THE FOURTH REPORT ON THE Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Heart, Lung, and Blood Institute THE FOURTH REPORT ON THE Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Heart, Lung, and Blood Institute NIH Publication No. 05-5267 Originally printed September 1996 (96-3790) Revised May 2005 Acknowledgments THE FOURTH REPORT ON NATIONAL INSTITUTES OF THE DIAGNOSIS, EVALUATION, HEALTH STAFF AND TREATMENT OF HIGH Edward J. Roccella, Ph.D., M.P.H. BLOOD PRESSURE IN (National Heart, Lung, and Blood CHILDREN AND ADOLESCENTS Institute, Bethesda, MD); Tracey Hoke, M.D., M.Sc. (National Heart, Lung, and CHAIR Blood Institute, Bethesda, MD); Carl E. Bonita Falkner, M.D. (Thomas Jefferson Hunt, M.D. (National Center on Sleep University, Philadelphia, PA) Disorders Research, National Heart, Lung, and Blood Institute, Bethesda, MEMBERS MD); Gail Pearson, M.D., Sc.D. Stephen R. Daniels, M.D., Ph.D. (National Heart, Lung, and Blood (Cincinnati Children’s Hospital Medical Institute, Bethesda, MD) Center, Cincinnati, OH); Joseph T. Flynn, M.D., M.S. (Montefiore Medical Center, STAFF Bronx, NY); Samuel Gidding, M.D. Joanne Karimbakas, M.S., R.D., and (DuPont Hospital for Children, Ann Horton, M.S. (American Institutes Wilmington, DE); Lee A. Green, M.D., for Research Health Program, Silver M.P.H. (University of Michigan, Ann Spring, MD) Arbor, MI); Julie R. Ingelfinger, M.D. (MassGeneral Hospital for Children, FINANCIAL DISCLOSURES Boston, MA); Ronald M. Lauer, M.D. Dr. Flynn has served as a consultant/ (University of Iowa, Iowa City, IA); advisor for Pfizer Inc., AstraZeneca LP, Bruce Z. Morgenstern, M.D. (Mayo ESP-Pharma, and Novartis Pharmaceuticals; Clinic, Rochester, MN); Ronald J. he received funding/grant support for Portman, M.D. (The University of Texas research projects from Pfizer, AstraZeneca, Health Science Center at Houston, and Novartis. Houston, TX); Ronald J. Prineas, M.D., Ph.D. (Wake Forest University School ACKNOWLEDGMENTS of Medicine, Winston-Salem, NC); Albert We would like to thank the American P. Rocchini, M.D. (University of Michigan, Academy of Pediatrics for its help in dis- C.S. Mott Children’s Hospital, Ann Arbor, seminating this report. We appreciate the MI); Bernard Rosner, Ph.D. (Harvard assistance by: Carol Creech, M.I.L.S., School of Public Health, Boston, MA); Heather Banks, M.A., and Angela Jehle Alan Robert Sinaiko, M.D. (University of (American Institutes for Research Health Minnesota Medical School, Minneapolis, Program, Silver Spring, MD). MN); Nicolas Stettler, M.D., M.S.C.E. (The Children’s Hospital of Philadelphia, Philadelphia, PA); Elaine Urbina, M.D. (Cincinnati Children’s Hospital Medical Center, Cincinnati, OH) Acknowledgments iii THE NATIONAL HIGH BLOOD American Society of Health-System PRESSURE EDUCATION Pharmacists PROGRAM COORDINATING American Society of Hypertension COMMITTEE MEMBER American Society of Nephrology ORGANIZATIONS Association of Black Cardiologists American Academy of Family Physicians Citizens for Public Action on High Blood American Academy of Insurance Medicine Pressure and Cholesterol, Inc. American Academy of Neurology Hypertension Education Foundation, Inc. American Academy of Ophthalmology International Society on Hypertension American Academy of Physician Assistants in Blacks American Association of Occupational National Black Nurses Association, Inc. Health Nurses National Heart, Lung, and Blood Institute American College of Cardiology Ad Hoc Committee on Minority American College of Chest Physicians Populations American College of Occupational National Hypertension Association, Inc. and Environmental Medicine National Kidney Foundation, Inc. American College of Physicians– National Medical Association American Society of Internal Medicine National Optometric Association American College of Preventive Medicine National Stroke Association American Dental Association Society for Nutrition Education American Diabetes Association The Society of Geriatric Cardiology American Dietetic Association American Heart Association Federal Agencies: American Hospital Association Agency for Healthcare Research and Quality American Medical Association Centers for Medicare and Medicaid Services American Nurses Association Department of Veterans Affairs American Optometric Association Health Resources and Services Administration American Osteopathic Association National Center for Health Statistics American Pharmaceutical Association National Heart, Lung, and Blood Institute American Podiatric Medical Association National Institute of Diabetes and Digestive American Public Health Association and Kidney Diseases American Red Cross iv The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents Contents FOREWORD . .VII INTRODUCTION . .1 METHODS . .3 DEFINITION OF HYPERTENSION . .4 MEASUREMENT OF BLOOD PRESSURE IN CHILDREN . .5 Ambulatory Blood Pressure Monitoring . .7 BLOOD PRESSURE TABLES . .8 Using the Blood Pressure Tables . .9 PRIMARY HYPERTENSION AND EVALUATION FOR COMORBIDITIES . .16 EVALUATION FOR SECONDARY HYPERTENSION . .18 Physical Examination . .18 Additional Diagnostic Studies for Hypertension . .19 Renin Profiling . .19 Evaluation for Possible Renovascular Hypertension . .19 Invasive Studies . .19 TARGET-ORGAN ABNORMALITIES IN CHILDHOOD HYPERTENSION . .22 Clinical Recommendation . .23 THERAPEUTIC LIFESTYLE CHANGES . .24 PHARMACOLOGIC THERAPY OF CHILDHOOD HYPERTENSION . .26 APPENDIX A. DEMOGRAPHIC DATA . .34 APPENDIX B. COMPUTATION OF BLOOD PRESSURE PERCENTILES FOR ARBITRARY SEX, AGE, AND HEIGHT . .36 SCHEME USED FOR CLASSIFICATION OF THE EVIDENCE . .39 REFERENCES . .40 Contents v List of Tables TABLE 1. Conditions Under Which Children <3 Years Old Should Have . .5 Blood Pressure Measured . TABLE 2. Recommended Dimensions for Blood Pressure Cuff Bladders . .6 TABLE 3. Blood Pressure Levels for Boys by Age and Height Percentile . .10 TABLE 4. Blood Pressure Levels for Girls by Age and Height Percentile . .12 TABLE 5. Classification of Hypertension in Children and Adolescents, . .14 With Measurement Frequency and Therapy Recommendations . TABLE 6. Indications for Antihypertensive Drug Therapy in Children . .14 TABLE 7. Clinical Evaluation of Confirmed Hypertension . .15 TABLE 8. Examples of Physical Examination Findings Suggestive . .20 of Definable Hypertension . TABLE 9. Antihypertensive Drugs for Outpatient Management . .28 of Hypertension in Children 1–17 Years Old . TABLE 10. Antihypertensive Drugs for Management of Severe Hypertension . .33 in Children 1–17 Years Old . TABLE A–1. Demographic Data on Height/Blood Pressure Distribution Curves . .35 by Study Population . TABLE B–1. Regression Coefficients From Blood Pressure Regression Models . .38 List of Figures FIGURE 1. Management Algorithm . .32 vi The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents Foreword This is the fourth report from the National adolescents with hypertension; provides the High Blood Pressure Education Program rationale for early identification and treat- (NHBPEP) Working Group on Children ment; and provides revised recommendations, and Adolescents; it updates the previous pub- based on recent studies, for the use of antihy- lication, Update on the Task Force Report pertensive drug therapy. Treatment recom- (1987) on High Blood Pressure in Children mendations also include updated evaluation and Adolescents (Pediatrics. 1996;98:649–58). of nonpharmacologic therapies to reduce The purpose of this report is to update clini- additional cardiovascular risk factors. The cians on the latest recommendations report describes how to identify hypertensive concerning the diagnosis, evaluation, and children who need additional evaluation for treatment of hypertension in children; recom- sleep disorders that may be associated with mendations are based on English-language, BP elevation. peer-reviewed, scientific evidence (from 1997 to 2004) and the consensus expert opinion of Dr. Bonita Falkner has our deep appreciation the NHBPEP Working Group. for leading the members of the NHBPEP Working Group in developing this new report. This report includes new data from the Dr. Falkner and the Working Group per- 1999–2000 National Health and Nutrition formed diligently and brilliantly to assemble Examination Survey (NHANES), as well as this document in a timely manner. Applying revised blood pressure (BP) tables that include these recommendations to clinical practice will the 50th, 90th, 95th, and 99th percentiles by address the important public health issue of sex, age, and height. Hypertension in children improving inadequate BP control. and adolescents continues to be defined as systolic BP (SBP) and/or diastolic BP (DBP) that is, on repeated measurement, at or above the 95th percentile for sex, age, and height. BP between the 90th and 95th percentile in childhood is now termed “prehypertension” and is an indication for lifestyle modifications. Barbara M. Alving, M.D. New guidelines are provided for the staging of Acting Director hypertension in children and adolescents, as National Heart, Lung, and Blood Institute well as updated recommendations for diag- and nostic evaluation of hypertensive children. Chair In addition, the report evaluates the evidence