Children and adolescents who have hypertension may be at risk for complications when exercise causes their blood pressure to rise even higher. The purpose of this statement is to update recommendations concerning the athletic participation of individuals with hypertension, including special populations such as those with spinal cord injuries or obesity, by using the guidelines from “The 36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities”; “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents”; and “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.”

Hypertension is the most common cardiovascular condition seen in people who engage in competitive athletics.1  In 2005, the 36th Bethesda Conference guidelines, which contained new recommendations concerning the participation of athletes who have heart disease, was released.1  The “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents” (hereafter referred to as the Fourth Report), published in 2004, briefly addressed exercise for youths with hypertension.2  The 2003 “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure” (hereafter referred to as the JNC 7 report)3  established new adult hypertension guidelines. This policy statement summarizes the updated recommendations of these 3 groups of experts and makes these guidelines more available to the general pediatrician.

The Fourth Report updated hypertension guidelines to be consistent with the modified adult hypertension classifications proposed in the JNC 7 report and new pediatric blood pressure data.2,3  The JNC 7 authors created a prehypertension classification based on recent data reporting lifetime risk of developing hypertension in those who are normotensive, indicating a need for increased surveillance at lower blood pressure levels.3  For these adult guidelines, the importance of lifestyle changes (weight reduction, balanced eating, reduction of dietary sodium, increased physical activity, and limited alcohol consumption) for management of hypertension was also recognized.3  New pediatric blood pressure data, obtained from the 1999–2000 National Health and Nutrition Examination Survey (NHANES), and new height-percentile data for blood pressure/height comparison, made available by the Centers for Disease Control and Prevention (www.cdc.gov/growthcharts), were also included in the Fourth Report guidelines.2  The 99th percentile for hypertension was added to facilitate clinical decision-making and delineate the severity of hypertension.2 

The new adult and pediatric guidelines for hypertension include 3 categories: prehypertension; stage 1 hypertension; and stage 2 hypertension. Tables 1 and 2 provide the latest pediatric blood pressure tables (www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.pdf).2  The Fourth Report defines childhood hypertension as measurements at or above the 95th percentile for gender, age, and height on 3 or more occasions.2  In children and adolescents younger than 18 years, prehypertension is defined as blood pressure measurements of ≥90th percentile but <95th percentile.2  In this age group, prehypertension is also defined as blood pressure measurements of ≥120/ 80 but <95th percentile.2  Stage 1 hypertension is defined as blood pressure measurements from the 95th percentile to 5 mm Hg above the 99th percentile.2  Stage 2 hypertension is defined as blood pressure measurements >5 mm Hg above the 99th percentile.2  For those who are 18 years or older, prehypertension is defined as blood pressure measurements of 120 to 139 systolic and/or 80 to 89 diastolic; stage 1 hypertension is defined as 140 to 159 systolic and/or 90 to 99 diastolic; and stage 2 hypertension is defined as ≥160 systolic and/or ≥100 diastolic, as defined in the 36th Bethesda Conference guidelines and the JNC 7 report.1,3  All values given apply to patients who are not taking antihypertensive drugs and who are not acutely ill. When the systolic and diastolic pressures fall into different categories, the higher category should be selected to classify the patient's blood pressure status.

TABLE 1

Blood Pressure Levels for Boys According to Age and Height Percentile

Age, yBP PercentileSBP, mm Hg
DBP, mm Hg
Percentile of Height
Percentile of Height
5th10th25th50th75th90th95th5th10th25th50th75th90th95th
50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39 
 90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54 
 95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58 
 99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66 
50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44 
 90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59 
 95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63 
 99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71 
50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48 
 90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63 
 95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67 
 99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75 
50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52 
 90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67 
 95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71 
 99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79 
50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55 
 90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70 
 95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74 
 99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82 
50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57 
 90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72 
 95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76 
 99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84 
50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59 
 90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74 
 95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78 
 99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86 
50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61 
 90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76 
 95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80 
 99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88 
50th 95 96 99 100 102 103 104 57 58 59 60 61 61 62 
 90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77 
 95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81 
 99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89 
10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63 
 90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78 
 95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82 
 99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90 
11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63 
 90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78 
 95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82 
 99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90 
12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64 
 90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79 
 95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83 
 99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91 
13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64 
 90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79 
 95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83 
 99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91 
14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65 
 90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80 
 95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84 
 99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92 
15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66 
 90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81 
 95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85 
 99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93 
16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67 
 90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82 
 95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87 
 99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94 
17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70 
 90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84 
 95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89 
 99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97 
Age, yBP PercentileSBP, mm Hg
DBP, mm Hg
Percentile of Height
Percentile of Height
5th10th25th50th75th90th95th5th10th25th50th75th90th95th
50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39 
 90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54 
 95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58 
 99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66 
50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44 
 90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59 
 95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63 
 99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71 
50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48 
 90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63 
 95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67 
 99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75 
50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52 
 90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67 
 95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71 
 99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79 
50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55 
 90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70 
 95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74 
 99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82 
50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57 
 90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72 
 95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76 
 99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84 
50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59 
 90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74 
 95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78 
 99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86 
50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61 
 90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76 
 95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80 
 99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88 
50th 95 96 99 100 102 103 104 57 58 59 60 61 61 62 
 90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77 
 95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81 
 99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89 
10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63 
 90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78 
 95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82 
 99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90 
11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63 
 90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78 
 95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82 
 99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90 
12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64 
 90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79 
 95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83 
 99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91 
13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64 
 90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79 
 95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83 
 99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91 
14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65 
 90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80 
 95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84 
 99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92 
15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66 
 90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81 
 95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85 
 99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93 
16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67 
 90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82 
 95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87 
 99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94 
17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70 
 90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84 
 95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89 
 99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97 

BP indicates blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure.

(Reproduced with Permission from National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114[2 suppl 4th report]:558.)

TABLE 2

Blood Pressure Levels for Girls According to Age and Height Percentile

Age, yBP PercentileSBP, mm Hg
DBP, mm Hg
Percentile of Height
Percentile of Height
5th10th25th50th75th90th95th5th10th25th50th75th90th95th
50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42 
 90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56 
 95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60 
 99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67 
50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47 
 90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61 
 95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65 
 99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72 
50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51 
 90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65 
 95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69 
 99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76 
50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54 
 90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68 
 95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72 
 99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79 
50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56 
 90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70 
 95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74 
 99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81 
50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58 
 90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72 
 95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76 
 99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83 
50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59 
 90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73 
 95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77 
 99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84 
50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60 
 90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74 
 95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78 
 99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86 
50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61 
 90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75 
 95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79 
 99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87 
10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62 
 90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76 
 95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80 
 99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88 
11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63 
 90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77 
 95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81 
 99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89 
12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64 
 90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78 
 95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82 
 99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90 
13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65 
 90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79 
 95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83 
 99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91 
14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66 
 90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80 
 95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84 
 99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92 
15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67 
 90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81 
 95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85 
 99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93 
16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68 
 90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82 
 95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86 
 99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93 
17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68 
 90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82 
 95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86 
 99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93 
Age, yBP PercentileSBP, mm Hg
DBP, mm Hg
Percentile of Height
Percentile of Height
5th10th25th50th75th90th95th5th10th25th50th75th90th95th
50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42 
 90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56 
 95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60 
 99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67 
50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47 
 90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61 
 95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65 
 99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72 
50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51 
 90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65 
 95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69 
 99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76 
50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54 
 90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68 
 95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72 
 99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79 
50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56 
 90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70 
 95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74 
 99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81 
50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58 
 90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72 
 95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76 
 99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83 
50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59 
 90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73 
 95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77 
 99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84 
50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60 
 90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74 
 95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78 
 99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86 
50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61 
 90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75 
 95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79 
 99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87 
10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62 
 90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76 
 95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80 
 99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88 
11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63 
 90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77 
 95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81 
 99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89 
12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64 
 90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78 
 95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82 
 99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90 
13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65 
 90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79 
 95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83 
 99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91 
14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66 
 90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80 
 95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84 
 99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92 
15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67 
 90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81 
 95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85 
 99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93 
16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68 
 90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82 
 95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86 
 99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93 
17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68 
 90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82 
 95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86 
 99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93 

BP indicates blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure.

(Reproduced with Permission from National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114[2 suppl 4th report]:559.)

When hypertension and other cardiovascular diseases coexist, eligibility for participation in competitive athletics is usually based on the type and severity of the other cardiovascular disease.1  The heart can become enlarged nonpathologically as a result of adaptations during high levels of training in some athletes—usually males; this condition is commonly referred to as “athlete's heart.”4  Left ventricular hypertrophy (LVH) beyond that seen with athlete's heart should limit participation until blood pressure is normalized with drug therapy.1  Child and adolescent athletes with LVH and/or athlete's heart should be followed and managed by pediatric medical subspecialists (cardiologists).

Care must be taken to obtain reliable blood pressure recordings.1,2  The athlete should be seated and resting quietly for 5 minutes with the arm supported at the level of the heart. A right arm reading is suggested for consistency and for evaluation for a coarctation (the left arm may give falsely low readings with a coarctation). Appropriately sized cuffs should be used, because cuffs that are too small may overestimate blood pressure readings. Some athletes have exceedingly large biceps or triceps, have long extremities, or are obese; hence, they may require measurements taken by using an adult or thigh cuff. The width of the blood pressure bladder must be adequate to cover at least 80% of the individual's upper arm (measured between the top of the shoulder and the olecranon), and the bladder length should encircle the arm completely.2  A measurement of >90th percentile obtained by oscillometric devices should be repeated by manual auscultation.1  Only after several elevated readings (3 readings recommended in the Fourth Report and 2 readings recommended in the 36th Bethesda Conference guidelines) have been obtained on separate occasions should the diagnosis of hypertension be made. Out-of-office blood pressure measurements may be taken to delineate true high blood pressure if the diagnosis is in question.1  Further details concerning the measurement of blood pressure are available.1,2 

Once the diagnosis of hypertension is confirmed, an evaluation that includes a history, a thorough physical examination, and appropriate laboratory testing should be performed, as outlined in the Fourth Report. Updated recommendations from the Fourth Report for evaluation of values >95th percentile include an echocardiogram, retinal examination, and consideration of a workup for sleep disorders.2  Sleep apnea, especially in overweight children, may be associated with cardiovascular disease and an increased risk of hypertension.2 

Children and adolescents should be encouraged to participate in regular, noncompetitive physical activity, because exercise has been shown to help reduce both systolic and diastolic pressures in those with hypertension.1,,3 

Reports of cerebrovascular accidents during maximal exercise have raised concerns that the increase in blood pressure accompanying strenuous activity may cause harm.1  The following guidelines recommend temporary restriction for those athletes who have stage 2 hypertension until normal blood pressure is achieved. However, available data do not indicate that strenuous dynamic exercise places these athletes at risk of acute complications of hypertension during exercise or of worsening of their baseline blood pressure values.1 

In dynamic exercise (exerting muscles through joint movement), intramuscular force is not greatly increased as muscles lengthen and contract and joints move through their range of motion. There is a sizable increase in systolic blood pressure, a moderate increase in mean arterial pressure, and a decrease in diastolic pressure and total peripheral resistance. In static exercise (exerting muscles without joint movement), relatively large intramuscular forces develop without much change in muscle length or joint motion. Systolic, mean arterial, and diastolic pressures increase significantly, and total peripheral resistance remains essentially unchanged. It is the acute increase in diastolic pressure that particularly concerns the experts, as well as the possible increases in muscle mass that may elevate resting blood pressure. Although the limited evidence shows no greater risk with highly static exercise1  (Fig 1), experts are more cautious about allowing athletes with stage 2 hypertension to participate in this type of activity. Most physical activities and sports have both static and dynamic components. Guidelines for restricting participation should be based on the cardiovascular demands of the activity and the demands of the practice, training, and/or preparation for that activity.

FIGURE 1

Classification of sports according to cardiovascular demands (based on combined static and dynamic components). This classification is based on peak static and dynamic components achieved during competition. It should be noted, however, that the higher values may be reached during training. The increasing dynamic component is defined in terms of the estimated percent of maximal oxygen uptake (MaxO2) achieved and results in an increasing cardiac output. The increasing static component is related to the estimated percent of maximal voluntary contraction (MVC) reached and results in an increasing blood pressure load. The lowest total cardiovascular demands (cardiac output and blood pressure) are shown in Box IA and the highest are shown in Box IIIC. Boxes IIA, IB, IIIA, IIB, IC, IIIB and IIC depict low-moderate, moderate, and high-moderate total cardiovascular demands. These categories progress diagonally across the table from lower left to upper right. *Danger of bodily collision. Increased risk if syncope occurs. Participation not recommended by the American Academy of Pediatrics. +The American Academy of Pediatrics classifies cricket in the IB box (low static, moderate dynamic). (Reprinted from Rice SG; American Academy of Pediatrics, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841–848 (originally adapted from Mitchell JH, Haskell W, Snell P, Van Camp SP. 38th Bethesda Conference. J Am Coll Cardiol. 2005;45(8):1364–1367, with permission from Elsevier).

FIGURE 1

Classification of sports according to cardiovascular demands (based on combined static and dynamic components). This classification is based on peak static and dynamic components achieved during competition. It should be noted, however, that the higher values may be reached during training. The increasing dynamic component is defined in terms of the estimated percent of maximal oxygen uptake (MaxO2) achieved and results in an increasing cardiac output. The increasing static component is related to the estimated percent of maximal voluntary contraction (MVC) reached and results in an increasing blood pressure load. The lowest total cardiovascular demands (cardiac output and blood pressure) are shown in Box IA and the highest are shown in Box IIIC. Boxes IIA, IB, IIIA, IIB, IC, IIIB and IIC depict low-moderate, moderate, and high-moderate total cardiovascular demands. These categories progress diagonally across the table from lower left to upper right. *Danger of bodily collision. Increased risk if syncope occurs. Participation not recommended by the American Academy of Pediatrics. +The American Academy of Pediatrics classifies cricket in the IB box (low static, moderate dynamic). (Reprinted from Rice SG; American Academy of Pediatrics, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841–848 (originally adapted from Mitchell JH, Haskell W, Snell P, Van Camp SP. 38th Bethesda Conference. J Am Coll Cardiol. 2005;45(8):1364–1367, with permission from Elsevier).

Medications, alcohol, tobacco, drugs of abuse, stimulants, and caffeine may affect blood pressure (Table 3). The young athlete with hypertension, regardless of severity, should be strongly encouraged to adopt healthy behaviors, including the avoidance of exogenous androgens, growth hormone, illicit drugs (especially cocaine), alcohol, use of tobacco (all forms), nonprescribed stimulants, certain over-the-counter supplements (especially those that contain ephedra or other stimulants), and excessive consumption of energy drinks and caffeinated beverages.1,3,5  Because certain medications (Table 3) may increase blood pressure, medications should be monitored and reviewed during the evaluation and treatment of patients with hypertension. Blood pressure should be remeasured after the offending substance has been removed from the athlete's system.

TABLE 3

Medications and Substances That May Increase Blood Pressure

Acetaminophen
Alcohol 
Antidepressants 
Caffeine 
Decongestants 
Herbal supplements 
Illicit drugs 
Immunosuppressants 
Nonsteroidal anti-inflammatory drugs 
Oral contraceptives 
Stimulants 
Tobacco 
Acetaminophen
Alcohol 
Antidepressants 
Caffeine 
Decongestants 
Herbal supplements 
Illicit drugs 
Immunosuppressants 
Nonsteroidal anti-inflammatory drugs 
Oral contraceptives 
Stimulants 
Tobacco 

Sodium balance can affect blood pressure, and restricting sodium intake is typically recommended for those with hypertension. Current sodium recommendations for youth are 1.2 g/day for children 4 to 8 years of age,2  1.5 g/day for older children,2  and 2.4 g/day for adults.3  For some youth athletes, however, a significant total-body sodium deficit can develop as a result of extensive sweating during extended or repeated bouts of exercise, practice, or competition.5,6  Accordingly, rehydration often requires deliberate concomitant intake of additional salt-containing fluids and foods to ensure greater body-water retention and distribution to all fluid compartments.7,,10 

Athletes should be advised that the use of diuretic medications and β blockers, which are commonly used to treat hypertension, have been prohibited by some athletic governing bodies. These drugs can also decrease athletic performance in certain individuals. In these instances, other types of medications may need to be considered to control hypertension. All medications should be registered with the appropriate sport governing body to request a therapeutic exemption when appropriate.

Obese athletes are at greater risk of hypertension than their nonobese counterparts. In certain sports and team positions, bulk and body mass are valued, expected, and promoted. This practice should not be encouraged because of the health risks associated with obesity, including but not limited to hypertension, cardiovascular disease, diabetes, dyslipidemia, and arthritis.

Athletes with spinal cord injuries may have difficulties regulating blood pressure. In these athletes, hypertension may be a sign of autonomic dysreflexia (uncontrolled systemic sympathetic response) as a result of pain, illness, infection, or bowel or bladder distension.11  These athletes should be evaluated and managed accordingly. Some athletes with spinal cord injuries above the T6 level may participate in a practice called “boosting,” in which they induce blood pressure elevations via voluntary bladder distension in hopes of enhancing athletic performance.11  This intentional autonomic dysreflexia is banned by the International Paralympic Committee (www.paralympic.org) and should be discouraged because serious health problems may occur as a result.

The American Academy of Pediatrics makes the following recommendations.

  1. Lifestyle modifications, including daily physical activity and a well-balanced diet, should be discussed and encouraged at all well-child visits regardless of whether the patient has hypertension or normal blood pressure.

  2. The presence of prehypertension should not limit a person's eligibility for competitive athletics. Lifestyle modifications, including weight management, daily physical activity, and a well-balanced diet, should be discussed and encouraged. Patients with prehypertension should have their blood pressure measured every 6 months.

  3. Stage 1 hypertension in the absence of end organ damage, including LVH or concomitant heart disease, should not limit a person's eligibility for competitive athletics. These athletes should have their blood pressure rechecked in 1 to 2 weeks to confirm the hypertension or sooner if they are symptomatic. Appropriate referrals to qualified pediatric medical subspecialists need to be made if patients are symptomatic, have LVH or concomitant heart disease, or have persistently elevated blood pressure on 2 additional occasions. Lifestyle modifications should be discussed and encouraged.

  4. Youth with stage 2 hypertension in the absence of end organ damage, including LVH or concomitant heart disease, should be restricted from high-static sports (classes IIIA to IIIC in Fig 1) until their blood pressure is in the normal range after lifestyle modification and/or drug therapy. These athletes should be promptly referred and evaluated by a qualified pediatric medical subspecialist within 1 week if they are asymptomatic or immediately if they are symptomatic. Lifestyle modifications should be discussed and encouraged.

  5. When hypertension and other cardiovascular diseases coexist, eligibility for participation in competitive athletics should usually be based on the type and severity of the other cardiovascular disease.

  6. Medication, caffeine, drug, tobacco, and stimulant use should be reviewed with any athlete with hypertension because of the effects these substances may have on blood pressure.

  7. Although restricting sodium intake is typically recommended for those with hypertension, for some young athletes rehydration often requires deliberate concomitant intake of additional salt-containing fluids and foods to ensure greater body-water retention and distribution to all fluid compartments.

  8. Care should be taken to appropriately diagnose and monitor athletes who are at higher risk for hypertension, such as obese athletes and athletes with spinal cord injuries.

Teri M. McCambridge, MD, Chairperson

Holly J. Benjamin, MD

Joel S. Brenner, MD, MPH

Charles T. Cappetta, MD

Rebecca A. Demorest, MD

Andrew J. M. Gregory, MD

Mark Halstead, MD

Chris G. Koutures, MD

Cynthia R. LaBella, MD

Stephanie Martin, MD

Stephen G. Rice, MD, PhD, MPH

Rebecca A. Demorest, MD

Reginald L. Washington, MD, Past Chairperson

Claire M. A. LeBlanc, MD

Canadian Paediatric Society

James Raynor, MS, ATC

National Athletic Trainers Association

Michael F. Bergeron, PhD, FACSM

Anjie Emanuel, MPH

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

     
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    left ventricular hypertrophy

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Competing Interests

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.