Athletic Participation by Children and Adolescents Who Have Systemic Hypertension

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.

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.

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.

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