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 medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes. | C, moderate |
| 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 at 3 different visits. | C, moderate |
| 4. Organizations with EHRs used in an office setting should consider including flags for abnormal BP values, both when the values are being entered and when they are being viewed. | C, weak |
| 5. Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a 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. | B, strong |
| 6. ABPM should be performed for confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits. | C, moderate |
| 7. Routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions (see Table 12) to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage. | B, moderate |
| 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. | C, moderate |
| 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%. | B, strong |
| 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 measurement after HTN has been diagnosed. | C, moderate |
| 11. Children and adolescents ≥6 y 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 examination findings (Table 14) suggestive of a secondary cause of HTN. | C, moderate |
| 12. Children and adolescents who have undergone coarctation repair should undergo ABPM for the detection of HTN (including MH). | B, strong |
| 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 physical examination to identify findings suggestive of secondary causes of HTN. | B, strong |
| 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, and function) at the time of consideration of pharmacologic treatment of HTN. | C, moderate |
| 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-wt children and adolescents ≥8 y of age who are suspected of having renovascular HTN and who will cooperate with the procedure. | C, moderate |
| 17. In children and adolescents suspected of having RAS, either CTA or MRA may be performed as noninvasive imaging studies. Nuclear renography is less useful in pediatrics and should generally be avoided. | D, weak |
| 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 should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥ 13 years old. | C, moderate |
| 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 recommend moderate to vigorous physical activity at least 3 to 5 d per week (30–60 min per session) to help reduce BP. | C, weak |
| 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 factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic. | B, moderate |
| 22. ABPM may be used to assess treatment effectiveness in children and adolescents with HTN, especially when clinic and/or home BP measurements indicate insufficient BP response to treatment. | B, moderate |
| 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 |
| 26. Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP ≥95th percentile or >130/80 mm Hg in adolescents ≥13 y of age. | C, moderate |
| 27. In children and adolescents with acute severe HTN and life-threatening symptoms, immediate treatment with short-acting antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 h. | Expert opinion, D, weak |
| 28. Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and cardiovascular risk have been assessed. | C, moderate |
| 29. Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participation in competitive sports. | C, moderate |
| 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 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. | X, strong |
| 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 medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes. | C, moderate |
| 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 at 3 different visits. | C, moderate |
| 4. Organizations with EHRs used in an office setting should consider including flags for abnormal BP values, both when the values are being entered and when they are being viewed. | C, weak |
| 5. Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a 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. | B, strong |
| 6. ABPM should be performed for confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits. | C, moderate |
| 7. Routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions (see Table 12) to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage. | B, moderate |
| 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. | C, moderate |
| 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%. | B, strong |
| 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 measurement after HTN has been diagnosed. | C, moderate |
| 11. Children and adolescents ≥6 y 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 examination findings (Table 14) suggestive of a secondary cause of HTN. | C, moderate |
| 12. Children and adolescents who have undergone coarctation repair should undergo ABPM for the detection of HTN (including MH). | B, strong |
| 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 physical examination to identify findings suggestive of secondary causes of HTN. | B, strong |
| 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, and function) at the time of consideration of pharmacologic treatment of HTN. | C, moderate |
| 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-wt children and adolescents ≥8 y of age who are suspected of having renovascular HTN and who will cooperate with the procedure. | C, moderate |
| 17. In children and adolescents suspected of having RAS, either CTA or MRA may be performed as noninvasive imaging studies. Nuclear renography is less useful in pediatrics and should generally be avoided. | D, weak |
| 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 should be a reduction in SBP and DBP to <90th percentile and <130/80 mm Hg in adolescents ≥ 13 years old. | C, moderate |
| 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 recommend moderate to vigorous physical activity at least 3 to 5 d per week (30–60 min per session) to help reduce BP. | C, weak |
| 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 factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic. | B, moderate |
| 22. ABPM may be used to assess treatment effectiveness in children and adolescents with HTN, especially when clinic and/or home BP measurements indicate insufficient BP response to treatment. | B, moderate |
| 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 |
| 26. Children and adolescents with T1DM or T2DM should be evaluated for HTN at each medical encounter and treated if BP ≥95th percentile or >130/80 mm Hg in adolescents ≥13 y of age. | C, moderate |
| 27. In children and adolescents with acute severe HTN and life-threatening symptoms, immediate treatment with short-acting antihypertensive medication should be initiated, and BP should be reduced by no more than 25% of the planned reduction over the first 8 h. | Expert opinion, D, weak |
| 28. Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and cardiovascular risk have been assessed. | C, moderate |
| 29. Children and adolescents with HTN should receive treatment to lower BP below stage 2 thresholds before participation in competitive sports. | C, moderate |
| 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 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. | X, strong |