RESUMO

Em adultos, eventos cardiovasculares associados à hipertensão arterial (HA) apresentam grande repercussão na morbimortalidade. À luz dos novos conhecimentos, a HA na criança tem sido interpretada como doença cardiovascular (DCV) precoce, enquanto a exposição da criança aos fatores de risco CV revela-se preditora de DCV subclínica em adultos. As classificações da medida de pressão arterial (PA) no adulto e na faixa pediátrica foram recentemente atualizadas pelo American College of Cardiology/American Heart Association. A HA primária na criança é em geral assintomática, e se associa com história familiar de HA, sobrepeso/obesidade e normalidade morfofuncional do sistema urinário. Quanto mais jovem a criança e mais elevada a PA, maior a chance de se tratar de HA secundário. A investigação da etiologia da HA inicia-se com anamnese detalhada, que deve incluir informações clínicas e de utilização de medicamentos, fumo e álcool, desde o período perinatal até o momento da consulta. A modificação de fatores de risco, com redução do peso, redução do consumo de álcool e aumento do consumo de vegetais, entre a infância e a idade adulta, mostrou associação com a resolução da HA na transição infância-idade adulta e com a reversão dos efeitos adversos cardiometabólicos nos indivíduos adultos não obesos. A terapêutica farmacológica deve ser iniciada para casos de HA sintomática, HA secundária a doença renal crônica ou a diabetes mellitus, presença de lesões de órgão alvo, HA estágio 2 sem causa modificável e HA persistente não responsiva à mudança de estilo de vida.

Descritores
Hipertensão; Criança; Anormalidades Cardiovasculares

Introduction

The causes of death and disability can be grouped into three broad categories: communicable diseases, maternal, perinatal and nutritional conditions, and non-communicable diseases. Monitoring mortality associated with these three conditions should guide health systems’ actions, promoting responses across multiple sectors and strengthening the various levels of health prevention. The result of this integrated action translates into a reduction in preventable deaths and agility in the event of changes in epidemiological circumstances¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... .

The latest World Health Organization (WHO) report, covering the period 2000–2019¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... , indicates that non-communicable diseases have become more prominent, while communicable diseases are declining. Ischemic heart disease emerged as the leading cause of death in the period 2000–2019, accounting for the largest increase in deaths - more than 2 million - in the past two decades¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... .

An estimated 17.9 million people died from cardiovascular disease (CVD) in 2019¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... , representing 32% of all deaths¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... . Of these deaths, 85% were due to ischemic heart disease and stroke. More than three-quarters of CVD deaths occur in low- and middle-income countries¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... .

Eight risk factors (alcohol use, tobacco use, high blood pressure, overweight/obesity, hypercholesterolemia, diabetes mellitus, a diet low in fruit and vegetables and high in salt, and a sedentary lifestyle) are responsible for 61% of cardiovascular deaths²2. World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.. The combination of these factors accounts for more than three-quarters of cases of ischemic heart disease, which is the primary cause of death worldwide²2. World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.. Additionally, over 84% of the total global burden of diseases associated with these factors occurs in low- and middle-income countries²2. World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.. Table 1 presents the American Heart Association recommendations for optimal cardiovascular health in adults and children.

The development of arterial hypertension (AH), diabetes mellitus, dyslipidemia, overweight, and obesity is the clinical translation of continuous exposure to CV risk factors¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... . Conversely, there is evidence of a reduction in the risk of CVD following smoking cessation, reduced salt intake in the diet, increased consumption of fruit and vegetables, regular physical activity, and prevention of harmful alcohol consumption²2. World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.. Health policies should promote environments conducive to making healthy choices accessible and available in order to motivate individuals to adopt and maintain healthy behaviors¹1. World Health Organization. Global health estimates: leading causes of death: cause-specificmortality, 2000-2019 [Internet]. Geneva: WHO; 2020 [cited 2024 Mar 7]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.
https://www.who.int/data/gho/data/themes... . In Brazil, according to WHO data in 2019, ischemic heart disease is also the leading cause of death in both sexes, as shown in Table 2³3. Qureshi F, Bousquet-Santos K, Okuzono SS, Tsao E, Delaney S, Guimond AJ, et al. The social determinants of ideal cardiovascular health: a global systematic review. Ann Epidemiol. 2022;76:20–38. doi: http://dx.doi.org/10.1016/j.annepidem.2022.09.006. PubMed PMID: 36191736.
https://doi.org/10.1016/j.annepidem.2022... .

Children may develop hypertension due to primary or secondary causes⁴4. World Health Organization. World health statistics 2023 [Internet]. Geneva: WHO; 2023 [cited 2024 Mar 7]. Available from: https://data.who.int.
https://data.who.int... ,⁵5. Hardy ST, Urbina EM. Blood pressure in childhood and adolescence. Am J Hypertens. 2021;34(3):242–9. doi: http://dx.doi.org/10.1093/ajh/hpab004. PubMed PMID: 33821942.
https://doi.org/10.1093/ajh/hpab004... . Risk factors for pediatric primary hypertension are the same as those previously mentioned for adults, including adverse perinatal events, family history of hypertension, minority race/ethnicity, inadequate sleep duration (≤8 hours/night) and quality, in addition to social determinants such as poverty and multiple adverse childhood experiences⁴4. World Health Organization. World health statistics 2023 [Internet]. Geneva: WHO; 2023 [cited 2024 Mar 7]. Available from: https://data.who.int.
https://data.who.int... ,⁵5. Hardy ST, Urbina EM. Blood pressure in childhood and adolescence. Am J Hypertens. 2021;34(3):242–9. doi: http://dx.doi.org/10.1093/ajh/hpab004. PubMed PMID: 33821942.
https://doi.org/10.1093/ajh/hpab004... . The association between maternal cardiovascular health during pregnancy and its effect on offspring cardiovascular health was assessed in a multinational cohort study⁶6. Perak AM, Lancki N, Kuang A, Labarthe DR, Allen NB, Shah SH, et al. Associations of maternal cardiovascular health in pregnancy with offspring cardiovascular health in early adolescence. JAMA. 2021;325(7):658–68. http://dx.doi.org/10.1001/jama.2021.0247. PubMed PMID: 33591345.
https://doi.org/10.1001/jama.2021.0247... . By assessing exposure to risk factors known to be associated with CVD, it was confirmed that better maternal cardiovascular health conditions at 28 weeks of pregnancy are associated with improved offspring cardiovascular health indices at ages 10 to 14 years⁶6. Perak AM, Lancki N, Kuang A, Labarthe DR, Allen NB, Shah SH, et al. Associations of maternal cardiovascular health in pregnancy with offspring cardiovascular health in early adolescence. JAMA. 2021;325(7):658–68. http://dx.doi.org/10.1001/jama.2021.0247. PubMed PMID: 33591345.
https://doi.org/10.1001/jama.2021.0247... . Data compiled from longitudinal studies mapping cardiovascular risk factors⁷7. Oikonen M, Nuotio J, Magnussen CG, Viikari JS, Taittonen L, Laitinen T, et al. Repeated blood pressure measurements in childhood in prediction of hypertension in adulthood. Hypertension. 2016;67(1):41–7. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.115.06395. PubMed PMID: 26553229.
https://doi.org/10.1161/HYPERTENSIONAHA.... and CVD from childhood to adulthood demonstrate that the diagnosis of AH in childhood, especially with multiple measurements, is associated with the risk of AH in adulthood. Furthermore, exposure to cardiovascular risk factors in childhood is a predictor of subclinical CVD in adults⁷7. Oikonen M, Nuotio J, Magnussen CG, Viikari JS, Taittonen L, Laitinen T, et al. Repeated blood pressure measurements in childhood in prediction of hypertension in adulthood. Hypertension. 2016;67(1):41–7. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.115.06395. PubMed PMID: 26553229.
https://doi.org/10.1161/HYPERTENSIONAHA.... . The child’s body mass index, family socioeconomic status, parental risk factors, as well as genetic polymorphisms, are independent predictors of adult obesity, AH and dyslipidemia⁸8. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8.e2. doi: http://dx.doi.org/10.1016/j.jpeds.2015.07.055. PubMed PMID: 26342719.
https://doi.org/10.1016/j.jpeds.2015.07.... . Lifestyle habits in childhood starting at the age of 9 (diet, physical activity, smoking), as well as dyslipidemia, obesity, high BP, are associated with subclinical atherosclerosis⁹9. Raitakari OT, Juonala M, Kähönen M, Taittonen L, Laitinen T, Mäki-Torkko N, et al. Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the cardiovascular risk in young finns study. JAMA. 2003;290(17):2277–83. doi: http://dx.doi.org/10.1001/jama.290.17.2277. PubMed PMID: 14600186.
https://doi.org/10.1001/jama.290.17.2277... , carotid intima-media thickness (C-IMT) and its progression into adulthood⁹9. Raitakari OT, Juonala M, Kähönen M, Taittonen L, Laitinen T, Mäki-Torkko N, et al. Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the cardiovascular risk in young finns study. JAMA. 2003;290(17):2277–83. doi: http://dx.doi.org/10.1001/jama.290.17.2277. PubMed PMID: 14600186.
https://doi.org/10.1001/jama.290.17.2277... . However, modifying risk factors by reducing BMI⁸8. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8.e2. doi: http://dx.doi.org/10.1016/j.jpeds.2015.07.055. PubMed PMID: 26342719.
https://doi.org/10.1016/j.jpeds.2015.07.... , decreasing alcohol consumption⁸8. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8.e2. doi: http://dx.doi.org/10.1016/j.jpeds.2015.07.055. PubMed PMID: 26342719.
https://doi.org/10.1016/j.jpeds.2015.07.... , and increasing vegetable intake from childhood⁸8. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8.e2. doi: http://dx.doi.org/10.1016/j.jpeds.2015.07.055. PubMed PMID: 26342719.
https://doi.org/10.1016/j.jpeds.2015.07.... to adulthood have been associated with the resolution of AH in the childhood-adulthood transition, and with the clinical reversal of adverse cardiometabolic effects in individuals who become non-obese adults⁷7. Oikonen M, Nuotio J, Magnussen CG, Viikari JS, Taittonen L, Laitinen T, et al. Repeated blood pressure measurements in childhood in prediction of hypertension in adulthood. Hypertension. 2016;67(1):41–7. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.115.06395. PubMed PMID: 26553229.
https://doi.org/10.1161/HYPERTENSIONAHA.... ,⁸8. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8.e2. doi: http://dx.doi.org/10.1016/j.jpeds.2015.07.055. PubMed PMID: 26342719.
https://doi.org/10.1016/j.jpeds.2015.07.... ,⁹9. Raitakari OT, Juonala M, Kähönen M, Taittonen L, Laitinen T, Mäki-Torkko N, et al. Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the cardiovascular risk in young finns study. JAMA. 2003;290(17):2277–83. doi: http://dx.doi.org/10.1001/jama.290.17.2277. PubMed PMID: 14600186.
https://doi.org/10.1001/jama.290.17.2277... ,¹⁰10. Juonala M, Viikari JS, Raitakari OT. Main findings from the prospective Cardiovascular Risk in Young Finns Study. Curr Opin Lipidol. 2013;24(1):57–64. doi: http://dx.doi.org/10.1097/MOL.0b013e32835a7ed4. PubMed PMID: 23069987.
https://doi.org/10.1097/MOL.0b013e32835a... ,¹¹11. Juonala M, Singh GR, Davison B, van Schilfgaarde K, Skilton MR, Sabin MA, et al. Childhood metabolic syndrome, inflammation and carotid intima-media thickness. The Aboriginal Birth Cohort Study. Int J Cardiol. 2016;203:32–6. doi: http://dx.doi.org/10.1016/j.ijcard.2015.10.073. PubMed PMID: 26492305.
https://doi.org/10.1016/j.ijcard.2015.10... . A recent study confirms the association between AH in adolescence and cardiovascular events with repercussions on cardiovascular morbidity and mortality in adults. It suggests that elevated BP in children and adolescents should be clinically interpreted as early CVD¹²12. Jacobs Jr DR, Woo JG, Sinaiko AR, Daniels SR, Ikonen J, Juonala M, et al. Childhood cardiovascular risk factors and adult cardiovascular events. N Engl J Med. 2022;386(20):1877–88. doi: http://dx.doi.org/10.1056/NEJMoa2109191. PubMed PMID: 35373933.
https://doi.org/10.1056/NEJMoa2109191... .

Primary AH in children is usually diagnosed as a clinical examination finding in asymptomatic children with a family history of hypertension, overweight/obesity, and normal morphofunctional characteristics of the urinary system. The diagnosis of secondary hypertension is based on information from history and clinical examination, with particular emphasis on obstructive sleep apnea, heart disease, endocrinopathies, nephropathies, and renovascular disease. In addition, there is the possibility of AH associated with medication use (decongestants, caffeine, nonsteroidal anti-inflammatory drugs, medications for neurological disorders, corticosteroids, hormonal contraceptives, tricyclic antidepressants, amphetamines) or induced by the use of illicit drugs. Secondary AH should always be considered when hypertension is diagnosed in young children with any instance of hypertensive urgency or emergency, and whenever AH accompanies signs of systemic disease, sexual development disorders, or hydroelectrolytic/acid-base imbalances¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

Definition

Blood pressure (BP) in children varies depending on their age, sex and height¹⁴14. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA. 2004;291(17):2107–13. doi: http://dx.doi.org/10.1001/jama.291.17.2107. PubMed PMID: 15126439.
https://doi.org/10.1001/jama.291.17.2107... . In newborns and infants, values may vary more in the first few days of life, particularly in preterm newborns, due to the influence of birth weight and maternal conditions¹⁴14. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA. 2004;291(17):2107–13. doi: http://dx.doi.org/10.1001/jama.291.17.2107. PubMed PMID: 15126439.
https://doi.org/10.1001/jama.291.17.2107... .

Starting in 1977, with a study conducted by the “Task Force on Blood Pressure in Chidren”¹⁵15. Blumenthal S, Epps RP, Heavenrich R, Lauer RM, Lieberman E, Mirkin B, et al. Report of the task force on blood pressure control in children. Pediatrics. 1977;59(5 2, suppl):I-II, 797–820. PubMed PMID: 859728., the BP measurement in children started to be valued. Subsequent publications in 1987, 1996 and 2004¹⁶16. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987;79(1):1–25. doi: http://dx.doi.org/10.1542/peds.79.1.1. PubMed PMID: 3797155.
https://doi.org/10.1542/peds.79.1.1... –¹⁸18. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2, Suppl 4):555–76. doi: http://dx.doi.org/10.1542/peds.114.S2.555. PubMed PMID: 15286277.
https://doi.org/10.1542/peds.114.S2.555... strengthened the methodological aspects of BP measurement in children and adolescents, as well as the design of investigation and treatment protocols for pediatric AH. Except for the first two years of life, when the oscillometric methodology shows greater technical feasibility, it is preferable to perform BP measurements using the auscultatory method, while considering the child’s sex, age and height percentile¹⁶16. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987;79(1):1–25. doi: http://dx.doi.org/10.1542/peds.79.1.1. PubMed PMID: 3797155.
https://doi.org/10.1542/peds.79.1.1... –¹⁸18. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2, Suppl 4):555–76. doi: http://dx.doi.org/10.1542/peds.114.S2.555. PubMed PMID: 15286277.
https://doi.org/10.1542/peds.114.S2.555... .

In 2017, the American Academy of Pediatrics (AAP) published a new guideline¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... with modifications to the diagnosis and management of AH. It excluded from the database previously used to develop earlier guidelines¹⁶16. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987;79(1):1–25. doi: http://dx.doi.org/10.1542/peds.79.1.1. PubMed PMID: 3797155.
https://doi.org/10.1542/peds.79.1.1... –¹⁸18. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2, Suppl 4):555–76. doi: http://dx.doi.org/10.1542/peds.114.S2.555. PubMed PMID: 15286277.
https://doi.org/10.1542/peds.114.S2.555... the BP data of overweight and obese children. This new document¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... updates reference values by modifying the blood pressure values for the diagnosis of high BP, stages 1 and 2 AH for children between 1 and 13 years of age, and by adopting adult BP reference values, according to the American Heart Association and American College of Cardiology guidelines¹⁹19. Whelton PK, Carey RM, Mancia G, Kreutz R, Bundy JD, Williams B. Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations. Circulation. 2022;146(11):868–77. doi: http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054602. PubMed PMID: 35950927.
https://doi.org/10.1161/CIRCULATIONAHA.1... , for children over 13 years of age. Other innovations include replacing the term “pre-hypertension” with “high BP”, simplifying recommendations for preventive assessment in routine visits, improving initial management for patients diagnosed with high BP or AH, and recommending ambulatory BP monitoring (ABPM) for the final diagnosis and management of pediatric AH. These innovations suggested by the American College of Cardiology/American Heart Association and supported by the American Academy of Pediatrics (AAP) have not yet reached international consensus. However, efforts are underway to standardize the diagnosis of AH worldwide¹⁹19. Whelton PK, Carey RM, Mancia G, Kreutz R, Bundy JD, Williams B. Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations. Circulation. 2022;146(11):868–77. doi: http://dx.doi.org/10.1161/CIRCULATIONAHA.121.054602. PubMed PMID: 35950927.
https://doi.org/10.1161/CIRCULATIONAHA.1... ,²⁰20. Rabi DM, McBrien KA, Sapir-Pichhadze R, Nakhla M, Ahmed SB, Dumanski SM, et al. Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Can J Cardiol. 2020;36(5):596–624. doi: http://dx.doi.org/10.1016/j.cjca.2020.02.086. PubMed PMID: 32389335.
https://doi.org/10.1016/j.cjca.2020.02.0... .

Table 3 presents the updated definition of normal BP, high BP, stages 1 and 2 of AH in children and adolescents, according to age, sex, and height percentile¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

Prevalence

The prevalence of pediatric AH is approximately 3.5%. It is higher in children with obesity, chronic kidney disease and a history of prematurity²¹21. McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and prehypertension among adolescents. J Pediatr. 2007;150(6):640–4, 644.e1. doi: http://dx.doi.org/10.1016/j.jpeds.2007.01.052. PubMed PMID: 17517252.
https://doi.org/10.1016/j.jpeds.2007.01.... . Epidemiological data from the United States show an increased prevalence of AH in African-American boys and adolescents²¹21. McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and prehypertension among adolescents. J Pediatr. 2007;150(6):640–4, 644.e1. doi: http://dx.doi.org/10.1016/j.jpeds.2007.01.052. PubMed PMID: 17517252.
https://doi.org/10.1016/j.jpeds.2007.01.... , as well as high BP in 10–15% of the individuals²¹21. McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ. Prevalence of hypertension and prehypertension among adolescents. J Pediatr. 2007;150(6):640–4, 644.e1. doi: http://dx.doi.org/10.1016/j.jpeds.2007.01.052. PubMed PMID: 17517252.
https://doi.org/10.1016/j.jpeds.2007.01.... ,²²22. Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. 2004;113(3 Pt 1):475–82. doi: http://dx.doi.org/10.1542/peds.113.3.475. PubMed PMID: 14993537.
https://doi.org/10.1542/peds.113.3.475... . In obese children aged 7 to 12, the prevalence of high BP and AH is 4.7% and 1.9%, respectively²³23. Kit BK, Kuklina E, Carroll MD, Ostchega Y, Freedman DS, Ogden CL. Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999–2012. JAMA Pediatr. 2015;169(3):272–9. doi: http://dx.doi.org/10.1001/jamapediatrics.2014.3216. PubMed PMID: 25599372.
https://doi.org/10.1001/jamapediatrics.2... ,²⁴24. Dong Y, Ma J, Song Y, Ma Y, Dong B, Zou Z, et al. Trends in Blood Pressure and Overweight and Obesity in Chinese Boys and Girls Aged 7 to 17 Years From 1995 to 2014. Hypertension. 2018;72(2):298–305. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.118.11291. PubMed PMID: 29866739.
https://doi.org/10.1161/HYPERTENSIONAHA.... . In China, from 1995 to 2014, there was an increase in the prevalence of overweight among children aged 7 to 17, rising from 4.3% in 1995 to 18.4% in 2014. Meanwhile, the prevalence of hypertension ranged from 4.4% to 6.4% during this period. Despite significant increases in the prevalence of overweight among Chinese children from 1995 to 2014, the prevalence of AH remained relatively stable. This suggests that other independent factors may play a role in moderating the development of AH in the pediatric population²⁴24. Dong Y, Ma J, Song Y, Ma Y, Dong B, Zou Z, et al. Trends in Blood Pressure and Overweight and Obesity in Chinese Boys and Girls Aged 7 to 17 Years From 1995 to 2014. Hypertension. 2018;72(2):298–305. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.118.11291. PubMed PMID: 29866739.
https://doi.org/10.1161/HYPERTENSIONAHA.... .

In a study conducted in Brazil with 73,399 students aged 12 to 17, the prevalence of high BP ranged from 14.5% to 29.3% in boys aged 15–17, while the prevalence of AH was 9.6%²⁵25. Bloch KV, Klein CH, Szklo M, Kuschnir MC, Abreu Gde A, Barufaldi LA, et al. ERICA: prevalences of hypertension and obesity in Brazilian adolescents. Rev Saúde Pública. 2016;50(Suppl 1):9s. doi: http://dx.doi.org/10.1590/S01518-8787.2016050006685.
https://doi.org/10.1590/S01518-8787.2016... , with 17.8% of the AH prevalence attributable to obesity²⁵25. Bloch KV, Klein CH, Szklo M, Kuschnir MC, Abreu Gde A, Barufaldi LA, et al. ERICA: prevalences of hypertension and obesity in Brazilian adolescents. Rev Saúde Pública. 2016;50(Suppl 1):9s. doi: http://dx.doi.org/10.1590/S01518-8787.2016050006685.
https://doi.org/10.1590/S01518-8787.2016... .

The changes proposed in the 2017 guideline¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... resulted in increased prevalence of high BP and AH, with a greater correlation between high BP and target organ damage⁵5. Hardy ST, Urbina EM. Blood pressure in childhood and adolescence. Am J Hypertens. 2021;34(3):242–9. doi: http://dx.doi.org/10.1093/ajh/hpab004. PubMed PMID: 33821942.
https://doi.org/10.1093/ajh/hpab004... ,²⁶26. Khoury M, Khoury PR, Dolan LM, Kimball TR, Urbina EM. Clinical Implications of the Revised AAP Pediatric Hypertension Guidelines. Pediatrics. 2018;142(2):e20180245. doi: http://dx.doi.org/10.1542/peds.2018-0245. PubMed PMID: 29976572.
https://doi.org/10.1542/peds.2018-0245... ,²⁷27. Bell CS, Samuel JP, Samuels JA. Prevalence of hypertension in children. Hypertension. 2019;73(1):148–52. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.118.11673. PubMed PMID: 30571555.
https://doi.org/10.1161/HYPERTENSIONAHA.... .

BP Measurement

The indirect blood pressure measurement method was developed in 1896 by Riva-Rocci²⁸28. Riva-Rocci S. Un nuovo sfigmomanometro. Gaz Med Torino. 1896;47:981–96., and the auscultatory method in 1905, by Korotkoff²⁹29. Korotkoff NS. On the subject of methods of measuring blood pressure. Bull Imp Military Med St Peterburg. 1905;11:365–7.. In recent years, technical advancements in BP measurement have greatly improved its accuracy. This measurement has become crucial for the diagnosis and treatment of hypertension³⁰30. O’Brien E, Asmar R, Beilin L, Imai Y, Mallion JM, Mancia G, et al. European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens. 2003;21(5):821–48. doi: http://dx.doi.org/10.1097/00004872-200305000-00001. PubMed PMID: 12714851.
https://doi.org/10.1097/00004872-2003050... . The procedures for measuring blood pressure require careful attention, which is not always observed. This often leads to inadequate assessment of the patient’s blood pressure values and, consequently, to misdiagnosis.

In children, BP measurements may vary between visits, and even within the same visit to the doctor. Generally, BP values tend to decrease with repeated measurements¹⁸18. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2, Suppl 4):555–76. doi: http://dx.doi.org/10.1542/peds.114.S2.555. PubMed PMID: 15286277.
https://doi.org/10.1542/peds.114.S2.555... ,³¹31. Yetman RJ, Portman RJ. Technical aspects of blood pressure measurement in pediatric patients. Blood Press Monit. 1999 Jun-Aug;4(3-4):155–9. PubMed PMID: 10490868..

BP shows variations associated with physical and mental activities that, acting on respiratory, diurnal and seasonal variations, generate patterns of BP behavior with higher levels during the day and a decrease of 15% to 25% in nighttime blood pressure levels³¹31. Yetman RJ, Portman RJ. Technical aspects of blood pressure measurement in pediatric patients. Blood Press Monit. 1999 Jun-Aug;4(3-4):155–9. PubMed PMID: 10490868.. Therefore, in order to confirm AH, the diagnosis depends on multiple blood pressure measurements taken at several medical visits¹⁶16. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987;79(1):1–25. doi: http://dx.doi.org/10.1542/peds.79.1.1. PubMed PMID: 3797155.
https://doi.org/10.1542/peds.79.1.1... .

The current recommendation from the Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... considers it mandatory to measure BP annually from the age of 3. In the case of obesity, kidney disease, use of medications with an effect on BP, history of coarctation of the aorta or diabetes, it should be measured at every visit. In children under 3 years of age, this measurement should be performed in situations of increased risk of developing hypertension¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . These include prematurity, neonates with very low birth weight, or small for gestational age, or those who required neonatal intensive care; children with diseases associated with hypertension; malformation of the urinary system, urinary tract infections or use of medications with an effect on BP¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . It is worth noting the multiplicity of clinical situations routinely faced by pediatricians that require the systematic inclusion of blood pressure measurement in pediatric physical examinations. BP varies with age, with a progressive increase in values during childhood, reaching adult values by adolescence⁸8. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8.e2. doi: http://dx.doi.org/10.1016/j.jpeds.2015.07.055. PubMed PMID: 26342719.
https://doi.org/10.1016/j.jpeds.2015.07.... .

The most commonly used technique is casual BP measurement in office, using auscultation with an aneroid sphygmomanometer³²32. Sociedade Brasileira de Cardiologia-SBC, Sociedade Brasileira de Hipertensão-SBH, Sociedade Brasileira de Nefrologia-SBN. V Diretrizes Brasileiras de Hipertensão Arterial. Arq Bras Cardiol. 2007;89(3):e24–79. PubMed PMID: 17906811.. It is known that the accuracy of these measurements will influence the diagnosis and therapeutic evaluation³¹31. Yetman RJ, Portman RJ. Technical aspects of blood pressure measurement in pediatric patients. Blood Press Monit. 1999 Jun-Aug;4(3-4):155–9. PubMed PMID: 10490868.. This assessment is subject to errors, such as poor equipment calibration, anxiety or severe crying, noisy surroundings that hinder BP auscultation, and false diagnoses³¹31. Yetman RJ, Portman RJ. Technical aspects of blood pressure measurement in pediatric patients. Blood Press Monit. 1999 Jun-Aug;4(3-4):155–9. PubMed PMID: 10490868..

In children, BP measurement requires more time available than it does in adults, also requiring a greater variety of cuff sizes¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . The selection of the cuff should be appropriate to the child /adolescent’s arm circumference. The width of the inflatable cuff bladder should encircle 40% of the arm circumference (measured at the midpoint between the olecranon and the acromion) and the bladder length should be 80 to 100% of this measurement¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

Regarding the technique used, in children over 3 years old, BP should be measured with the child seated, with the right arm at heart level¹⁶16. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987;79(1):1–25. doi: http://dx.doi.org/10.1542/peds.79.1.1. PubMed PMID: 3797155.
https://doi.org/10.1542/peds.79.1.1... ,³¹31. Yetman RJ, Portman RJ. Technical aspects of blood pressure measurement in pediatric patients. Blood Press Monit. 1999 Jun-Aug;4(3-4):155–9. PubMed PMID: 10490868., while those under 3 years old should be assessed in the supine position¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . Auscultation of Korotkoff phase I and the disappearance of the sounds (Korotkoff phase V) correspond to systolic blood pressure (SBP) and diastolic blood pressure (DBP), respectively. If Korotkoff phase V is heard at 0 mmHg, Korotkoff phase IV (muffling of sound) should be taken as the DBP value¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

The prone position can be used to measure BP in lower limbs. In this case, the cuff is placed in the calf region, covering at least 2/3 of the distance between the knee and the ankle. Due to distal pulse amplification, the SBP value at this site shows an increase of 10% to 20% compared to the measurement in the brachial artery¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

The 2017 pediatric AH evaluation guideline allows BP screening to be performed using oscillometric techniques, with oscillometric devices validated for the pediatric population¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . However, these oscillometric devices can be inaccurate, especially in diastolic BP, compared to the auscultatory method³³33. Ringrose JS, Alabbas A, Jalali A, Khinda H, Morgan C, Yiu V, et al. Comparability of oscillometric to simultaneous auscultatory blood pressure measurement in children. Blood Press Monit. 2019;24(2):83–8. doi: http://dx.doi.org/10.1097/MBP.0000000000000367. PubMed PMID: 30856623.
https://doi.org/10.1097/MBP.000000000000... . Therefore, if AH is suspected with the oscillometric device, confirmatory measurements should be taken using the auscultatory method¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . A compilation of normative values for BP in neonatal period is available for neonates aged 15 days and older, with postnatal gestational age ranging from 26 to 44 weeks³⁴34. Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol. 2012;27(1):17–32. doi: http://dx.doi.org/10.1007/s00467-010-1755-z. PubMed PMID: 21258818.
https://doi.org/10.1007/s00467-010-1755-... . The validated oscillometric devices for use in the pediatric age group³⁰30. O’Brien E, Asmar R, Beilin L, Imai Y, Mallion JM, Mancia G, et al. European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens. 2003;21(5):821–48. doi: http://dx.doi.org/10.1097/00004872-200305000-00001. PubMed PMID: 12714851.
https://doi.org/10.1097/00004872-2003050... can be used for non-invasive BP assessment in NB and infants until they are able to cooperate with auscultatory BP measurement. The selection of cuffs for these devices should follow the same rules used for auscultatory BP measurement¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . The list of validated oscillometric devices for children and adolescents can be found at https://bihsoc.org/bp-monitors/ (BHS); https://www.validatebp.org (US/AMA); https://hypertension.ca/bpdevices (CANADA); https://www.stridebp.org/bp-monitors (STRIDE BP, a joint initiative of ESH, ISH and the World Hypertension League).

BP Assessment by ABPM

Current studies have demonstrated a correlation between high BP values in childhood and adolescence and target organ damage in adulthood³⁵35. Tapp RJ, Hughes AD, Kähönen M, Wong TY, Witt N, Lehtimäki T, et al. Cardiometabolic health among adult offspring of hypertensive pregnancies: the cardiovascular risk in young finns study. J Am Heart Assoc. 2018;7(1):e006284. doi: http://dx.doi.org/10.1161/JAHA.117.006284. PubMed PMID: 29306901.
https://doi.org/10.1161/JAHA.117.006284... ,³⁶36. Koskinen JS, Kytö V, Juonala M, Viikari JSA, Nevalainen J, Kähönen M, et al. Childhood risk factors and carotid atherosclerotic plaque in adulthood: the cardiovascular risk in young finns study. Atherosclerosis. 2020;293:18–25. doi: http://dx.doi.org/10.1016/j.atherosclerosis.2019.11.029. PubMed PMID: 31830725.
https://doi.org/10.1016/j.atherosclerosi... .

Normative outpatient definitions for ABPM values in the pediatric population are derived from studies in the normal population. Recommendations for the use of ABPM in this population are based on expert opinions rather than evidence from well-designed studies for this purpose³⁷37. Flynn JT, Daniels SR, Hayman LL, Maahs DM, McCrindle BW, Mitsnefes M, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63(5):1116–35. doi: http://dx.doi.org/10.1161/HYP.0000000000000007. PubMed PMID: 24591341.
https://doi.org/10.1161/HYP.000000000000... .

ABPM is considered a mandatory procedure for confirming the diagnosis of arterial hypertension (AH) in children and adolescents¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... presenting with office measurements at a high BP level for 1 year or more, or at a stage 1 hypertension level over 3 consecutive clinic visits¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . Additionally, ABPM is recommended for evaluating AH and the occurrence of abnormal circadian BP patterns in children and adolescents with high-risk conditions, such as chronic kidney disease, type 1 and type 2 diabetes mellitus, pre and postoperative coarctation of the aorta, solid organ transplantation, obstructive sleep apnea syndrome, obesity, suspected masked hypertension or white coat hypertension and genetic syndromes associated with AH, such as Williams syndrome, Turner syndrome and neurofibromatosis¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . In children with chronic kidney disease, BP should be assessed using ABPM at least annually to exclude masked AH, regardless of apparent office BP control¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

The equipment used for measuring ABPM could be either oscillometric or auscultatory¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . The list of validated devices for children and adolescents can be found on the websites of British and Irish Hypertension Society (https://bihsoc.org/bp-monitors/), American Medical Association (US Blood Pressure Validated Device Listing: www.validatebp.org), Hypertension Canada (https://hypertension.ca/bpdevices) or STRIDE BP, a joint initiative of the European Society of Hypertension, International Society of Hypertension and World Hypertension League (https://www.stridebp.org/bp-monitors).

In 2017, the new guideline for the diagnosis and management of pediatric AH¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... eased the transition from adolescence to young adulthood by establishing for adolescents ≥13 years of age the same casual BP cutoff point adopted by the adult guideline³⁸38. Whelton PK, Carey RM, Aronow WS, Casey Jr DE, Collins KJ, Dennison Himmelfarb C, et al., 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/ NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13–115. doi: http://dx.doi.org/10.1161/HYP.0000000000000065.
https://doi.org/10.1161/HYP.000000000000... .

Regarding ABPM, new American guidelines for adults have included the adoption of lower thresholds to define hypertension by ABPM in adults (mean awake BP, 130/80 mmHg, equivalent to casual BP; mean nighttime BP, 110/65 mmHg; and 24-hour mean BP, 125/75 mmHg). However, similar measures had not been taken regarding normative values for pediatric ABPM, which had been subject to controversy in the literature. In a 2014 publication³⁷37. Flynn JT, Daniels SR, Hayman LL, Maahs DM, McCrindle BW, Mitsnefes M, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63(5):1116–35. doi: http://dx.doi.org/10.1161/HYP.0000000000000007. PubMed PMID: 24591341.
https://doi.org/10.1161/HYP.000000000000... , Flynn et al. used the 95th percentiles of BP as a cutoff point for all pediatric ages. Meanwhile, the European Society of Hypertension (ESH), in 2016³⁹39. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016;34(10):1887–920. doi: http://dx.doi.org/10.1097/HJH.0000000000001039. PubMed PMID: 27467768.
https://doi.org/10.1097/HJH.000000000000... ,⁴⁰40. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–104. doi: http://dx.doi.org/10.1093/eurheartj/ehy339. PubMed PMID: 30165516.
https://doi.org/10.1093/eurheartj/ehy339... , recommended adopting the 95th percentile of BP measured by ABPM, until they were lower than the adult cutoff points in force in Europe: awake BP, 135/85 mmHg; nighttime BP, 120/70 mmHg; and 24-hour BP, 130/80 mmHg³⁹39. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016;34(10):1887–920. doi: http://dx.doi.org/10.1097/HJH.0000000000001039. PubMed PMID: 27467768.
https://doi.org/10.1097/HJH.000000000000... ,⁴⁰40. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–104. doi: http://dx.doi.org/10.1093/eurheartj/ehy339. PubMed PMID: 30165516.
https://doi.org/10.1093/eurheartj/ehy339... .

Furthermore, recent evidence has shown no additive value of pressure load in risk stratification or prediction of intermediate clinical outcomes (left ventricular hypertrophy) or progression to end-stage renal disease, favoring the elimination of pressure load measurement in pediatric ABPM classification⁴¹41. Hamdani G, Mitsnefes MM, Flynn JT, Becker RC, Daniels S, Falkner BE, et al. Pediatric and adult ambulatory blood pressure thresholds and blood pressure load as predictors of left ventricular hypertrophy in adolescents. Hypertension. 2021;78(1):30–7. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16896. PubMed PMID: 33966453.
https://doi.org/10.1161/HYPERTENSIONAHA.... ,⁴²42. Lee J, McCulloch CE, Flynn JT, Samuels J, Warady BA, Furth SL, et al. Prognostic value of ambulatory blood pressure load in pediatric CKD. Clin J Am Soc Nephrol. 2020;15(4):493–500. doi: http://dx.doi.org/10.2215/CJN.10130819. PubMed PMID: 32160993.
https://doi.org/10.2215/CJN.10130819... ,⁴³43. Mitsnefes M, Flynn JT, Brady T, Baker-Smith C, Daniels SR, Hayman LL, et al. Pediatric Ambulatory blood pressure classification: the case for a change. Hypertension. 2021;78(5):1206–10. doi: http://dx.doi.org/10.1161/HYPERTENSIONAHA.121.18138. PubMed PMID: 34601972.
https://doi.org/10.1161/HYPERTENSIONAHA.... ,⁴⁴44. Flynn JT, Urbina EM, Brady TM, Baker-Smith C, Daniels SR, Hayman LL, et al. Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association. Hypertension. 2022;79(7):e114–24. doi: http://dx.doi.org/10.1161/HYP.0000000000000215. PubMed PMID: 35603599.
https://doi.org/10.1161/HYP.000000000000... .

The recently published new guidelines for ABPM in children and adolescents⁴⁴44. Flynn JT, Urbina EM, Brady TM, Baker-Smith C, Daniels SR, Hayman LL, et al. Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association. Hypertension. 2022;79(7):e114–24. doi: http://dx.doi.org/10.1161/HYP.0000000000000215. PubMed PMID: 35603599.
https://doi.org/10.1161/HYP.000000000000... respond to these concerns by presenting new data for classifying BP measurements through ABPM. Additionally, besides favoring the transition of care from adolescent to young adult patients, it eliminates the use of the pressure load (Table 4)⁴⁴44. Flynn JT, Urbina EM, Brady TM, Baker-Smith C, Daniels SR, Hayman LL, et al. Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association. Hypertension. 2022;79(7):e114–24. doi: http://dx.doi.org/10.1161/HYP.0000000000000215. PubMed PMID: 35603599.
https://doi.org/10.1161/HYP.000000000000... . When office BP and ABPM BP are both within normal range, the patient should be considered normotensive. When both are abnormal, the patient is diagnosed with ambulatory hypertension. If there is a divergence between the BP measured by the two techniques, the patient has white coat AH or masked hypertension (see Table 4).

Clinical Picture and Diagnosis

The diagnosis of pediatric AH is based on the confirmation of BP values ≥95th percentile at three different visits using auscultatory methodology¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

In many cases, AH in children and adolescents develops asymptomatically but with significant sequelae, such as increased carotid intima-media thickness, reduced arterial distensibility, retinal arteriolar narrowing⁴⁵45. Lurbe E, Cifkova R, Cruickshank JK, Dillon MJ, Ferreira I, Invitti C, et al. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009;27(9):1719–42. doi: http://dx.doi.org/10.1097/HJH.0b013e32832f4f6b. PubMed PMID: 19625970.
https://doi.org/10.1097/HJH.0b013e32832f... and left ventricular hypertrophy (LVH), which is present in up to 40% of cases at the time of initial diagnosis⁴⁶46. Kavey RE. Left ventricular hypertrophy in hypertensive children and adolescents: predictors and prevalence. Curr Hypertens Rep. 2013;15(5):453–7. doi: http://dx.doi.org/10.1007/s11906-013-0370-3. PubMed PMID: 23893038.
https://doi.org/10.1007/s11906-013-0370-... , and may be a precursor to arrhythmias and heart failure in adults⁴⁴44. Flynn JT, Urbina EM, Brady TM, Baker-Smith C, Daniels SR, Hayman LL, et al. Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association. Hypertension. 2022;79(7):e114–24. doi: http://dx.doi.org/10.1161/HYP.0000000000000215. PubMed PMID: 35603599.
https://doi.org/10.1161/HYP.000000000000... .

The investigation into the etiology of AH begins with a thorough anamnesis and collection of information from the perinatal period up to the present moment. During investigation, it is essential to inquire history of the need for neonatal or pediatric ICU admission, umbilical vein catheterization, personal history of illness or trauma, and sleep disorders, with particular attention to sleep apnea. Also important to consider the coexistence of systemic diseases, weight loss or gain, use of medications with effects on BP, such as vasoactive drugs, immunosuppressants, and steroids, as well as the use of illicit drugs, and smoking habits¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . Other diagnoses, such as coarctation of the aorta, central nervous system alterations, and increased intracranial pressure¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... , represent less than 10% of the etiology of AH in children¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... ,¹⁸18. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2, Suppl 4):555–76. doi: http://dx.doi.org/10.1542/peds.114.S2.555. PubMed PMID: 15286277.
https://doi.org/10.1542/peds.114.S2.555... .

Physical examination should be comprehensive, including palpation of pulses in all 4 limbs, detection of abdominal murmurs through abdominal auscultation, and skin changes such as neurofibromas or acanthosis nigricans¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . The presence of hypertensive retinopathy, enlarged heart, heart failure or neurological deficit generally correlates with the chronicity and severity of hypertension¹⁷17. National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 Task Force report on high blood pressure in children and adolescents: a working group report from the National High Blood Pressure Education Program. Pediatrics. 1996;98(4 Pt 1):649–58. PubMed PMID: 8885941.. The diagnostic evaluation of hypertension in children and adolescents should be adapted to the clinical picture, family history, BP value and age at presentation¹⁷17. National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 Task Force report on high blood pressure in children and adolescents: a working group report from the National High Blood Pressure Education Program. Pediatrics. 1996;98(4 Pt 1):649–58. PubMed PMID: 8885941.,⁴⁷47. Sinaiko AR. Current concept: hypertension in children. N Engl J Med. 1996;335(26):1968–73. doi: http://dx.doi.org/10.1056/NEJM199612263352607. PubMed PMID: 8960478.
https://doi.org/10.1056/NEJM199612263352... . Secondary hypertension usually occurs in younger children, with markedly elevated BP values, with 60% to 90% of cases caused by parenchymal or obstructive nephropathy or renal artery stenosis¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

Renovascular hypertension (RVH) is a potentially reversible cause of secondary hypertension. It may be caused by partial or total, unilateral or bilateral renal artery stenosis (RAS) or its branches, triggering and maintaining renal ischemia. Evaluation with renal Doppler ultrasound is the recommended non-invasive method for screening this clinical situation, with estimated sensitivity and specificity of 75% and 90%, respectively⁴⁸48. Vasbinder GB, Nelemans PJ, Kessels AG, Kroon AA, de Leeuw PW, van Engelshoven JM. Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med. 2001;135(6):401–11. doi: http://dx.doi.org/10.7326/0003-4819-135-6-200109180-00009. PubMed PMID: 11560453.
https://doi.org/10.7326/0003-4819-135-6-... . Magnetic resonance angiography (MRA) by digital subtraction or BOLD method or spiral CT have equal accuracy and greater sensitivity and specificity when compared to ultrasound⁴⁹49. Expert Panels on Urologic Imaging and Vascular Imaging, Harvin HJ, Verma N, Nikolaidis P, Hanley M, Dogra VS, et al. ACR Appropriateness Criteria® Renovascular Hypertension. J Am Coll Radiol. 2017;14(11S):S540–9. doi: http://dx.doi.org/10.1016/j.jacr.2017.08.040. PubMed PMID: 29101991.
https://doi.org/10.1016/j.jacr.2017.08.0... .

Endocrine disorders may account for up to 5% of AH cases, through multiple pathophysiological mechanisms, such as mineralocorticoid excess, corticoids or catecholamines; thyroid disease or hyperparathyroidism. Catecholamine-secreting tumors arising from chromaffin cells of the sympathetic-adrenal-medullary axis⁵⁰50. van Berkel A, Lenders JW, Timmers HJ. Diagnosis of endocrine disease: biochemical diagnosis of phaeochromocytoma and paraganglioma. Eur J Endocrinol. 2014;170(3):R109–19. doi: http://dx.doi.org/10.1530/EJE-13-0882. PubMed PMID: 24347425.
https://doi.org/10.1530/EJE-13-0882... are characterized by the classic triad of headache, hyperhidrosis and palpitations with permanent or paroxysmal AH (50%; hypertensive peaks alternating with moments of normal BP). They could be either pheochromocytomas or paragangliomas (PPGLs), and depending on their underlying germline or somatic mutations, they could be classified into 3 groups that also differ in clinical presentation, biochemical and imaging profile⁵¹51. Nölting S, Bechmann N, Taieb D, Beuschlein F, Fassnacht M, Kroiss M, et al. Personalized management of pheochromocytoma and paraganglioma. Endocr Rev. 2022;43(2):199–239. doi: http://dx.doi.org/10.1210/endrev/bnab019. PubMed PMID: 34147030.
https://doi.org/10.1210/endrev/bnab019... . Group 1 and probably group 3 tumors generally present with more aggressive symptoms and a higher metastatic risk when compared to those in group 2. Tumors from group 1 (located mainly extra-adrenal) have a noradrenergic biochemical phenotype with a tendency towards arterial hypertension, while those from group 2 (primarily located in the adrenal) have an adrenergic biochemical phenotype with intermittent secretion of catecholamines with sporadic symptoms. Plasma free metanephrine (metanephrine and normetanephrine) levels have high sensitivity (97%) and specificity (93%)⁵⁰50. van Berkel A, Lenders JW, Timmers HJ. Diagnosis of endocrine disease: biochemical diagnosis of phaeochromocytoma and paraganglioma. Eur J Endocrinol. 2014;170(3):R109–19. doi: http://dx.doi.org/10.1530/EJE-13-0882. PubMed PMID: 24347425.
https://doi.org/10.1530/EJE-13-0882... for diagnosing these tumors; however, they are very expensive⁵⁰50. van Berkel A, Lenders JW, Timmers HJ. Diagnosis of endocrine disease: biochemical diagnosis of phaeochromocytoma and paraganglioma. Eur J Endocrinol. 2014;170(3):R109–19. doi: http://dx.doi.org/10.1530/EJE-13-0882. PubMed PMID: 24347425.
https://doi.org/10.1530/EJE-13-0882... . Urinary metanephrine measurement alone or in combination with urinary catecholamines (epinephrine, norepinephrine, and dopamine) has also been used at lower cost, although it is less sensitive. Increased values (>2 times the upper limit of normal) of urinary catecholamines indicate a high diagnostic probability⁵²52. Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(6):1915–42. doi: http://dx.doi.org/10.1210/jc.2014-1498. PubMed PMID: 24893135.
https://doi.org/10.1210/jc.2014-1498... . Urinary catecholamines and vanillylmandelic acid levels are less sensitive for diagnosing PPGLs⁵³53. Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002;287(11):1427–34. doi: http://dx.doi.org/10.1001/jama.287.11.1427. PubMed PMID: 11903030.
https://doi.org/10.1001/jama.287.11.1427... than urinary metanephrine levels. The location of adrenal tumors can be investigated using computed tomography, with a sensitivity of 89%, or nuclear magnetic resonance imaging (pheochromocytoma shows hyperintense signal in T2-weighted images), with a sensitivity of 98%⁵⁴54. Tsirlin A, Oo Y, Sharma R, Kansara A, Gliwa A, Banerji MA. Pheochromocytoma: a review. Maturitas. 2014;77(3):229–38. doi: http://dx.doi.org/10.1016/j.maturitas.2013.12.009. PubMed PMID: 24472290.
https://doi.org/10.1016/j.maturitas.2013... . Whole-body scintigraphy with 123I-MIBG or 68Ga DOTATE-PET-CT is highly effective in locating pheochromocytoma and paragangliomas, metastatic disease or multiple chromaffin tumors⁵⁵55. Calabrò D, Allegri V, Fanti S, Ambrosini V. 68Ga-DOTANOC and 18F-DOPA PET/CT: a site-specific approach to the imaging of parangliomas of the head and neck and of the abdomen. Eur J Nucl Med Mol Imaging. 2019;46(6):1393. doi: http://dx.doi.org/10.1007/s00259-019-04299-3. PubMed PMID: 30874857.
https://doi.org/10.1007/s00259-019-04299... . Characterizing the grouping to which the PPGL belongs, in addition to diagnostic implications, can also guide follow-up and therapeutic choices, facilitating a personalized therapeutic plan according to each patient’s specific grouping.

Monogenic AH is a cause of secondary hypertension with a familial inheritance pattern, often caused by a mutation in a single gene. It should be suspected in patients with a family history of early-onset hypertension, hypokalemia, suppressed plasma renin activity or elevated aldosterone-to-renin ratio. Among the multiple etiologies, familial hyperaldosteronism, Liddle’s syndrome and congenital adrenal hyperplasia are worth mentioning⁵⁶56. Raina R, Krishnappa V, Das A, Amin H, Radhakrishnan Y, Nair NR, et al. Overview of monogenic or mendelian forms of hypertension. Front Pediatr. 2019;7:263. doi: http://dx.doi.org/10.3389/fped.2019.00263. PubMed PMID: 31312622.
https://doi.org/10.3389/fped.2019.00263... ,⁵⁷57. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Diretrizes Brasileiras de Hipertensão Arterial – 2020. Arq Bras Cardiol. 2021 Mar;116(3):516–658. doi: http://dx.doi.org/10.36660/abc.20201238.
https://doi.org/10.36660/abc.20201238... . Genetic diagnosis may lead to appropriate treatment and enable family genetic counseling and early screening in asymptomatic family members⁵⁶56. Raina R, Krishnappa V, Das A, Amin H, Radhakrishnan Y, Nair NR, et al. Overview of monogenic or mendelian forms of hypertension. Front Pediatr. 2019;7:263. doi: http://dx.doi.org/10.3389/fped.2019.00263. PubMed PMID: 31312622.
https://doi.org/10.3389/fped.2019.00263... .

Primary AH is more common in older children and adolescents and is associated with overweight, obesity or a family history of AH. However, considering the wide range of secondary hypertension etiologies that may affect children or adolescents, the diagnosis of primary AH should be made with caution. In the medical history, detailed information should be provided on birth, growth and development, personal history of kidney, urological, endocrine, cardiac and neurological diseases and lifestyle habits, as well as the use of medication and other substances that may alter BP. Family history of AH, kidney disease, and other cardiovascular risk factors should also be investigated. As part of the physical examination, it is important to calculate body mass index⁵⁸58. Guimarães IC, Almeida AM, Santos AS, Barbosa DB, Guimarães AC. Blood pressure: effect of body mass index and of waist circumference on adolescents. Arq Bras Cardiol. 2008;90(6):393–9. doi: http://dx.doi.org/10.1590/s0066-782x2008000600007. PubMed PMID: 18592092.
https://doi.org/10.1590/s0066-782x200800... , and look for signs of secondary AH⁵⁹59. Daniels SR. Coronary risk factors in children. In: Shaddy RE, Penny DJ, Feltes TF, Cetta F, Mital S. Moss & Adams. Heart disease in infants, children and adolescents. Philadelphia: Williams & Wilkins; 2013. p. 1514–48.. Diagnostic investigation with more invasive tests should be conducted in children under 6 years of age with signs of secondary AH¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... ,¹⁶16. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children—1987. Pediatrics. 1987;79(1):1–25. doi: http://dx.doi.org/10.1542/peds.79.1.1. PubMed PMID: 3797155.
https://doi.org/10.1542/peds.79.1.1... .

Sleep studies, using polysomnography, are indicated for children and adolescents with sleep disorders detected by anamnesis¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... .

Laboratory and imaging tests requested in the investigation of AH aim to define the etiology (primary or secondary), and detect target organ damage (TOD) and cardiovascular risk factors associated with AH (Chart 1)¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . Target organ assessment should be performed in cases of stages 1 and 2 AH.

Treatment

In pediatric patients with BP values equal to or greater than the 90th percentile, non-pharmacological guidelines should be followed, focusing on weight reduction, physical exercise and dietary intervention¹⁸18. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2, Suppl 4):555–76. doi: http://dx.doi.org/10.1542/peds.114.S2.555. PubMed PMID: 15286277.
https://doi.org/10.1542/peds.114.S2.555... ,⁶⁰60. Mikkilä V, Rasanen L, Raitakari OT, Marniemi J, Pietinen P, Ronnemaa T, et al. Major dietary patterns and cardiovascular risk factors from childhood to adulthood: the Cardiovascular Risk in Young Finns Study. Br J Nutr. 2007;98(1):218–25. doi: http://dx.doi.org/10.1017/S0007114507691831. PubMed PMID: 17367571.
https://doi.org/10.1017/S000711450769183... . This is because weight reduction in obese children and adolescents has been shown to be important in the treatment of AH and in the cardiovascular prognosis of adults⁸8. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8.e2. doi: http://dx.doi.org/10.1016/j.jpeds.2015.07.055. PubMed PMID: 26342719.
https://doi.org/10.1016/j.jpeds.2015.07.... ,⁹9. Raitakari OT, Juonala M, Kähönen M, Taittonen L, Laitinen T, Mäki-Torkko N, et al. Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the cardiovascular risk in young finns study. JAMA. 2003;290(17):2277–83. doi: http://dx.doi.org/10.1001/jama.290.17.2277. PubMed PMID: 14600186.
https://doi.org/10.1001/jama.290.17.2277... .

Regular physical activity, that is, 30 to 60 minutes of moderate physical exercise, daily if possible, has a major impact on reducing weight and blood pressure, with a better effect on systolic blood pressure than on diastolic blood pressure⁶¹61. Rocchini AP, Katch V, Anderson J, Hinderliter J, Becque D, Martin M, et al. Blood pressure in adolescents: effect of weight loss. Pediatrics. 1988;82(1):16–23. PubMed PMID: 3288957.,⁶²62. Farpour-Lambert NJ, Aggoun Y, Marchand LM, Martin XE, Herrmann FR, Beghetti M. Physical activity reduces systemic blood pressure and improves early markers of atherosclerosis in pre-pubertal obese children. J Am Coll Cardiol. 2009;54(25):2396–406. doi: http://dx.doi.org/10.1016/j.jacc.2009.08.030. PubMed PMID: 20082930.
https://doi.org/10.1016/j.jacc.2009.08.0... . Resistance training, apart from weightlifting, can be performed by hypertensive children, but competitive sports are not recommended for patients with stage 2 hypertension⁶³63. Hansen HS, Hyldebrandt N, Froberg K, Nielsen JR. Blood pressure and physical fitness in a population of children – the Odense Schoolchild Study. J Hum Hypertens. 1990;4(6):615–20. PubMed PMID: 2096201..

In symptomatic AH patients with secondary forms of chronic kidney disease or diabetes mellitus, presence of target organ damage, stage 2 AH and resistant AH not responsive to lifestyle changes¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... , pharmacological therapy should be initiated with an antihypertensive agent at its lowest dose, and gradually increased until BP is reduced below the 90th percentile¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . In general, children have experienced few adverse events from antihypertensive agents¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... ,⁶⁴64. Chaturvedi S, Lipszyc DH, Licht C, Craig JC, Parekh P. Pharmacological interventions for hypertension in children. Evid Based Child Health. 2014;9(3):498–580. doi: http://dx.doi.org/10.1002/ebch.1974. PubMed PMID: 25236305.
https://doi.org/10.1002/ebch.1974... , and in the short term the use of all classes of antihypertensive agents seems to be safe⁶⁴64. Chaturvedi S, Lipszyc DH, Licht C, Craig JC, Parekh P. Pharmacological interventions for hypertension in children. Evid Based Child Health. 2014;9(3):498–580. doi: http://dx.doi.org/10.1002/ebch.1974. PubMed PMID: 25236305.
https://doi.org/10.1002/ebch.1974... . International guidelines recommend as first line treatment the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, long-acting calcium channel blockers or thiazide diuretics. In cases of resistant AH, alpha blockers, beta blockers, centrally acting sympatholytics or potassium-sparing agents can be used¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... ,⁶⁴64. Chaturvedi S, Lipszyc DH, Licht C, Craig JC, Parekh P. Pharmacological interventions for hypertension in children. Evid Based Child Health. 2014;9(3):498–580. doi: http://dx.doi.org/10.1002/ebch.1974. PubMed PMID: 25236305.
https://doi.org/10.1002/ebch.1974... . The choice of antihypertensive medication should be made in line with the underlying pathophysiology, considering the comorbidities present in each case⁶⁵65. Rios-Leyvraz M, Bloetzer C, Chatelan A, Bochud M, Burnier M, Santschi V, et al. Sodium intake and blood pressure in children with clinical conditions: a systematic review with meta-analysis. J Clin Hypertens (Greenwich). 2019;21(1):118–26. doi: http://dx.doi.org/10.1111/jch.13436. PubMed PMID: 30489016.
https://doi.org/10.1111/jch.13436... ,⁶⁶66. Blowey DL. Update on the pharmacologic treatment of hypertension in pediatrics. J Clin Hypertens (Greenwich). 2012;14(6):383–7. doi: http://dx.doi.org/10.1111/j.1751-7176.2012.00659.x. PubMed PMID: 22672092.
https://doi.org/10.1111/j.1751-7176.2012... . Strict dietary guidance with reduced salt intake, improved adherence to drug treatment and optimization of antihypertensive drugs should be instituted in all patients with AH, especially those with resistant AH¹³13. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi: http://dx.doi.org/10.1542/peds.2017-1904. PubMed PMID: 28827377.
https://doi.org/10.1542/peds.2017-1904... . In the event of non-response to monotherapy for longer than 6 months, referral to a specialist in pediatric AH is considered⁶⁷67. Nerenberg KA, Zarnke KB, Leung AA, Dasgupta K, Butalia S, McBrien K, et al. Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cordial. 2018;34(5):506–25. doi: http://dx.doi.org/10.1016/j.cjca.2018.02.022. PubMed PMID: 29731013.
https://doi.org/10.1016/j.cjca.2018.02.0... .

Conclusion

This article highlights the importance of early diagnosis of hypertension and high blood pressure in children and adolescents, emphasizing the peculiarities and difficulties of measuring blood pressure in pediatrics, as well as the importance of secondary hypertension in this age group. AH is a frequently asymptomatic condition, and it tends to progress with structural and/or functional changes in target organs such as the heart, brain, kidneys and vessels. AH is the major modifiable risk factor with an independent, linear, and continuous association for cardiovascular diseases, chronic kidney disease and premature death. The diagnosis and treatment of cardiovascular risk factors in childhood have a significant impact on reducing cardiovascular morbidity and mortality in adults.

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