Report of the Second Task Force on Blood Pressure Control in Children—1987

VOLUME 79. JANUARY 1987. NUMBER 1

redtrics

Report

of the Second

Task

Force

on Blood

Pressure

Control

in Children-1987

Task Force on

Pressure

Control in Children*

From the National Heart, Lung, and Blood Institute, Bethesda, Maryland

ABSTRACT. Although the prevalence of clinical

hyper-tension is of a far lesser magnitude in children than

adults, there is ample evidence to support the concept that the roots of essential hypertension extend back into childhood. Prospective cohort data that could yield

pre-cise information about the relationship between

child-hood BP and cardiovascular risk are not yet available.

Nonetheless, high BP in children represents a significant

clinical problem which in 1977 was comprehensively

ad-dressed by the Task Force on Blood Pressure Control in

Children. Contained herein, 10 years later, is the revised

version of the original Task Force report including

nor-mative BP data derived from sampling more than 70,000

children, as well as advice on methodology and

instru-mentation for BP measurement, guidelines for detecting

children with high BP, and strategies for appropriate

diagnostic evaluation and pharmacologic and

nonphar-macologic treatment. Pediatrics 1987;79:1-25; blood pres-sure, hypertension.

Received for publication Dec 16, 1985; accepted March 31, 1986.

5Task Force Members: MichaelJ. Horan, MD, ScM (Chairman),

Hypertension and Kidney Diseases Branch, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood

Insti-tute, Bethesda, MD; Bonita Falkner, MD, Department of

Pedi-atric Nephrology and Hypertension, Hahnemann University, Philadelphia; Sue Y. S. Kimm, MD, Prevention and Demonstra-tion Research Branch, Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Be-thesda, MD; Jennifer M. H. Loggie, MD, Department of

Pedi-atrics, Division of Clinical Pharmacology, Children’s Hospital

Medical Center, Cincinnati; Ronald J. Prineas, MB, PhD, Di-vision of Epidemiology, School of Public Health, Minneapolis; Bernard Rosner, PhD, Department of Preventive Medicine and Clinical Epidemiology, Harvard Medical School, Boston; Janice

Hutchinson, MD, American Medical Association, Chicago;

Ron-aid Lauer, MD, Division of Pediatrics, University of Iowa

Hos-pita!, Iowa City; Shirley Mueller, MD, Indianapolis; Donald A.

Riopel, MD, Divison of Pediatric Cardiology, The Sanger Clinic,

Charlotte, NC; Alan Sinaiko, MD, Division of Clinical Phar-macology, Department of Pediatrics and Pharmacology,

Univer-sity of Minnesota, Minneapolis; William H. Weidman, MD,

Division of Pediatric Cardiology, Department of Pediatrics, and Division of Hypertension, Mayo Clinic, Rochester, MN.

Con-sultants: Gerald Berenson, MD, David Fixier, MD, Joseph

Schachter, MD.

Reprint requests to (M.J.H.) National Heart, Lung, and Blood

Institute, 7550 Wisconsin Aye, Room 4C12, Bethesda, MD

20892.

PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the

American Academy of Pediatrics.

In 1977, the National Heart, Lung, and Blood

Institute

commissioned

the

first

“Report

of the

Task Force on Blood Pressure Control in

Chil-then.”1 Under the chairmanship of Dr Sidney

Blu-menthal a very useful document was produced

which has since enjoyed wide distribution and has

indeed become the major reference for BP

stand-ards in children. In 1977, data linking

cardiovas-cular risk with systolic and diastolic BPs in children

were not available and, unfortunately, are not yet

available. However, better epidemiologic data on

normal BP distributions throughout the pediatric

age range are now available. Because of this, and

because of the growing concern about the possible

relationship between BP patterns in youth and the

subsequent development of adult essential

hyper-tension, the time is ripe for revising the original

Report of the Task Force on Blood Pressure

Con-trol in Children. The objectives of the Report of the

Second Task Force on Blood Pressure Control in

Children-1987 are (1) to identify the proper

tech-niques for measuring BP in infants (birth to 2

to 18 years); (2) to characterize the existing data

base on BP distributions throughout childhood and

to prepare distribution curves of BP by age

accom-panied by height and weight information; (3) to

recommend BP ranges for children denoting

nor-mal, high normal, and hypertensive; (4) to present

guidelines for detecting children with hypertension

and, at the same time, guard against inappropriate

labeling of children as hypertensive who are not

hypertensive; (5) to identify the appropriate

diag-nostic steps to be taken in the evaluation of children

with hypertension; (6) to delineate

nonpharmacol-ogic and pharmacologic treatment strategies in the

management of children with hypertension.

This report, although similar in format to the

1977 report, differs in some key areas: (1) The data

used in this report to compute normal BP

distri-butions were taken from nine different sources from

studies performed in the United States and Great

Britain involving more than 70,000 white, black,

and Mexican-American children.2’8 (2)

Hyper-tension has been defined in terms of high

BP

age and sex, but height and weight have also been

taken into account. (3) A new algorithm for

distin-guishing between normotensive and hypertensive

children has been developed. (4) The section on

diagnostic testing has been amplified. (5) The

treatment section contains a renewed emphasis on

nonpharmacologic therapies.

Despite the many well-described

pathophysio-logic causes of secondary hypertension in children,

the etiology in most cases is not understood. These

individuals fall into a category characterized as

primary (essential) hypertension. There is a need

for early identification of these children so that

they may be placed under surveillance and possibly

benefit from the hygienic measures described in

this report. The goal in caring for children is

sur-veillance and possible prevention, as well as

iden-tification of fixed hypertension requiring treatment

when such cases cannot be prevented.

All physicians who care for children 3 years of

age through adolescence should be encouraged to

measure BPs once a year, when the child is well.

This is because BP is a physiologic parameter,

which when elevated becomes a risk factor, either

for the development of hypertension itself or for

the development of premature cardiovascular

mor-bidity, if not during childhood, then during

adult-hood.

BP

physical examination as part of the continuing care

of the child, not as an isolated procedure. BPs

should also be measured in symptomatic children,

children in emergency rooms and intensive care

units, and in high-risk infants (Table 1), because

an elevated BP may complicate certain diseases or

TABLE 1. Conditions Suggesting Increased

Hyperten-sion Risk for Infants

Abdominal bruit

Abdominal mass(es), eg, Wiims tumor, neurobiastoma

Certain acute clinical situations, eg, burns,

hemolytic-uremic syndrome

Coarctation of the aorta

Congenital adrenal hyperplasia Neurofibromatosis

Failure to grow

Indwelling umbilical artery catheter

Administration of glucocorticoids and/or ACTH

Orbital tumor

Suspected renal disease (hematuria, proteinuria)

Turner syndrome

Unexplained heart failure Unexplained seizures

be a marker of future hypertension. At the time of

examination, the patient or parent should be told

that the BP is normal, high normal, or hypertensive

and whether further surveillance is indicated. It

should be clearly stated that the finding of a single

modestly elevated reading does not constitute a

diagnosis of hypertension but does indicate the

need for further evaluation including repeated

mea-surements over time. Children with severely

ele-vated readings should be evaluated immediately.

It is appropriate for nurses or other properly

trained and supervised nonphysician health

person-nel to obtain BP readings and to subsequently

manage the child with an elevated BP reading.

Systematic follow-up requires that the patient be

seen as a complex and individual human being

functioning as a member of a family. Skills of

teaching, guiding, and supporting are vital tools for

the health care provider. This report recommends

systematic follow-up as an important step in the

management of high BP in children.

During the next few years it will be essential that

research be conducted with an aim toward

enhanc-ing our ability to identify, with a high degree of

probability, the “prehypertensive state” early in

human development. Information must also be

de-veloped to enable establishment ofbetter diagnostic

procedures and more sophisticated therapeutic

strategies.

As was the case in 1977, there remain a number

of fundamental questions in need of attention.

Which infants, children, and adolescents should be

treated

and

initiated? What hazards should be anticipated from

early therapeutic intervention? The members of

the Task Force recognize that the proposed

guide-lines are based upon ajudgment of the present state

of the art. As new information becomes available

epide-miologic research, revision of this 1987 report will

become necessary.

METHODOLOGY AND INSTRUMENTATION FOR

BP MEASUREMENT IN CHILDREN

BP values obtained by indirect methods can be

reliable and consistent if recorded under

standard-ized conditions with a well-functioning manometer.

Measurements of BP in children should be obtained

and recorded during the course of their continuous

care. Repeated measurements over time, rather

than a single, isolated determination, are required

to establish consistent and significant observations.

Measuring and interpreting BPs in infants and

children is difficult because of the following factors:

(1) Various arm sizes require the availability and

selection of a cuff of appropriate size. (2) Readings

are difficult to obtain and interpret in anxious or

restless infants

and

generated in Korotkoff sounds by heavy pressure

on the stethoscope held in the antecubital fossa.

(4) BP in children changes in association with

growth and development.

Instruments For

Measurement

of

Manometers in conventional use are of the

mer-cury-gravity or aneroid type. The mercury-gravity

manometer has the advantages of widespread

gen-eral usage, reliability, accuracy, and not requiring

recalibration. Its reservoir must be properly filled

with mercury, the air vent kept clean, and the glass

tube free of dust or oxidated particles. The aneroid

manometer, which operates by means of a metal

bellows, is less bulky but requires calibration at

least yearly against a mercury manometer

depend-ing upon frequency of use. BP devices using the

Doppler or oscillometric techniques are electronic

units that provide accurate systolic BP

measure-ments in infants and children in whom auscultatory

BP measurements may prove difficult to obtain.

Reliability for recording accurate diastolic BPs has

been documented for the Dynamap oscillometric

unit only.’9 These devices are relatively expensive;

nevertheless, they should be standard equipment

wherever sick infants are treated, particularly in

operating rooms, intensive care units, and

emer-gency rooms. These automatic devices should also

be serviced regularly to assure continued accuracy.

Selection of Appropriate Compression Cuff

Proper cuff size is essential for measuring BP

accurately. References to cuff size apply only to the

inner inflatable bladder rather than to the cloth

covering, the inner bladder usually being

signifi-cantly narrower and shorter than the cloth

cover-ing. Errors in cuff selection can be minimized by

selecting the largest cuff that will fit the child’s

arm.

The appropriate-sized cuff for a given individual

should be long enough to completely encircle the

circumference of the

arm

and wide enough to cover approximately 75% of the

upper arm between the top of the shoulder and the

olecranon, leaving sufficient room both at the

an-tecubital fossa to comfortably place the bell of the

stethoscope and at the upper edge of the cuff to

prevent obstruction of the axilla.

Available cuff sizes are listed in Table 2. The cuff

name does not guarantee that the cuff will be the

appropriate size for a child within that age range.

In general, selection of the proper-sized cuff will

result whether circumference or width is used as a

selection criterion. If there is a question between

two cuffs regarding appropriate cuff width, use of

the smaller width may result in an artificially

ele-vated BP, whereas use of a cuff that is slightly

wider than needed is unlikely to mask hypertensive

levels of BP.

Measurement

and Recording of

Proper preparation of the child is essential for

accurate determination of BP. The examining area

should be quiet and the child reassured. Sufficient

time should be allowed for recovery from recent

activity or apprehension. The procedure should be

fully explained and stressful circumstances should

be eliminated whenever possible. The child should

be in a comfortable sitting position (infants may be

supine) with the right arm fully exposed and resting

on a supportive surface at the heart level. When a

mercury manometer is used, the center of the scale

should be placed at the observer’s eye level to avoid

the effects of parallax.

After the appropriately sized cuff is selected, it

should be applied snugly around the right arm so

that its lower edge is above the antecubital fossa,

allowing room for placement of the bell of the

stethoscope lightly over the brachial artery. The

cuff is then rapidly inflated to about 20 mm Hg

TABLE 2. Common ly Available B loo d Pressure Cuffs

Cuff Name#{176} Bladder

Width (cm)

Bladder

Length

(cm)

Newborn 2.5-4.0 5.0-9.0

Infant 4.0-6.0 11.5-18.0

Child 7.5-9.0 - 17.0-19.0

Adult 11.5-13.0 22.0-26.0

Large arm 14.0-15.0 30.5-33.0

Thigh 18.0-19.0 36.0-38.0

* Cuff name does not guarantee that the cuff will be

above the point at which the radial pulse

disap-pears. The pressure within the cuff is then released

at a rate of about 2 to 3 mm Hg per second while

auscultation is performed over the brachial artery.

Deflation at too rapid or too slow a rate gives

inaccurate readings.

As the pressure in the occluding cuff is released,

the wall of the collapsed vessel is suddenly

dis-tended and there is the onset of a clear tapping

sound (Korotkoff sounds) defined as phase I (Ki).

The onset of the sound in phase I corresponds to

systolic BP. When the cuff is further deflated,

phase II (K2) begins and the tapping sounds are

followed by a murmur of the turbulent blood flow

through the artery narrowed by the cuff. As the

pressure in the cuff is reduced further, phase III

(K3) occurs, during which the sounds are crisper

and increase in intensity. When the cuff pressure

decreases further, phase IV (K4) occurs, which is

characterized by low-pitched, muffled sounds. The

last phase, phase V (K5), is characterized by the

disappearance of all sounds. Frequently, the fourth

and fifth phases occur simultaneously, and in

chil-dren the fifth phase may not occur at all.

Because required cuff size changes with growth

of the individual, and because use of the fourth

Korotkoff phase in childhood is replaced with that

of the fifth by adolescence, it is important to

accu-rately record BP. The position of the subject during

the measurement, the limb, and the cuff size used

should all be recorded, as well as the fourth and

fifth Korotkoff phases if both are heard, eg, BP =

1 10/78/70 mm Hg, right arm, sitting, with child

cuff.

Measurement

of

There is an increasing recognition of

hyperten-sion in young infants managed in neonatal

inten-sive care units, particularly those with

bronchopul-monary dysplasia2#{176} or with indwelling umbilical

artery catheters. In the latter, the incidence of

hypertension is reported to be 3%, and the clinical

incidence of hypertension caused by renal artery

thrombosis is said to be one per 1,000 live births.2’

For these reasons, and also because hypotension

accompanies many serious illnesses of infancy, it is

mandatory that devices for measuring BP as

accu-rately as possible be standard equipment in every

hospital caring for babies.

Devices using Doppler or oscillometric principles

are now available and are more practical than

pre-viously mentioned methods for measuring BP in

infants. They suffer from a number of problems:

(1) hospital personnel are rarely trained adequately

in their use; (2) frequently, only systolic BP can be

measured accurately; (3) they are infrequently

pre-tested for accuracy against intraarterial pressure in

the neonatal age group; and (4) they are expensive.

For practicing pediatricians outside the hospital

setting with limited resources for purchasing very

expensive equipment, it may be difficult to

rou-tinely measure BP in infants and children 2 to 3

years of age. Infants currently known to be at risk

for hypertension are given in Table 1. When such

infants are encountered and their BPs cannot be

accurately measured, they should be sent for BP

measurements to facilities having the capability of

measuring BPs in this age group.

BP STANDARDS

BP variance in the child and adolescent is

de-pendent upon a multitude of factors, both genetic

and environmental, many of which are unknown.

Several observations can be made. BP increases

with age during the preadult years. This occurs in

all populations that have been studied, although

the level and trend vary from population to

popu-lation.2225 Larger children (heavier and/or taller)

have higher BPs than smaller children of the same

age.3’6’20-3’ Obese children have higher BPs than

lean children.0-’#{176}

Therefore, the level of a given child’s or

adoles-cent’s BP must be considered with respect to the

individual’s body size as well as age. Height and

weight should be used in assessing medical

signifi-cance of BP recordings judged to be high on age-I

sex-specific distributions.

Extensive, normative BP data from a probability

sampling of US children are not available. The task

force did, however, have access to nine reasonably

well-conducted studies with compatible data (Table

3)#{149}218 Because some of these studies provided

uni-formly low BP values and others provided higher

values, pooling and averaging the data were

per-formed, as this represented the best available

method for estimating normative BPs in infants,

children, and adolescents. The K5 diastolic

pres-sures are often difficult to obtain in children and,

for the most part, were not available in these data

sets. The K5 diastolic pressures are, however, more easily obtainable on adolescents, and they were

provided in these data sets. Therefore, K4 diastolic

BPs were used in the standards for infants and

children 3 to 12 years of age, and K5 diastolic BPs

were used in the standards for adolescents 13 to 18

years of age.

All BP data on children were obtained in the

sitting position, using a mercury

sphygmomano-meter or, in the case of infants, supine using a

Doppler instrument. Of the nine studies used for

a.

U 0 U,

U)

115 110 105 100

95 90 85 80 75 70 65

75

70

65

U

060

3-U)

o56

50

106 106 106 105 68606060 76777880

10 10 11 11

TABLE 3. Data Sources for Age/Blood Pressure Distribution Curves

Source Age(yr) N

Muscatine, 1A2’ 5-19 4,208

University of South Carolina5 4-20 6,657

University of Texas, Houston6 3-17 2,922

Bogalusa, LA79 1-20 16,442

Second National Health and Nutrition 6-20 4,563

Examination Survey’0

University of Texas-Dallas”2 13-19 24,792

University of Pittsburgh’3 Newborn-S 1,554

Providence, RI’4 Newborn-3 3,487

Brompton, England8 Newborn-3 7,804

BP measurement per subject. Consequently, for

each study, the first BP reading was used,

regard-less of the number of additional measurements that

were available. There were approximately equal

numbers of boys and girls. Black,

Mexican-Amen-can, and white children were represented in the

sample, and there were no differences in BP

read-ings among these groups. Therefore, race-specific

BP curves were not developed. The curves

pub-lished in this report appear to be applicable to all

races.

Multiple regression and spline-fitting methods

were used to generate percentiles of the

age-/sex-specific BP distributions. In this regard,

adjust-ments were made for study and sleep status effects

in fitting the multiple regression models. The data

in Figs 1 to 6 represent the BP percentiles for

children who are awake. Because BP is lower in

sleeping compared with awake infants, the task

force computed correction factors of 7 mm Hg for

systolic BP and 5 mm Hg for diastolic BP which

should be added to BP measurements obtained on

sleeping infants when their pressures are compared

to the task force BP standards.

Curves describing the age-specific distributions

of systolic and diastolic BPs for boys

and

1 to 6) are intended to replace those distribution

curves published in the “Report of Task Force on

Blood Pressure Control in Children” in 1977.’ It

should be noted that at all ages the BP values tend

to be lower than those published in 1977. On the

abscissa, the 90th percentile for BP in millimeters

of mercury, height in centimeters, and weight in

kilograms are listed for each age to facilitate taking

height and weight into account when BP values

exceed the 90th percentile.

Finally, as is the case in adults, there are no data

to support the rigorous definition of BPs as

nor-motensive or hypertensive or to further delineate

hypertensive categories. Nonetheless, it becomes a

matter of practical necessity to have definitions

and classifications of hypertension to describe when

and how vigorously one should treat hypertension.

45

0 1 2 3 4 5 6 7 8 9101112

MONTHS

75TH

50TH

I I I I

0 1 2 3 4 5 6 7 8 9101112

MONTHS

90TH

PERCENTILE

SYSTOLIC BP 87 101 106 106 106 105 105 105 106

DIASTOLICBP 68 ffi 63 63 63 ffi 06 67 ffi

HEIGHTCM 51 50 63 66 68 70 12 73 74

WEIGHTKG 4 4 5 5 6 7 8 9 9

Fig 1. Age-specific percentiles of BP measurements in

boys-birth to 12 months of age; Korotkoff phase IV

(K4) used for diastolic BP.

The task force, therefore, developed definitions

(Table 4) and a classification of hypertension

(Ta-ble 5), based not upon risk data but upon clinical

experience and consensus. In conjunction with the

new BP standards presented in this report, normal

BP is defined as systolic and diastolic BPs less than

the 90th percentile for age and sex; high normal BP

is defined as average systolic and/or diastolic BP

between the 90th and 95th percentiles for age and

sex; high BP or hypertension is defined as average

systolic and/or diastolic BP equal to or greater than

the 95th percentile for age and sex on at least three

occasions. Two classes of hypertension are

pre-sented (Table 5): significant hypertension, based

upon BP measurements persistently between the

0 1 2 3 4 5 6 7 8 9 10 11 12 MONTHS

75

70

66

I:

46

125

120

115

110 U,

; 105 100

95 90

85

a. 75

in

7O 0

060

55 50

95TH

90TH

\.*...._____________________.____._.._______.____-___75TH

50TH

a.

U

0 I-(I)

>. in

65 80

95TH

50TH

YEARS

140

135

130

125

120

115 110 106

90

95

a.80 a

U

75

3-70 68

60

96TH

50TH

severe hypertension, based upon BP measurements

persistently at or above the 99th percentile for age

and sex.

YEARS

90TH

PERCENTILE

SYSTOLIC BP 124 126 129 131 134 136

DIASTOLICBP 77 78 79 81 50

HEIGHTCM 165 lfl 178 160 184 iss

WEIGHTKG 62 66 74 80 84 95

Fig 5. Age-specific percentiles of BP measurements in

boys-13 to 18 years of age; Korotkoffphase V (K5) used

for diastolic BP.

GUIDELINES FOR DETECTING CHILDREN WITH

HIGH BP

BP patterns in children and adolescents differ

from those in adults. The variations in BP readings

130

115 110

106

100

u96

ins0 75 70

68

0 1 2 3 4 5 6 7 9 10 11 12

90TH MONTHS

PERCENTILE

SYSTOUCBP 75 68 101 104 106 106 105 106 106 105 106 1% 106

DIASTOUCBP 68 66 64 64 65 66 06 56 56 67 67 57 67

HEIGHTCM U 68 56 68 61 60 66 68 70 72 74 75 77

WEIGHTKG 4 4 4 5 5 6 7 8 9 9 10 10 11

Fig 2. Age-specific percentiles of BP measurements in

girls-birth to 12 months ofage; Korotkoffphase IV (K4)

used for diastolic BP.

60

1 2 3 4 5 6 7 8 9 10 11 12 13

YEARS 60Th

PERCENTiLE

SYSTOUCBP 106 106 107 108 109 111 112 114 115 117 119 121 124

DIASTOUC BP 69 60 68 69 69 70 71 73 74 75 75 77 79

HEIGHTM 90 91 100 108 115 lfl 1 135 141 147 1 160 165

WEIGHTKG 11 14 16 18 fl 34 39 44 5 65

Fig 3. Age-specific percentiles of BP measurements in

boys-i to 13 years of age; Korotkoff phase IV (K4) used for diastolic BP.

YEARS

50TH

I I I I I I I I I I I 1

1 2 3 4 5 6 7 8 9 10 11 12 13

90TH YEARS

PERCENTILE

SYSTOLICBP 106 105 106 107 109 111 112 114 115 117 119 122 124

DIASTOLICBP 67 60 69 69 69 70 71 72 74 75 77 78 80

HEIGHTCM 77 89 98 107 115 122 179 135 142 148 154 160 165

WEIGHTKG 11 13 15 18 22 25 30 35 40 45 51 58 63

Fig 4. Age-specific percentiles of BP measurements in

girls-i to 13 years of age; Korotkoff phase IV (K4) used

for diastolic BP.

I I I I

13 14 15 16 17 18

YEARS

80TH 95TH90TH75TH

- I I I

95TH 90TH

--- 50TH

140

136

130 a 5.1 125

120

U)

110

106

90

86

80

U

75

3-70

13 14 15 16 17 18

YEARS

1111111111111190TH

68

Normal BP Systolic and diastolic BPs

<90th percentile for age and

High normal BP8

60

90TH PERCENTILE

SYSTOLIC B 124 DIASTOLIC BP 78

HEIGHT CM 166

WEIGHTKG 83

13 14 15 16 17 18

sex

Average systolic and/or average

diastolic BP between 90th

and 95th percentiles for age

and sex

._________________________________ High BP (hyperten- Average systolic and/or average

sion) diastolic BPs 95th

percent-YEARS ile for age and sex with

mea-surements obtained on at

least three occasions

125 135 127 In 127

81 83 81 80 80

168 169 170 170 170

87 70 72 73 74

Fig 6. Age-specific percentiles of BP measurements in girls-13 to 18 years of age; Korotkoffphase V (K5) used

for diastolic BP.

CIf the BP reading is high normal for age, but can be

accounted for by excess height for age or excess lean body

mass for age, such children are considered to have normal BP.

that may occur without the presence of sustained

hypertension or other detectable disease make the

BP readings on a single occasion insufficient for

identifying subjects with hypertension. Ideally, BP

measurements for children and adolescents should

be a part of total health care, for which prolonged

follow-up can be assured. Measurements that are

above the 90th percentile should be repeated during

subsequent visits under circumstances in which

apprehension and anxiety are minimized.

This task force report focuses on BP surveillance

of children under continuous care by a primary

physician. The task force does not recommend mass

community BP screening programs for children and

adolescents. Such screening programs will not be

cost-effective in case detection. Furthermore,

with-out sufficient training and support resources, there

may be difficulty in standardization of technique

and interpretation of measurements. However, it is

recognized that not all children are under

continu-ous medical supervision and that such children

could benefit from a targeted BP screening

pro-gram. When such a program is instituted, it should

include skilled examiners and resources for

coun-seling, referral, and follow-up. Likewise, school

nurses who elect to measure children’s BPs should

be mindful of the need for appropriate follow-up

care when elevated BPs are detected.

TABLE 4. Definitions

Term Definition

TABLE 5. Classification of H ypertension by Age Group

Age Group Significant

Hypertension

(mm Hg)

Severe

Hypertension (mm Hg)

Newborn 7 d

8-30 d

Infant (<2 yr)

Systolic BP 96

Systolic BP 104

Systolic BP 112 Diastolic BP 74

Systolic BP 106

Systolic BP 110

Systolic BP 118 Diastolic BP 82

Children (3-5 yr) Systolic BP 116

Diastolic BP ?76

Systolic BP 124 Diastolic BP 84

Children (6-9 yr) Systolic BP 122

Diastolic BP 78

Systolic BP 130 Diastolic BP 86

Children (10-12 yr) Systolic BP 126

Diastolic BP 82

Systolic BP 134 Diastolic BP 90

Adolescents (13-15 yr) Systolic BP 136

Diastolic BP 86

Systolic BP 144 Diastolic BP 92

Adolescents (16-18 yr) Systolic BP 142

Diastolic BP 92

Systolic BP 150

If 5P pemists ata%%

Dxsvslu.tion;

de sddm& -I trsstmsnt and

- thug th

Fig 7. Algorithm for identifying children with high BP.

Note: Whenever BP measurement is stipulated, the

av-erage of at least two measurements should be used.

Periodic BP determinants in accordance with the

guidelines of the American Academy of Pediatrics,

annually at 3 to 20 years of age, are recommended.

The primary physician, observing a child for a

number of years, has a unique opportunity to

pro-vide continuity of care. In routine preventive health

examinations in the practitioner’s office, BPs

should be measured and recorded on all children.

Examinations for episodic illnesses offer an

oppor-tunity to include preventive health care. Physicians

and others can be most effective in educating the

family and emphasizing the necessity for follow-up

services. In addition to the primary care physician,

there are other mechanisms for providing

continu-ing health care such as maternal and child health

programs.

The difficulty in defining juvenile hypertension

and the arbitrary nature ofthe standards separating

normotensive from hypertensive BPs render the

development of an algorithm for making decisions

about children with elevated BPs difficult. The task

force’s best judgment regarding the systematic

identification of children with elevated BP

mea-surements in need of diagnostic evaluation and

treatment is shown in Fig 7.

As indicated in the previous section, numerous

factors influence BP, including height and weight.

Based upon current information about high BP for

age4 and upon the availability of normative data for

height and weight from the nine data sources used

to compute the BP standards, the task force has

conceptualized that children with BP values greater

than the 90th percentile for age have such pressures

either because they are tall for their age, heavy for

their age, or truly have elevated BPs.

If a child is tall with weight proportional for age,

a BP reading greater than the 90th percentile for

age is probably normal for that child’s body size.

For a child who is tall and lean, a BP reading

greater than the 90th percentile for age may be

normal for that child’s height.

A BP value greater than the 90th percentile for

age may be considered normal if lean body mass is

increased but abnormal ifthe elevation is secondary

to adiposity. Obese children are unlikely to have a

cause for their high BP other than their excessive

ponderosity.95 However, obesity appears to be of

medical importance because of its known

relation-ship to high BP in children and adults.

If a child or adolescent has an average BP value

greater than the 90th percentile for age but is not

tall or heavy, there is a greater probability that the

elevation is the result of some pathologic process

and that the child needs special consideration. This

is particularly indicated if there is a family history

of essential hypertension. Repeated BP

measure-ments are necessary to demonstrate that the

ele-vation is sustained. The extent of the medical

eval-uation will depend upon the severity of the

eleva-tion.

Except in cases of severe hypertension with

man-ifest target organ damage, identifying children with

high BP requires multiple BP measurements on

several visits. On the first visit and, indeed, during

all subsequent visits, elevated BP readings should

signal the need for repeated measurements. The

average BP measurement is then plotted on a

fac-simile of the appropriate BP/age percentile chart

provided in this report. (The task force

recom-mends this approach, ie, the BP values used in

construction ofthe age-specific BP curves were first

BP

that the health care provider will plot “average

BPs.” Because the average of multiple BP

mea-surements is usually lower than the first BP

mea-surement, this approach will tend to reduce the

number of children classified as hypertensive. The

intent is to be conservative in diagnosing

hyperten-sion to minimize the number of children subjected

to antihypertensive interventions.) As indicated in

Fig 7, if this BP value ranks the child below the

90th percentile, the child resumes continuing

health care with a repeat BP determination in 1

year. If the BP value is above the 90th percentile,

the child is scheduled for repeat BP measurements,

usually over several visits. Ifthe average BP reading

is below the 90th percentile, the child returns to

continuing health care. If the average BP reading

is between the 90th and 95th percentiles for age,

the height and weight for the 90th percentile of age,

which are displayed at the bottom of each of the

not obese, he or she returns to continuing health

care. If the weight is above the 90th percentile but

is the result of an increase in lean body mass, the

BP may be considered normal for weight. If the

weight is above the 90th percentile as a result of

obesity (a clinical judgment), weight control is

rec-ommended with monitoring of BP. If the high

nor-mal BP reading cannot be accounted for by either

excess height or weight for age, the child should

remain under surveillance with BPs measured at

least every 6 months.

If the child’s average BP measurement after

sev-eral visits places him or her at the 95th percentile

or higher, he or she should be diagnostically

evalu-ated and consideration should be given to therapy,

unless he or she is obese, in which case a trial of

weight control may be attempted before proceeding

to diagnostic evaluation and other therapies.

Under optimal circumstances, children will be

receiving their care from a continuing source and

good records will be kept of their clinical progress,

be it in the office of a private practitioner or in a

clinic. The task force suggests that a record of the

patient’s BP measurements be maintained

through-out the years and plotted on facsimiles of the BP/

age percentile charts provided in this report. In this

way, the health care provider will be able to

deter-mine at a glance whether the child is trending in a

favorable or an unfavorable direction which will

provide guidance for determining how closely the

child should be monitored.

The algorithm outlined above does not address

all of the variables that affect BP in the preadult

years; however, these guidelines will make

assess-ment more precise than when age alone is used.

The choice of the 90th percentile of BP on age and

body size is arbitrary because, if children and

ado-lescents respond to BP elevation as adults do, risk

can be expected to increase as BP increases with

no absolute cutoff point separating normotension

from hypertension. However, just as it is important

for children “probably at risk” to receive a

thera-peutic intervention, it is also important that

chil-dren at “marginal risk” not receive potentially

harmful treatment.

DIAGNOSTIC EVALUATION

Youths with systolic and/or diastolic BP readings

at the 90th to 95th percentiles for age and most

children with significant hypertension (Table 5)

should be followed in the doctor’s office or clinic

setting and generally do not need referral. For

difficult cases and for children and adolescents with

severe hypertension (Table 5), consultation with

someone more knowledgeable is often wise,

espe-cially because the number of specialized diagnostic

studies now available is fairly large.

For each hypertensive child or adolescent, the

diagnostic evaluation should be tailored to that

individual’s presentation, with particular reference

to such determinants as patient’s age, race, sex,

level of systolic and diastolic BP, and family

his-tory. The clinician should attempt on a clinical

basis, and when indicated, on a laboratory basis, to

identify secondary causes of hypertension. These

are conditions in which the hypertension is not

primary (essential) but secondary to another

proc-ess that may be amenable to specific therapy, such

that correction of the pathologic condition that

gave rise to the hypertension results in

normaliza-tion of the BP.

Statistically, some conditions are more common

at one age than another; therefore, it is appropriate

to look systematically for these causes (Table 6).

In newborn infants with established hypertension,

the most likely causes are renal artery thrombosis

or stenosis, congenital renal malformations, or

coarctation of the aorta.2’ The last condition

gen-erally presents with greater elevations in systolic

than diastolic BP values. In children between

in-fancy and 6 years of age, coarctation of the aorta,

renal parenchymal diseases, and renal artery

ste-nosis remain the commonest causes of

hyperten-sion.32 In children older than 6 years of age, renal

TABLE Childre

6. Commonest

n and Adolescents

Causes by Age Group of Chronic Sustained Hypertension in

Seen in Clinic Populations*

Age Group Cause

Newborn infants

Infancy-6 yr

6-10 yr

Adolescence

Renal artery thrombosis, renal artery stenosis,

congenital renal malformations, coarctation of

the aorta, bronchopulmonary dysplasia90

Renal parenchymal diseases,t coarctation of the

aorta, renal artery stenosis

Renal artery stenosis, renal parenchymal diseases,

primary hypertension

Primary hypertension, renal parenchymal diseases

* No good population data are available for estimating the true prevalence of these

conditions.

artery stenosis and renal parenchymal diseases are

leading causes of diastolic BP measurements in

excess of 90 to 100 mm Hg. Over the age of 6 years,

particularly in white boys and black children of

both sexes, primary hypertension is the leading

cause of milder hypertension.33 This, of course, is

not to say that young white girls never have primary

hypertension, because some do. Finally, in

adoles-cent girls inquiry should be made about the use of

oral contraceptive pills because these increase BP.

It is important to recognize that persistent

iso-lated systolic hypertension is not normal in the

young. In the absence of anemia, thyrotoxicosis, or

an arteriovenous malformation, its significance is

not as clear as in elderly adults. However, it may

be a marker for the development of later primary

hypertension, and some youths with isolated

sys-tolic hypertension do have evidence of target organ

damage.’ They should be followed and evaluated

in the same way as youths with mildly elevated

diastolic BP values and should be periodically

as-sessed for the development of end organ damage,

as well as the presence of other coronary artery risk

factors.

Family History

A detailed history and physical examination are

very important in the evaluation of children and

adolescents with hypertension. Many of these

chil-dren have a positive family history for

hyperten-sion. Therefore, one of the most important aspects

of their diagnostic evaluation is an extensive family

history with emphasis on age of onset of

hyperten-sion and age of occurrence of complications such as

stroke, renal failure, and heart failure. Because

coronary artery disease risk factors cluster even in

early life, it is also important to obtain a detailed

family history (including age of occurrence) of heart

attack, peripheral vascular disease, and diabetes in

first- and second-degree relatives. In older children

and adolescents, a history of smoking should also

be elicited. When parents have not had their BPs

measured for a year or more, or do not know if their

last measurements were normal, their BPs should

be measured. Likewise, when a child or adolescent

presents with an elevated BP measurement, other

siblings should have their BPs measured. In this

way, families with primary hypertension may be

identified from an index child or adolescent. In

children with severe hypertension, a detailed family

history of elevated BP readings and the cause is

also important because some tumors (eg,

pheochro-mocytoma) and some forms of renal disease (eg,

polycystic kidneys) are familial.

Past and Personal History and Physical

Examination Results

With the increased use of umbilical artery

cath-eters in sick infants during the past decade, there

has been an increasing incidence of renal and

re-novascular hypertension in the newborn period. If

an elevated BP is overlooked during this period,35

it may present later in childhood with diastolic BP

readings far in excess of the 95th percentile.

There-fore, it is also important to obtain a birth and

neonatal history when preteenage children present

with hypertension. The historical and physical

clues that one attempts to elicit when evaluating a

young person with a finding of elevated BP are

listed in Tables 7 and 8. It remains a truism that,

the younger the child and the more severe the

hypertension, the more likely one is to identify an

underlying cause.42

It is unclear at what level of BP in childhood or

adolescence headaches and dizziness present as

symptoms ofhypertension. These are commonplace

complaints in teenagers even when they are

nor-motensive. However, severe headaches, particularly

when they are occipital and occur on awakening,

may be due to a markedly elevated BP. The

head-aches may mimic those found sometimes in children

with brain tumors, and they may be accompanied

by vomiting in the preencephalopathic state. Severe

paroxysmal headaches that are associated with an

acute increase in BP should raise the suspicion of

pheochromocytoma, although some young people

with hypertension and migraine headaches may

become more hypertensive when they have one of

their headaches. The character of the headache, as

well as family history of migraine, may help to

differentiate these conditions on clinical grounds.

In some cases, further biochemical evaluation may

be necessary.

Failure to grow and/or gain weight in younger

children with diastolic BP values 90 mm Hg

sug-gests a renal or renovascular cause. When weight

loss or failure to gain weight is accompanied by

other symptoms such as pallor, flushing, sweating,

palpitations, or unexplained fever,

pheochromocy-toma should be suspected.43 This is a rare tumor

which in girls tends to occur at menarche, whereas

in boys it occurs across the age distribution.44

Other hormonal forms of hypertension are also

uncommon in childhood and adolescence. For

ex-ample, it is rare for neuroblastomas to be associated

with hypertension, but they should be considered

when a child younger than 5 years of age presents

with a mass and evidence of catecholamine excess.

Primary aldosteronism due to an adrenal adenoma