent can be added to the patent protection have not been, and adolescents who have failed lifestyle regimen and titrated as with the are unlikely to be, studied in children modifications (particularly those Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 39

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics who have LV hypertrophy on echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting Comments calcium channel blocker, or thiazide diuretic (grade B, moderate recommendation).7.3c Treatment: Follow-Up and Monitoring profound bradycardia contraindications tacrolimus levels renal failure; or coadminister with sodium thiosulfate BP rates receiving azole antifungal agents Give every 4 h when given intravenous bolus Adverse effects include dry mouth and drowsiness Half-life varies with genetically determined acetylation Exaggerated decrease in BP can be seen patients Most potent oral vasodilator, long acting Most potent oral vasodilator, Treatment of a child or adolescent with HTN requires ongoing

monitoring because472 goal BP can be difficult to achieve. If the decision has been made to initiate treatment –

Route with medication, the patient should be seen frequently (every 4 6 weeks) for dose adjustments and/or addition Intravenous infusion Short acting, constant infusion preferred. May cause Intravenous, intramuscular Causes tachycardia Intravenous bolus or infusion Asthma and overt heart failure are relative Intravenous bolus or infusion May cause reflex tachycardia. Increases cyclosporine and Intravenous infusion Monitor cyanide levels with prolonged (>72 h) use or in Oral Intravenous infusion Higher doses worsen tachycardia without further reducing Oral Oral Oral of a second or third agent until goal BP has been achieved (see the preceding section). After that, the frequency of visits can be extended to every 3 to 4 months. If the decision has been made to proceed with lifestyle changes only, – Dose then follow-up visits can occur at longer intervals (every 3 6 months) so that adherence to lifestyle change can be reinforced and the need per dose per dose dose given every 6 – 8 h per min given every 6 – 8 h dose given every 6 – 8 h dose given Q 8 – 12 h for initiation of medication can be 100 – 500 μ g/kg per min 0.1 – 0.2 mg/kg per dose up to 0.4 Bolus: 0.20 – 1.0 mg/kg per dose up to 40 mg Infusion: 0.25 – 3.0 mg/kg per h Bolus: 30 μ g/kg up to 2 mg per dose Infusion: 0.5 – 4 μ g/kg per min Starting: 0 – 3 μ g/kg per min Maximum: 10 μ g/kg per min 2 – 5 Μ g/kg per dose up to 10 0.2 – 0.5 Μ g/kg per min up to 0.8 0.25 mg/kg per dose up to 25 mg 0.05 – 0.1 mg/kg per dose up to 5 mg 0.1 – 0.2 mg/kg per dose up to 10 mg reassessed. Useful for Severely Hypertensive Patients With Less Significant Symptoms Useful for Severely Hypertensive Patients With Life-Threatening Symptoms In patients treated with antihypertensive medications, home BP measurement is frequently “ used to get a better assessment ” of BP control (see At-Home

Class Measurement ). Repeat ABPM may also be used to assess BP control and tensive Medications for Acute Severe HTN “ is especially important in patients ” with CKD (see Treatment: Use of ABPM and Assessment ). -adrenergic blocker β -adrenergic Direct vasodilator -adrenergic blocker α - and β -adrenergic Calcium channel blocker Central α -agonist Dopamine receptor agonist Direct vasodilator Calcium channel blocker Direct vasodilator At each follow-up visit, the patient should be assessed for adherence to prescribed therapy and for any adverse effects of the prescribed medication; such assessment may Oral and Intravenous Antihyper include laboratory testing depending on the medication (for example, Esmolol Hydralazine Drug Labetalol Nicardipine Sodium nitroprusside Direct vasodilator Clonidine Fenoldopam Hydralazine Isradipine Minoxidil

TABLE 19 electrolyte monitoring if the patient is on a diuretic). It is also important to continually reinforce adherence Downloaded from www.aappublications.org/news by guest on September 25, 2021 40 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 21. In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy on echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable despite treatment with 3 or more factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an antihypertensive agents of different ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic (grade classes. All of these drugs should be B, moderate recommendation). prescribed at maximally effective Aggregate Evidence Quality Grade B doses, and at least 1 should be a Benefits Potential prevention of progressive CVD; regression or avoidance of diuretic. Key to the identification target organ damage; resolution of hypertensive symptoms; improved of patients with true resistant HTN cognition; avoidance of worsening HTN; potential avoidance of stroke, is correct office BP measurement, heart failure, coronary artery disease, kidney failure confirmation of adherence to Risks, harm, cost Potential for hypotension, financial cost, chronic medication treatment, adverse medication effects, impact on insurability (health and life) current therapy, and confirmation of Benefit–harm assessment Preponderance of benefits over harms treatment resistance by ABPM. Intentional vagueness None The treatment of patients with Role of patient preferences The choice of which antihypertensive medication to use should be made in close discussion with the patient and parent regarding risk, resistant HTN includes dietary benefits, and adverse effects sodium restriction, the elimination Exclusions None of substances known to elevate Strength Moderate recommendation BP, the identification of previously Key references 452,455,467 undiagnosed secondary causes of HTN, the optimization of current

therapy, and the addition of 475 additional agents as needed. Recent clinical trial data suggest that to lifestyle changes because effective treatment, ABPM results indicated an aldosterone receptor antagonist treatment will depend on the that treatment-goal BP was achieved (such as spironolactone) is the combination of effects from both in only17 one-third of children with optimal additional agent in adults medication and lifestyle measures. HTNKey Action. Statement 22 with resistant HTN; it helps address Finally, known hypertensive target volume excess as well as untreated organ damage (such as LVH) should “ hyperaldosteronism, which is be reassessed according to the ABPM may be used to assess common in adult476, patients477 with true recommendations in Imaging treatment effectiveness in children resistant HTN. ‍ Evaluation, Echocardiography: ” and adolescents with HTN, especially Coarctation of the Aorta and At present, there are no data on when clinic and/or home BP Detection of Target Organ Damage. whether true treatment-resistant 7.3d Treatment: Use of ABPM to Assess measurements indicate insufficient HTN exists in pediatric patients. Treatment BP response to treatment (grade B, Evaluation and management 7.4moderate Treatment- recommendation).Resistant HTN strategies similar to those proven effective in adults with resistant HTN ABPM can be an objective method would be reasonable in children to evaluate treatment effect during Resistant HTN in adults is defined and adolescents who present with antihypertensive drug therapy. Data asKey persistently Action Statement elevated 22. BPABPM may be usedapparent to assess treatment treatment resistance.effectiveness in children and adolescents with HTN, especially when clinic and/or home BP obtained in a multicenter, single-blind, measurements indicate insufficient BP response to treatment (grade B, moderate crossover study in which hypertensive recommendation). children received a placebo or no treatment demonstrated no Aggregate Evidence Quality Grade B Benefits ABPM results can guide adjustment in medication. ABPM can facilitate change in ABPM473 after receiving the placebo. A report from a achieving treatment-goal BP levels Risks, harm, cost Inconvenience and patient annoyance in wearing an ABPM monitor. single center found that among Cost of ABPM monitors hypertensive children receiving Benefit–harm assessment Overall benefit antihypertensive drugs, BP data Intentional vagueness None from ABPM resulted in medication Role of patient preferences Patients may choose not to wear the ambulatory BP monitor 474 repeatedly, which may necessitate alternative approaches to changes in 63% of patients. evaluate treatment efficacy Another study of 38 hypertensive Exclusions Uncomplicated HTN with satisfactory BP control children used ABPM to evaluate the Strength Moderate recommendation effectiveness of antihypertensive Key references 17,474,475 therapy (nonpharmacologic and pharmacologic). After 1 year of Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 41

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics 8. Treatment in Special Populations to intensive BP control (24-hour beneficial for preserving renal 8.1 Treatment in Patients With CKD MAP <50th percentile by ABPM). function. Researchers in multiple and Proteinuria The study demonstrated fewer studies have evaluated the utility– of

8.1a CKD composite CKD outcomes173 in children RAAS blockade therapy452,464, in465, patients484 487 with the lower BP target. Recent with CKD and HTN. ‍ ‍ ‍ ‍ adult data from the Systolic Blood These medications have been shown Children and adolescents with Pressure Intervention Trial suggest to benefit both BP and proteinuria. lower BP targets may be beneficial CKD often478 present with or develop The benefit of such therapies may in preventing other, adverse CV 173,488 HTN. HTN is a known risk factor 482 not be sustained, however. ‍ The outcomesKey Action Statementas well. 23 for the progression of kidney173,479, 480 disease Effect of Strict Blood Pressure Control in adults and children. ‍ ‍ and ACE-Inhibition on Progression Evidence suggests that the treatment of Chronic Renal Failure in Pediatric of HTN in children with CKD might 1. Children and adolescents with Patients study demonstrated an slow the progression173, of415 or reverse CKD should be evaluated for HTN initial 50% reduction in proteinuria end organ damage. ‍ When at each medical encounter; in children with CKD after treatment evaluated by 24-hour ABPM, children with ramipril but450, with464, 488a rebound effect and adolescents with CKD often 2. Children or adolescents with both CKD and HTN should be treated after 36 months. ‍ This study have poor BP control even if BP also showed that BP reduction with measured in the clinic appears to be to lower 24-hour MAP to <50th 48 percentile by ABPM; and a ramipril-based antihypertensive normal. MH is associated with203,481 end regimen improved renal outcomes. organ damage, such as LVH. ‍ 3. Regardless of apparent control of In children with HTN related to Threshold values that define HTN are BP with office measures, children underlying CKD, the assessment of not different in children with CKD, and adolescents with CKD and a proteinuria and institution of RAAS although there is some evidence that history of HTN should have BP blockade therapy appears to have lower treatment goals might improve assessed by ABPM at least yearly importantKey Action Statementprognostic 24implications. outcomes. to screen for MH (grade B; strong recommendation). In the European Effect of Strict Blood 8.1b Proteinuria Pressure Control and ACE-Inhibition Children and adolescents with on Progression of Chronic Renal CKD and HTN should be evaluated Failure in Pediatric Patients study, Proteinuric renal disease is often for proteinuria (grade B, strong researchers randomly assigned associated with HTN and a rapid483 Keyrecommendation). Action Statement 25 children with CKD to standard decline in glomerular filtration. antihypertensive therapy (with Studies in both adults and children a treatment goal of 24-hour MAP have indicated that both BP control Children and adolescents with CKD, <90th percentile by ABPM) or and a reduction in proteinuria are Key Action Statement 23. Children and adolescents with CKD should be evaluated HTN, and proteinuria should be for HTN at each medical encounter; treated with an ACE inhibitor or ARB (grade B, strong recommendation). Children or adolescents with both CKD and HTN should be treated to lower 24-hour 8.2. Treatment in Patients With MAP to <50th percentile by ABPM; and Diabetes Regardless of apparent control of BP with office measures, children and adolescents with CKD and a history of HTN should have BP assessed by ABPM at least yearly to screen for MH (grade B; strong recommendation). Based on the Fourth Report1 criteria Aggregate Evidence Quality Grade B for the diagnosis of HTN, between Benefits Control of BP in children and adolescents with CKD has been shown 4% and 16% of children and to decrease CKD progression and lead to resolution of LVH – Risks, harm, cost Cost of ABPM and BP control, both financial and nonfinancial adolescents14, with489 491 T1DM are found to Benefit–harm assessment Benefits of BP control in patients with CKD outweigh treatment risks have HTN. ‍ ‍ In the SEARCH Intentional vagueness Threshold study of 3691 youth between the Role of patient preferences Patients may not want to wear the ambulatory BP monitor ages of 3 and 17 years, elevated BP repeatedly, which should lead to detailed counseling regarding the was documented in 6% of children benefits of this procedure in CKD Exclusions None with T1DM, with the highest Strength Strong recommendation prevalence in Asian Pacific Islander Key references 47,173,203,415,480–483 and American Indian children followed by African American and Hispanic children and those with Downloaded from www.aappublications.org/news by guest on September 25, 2021 42 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics 499 higher14 glycosylated hemoglobin A1c Association, the International may have507 OSAS and consequent levels. An office-based study in Society for500 Pediatric110 and Adolescent HTN. The more severe the OSAS, Australia found much higher rates Diabetes, AHA, and the National the more likely a child is to have 501 44,45 Key Action Statement 26 (16%) and490 a positive correlation Heart, Lung, and Blood Institute. elevated BP (see Table 18). with BMI. BP >130/90 mmHg Children with moderate to severe has been associated with a more- OSAS are at increased risk for HTN. than-fourfold increase in the relative Children and adolescents with T1DM However, it is not known whether or T2DM should be evaluated for risk of coronary artery disease and ≥ OSAS treatment with continuous HTN at each medical encounter and mortality at 10-year follow-up492 of positive airway pressure results44 treated if BP is 95th percentile individuals with T1DM. ≥ in improved BP in all children. or >130/80 mmHg in adolescents The prevalence of HTN is higher in Furthermore, adenotonsillectomy 13 years of age (grade C, moderate youth with T2DM compared with may not result in BP improvement N recommendation). T1DM, ranging from 12% at baseline in all children with OSAS. In 9. Comorbidities ( = 699) in the Treatment Options particular, children who have obesity N and OSAS may be less likely to for Type 2 Diabetes in Adolescents 9.1 Comorbidities: Dyslipidemia 493 experience a lowering of BP after an and Youth study to 31% ( = 598) 508 adenotonsillectomy. in the Pediatric Diabetes Consortium494 Type 2 Diabetes Clinic Registry. Children and adolescents with Therefore, children with signs of BP and arterial stiffness in cohort “ HTN are at increased risk for lipid OSAS (eg, daytime fatigue, snoring, studies have correlated with BMI, ” disorders attributable502 to the common hyperactivity, etc) should undergo male sex, African American race, and 14,494, 495 soil phenomenon, in which poor evaluation for elevated BP regardless age of onset of diabetes. ‍ diet, inactivity, and obesity contribute of treatment status. Given that both Unlike T1DM, HTN in T2DM is to both disorders.– Some observational nighttime and daytime BP is affected not correlated with glycosylated pediatric data503 confirm506 this by OSAS, the use of ABPM is the hemoglobin A1c levels or glycemic association. ‍ Furthermore, both recommended method for assessing failure, and it develops early in 496 HTN and dyslipidemias are associated206 the BP of children with suspected the course of the disease. It is with subclinical atherosclerosis OSAS. also associated with rapid onset of 111,497 and are503 risk factors for future 9.3 Comorbidities: Cognitive adverse cardiac changes ‍ and425 CVD. Screening is recommended Impairment may not respond to diet changes. to identify those at increased503 risk for The concurrence of obesity and early atherosclerosis. Treatment T2DM compounds the111,498 risks for target of lipid disorders identified in the Data from studies conducted in end organ damage. ‍ setting of HTN should follow existing adults suggest that the central pediatric lipid guidelines with lifestyle Empirical evidence shows a poor nervous system is a target organ advice, including weight loss and 419 awareness of HTN14 in youth with 503 that can be affected by HTN. pharmacotherapy, as necessary. T1DM and T2DM. Additionally, 9.2 Comorbidities: OSAS Preliminary studies suggest that only a fraction of children with HTN this is true in children as well. and diabetes were found14, to490, be498, on499 Hypertensive children score lower pharmacologic therapy ‍ ‍ Children with snoring, daytime on tests of neurocognition and on despite treatment recommendations sleepiness (in adolescents), or parental reports of executive function from the American Diabetes hyperactivity (in younger children) compared with normotensive Key Action Statement 24. Children and adolescents with CKD and HTN should be 509,510 511 evaluated for proteinuria (grade B, strong recommendation). controls. ‍ Adams et al found an increased prevalence of learning Aggregate Evidence Quality Grade B disabilities in children with primary Benefits Detection of proteinuria among children with CKD and HTN may foster early detection and treatment of children at risk for more HTN compared with normotensive advanced renal disease controls. The postulated mechanism– Risks, harm, cost Additional testing for these findings is impaired512 515 Benefit–harm assessment Benefit of detection of a higher-risk group exceeds the risk of testing cerebrovascular reactivity. ‍‍ At Intentional vagueness Whether to screen children with HTN without CKD for proteinuria the present time, these findings do not Role of patient preferences None Exclusions Children without CKD have specific clinical implications with Strength Strong recommendation respect to the diagnostic evaluation Key references 47,484 of childhood HTN, although they underscore the importance of early detection and treatment. Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 43

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 25. Children and adolescents with CKD, HTN, and proteinuria should be treated with an ACE inhibitor or ARB (grade B, strong recommendation). over the past decade by the Aggregate Evidence Quality Grade B Benefits ACE inhibitor and ARB therapy has been shown in the short-term to publication of several pediatric be effective in reducing urine proteinuria clinical trials and case series of – Risks, harm, cost Positive effect on urine protein concentrations after the receipt of antihypertensive agents that465, can523 be530 an ACE inhibitor may not be sustained over time used to treat such patients. ‍ ‍ Benefit–harm assessment Treatment with an ACE inhibitor or ARB may lower the rate of progression of renal disease even if the effect is not sustained in the long-term Although children and adolescents Intentional vagueness Whether to aggressively treat the BP so that it is <90th percentile can become symptomatic from HTN Role of patient preferences Patients may have concerns about the choice of medication, which at lesser degrees of BP elevation, should be addressed in general, patients who present Exclusions Children without CKD with acute severe HTN will have BP Strength Strong recommendation Key references 173,464,465,485,487,488 elevation well above the stage 2 HTN threshold. In a study of 55 children Key Action Statement 26. Children and adolescents with T1DM or T2DM should presenting to a pediatric ED in be evaluated for HTN at each medical encounter and treated if BP is ≥95th Taiwan with hypertensive crisis, 96% percentile or >130/80 mm Hg in adolescents ≥13 years of age (grade C, moderate had SBP greater than that of stage recommendation). 2 HTN, and 76% had DBP531 greater Aggregate Evidence Quality Grade C than that of stage 2 HTN. The major clinical issue in such children Benefits Early detection and treatment of HTN in children with T1DM and T2DM may reduce future CV and kidney disease is that this level of BP elevation may produce acute target organ Risks, harm, cost Risk of drug adverse effects and polypharmacy effects, including encephalopathy, Benefit–harm assessment Preponderance of benefit acute kidney injury, and congestive Intentional vagueness None heart failure. Clinicians should be ’ Role of patient preferences Family concerns about additional testing and/or medication may concerned about the development of

need to be addressed these complications when a child s Exclusions None BP increases 30 mmHg or more Strength Weak to moderate recommendation above the 95th percentile. Key references 14,110,111,494 Although a few children with primary

HTN may present with532 features of acute severe HTN, the vast 10. Sex, Racial, and Ethnic majority will have an underlying532,533 Differences in BP and Medication secondary cause of HTN. ‍ Choice in response to ACE inhibitors471 in the Thus, for patients who present with pediatric age group, the strength acute severe HTN, an evaluation for of available evidence is insufficient to secondary causes is appropriate and BP differences between various ethnic recommend using racial, sex, or ethnic should be conducted expediently. factors to inform the evaluation or groups are well216,516 described in the adult Additionally, target organ effects population. ‍ Large, cross-sectional management of HTN in children. should be assessed with renal studies have demonstrated that, per 11. Special Populations and function, echocardiography, and capita, minority ethnic groups have Situations central nervous system imaging, both a higher prevalence of HTN and among others. more significant end organ damage 517,518 11.1 Acute Severe HTN and outcomes. ‍ Although a Given the potential for the growing body of evidence indicates– development of potentially life-

that racial and ethnic differences519 521 in BP threatening complications, expert appear during adolescence, ‍‍ the There is a lack of robust evidence opinion holds that children and cause of these differences and when to guide the evaluation and adolescents who present with acute they develop in childhood are yet to management of children and severe HTN require immediate be fully determined. The risk of HTN adolescents with acute presentations treatment with short-acting

correlates more with obesity status of severe HTN. Thus, much of what antihypertensive medications533,534 that than with ethnicity or race, although216 is known is derived from studies may abort such sequelae. there may be some interaction. At conducted in adults,522 including Treatment may be initiated with this time, although limited data suggest medication choice. The evidence oral agents if the patient is able that there may be a racial difference base has been enhanced somewhat to tolerate oral therapy and if Downloaded from www.aappublications.org/news by guest on September 25, 2021 44 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics life-threatening complications have not yet developed. Intravenous agents are indicated when oral ’ therapy is not possible because of the patient s clinical status or when be arranged and interpreted correctly ABPM results in fewer false-positive screening results benefit for correctly diagnosed HTN has no complications — — — Assumes ABPM can WCH estimated at 35%, — Assumes treatment — a severe complication has developed (such as congestive heart failure) that warrants a more controlled BP reduction. In such situations, the BP should be reduced by no more ’ s values than 25% of the planned reduction

Preferred Option Assumptions Made over the first 8 hours, with the on family remainder of the planned reduction — — — C B C C 533,534 over the next 12 to 24 hours. The ultimate short-term BP goal in such patients should generally be around the 95th percentile. Table 19 lists suggested doses for oral and intravenous antihypertensive medications that may be used to treat patients with acute severe HTN. Option C (ABPM Only) Key Action Statement 27 only used ABPM interpret ABPM for all patients term outcome laboratory tests fewer complications who are treated Patients referred to provider who Assumes 100% Additional work to arrange and If HTN, treatment improves long- $1880 for visits, ABPM, and All patients correctly diagnosed In children and adolescents with acute severe HTN and life- threatening symptoms, immediate treatment with short-acting antihypertensive medication should

ABPM) be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 then ABPM interpret confirmatory ABPM term outcome laboratory tests undiagnosed HTN hours (grade expert opinion D, weak Assumes 100% Additional work to arrange or Less desirable to have more visits; better accuracy Family opinion depends If HTN, treatment improves long- 30% undiagnosed patients All patients correctly diagnosed; Increased mortality for not treating recommendation). 11.2 HTN and the Athlete

Sports participation and increased physical activity should be

tality for not treating encouraged in children with HTN. In adults, physical fitness is

Option A (Clinic BP Alone) Option B (Clinic BP Confirmed by associated536 with lower all-cause those diagnosed with WCH undiagnosed HTN; inconvenience of treatment patients with WCH mortality. Although meta-analyses Auscultatory or oscillatory BP >95% Auscultatory or oscillatory BP >90% Assumes 100% Baseline Baseline Baseline $1860 for visits and laboratory tests $1330 for visits, ABPM, and 60% undiagnosed patients; 35% of Increased mor and randomized controlled trials

consistently show lower BP535 after exercise training in adults, the 340 results are less robust in children. On the basis of this evidence, sports participation should improve BP over time. Additionally, there is Comparison of HTN Screening Strategies

evidence that exercise itself has a of 80%) estimated cost for 1 patient) treatment beneficial effect537 on cardiac structure nephrology referred patients; analyzed at single-patient level Percent adherence to care (goal Care delivery team effects Patient, family effects Clinical significance Visit, diagnosis costs (annual Likelihood of nonoptimal Costs of nonoptimal treatment in adolescents. Dimension Population: 170 cardiology,

Operational factors

Benefits

Cost of options

Costs from complications, adverse events, nonoptimal treatment

— , none. TABLE 20 The athlete interested in participating in competitive sports Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 45

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics and/or intense training presents It should be acknowledged that there transplants, the presence of native a special circumstance. Existing are no data linking the presence kidneys, CKD, and transplant

guidelines present conflicting1,538 of HTN to sudden death related to glomerulopathy are additional risk recommendations. ‍ Although sports participation in children, factors for HTN. HTN rates are higher

increased LV wall dimension may be360 although many cases of sudden death by 24-hour ABPM compared with a consequence of athletic training, are of unknown etiology. That said, clinic BP measurements– because these

recommendations from AHA and athletes identified as hypertensive populations commonly179 183,542 have MH and ACC include the following: (1) limiting (eg, during preparticipation nocturnal HTN. ‍‍ Control competitive athletic participation sports screening) should undergo of HTN in renal-transplant patients ’ among athletes with LVH beyond appropriate evaluation as outlined has been improved184,185 with the use of that seen with athlete s heart until above. For athletes with more severe annual ABPM. ‍ Therefore, ABPM BP is normalized by appropriate HTN (stage 2 or greater), treatment should be used to identify and monitor antihypertensive drug therapy, and should be initiated before sports nocturnal BP abnormalities and MH in (2) restricting athletes with stage participation.Key Action Statement 28 pediatric kidney and heart-transplant 2 HTN (even among those without recipients. The use of home BP evidence of target organ injury) from assessment may provide a comparable

participating in high-static sports Children and adolescents with HTN alternative to ABPM for186 BP assessment (eg, weight lifting, boxing, and may participate in competitive after transplant as well. wrestling) until HTN is controlled sports once hypertensive target The management of identified HTN with either lifestyle modification or organ effects and risk have been 539 in the pediatric transplant patient drug therapy. “ assessed (grade C, moderate can be challenging. Rates of control recommendation).Key Action Statement 29 The AAP policy statement Athletic of HTN in renal-transplant patients180, Participation by Children and generally range from 33% to 55%. ” 187 188 Adolescents Who Have Systemic ‍ In studies by Seeman et al, Children and adolescents with HTN Hypertension recommends that intensified antihypertensive should receive treatment to lower children with stage 2 HTN be treatment in pediatric renal- BP below stage 2 thresholds before restricted from high-static sports transplant recipients improved participating in competitive sports (classes IIIA to IIIC) in the absence nocturnal SBP and significantly (grade C, weak recommendation). 543 of end organ damage, including LVH 11.3 HTN and the Posttransplant reduced proteinuria. Children or concomitant heart disease, until Patient in these studies who achieved their BP is in the normal range after normotension had stable graft

lifestyle 538modification and/or drug function, whereas those who therapy. It is further recommended HTN is common in children after remained hypertensive at 2

that athletes be promptly referred solid-organ transplants, with years had544 a progression of renal and evaluated by a qualified pediatric prevalence179,180, rates540,541 ranging from 50% disease. medical subspecialist within 1 week to 90%. ‍ ‍ Contributing Antihypertensive medications have if they are asymptomatic or factors include the use of steroids, rarely been systematically studied immediately if they are symptomatic. calcineurin inhibitors, and mTOR in this population. There is limited The subcommittee agrees with these (mammalian target of rapamycin) evidence that ACE inhibitors and ARBs recommendations. inhibitors. In patients with renal Key Action Statement 27. In children and adolescents with acute severe may be superior to other agents in HTN and life-threatening symptoms, immediate treatment with short-acting achieving BP control and improving antihypertensive medication should be initiated, and BP should be reduced by long-term graft survival185,543,544 in renal- no more than 25% of the planned reduction over the first 8 hours (grade expert transplant patients. ‍ However, opinion D, weak recommendation). the combination of ACE inhibitors Aggregate Evidence Quality Expert Opinion, D and ARBs in renal-transplant Benefits Avoidance of complications caused by rapid BP reduction patients has been associated with Risks, harm, cost Severe BP elevation may persist acidosis and hyperkalemia545 and is not Benefit–harm assessment Benefit outweighs harm recommended. Intentional vagueness None 12. Lifetime HTN Treatment and Role of patient preferences None Transition to Adulthood Exclusions Patients without acute severe HTN and life-threatening symptoms Strength Weak recommendation because of expert opinion Key references 240,533,535 For adolescents with HTN requiring ongoing treatment, the Downloaded from www.aappublications.org/news by guest on September 25, 2021 46 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 28. Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and risk have been assessed (grade C, moderate recommendation). demonstrated that the risk of HTN Aggregate Evidence Quality Grade C in early adulthood is dependent on Benefits Aerobic exercise improves CVD risk factors in children and childhood BP, with greater numbers adolescents with HTN of elevated BP measurements in Risks, harm, cost Unknown, but theoretical risk related to a rise in BP with strenuous childhood conferring an increased exercise may exist risk of adult HTN. Benefit–harm assessment The benefits of exercise likely outweigh the potential risk in the vast majority of children and adolescents with HTN Intentional vagueness None Because the tracking of BP Role of patient preferences Families may have different opinions about sports participation in levels in children has10 also been children with HTN well documented, it is not Exclusions None surprising that analyses of the Strength Moderate recommendation Key references 341,360,538,540,541 National Childhood BP database found 7% of adolescents with elevated BP per year progressed to Key Action Statement 29. Children and adolescents with HTN should receive true hypertensive BP levels. treatment to lower BP below stage 2 thresholds before participating in Of note, initial BMI and change in competitive sports (grade C, weak recommendation). BMI were major determinants22 of Aggregate Evidence Quality Grade C the development of HTN. Benefits Aerobic exercise improves CVD risk factors in children and Therefore, in both children adolescents with HTN and adults, efforts (discussed Risks, harm, cost Unknown, but theoretical risk related to a rise in BP with below) should be made to strenuous exercise may exist prevent progression to Benefit–harm assessment The benefits of exercise likely outweigh the potential risk in the vast majority of children and adolescents with HTN sustained HTN and to avoid the Intentional vagueness None development of hypertensive CV Role of patient preferences None diseases. Exclusions None 13.2 Strategies for Prevention Strength Weak recommendation Key references 341,360,538,540,541

One of the largest trials of preventing progression to HTN in adults, the Trial of Preventing transition from pediatric care to of information regarding HTN 546 ’ Hypertension study, proved an adult provider is essential. etiology and past manifestations and that 2 years of treatment with HTN definition and treatment complications of the patient s HTN candesartan reduced the number recommendations in this guideline (grade X, strong recommendation). of subjects with elevated BP from

are generally consistent with the developing stage 1 HTN even 547 forthcoming adult HTN treatment 13. Prevention of HTN after the drug was withdrawn. guideline, so diagnosis and treatment However, no similar study has should not typically change with 13.1 Importance of Preventing HTN been conducted in youth; for transition. this reason, prevention efforts Key Action Statement 30 to date have focused on lifestyle

BP levels tend to increase with modification,426 especially dietary549 time even after adult height is intervention, exercise,550 and Adolescents with elevated BP or reached. The rate of progression treatment of obesity. The best – HTN (whether they are receiving to frank HTN in a study of more evidence for the potential of such antihypertensive treatment) should than 12 000 Japanese adults (20 35 prevention strategies comes typically have their care transitioned years of age at baseline, followed from epidemiologic evidence for to an appropriate adult care provider for 9 years) was 36.5% and was risk factors for the development

by 22 years of age (recognizing greater with548 higher baseline BP of HTN or from studies focused that there may be individual cases category. The rate of progression on the treatment of established in which this upper age limit is may also be accelerated in African HTN. These risk factors include

exceeded, particularly in the case American individuals. Similarly,63 positive family history, obesity, a of youth with special health care both the Bogalusa60 Heart and Fels high-sodium diet, the absence of a needs). There should be a transfer Longitudinal studies have clearly DASH-type diet, larger amounts of Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 47

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Key Action Statement 30. Adolescents with elevated BP or HTN (whether they are receiving antihypertensive treatment) should typically have their care transitioned to an appropriate adult care provider by 22 years of age (recognizing The third challenge is for that there may be individual cases in which this upper age limit is exceeded, clinic personnel to be aware particularly in the case of youth with special health care needs). There should of what to do with high BP be a transfer of information regarding HTN etiology and past manifestations and measurements when they occur. complications of the patient’s HTN (grade X, strong recommendation). Knowing when to counsel patients, Aggregate Evidence Quality Grade X order tests or laboratory work, Benefits Provides continuity of care for patients and reach out for help is essential. Risks, harm, cost None Making this part of standard Benefit–harm assessment No risk Intentional vagueness None practice so every child follows Role of patient preferences Patient can pick adult care provider the prescribed pathway may be Exclusions None challenging. Strength Strong recommendation Key references 547 The final diagnosis of HTN also relies on a number of sequential visits. Ensuring that patients return for all of these – visits and are not lost to follow-up

sedentary time,551 and553 possibly other and avoidance of tobacco products may require new clinic processes dietary factors. ‍ ‍ are also reasonable strategies to or mechanisms. Information reduce CV risk. technology may help remind Because family history is immutable, providers to schedule these visits it is difficult to build a preventive These preventive strategies can and remind patients to attend strategy around it. However, a be implemented as part of routine these visits; even with that positive family history of HTN primary health care for children and assistance, however, completing all should suggest the need for closer adolescents. the visits may be difficult for some BP monitoring to detect HTN if it patients. occurs. 14. Challenges in the Implementation of Pediatric HTN Appropriate energy balance with Guidelines In addition, family medicine calories eaten balanced by calories physicians and general expended in physical activity is pediatricians may face challenges important. This is the best strategy in having normative pediatric to maintain an appropriate BMI Many studies have shown that BP values available for use at all percentile for age and sex and physicians fail to meet benchmarks times. Although adult BP cutoffs with respect to screening, especially are easy to memorize, pediatric to avoid554 the development of obesity. From a broader dietary universal7, screening115 for high BP in BP percentile cutoffs are greatly perspective, a DASH-type diet (ie, children. ‍ Although the reasons dependent on age and height. The high in fruits, vegetables, whole for this failure likely vary from BP tables in this guideline provide grains, and low-fat dairy, with practice to practice, a number of cutoffs to use for the proper decreased intake of foods high common challenges can be identified. diagnosis of HTN; their availability in saturated fat or sugar) may be will simplify the recognition of 423,427 The first challenge is determining how beneficial (see Table 16). ‍ abnormal BP values. to identify every child in a clinic who Avoiding high-sodium foods may merits a BP measurement. This could prove helpful in preventing HTN, The AAP Education in Quality be accomplished through flags in an particularly for individuals who are Improvement for Pediatric Practice EHR, documentation rules for specific more sensitive to dietary sodium module on HTN identification 555 patients, and/or clinic protocols. 556 intake. and management and its The second challenge is establishing accompanying557 implementation Adhering to recommendations a local clinic protocol for measuring guide should be of assistance to for 60 minutes a day of moderate BP correctly on the basis of the practitioners who wish to improve to vigorous physical activity can algorithms in this guideline. It their approach to identifying be important to maintaining an is important to determine the and managing childhood HTN. appropriate weight and may optimal approach on the basis of ’ This module is currently being be independently helpful344 to the available equipment, the skills updated to incorporate the new maintaining a lower BP. The of clinic personnel, and the clinic s recommendations in this achievement of normal sleep habits throughput needs. guideline. Downloaded from www.aappublications.org/news by guest on September 25, 2021 48 FROM THE AMERICAN ACADEMY OF PEDIATRICS

15.1 Economic Impact of BP screening strategies; these options choices lead to better decisions Management are summarized in the following executed in self-care. For clear

value-analysis560 framework (see judgments to be made, there needs Table‍ 20). It appears that the to be open communication between Researchers in a small number of implementation of ABPM for all physicians and families, a provision studies have examined the potential patients is not ensured. The next of appropriate education on optimal best option, screening clinic BP HTN management, and a strong economic impacts208, related558,559 to pediatric558 BP management. ‍ Wang et al with ABPM, is most likely to be partnership assembled within a estimated both the effectiveness and implementable and has significant multidisciplinary health care team cost-effectiveness of 3 screening clinical benefit given the high including physicians, advanced strategies and interventions to prevalence of WCH. practice providers, dietitians, normalize pediatric BP based on the nurses, and medical and clinical n 208 literature and through a simulation Swartz et al conducted a assistants. of children ( = 4017821). The 3 retrospective review of 267 It is important for physicians screening strategies included the children with elevated clinic BP to be mindful that children and following: (1) no screening; (2) measurements referred for ABPM. “ ” adolescents want, and need, to selected screening and treatment, as Of the 126 patients who received be involved in their medical care. well as treating everyone (ie, with ABPM, 46% had WCH, 49% had Pediatric HTN patients are likely population-wide interventions, such stage 1 HTN, and 5% had stage 2 to feel excluded when clinicians as targeted programs for overweight HTN. This is consistent with the or other providers speak to their adolescents [eg, weight-loss concept that screening with clinic parents instead of including them in programs, exercise programs, and BP alone results in high numbers the conversation. When patients are salt-reduction programs]); and (3) of false-positive results for HTN. neither included in the discussion nontargeted programs for exercise The diagnosis of HTN in this study nor encouraged to ask questions, and salt reduction. resulted in an additional $3420 for their anxiety can increase, thus evaluation (includes clinic visit, worsening their HTN. Keeping The simulation suggested that these facility fee, laboratory testing, renal an open line of communication various strategies could reduce ultrasound, and echocardiography) is important and is best done by mortality, with a modest expected vs $1265 (includes clinic visit, using a team approach consisting survival benefit of 0.5 to 8.6 days. facility fee, and ABPM). This of the patient, the family, health The researchers also examined suggests that ABPM is cost- care support staff, and physicians. quality-adjusted life-years (QALYs) effective because of the reduction With practical education on and the cost per QALY. Only 1 of unnecessary testing in patients HTN management provided in intervention, a nontargeted salt- with WCH. easily understandable terms, the reduction campaign, had a negative When examining these costs, patients will be more likely to cost per QALY. This intervention the availability of ABPM, and the apply the concepts presented to and the other 2 described in that availability of practitioners who are them. Education is important and article support the concept that skilled in pediatric interpretation, should be given in a way that is population-wide interventions the most cost-effective and appropriate for young children may be the most cost-effective way implementable screening solution and their families to understand. to improve CV health. The article is to measure clinic BP and confirm Education should consist of has serious limitations, however, suitable medication dosing, a 15.2elevated Patient readings Perspective by ABPM. and including the fact that population- proper diet and level of activity, Pediatric HTN wide interventions for exercise and the identification of symptoms, the reduction of sodium intake have and appropriate BP monitoring not, thus far, been effective. (including cuff size). Children and adolescents are 15.3 Parental Perspective and The accurate determination of not just patients; they are Pediatric HTN those who actually have HTN (as active participants in their opposed to WCH) is fundamental to health management. If children Parents play a key role in the providing sound care to patients. and adolescents lack a clear ’ Researchers in two studies understanding of what is happening management and care of their

examined the effects of using208,559 ABPM inside their bodies, they will not children s health. Parents and in the diagnosis559 of HTN. ‍ be able to make informed choices physicians should act as a cohesive Davis et al compared 3 HTN in their daily activities. Better unit to foster the best results. It Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017 49

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics ’ is vital for physicians to provide Understanding the family and the types of clinical trials that concise information in plain language patient s perception of HTN and are needed to produce high- and do so using a team approach. any underlying disease that may quality evidence. For example, This will facilitate parents having a be contributing to it is important no large pediatric cohort has clear understanding of the required to resolve any misconceptions ever been assembled to answer ’ tests, medications, follow-ups, and and encourage adherence to the the question of whether routine

outcomes. physician s recommendations. To BP measurement in childhood566 is attain therapeutic goals, proper useful to prevent adult CVD. education must be provided to the Given this, other types of evidence, Patient Perspective, by Matthew family as a whole. This education such as from cross-sectional and Goodwin“ should include proper medication observational cohort studies, must567 dosages, recommended sodium be examined to guide practice. I am not just a 13 year old, I am intake, any dietary changes, a teenager who has lived with exercise expectations, and any From the standpoint of the primary hypertension, renal disease, and other behavioral changes. It is care provider, the most significant midaortic syndrome since I was equally important to stress to evidence gaps relate to whether 4 years old. I have experienced the family the short- and long- diagnosing elevated BP and HTN in surgeries, extended hospitalizations, term effects of HTN if it is not children and adolescents truly has daily medications, procedures, properly managed. Parents with long-term health consequences, tests, continued blood pressure younger children will carry the whether antihypertensive monitoring, lifestyle changes, and ultimate burden of daily decisions medications should be used in a dietary restrictions. Hypertension as it applies to medications, food child or adolescent with elevated is a part of my everyday life. It will choices, and activity. Parents of BP, and what medications should be always be a component of me. I had older adolescents will partner with preferentially used. These evidence to learn the effects of hypertension the children to encourage the right gaps have been alluded to previously at a young age. I knew what would choices. Education as a family unit in this document. happen to me if I ate too much is important for everyone involved salt or did not fully hydrate, thus I to understand the consequences. Other important evidence gaps became watchful. I did this so I could should be highlighted, including the efficiently communicate with my A family-based approach is important following: physicians any changes I physically •• for all pediatric diseases but plays a felt or any symptoms that were new particular role in conditions that are or different regarding my illness. Is there a specific BP level in substantially influenced by lifestyle This has allowed me, my family, and childhood that predicts adverse behaviors. This has been shown my doctors to work effectively as outcomes, and can a single number in several pediatric populations, one unit. I am grateful for my doctors – (or numbers) be used to define ” including those with T2DM and •• listening to me as a person and not 561 565 HTN, as in adults? obesity. ‍ as a kid. Can and should ABPM ever replace auscultation in the diagnosis of 16. Evidence Gaps and Proposed ••childhood HTN? Future Directions Parents of children with Are the currently used, normative hypertensive issues can encounter standards for ABPM appropriate,

1 or more specialists in addition or are new568 normative data to their pediatric clinician. This In general, the pediatric HTN •• needed? can prove to be overwhelming, literature is not as robust as the What is the best diagnostic frightening, and may fill the parent adult HTN literature. The reasons evaluation to confidently exclude with anxiety. Taking these things for this are many, but the 2 most •• secondary causes of HTN? into account and creating unified important are as follows: (1) partners, built with the physician the lower prevalence of HTN in Are other assessments of and family, will encourage the childhood compared with adults, hypertensive target organ ’ family to be more involved in the and (2) the lack of adverse CV damage (such as urine MA or events (myocardial infarction, vascular studies) better than patient s health management. Plain •• language in a team approach will stroke, and death) attributable echocardiography? yield the most positive outcomes to HTN in young patients. These How confident can we be that a for the patient. factors make it difficult to conduct child or teenager with elevated BP Downloaded from www.aappublications.org/news by guest on September 25, 2021 50 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Susan K. Flinn, MA Bonita Falkner, MD Abbreviations will have HTN and/or CVD disease Samuel S. Gidding, MD as an adult? Celeste Goodwin Michael G. Leu, MD, MS, MHS, FAAP AAP: Ame rican Academy of Some of these questions may Makia E. Powers, MD, MPH, FAAP Pediatrics eventually be answered by research Corinna Rea, MD, MPH, FAAP ABPM: ambulatory blood pressure that is currently in progress, such as Joshua Samuels, MD, MPH, FAAP Madeline Simasek, MD, MSCP, FAAP monitoring further analysis of the International Vidhu V. Thaker, MD, FAAP ACC: Amer ican College of Childhood Cardiovascular Cohort 569 Elaine M. Urbina, MD, MS, FAAP Cardiology Consortium and the promising ACE: angiotensin-converting Adult Hypertension Onset in Youth Subcommittee on Screening enzyme study, which seeks to better define the and Management of High Blood AHA: Amer ican Heart Association level of BP in childhood that predicts Pressure in Children (Oversight ARB: angiotensin receptor blocker the development of hypertensive 570 by the Council on Quality ARR: aldosterone to renin ratio target organ damage. Other Improvement and Patient BP: blood pressure studies will need to be performed Safety) † BSA: body surface area in children and adolescents to fill Joseph T. Flynn, MD, MS, FAAP, Co-chair, Section on cIMT: carotid intimamedia thickness in the remaining gaps, including Nephrology CKD: chr onic kidney disease more rigorous validation studies of David Kaelber, MD, MPH, PhD, FAAP, Co-chair, CTA: computed tomographic automated BP devices in the pediatric Section on Medicine-Pediatrcs, Council on Clinical Information Technology angiography population, expanded trials of lifestyle Carissa M. Baker-Smith, MD, MS, MPH, CV: cardiovascular interventions, further comparative Epidemiologist and Methodologist CVD: cardiovascular disease trials of antihypertensive medications, Aaron Carroll, MD, MS, FAAP, Partnership for DASH: Dietary Approaches to Stop and studies of the clinical applicability Policy Implementation Hypertension of hypertensive target organ Stephen R. Daniels, MD, PhD, FAAP, Committee on Nutrition DBP: diastolic blood pressure assessments. Sarah D. de Ferranti, MD, MPH, FAAP, Committee ED: emergency department Furthermore, and perhaps more on Cardiology and Cardiac Surgery EHR: electr onic health record Michael G. Leu, MD, MS, MHS, FAAP, Council on FMD: flow-mediated dilation crucially, there needs to be prospective Quality Improvement and Patient Safety assessment of the recommendations Makia Powers, MD, MPH, FAAP, Committee on HTN: hypertension made in this document with regular Adolescence LVH: left ventricular hypertrophy updates based on new evidence as Corinna Rea, MD, MPH, FAAP, Section on Early LVMI: left ventricular mass index it is generated (generally, per AAP Career Physicians MA: microalbuminuria Joshua Samuels, MD, MPH, FAAP, Section on MAP: mean arterial pressure policy, these occur approximately Nephrology every 5 years). With such ongoing Madeline Simasek, MD, FAAP, Quality Improvement MH: masked hypertension reassessment and revision, it is hoped Innovation Networks MI: motivational interviewing that this document and its future Vidhu Thaker, MD, FAAP, Section on Obesity MRA: magnetic resonance angiography revisions will come to be viewed as NF-1: neurofibromatosis type 1 Liaisons an effective guide to practice and will OSAS: obstructive sleep apnea improve the care of the young patients Douglas Blowey, MD, American Society of syndrome Pediatric Nephrology PCC: pheochromocytoma who are entrusted to us. Janis Dionne, MD, FRCPC, Canadian Association of PICOT: Patient, Intervention/ Implementation tools for this Paediatric Nephrologists Bonita Falkner, MD, International Pediatric Indicator, Comparison, guideline are available on the AAP Hypertension Association Outcome, and Time Web site (https://www.aap.org/ Samuel Gidding, MD, American College of PRA: plasma renin activity en-us/about-the-aap/Committees- Cardiology, American Heart Association PWV: pulse wave velocity Councils-Sections/coqips/Pages/ Celeste Goodwin, National Pediatric Blood QALY: quality-adjusted life-year Implementation-Guide.aspx). Pressure Awareness Foundation Elaine Urbina, MD, FAAP, American Heart RAAS: renin-angiotensin- Authors Association AHOY Committee aldosterone system Joseph T. Flynn, MD, MS, FAAP RAS: renal artery stenosis David C. Kaelber, MD, PhD, MPH, FAAP, FACP, FACMI Medical Writer SBP: systolic blood pressure Carissa M. Baker-Smith, MD, MS, MPH, FAAP, FAHA Susan K. Flinn, MA Douglas Blowey, MD SDB: sleep-disordered breathing Aaron E. Carroll, MD, MS, FAAP T1DM: type 1 diabetes mellitus Staff Stephen R. Daniels, MD, PhD, FAAP T2DM: type 2 diabetes mellitus Sarah D. de Ferranti, MD, MPH, FAAP Kymika Okechukwu, MPA, Manager, Evidence- UA: uric acid Janis M. Dionne, MD, FRCPC Based Practice Initiatives WCH: white coat hypertension

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics Seattle, Washington; nDepartment of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia; oAssociate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts; Departments of pPediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas; qPediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; rDivision of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and sPreventive Cardiology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio

Drs Flynn and Kaelber served as the specialty and primary care chairs of the Subcommittee and had lead roles in developing the framework for the guidelines and coordinating the overall guideline development; Dr Baker-Smith served as the epidemiologist and led the evidence review and synthesis; Ms. Flinn compiled the first draft of the manuscript and coordinated manuscript revisions; All other authors were significantly involved in all aspects of the guideline creation including initial scoping, literature review and synthesis, draft manuscript creation and manuscript review; and all authors approved the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Endorsed by the American Heart Association.

DOI: https://doi.org/10.1542/peds.2017-1904

Address correspondence to Joseph T Flynn. Email: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FUNDING: The American Academy of Pediatrics provided funding to cover travel costs for subcommittee members to attend subcommittee meetings, to pay for the epidemiologist (Dr Baker-Smith) and consultant (Susan Flynn), and to produce the revised normative blood pressure tables.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated that they have no potential conflicts of interest to disclose.

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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics monitoring device in normotensive 162. Bjelakovic B, Jaddoe VW, Vukomanovic 171. Basiratnia M, Esteghamati M, Ajami GH, and hypertensive pediatric intensive V, et al. The relationship between et al. Blood pressure profile in renal care patients. J Clin Monit Comput. currently recommended ambulatory transplant recipients and its relation 2004;18(4):253–263 systolic blood pressure measures and to diastolic function: tissue Doppler 154. Cua CL, Thomas K, Zurakowski D, left ventricular mass index in pediatric echocardiographic study. Pediatr Laussen PC. A comparison of the hypertension. Curr Hypertens Rep. Nephrol. 2011;26(3):449–457 2015;17(4):534 Vasotrac with invasive arterial blood 172. Chaudhuri A, Sutherland SM, Begin pressure monitoring in children 163. 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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics regimen. J Heart Lung Transplant. 190. Lurbe E, Alvarez V, Redon J. Obesity, hypertension in children: association 2008;27(5):501–507 body fat distribution, and ambulatory with target-organ damage. Pediatr Nephrol. 2005;20(8):1151 1155 181. Paripovic D, Kostic M, Spasojevic blood pressure in children and – adolescents. J Clin Hypertens B, Kruscic D, Peco-Antic A. 201. Furusawa ÉA, Filho UD, Junior DM, Masked hypertension and hidden (Greenwich). 2001;3(6):362–367 Koch VH. Home and ambulatory uncontrolled hypertension after renal 191. Marcovecchio ML, Patricelli L, Zito blood pressure to identify white coat transplantation. Pediatr Nephrol. M, et al. 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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics 209. Briasoulis A, Androulakis E, Palla M, 218. Woroniecki RP, Flynn JT. How are 228. Ster giou GS, Rarra VC, Yiannes NG. Papageorgiou N, Tousoulis D. White- hypertensive children evaluated and Changing relationship between coat hypertension and cardiovascular managed? A survey of North American home and office blood pressure events: a meta-analysis. J Hypertens. pediatric nephrologists. Pediatr with increasing age in children: 2016;34(4):593–599 Nephrol. 2005;20(6):791–797 the Arsakeion School study. Am J Hypertens. 2008;21(1):41–46 210. Valent-Morić B, Zigman T, Zaja- 219. Mengden T, Hernandez Medina RM, 229. Salgado CM, Jardim PC, Viana JK, Franulović O, Malenica M, Cuk M. Beltran B, Alvarez E, Kraft K, Vetter The importance of ambulatory blood H. 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Flynn et al 2017 ROUGH GALLEY PROOF Clinical Practice Guideline for Screening https://doi.org/10.1542/peds.2017-1904 September 2017 and Management of High Blood Pressure in Children and Adolescents 3 140 Pediatrics phenotypes: a population study. J Am 391. Lagomarsino E, Orellana P, Muñoz J, in obese adolescents. Hypertension. Coll Cardiol. 2012;60(25):2643–2650 Velásquez C, Cavagnaro F, Valdés F. 2012;60(5):1148–1156 Captopril scintigraphy in the study of 383. Doyon A, Kracht D, Bayazit AK, et al; 401. Feig DI, Soletsky B, Johnson RJ. Effect arterial hypertension in pediatrics. 4C Study Consortium. Carotid of allopurinol on blood pressure of Pediatr Nephrol. 2004;19(1):66 70 artery intima-media thickness – adolescents with newly diagnosed and distensibility in children and 392. Abdulsamea S, Anderson P, Biassoni essential hypertension: a randomized adolescents: reference values and role L, et al. Pre- and postcaptopril renal trial. JAMA. 2008;300(8):924–932 of body dimensions. 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article-authors endPage startPage article-title issue volume buildID journal-title copyright proof doi pub-date Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents Joseph T. Flynn, David C. Kaelber, Carissa M. Baker-Smith, Douglas Blowey, Aaron E. Carroll, Stephen R. Daniels, Sarah D. de Ferranti, Janis M. Dionne, Bonita Falkner, Susan K. Flinn, Samuel S. Gidding, Celeste Goodwin, Michael G. Leu, Makia E. Powers, Corinna Rea, Joshua Samuels, Madeline Simasek, Vidhu V. Thaker, Elaine M. Urbina and SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN Pediatrics originally published online August 21, 2017;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2017/08/21/peds.2 017-1904 References This article cites 559 articles, 141 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2017/08/21/peds.2 017-1904#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Subcommittee on Screening and Management of High Blood Pressure in Children http://www.aappublications.org/cgi/collection/subcommittee-on-scre ening-and-management-of-high-blood-pressure-in-children Cardiology http://www.aappublications.org/cgi/collection/cardiology_sub Cardiovascular Disorders http://www.aappublications.org/cgi/collection/cardiovascular_disord ers_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 25, 2021 Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents Joseph T. Flynn, David C. Kaelber, Carissa M. Baker-Smith, Douglas Blowey, Aaron E. Carroll, Stephen R. Daniels, Sarah D. de Ferranti, Janis M. Dionne, Bonita Falkner, Susan K. Flinn, Samuel S. Gidding, Celeste Goodwin, Michael G. Leu, Makia E. Powers, Corinna Rea, Joshua Samuels, Madeline Simasek, Vidhu V. Thaker, Elaine M. Urbina and SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN Pediatrics originally published online August 21, 2017;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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