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American Academy of Pediatrics
SUPPLEMENT ARTICLE

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

; National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents
Pediatrics August 2004, 114 (Supplement 2) 555-576;
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    Fig 1

    Management algorithm. Rx indicates prescription; Q, every. *, See Tables 3, 4, and 5; †, diet modification and physical activity; ‡, especially if younger, very high BP, little or no family history, diabetic, or other risk factors.

Tables

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    • View popup
    TABLE 1.

    Conditions Under Which Children <3 Years Old Should Have BP Measured

    History of prematurity, very low birth weight, or other neonatal complication requiring intensive care
    Congenital heart disease (repaired or nonrepaired)
    Recurrent urinary tract infections, hematuria, or proteinuria
    Known renal disease or urologic malformations
    Family history of congenital renal disease
    Solid-organ transplant
    Malignancy or bone marrow transplant
    Treatment with drugs known to raise BP
    Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc)
    Evidence of elevated intracranial pressure
    • View popup
    TABLE 2.

    Recommended Dimensions for BP Cuff Bladders

    Age RangeWidth, cmLength, cmMaximum Arm Circumference, cm*
    Newborn4810
    Infant61215
    Child91822
    Small adult102426
    Adult133034
    Large adult163844
    Thigh204252
    • ↵* Calculated so that the largest arm would still allow the bladder to encircle arm by at least 80%.

    • View popup
    TABLE 3.

    BP Levels for Boys by Age and Height Percentile

    Age, yBP PercentileSBP, mm HgDBP, mm Hg
    Percentile of HeightPercentile of Height
    5th10th25th50th75th90th95th5th10th25th50th75th90th95th
    150th8081838587888934353637383939
    90th9495979910010210349505152535354
    95th989910110310410610654545556575858
    99th10510610811011211311461626364656666
    250th8485878890929239404142434444
    90th979910010210410510654555657585859
    95th10110210410610810911059596061626363
    99th10911011111311511711766676869707171
    350th8687899193949544444546474848
    90th10010110310510710810959596061626363
    95th10410510710911011211363636465666767
    99th11111211411611811912071717273747575
    450th8889919395969747484950515152
    90th10210310510710911011162636465666667
    95th10610710911111211411566676869707171
    99th11311411611812012112274757677787879
    550th9091939596989850515253545555
    90th10410510610811011111265666768696970
    95th10810911011211411511669707172737474
    99th11511611812012112312377787980818182
    650th91929496989910053535455565757
    90th10510610811011111311368686970717272
    95th10911011211411511711772727374757676
    99th11611711912112312412580808182838484
    750th929495979910010155555657585959
    90th10610710911111311411570707172737474
    95th11011111311511711811974747576777878
    99th11711812012212412512682828384858686
    850th9495979910010210256575859606061
    90th10710911011211411511671727273747576
    95th11111211411611811912075767778797980
    99th11912012212312512712783848586878788
    950th95969810010210310457585960616162
    90th10911011211411511711872737475767677
    95th11311411611811912112176777879808181
    99th12012112312512712812984858687888889
    1050th979810010210310510658596061616263
    90th11111211411511711911973737475767778
    95th11511611711912112212377787980818182
    99th12212312512712813013085868688888990
    1150th9910010210410510710759596061626363
    90th11311411511711912012174747576777878
    95th11711811912112312412578787980818282
    99th12412512712913013213286868788899090
    1250th10110210410610810911059606162636364
    90th11511611812012112312374757576777879
    95th11912012212312512712778798081828283
    99th12612712913113313413586878889909091
    1350th10410510610811011111260606162636464
    90th11711812012212412512675757677787979
    95th12112212412612812913079798081828383
    99th12813013113313513613787878889909191
    1450th10610710911111311411560616263646565
    90th12012112312512612812875767778797980
    95th12412512712813013213280808182838484
    99th13113213413613813914087888990919292
    1550th10911011211311511711761626364656666
    90th12212412512712913013176777879808081
    95th12612712913113313413581818283848585
    99th13413513613814014214288899091929393
    1650th11111211411611811912063636465666767
    90th12512612813013113313478787980818282
    95th12913013213413513713782838384858687
    99th13613713914114314414590909192939494
    1750th11411511611812012112265666667686970
    90th12712813013213413513680808182838484
    95th13113213413613813914084858687878889
    99th13914014114314514614792939394959697
    • The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.

      For research purposes, the SDs in Table B1 allow one to compute BP Z scores and percentiles for boys with height percentiles given in Table 3 (ie, the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles). These height percentiles must be converted to height Z scores given by: 5% = −1.645; 10% = −1.28; 25% = −0.68; 50% = 0; 75% = 0.68; 90% = 1.28; and 95% = 1.645, and then computed according to the methodology in steps 2 through 4 described in Appendix B. For children with height percentiles other than these, follow steps 1 through 4 as described in Appendix B.

    • View popup
    TABLE 4.

    BP Levels for Girls by Age and Height Percentile

    Age, yBP PercentileSBP, mm HgDBP, mm Hg
    Percentile of HeightPercentile of Height
    5th10th25th50th75th90th95th5th10th25th50th75th90th95th
    150th8384858688899038393940414142
    90th97979810010110210352535354555556
    95th10010110210410510610756575758595960
    99th10810810911111211311464646565666767
    250th8585878889919143444445464647
    90th989910010110310410557585859606161
    95th10210310410510710810961626263646565
    99th10911011111211411511669697070717272
    350th8687888991929347484849505051
    90th10010010210310410610661626263646465
    95th10410410510710810911065666667686869
    99th11111111311411511611773737474757676
    450th8888909192949450505152525354
    90th10110210310410610710864646566676768
    95th10510610710811011111268686970717172
    99th11211311411511711811976767677787979
    550th8990919394959652535354555556
    90th10310310510610710910966676768696970
    95th10710710811011111211370717172737374
    99th11411411611711812012078787979808181
    650th9192939496979854545556565758
    90th10410510610810911011168686970707172
    95th10810911011111311411572727374747576
    99th11511611711912012112280808081828383
    750th9393959697999955565657585859
    90th10610710810911111211369707071727273
    95th11011111211311511611673747475767677
    99th11711811912012212312481818282838484
    850th959596989910010157575758596060
    90th10810911011111311411471717172737474
    95th11211211411511611811875757576777878
    99th11912012112212312512582828383848586
    950th96979810010110210358585859606161
    90th11011011211311411611672727273747575
    95th11411411511711811912076767677787979
    99th12112112312412512712783838484858687
    1050th989910010210310410559595960616262
    90th11211211411511611811873737374757676
    95th11611611711912012112277777778798080
    99th12312312512612712912984848586868788
    1150th10010110210310510610760606061626363
    90th11411411611711811912074747475767777
    95th11811811912112212312478787879808181
    99th12512512612812913013185858687878889
    1250th10210310410510710810961616162636464
    90th11611611711912012112275757576777878
    95th11912012112312412512679797980818282
    99th12712712813013113213386868788888990
    1350th10410510610710911011062626263646565
    90th11711811912112212312476767677787979
    95th12112212312412612712880808081828383
    99th12812913013213313413587878889899091
    1450th10610610710911011111263636364656666
    90th11912012112212412512577777778798080
    95th12312312512612712912981818182838484
    99th13013113213313513613688888990909192
    1550th10710810911011111311364646465666767
    90th12012112212312512612778787879808181
    95th12412512612712913013182828283848585
    99th13113213313413613713889899091919293
    1650th10810811011111211411464646566666768
    90th12112212312412612712878787980818182
    95th12512612712813013113282828384858586
    99th13213313413513713813990909091929393
    1750th10810911011111311411564656566676768
    90th12212212312512612712878797980818182
    95th12512612712913013113282838384858586
    99th13313313413613713813990909191929393
    • * The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.

    • For research purposes, the SDs in Table B1 allow one to compute BP Z scores and percentiles for girls with height percentiles given in Table 4 (ie, the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles). These height percentiles must be converted to height Z scores given by: 5% = −1.645; 10% = −1.28; 25% = −0.68; 50% = 0; 75% = 0.68; 90% = 1.28; and 95% = 1.645 and then computed according to the methodology in steps 2 through 4 described in Appendix B. For children with height percentiles other than these, follow steps 1 through 4 as described in Appendix B.

    • View popup
    TABLE 5.

    Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations

    SBP or DBP Percentile*Frequency of BP MeasurementTherapeutic Lifestyle ChangesPharmacologic Therapy
    Normal<90thRecheck at next scheduled physical examinationEncourage healthy diet, sleep, and physical activity—
    Prehypertension90th to <95th or if BP exceeds 120/80 even if <90th percentile up to <95th percentile†Recheck in 6 moWeight-management counseling if overweight; introduce physical activity and diet management‡None unless compelling indications such as chronic kidney disease, diabetes mellitus, heart failure, or LVH exist
    Stage 1 hypertension95th–99th percentile plus 5 mm HgRecheck in 1–2 wk or sooner if the patient is symptomatic; if persistently elevated on 2 additional occasions, evaluate or refer to source of care within 1 moWeight-management counseling if overweight; introduce physical activity and diet management‡Initiate therapy based on indications in Table 6 or if compelling indications (as shown above) exist
    Stage 2 hypertension>99th percentile plus 5 mm HgEvaluate or refer to source of care within 1 wk or immediately if the patient is symptomaticWeight-management counseling if overweight; introduce physical activity and diet management‡Initiate therapy§
    • ↵* For gender, age, and height measured on at least 3 separate occasions; if systolic and diastolic categories are different, categorize by the higher value.

    • ↵† This occurs typically at 12 years old for SBP and at 16 years old for DBP.

    • ↵‡ Parents and children trying to modify the eating plan to the Dietary Approaches to Stop Hypertension Study eating plan could benefit from consultation with a registered or licensed nutritionist to get them started.

    • ↵§ More than 1 drug may be required.

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    TABLE 6.

    Indications for Antihypertensive Drug Therapy in Children

    Symptomatic hypertension
    Secondary hypertension
    Hypertensive target-organ damage
    Diabetes (types 1 and 2)
    Persistent hypertension despite nonpharmacologic measures
    • View popup
    TABLE 7.

    Clinical Evaluation of Confirmed Hypertension

    Study or ProcedurePurposeTarget Population
    Evaluation for identifiable causes
        History, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking alcohol; physical examinationHistory and physical examination help focus subsequent evaluationAll children with persistent BP ≥95th percentile
        BUN, creatinine, electrolytes, urinalysis, and urine cultureR/O renal disease and chronic pyelonephritisAll children with persistent BP ≥95th percentile
        CBCR/O anemia, consistent with chronic renal diseaseAll children with persistent BP ≥95th percentile
        Renal U/SR/O renal scar, congenital anomaly, or disparate renal sizeAll children with persistent BP ≥95th percentile
    Evaluation for comorbidity
        Fasting lipid panel, fasting glucoseIdentify hyperlipidemia, identify metabolic abnormalitiesOverweight patients with BP at 90th–94th percentile; all patients with BP ≥95th percentile; family history of hypertension or CVD; child with chronic renal disease
        Drug screenIdentify substances that might cause hypertensionHistory suggestive of possible contribution by substances or drugs.
        PolysomnographyIdentify sleep disorder in association with hypertensionHistory of loud, frequent snoring
    Evaluation for target-organ damage
        EchocardiogramIdentify LVH and other indications of cardiac involvementPatients with comorbid risk factors* and BP 90th–94th percentile; all patients with BP ≥95th percentile
        Retinal examIdentify retinal vascular changesPatients with comorbid risk factors and BP 90th–94th percentile; all patients with BP ≥95th percentile
    Additional evaluation as indicated
        ABPMIdentify white-coat hypertension, abnormal diurnal BP pattern, BP loadPatients in whom white-coat hypertension is suspected, and when other information on BP pattern is needed
        Plasma renin determinationIdentify low renin, suggesting mineralocorticoid-related diseaseYoung children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
    Positive family history of severe hypertension
    Renovascular imagingIdentify renovascular diseaseYoung children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
        Isotopic scintigraphy (renal scan)
        MRA
        Duplex Doppler flow studies
        3-Dimensional CT
        Arteriography: DSA or classic
        Plasma and urine steroid levelsIdentify steroid-mediated hypertensionYoung children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
        Plasma and urine catecholaminesIdentify catecholamine-mediated hypertensionYoung children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
    • BUN, blood urea nitrogen; CBC, complete blood count; R/O, rule out; U/S, ultrasound.

    • ↵* Comorbid risk factors also include diabetes mellitus and kidney disease.

    • View popup
    TABLE 8.

    Examples of Physical Examination Findings Suggestive of Definable Hypertension

    Finding*Possible Etiology
    Vital signsTachycardiaHyperthyroidism, pheochromocytoma, neuroblastoma, primary hypertension
    Decreased lower extremity pulses; drop in BP from upper to lower extremitiesCoarctation of the aorta
    EyesRetinal changesSevere hypertension, more likely to be associated with secondary hypertension
    Ear, nose, and throatAdenotonsillar hypertrophySuggests association with sleep-disordered breathing (sleep apnea), snoring
    Height/weightGrowth retardationChronic renal failure
    Obesity (high BMI)Primary hypertension
    Truncal obesityCushing syndrome, insulin resistance syndrome
    Head and neckMoon faciesCushing syndrome
    Elfin faciesWilliams syndrome
    Webbed neckTurner syndrome
    ThyromegalyHyperthyroidism
    SkinPallor, flushing, diaphoresisPheochromocytoma
    Acne, hirsutism, striaeCushing syndrome, anabolic steroid abuse
    Café-au-lait spotsNeurofibromatosis
    Adenoma sebaceumTuberous sclerosis
    Malar rashSystemic lupus erythematosus
    Acanthrosis nigricansType 2 diabetes
    ChestWidely spaced nipplesTurner syndrome
    Heart murmurCoarctation of the aorta
    Friction rubSystemic lupus erythematosus (pericarditis), collagen-vascular disease, end stage renal disease with uremia
    Apical heaveLVH/chronic hypertension
    AbdomenMassWilms tumor, neuroblastoma, pheochromocytoma
    Epigastric/flank bruitRenal artery stenosis
    Palpable kidneysPolycystic kidney disease, hydronephrosis, multicystic-dysplastic kidney, mass (see above)
    GenitaliaAmbiguous/virilizationAdrenal hyperplasia
    ExtremitiesJoint swellingSystemic lupus erythematosus, collagen vascular disease
    Muscle weaknessHyperaldosteronism, Liddle syndrome
    • Adapted from Flynn JT. Prog Pediatr Cardiol. 2001;12:177–188.

    • ↵* Findings listed are examples of physical findings and do not represent all possible physical findings.

    • View popup
    TABLE 9.

    Antihypertensive Drugs for Outpatient Management of Hypertension in Children 1–17 Years Old*

    ClassDrugDose†Dosing IntervalEvidence‡FDA Labeling§Comments‖Verbar;
    ACE inhibitorBenazeprilInitial: 0.2 mg/kg per d up to 10 mg/dqdRCTYes
    1. All ACE inhibitors are contraindicated in pregnancy; females of childbearing age should use reliable contraception.

    2. Check serum potassium and creatinine periodically to monitor for hyperkalemia and azotemia.

    3. Cough and angioedema are reportedly less common with newer members of this class than with captopril.

    4. Benazepril, enalapril, and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension.

    5. FDA approval for ACE inhibitors with pediatric labeling is limited to children ≥6 years of age and to children with creatinine clearance ≥30 ml/min per 1.73m2.

    Maximum: 0.6 mg/kg per d up to 40 mg/d
    CaptoprilInitial: 0.3–0.5 mg/kg/dosetidRCT, CSNo
    Maximum: 6 mg/kg per d
    EnalaprilInitial: 0.08 mg/kg per d up to 5 mg/dqd-bidRCTYes
    Maximum: 0.6 mg/kg per d up to 40 mg/d
    FosinoprilChildren >50 kg:qdRCTYes
    Initial: 5–10 mg/d
    Maximum: 40 mg/d
    LisinoprilInitial: 0.07 mg/kg per d up to 5 mg/dqdRCTYes
    Maximum: 0.6 mg/kg per d up to 40 mg/d
    QuinaprilInitial: 5–10 mg/dqdRCT, EONo
    Maximum: 80 mg/d
    Angiotensin-receptor blockerIrbesartan6–12 years: 75–150 mg/dqdCSYes
    1. All ARBs are contraindicated in pregnancy; females of childbearing age should use reliable contraception.

    2. Check serum potassium, creatinine periodically to monitor for hyperkalemia and azotemia.

    3. Losartan label contains information on the preparation of a suspension.

    4. FDA approval for ARBs is limited to children ≥6 years of age and to children with creatinine clearance ≥30 ml/min per 1.73m2.

    ≥13 years: 150–300 mg/d
    LosartanInitial: 0.7 mg/kg per d up to 50 mg/dqdRCTYes
    Maximum: 1.4 mg/kg per d up to 100 mg/d
    α- and β-BlockerLabetalolInitial: 1–3 mg/kg per dbidCS, EONo
    1. Asthma and overt heart failure are contraindications.

    2. Heart rate is dose-limiting.

    3. May impair athletic performance.

    4. Should not be used in insulin-dependent diabetics.

    Maximum: 10–12 mg/kg per d up to 1200 mg/d
    β-BlockerAtenololInitial: 0.5–1 mg/kg per dqd-bidCSNo
    1. Noncardioselective agents (propranolol) are contraindicated in asthma and heart failure.

    2. Heart rate is dose-limiting.

    3. May impair athletic performance.

    4. Should not be used in insulin-dependent diabetics.

    5. A sustained-release formulation of propranolol is available that is dosed once-daily.

    Maximum: 2 mg/kg per d up to 100 mg/d
    Bisoprolol/HCTZInitial: 2.5/6.25 mg/dqdRCTNo
    Maximum: 10/6.25 mg/d
    MetoprololInitial: 1–2 mg/kg per dbidCSNo
    Maximum: 6 mg/kg per d up to 200 mg/d
    PropranololInitial: 1–2 mg/kg per dbid-tidRCT, EOYes
    Maximum: 4 mg/kg per d up to 640 mg/d
    Calcium channel blockerAmlodipineChildren 6–17 years: 2.5–5 mg once dailyqdRCTYes
    1. Amlodipine and isradipine can be compounded into stable extemporaneous suspensions.

    2. Felodipine and extended-release nifedipine tablets must be swallowed whole.

    3. Isradipine is available in both immediate-release and sustained-release formulations; sustained-release form is dosed qd or bid.

    4. May cause tachycardia.

    FelodipineInitial: 2.5 mg/dqdRCT, EONo
    Maximum: 10 mg/d
    IsradipineInitial: 0.15–0.2 mg/kg per dtid-qidCS, EONo
    Maximum: 0.8 mg/kg per d up to 20 mg/d
    Extended-release nifedipineInitial: 0.25–0.5 mg/kg per dqd-bidCS, EONo
    Maximum: 3 mg/kg per d up to 120 mg/d
    Central α-agonistClonidineChildren ≥12 years:bidEOYes
    1. May cause dry mouth and/or sedation.

    2. Transdermal preparation also available.

    3. Sudden cessation of therapy can lead to severe rebound hypertension.

    Initial: 0.2 mg/d
    Maximum: 2.4 mg/d
    DiureticHCTZInitial: 1 mg/kg per dqdEOYes
    1. All patients treated with diuretics should have electrolytes monitored shortly after initiating therapy and periodically thereafter.

    2. Useful as add-on therapy in patients being treated with drugs from other drug classes.

    3. Potassium-sparing diuretics (spironolactone, triamterene, amiloride) may cause severe hyperkalemia, especially if given with ACE inhibitor or ARB.

    4. Furosemide is labeled only for treatment of edema but may be useful as add-on therapy in children with resistant hypertension, particularly in children with renal disease.

    5. Chlorthalidone may precipitate azotemia in patients with renal diseases and should be used with caution in those with severe renal impairment.

    Maximum: 3 mg/kg per d up to 50 mg/d
    ChlorthalidoneInitial: 0.3 mg/kg per dqdEONo
    Maximum: 2 mg/kg per d up to 50 mg/d
    FurosemideInitial: 0.5–2.0 mg/kg per doseqd-bidEONo
    Maximum: 6 mg/kg per d
    SpironolactoneInitial: 1 mg/kg per dqd-bidEONo
    Maximum: 3.3 mg/kg per d up to 100 mg/d
    TriamtereneInitial: 1–2 mg/kg per dbidEONo
    Maximum: 3–4 mg/kg per d up to 300 mg/d
    AmilorideInitial: 0.4–0.625 mg/kg per dqdEONo
    Maximum: 20 mg/d
    Peripheral α-antagonistDoxazosinInitial: 1 mg/dqdEONoMay cause hypotension and syncope, especially after first dose.
    Maximum: 4 mg/d
    PrazosinInitial: 0.05–0.1 mg/kg per dtidEONo
    Maximum: 0.5 mg/kg per d
    TerazosinInitial: 1 mg/dqdEONo
    Maximum: 20 mg/d
    VasodilatorHydralazineInitial: 0.75 mg/kg per dqidEOYes
    1. Tachycardia and fluid retention are common side effects.

    2. Hydralazine can cause a lupus-like syndrome in slow acetylators.

    3. Prolonged use of minoxidil can cause hypertrichosis.

    4. Minoxidil is usually reserved for patients with hypertension resistant to multiple drugs.

    Maximum: 7.5 mg/kg per d up to 200 mg/d
    MinoxidilChildren <12 years:qd-tidCS, EOYes
    Initial: 0.2 mg/kg per d
    Maximum: 50 mg/d Children ≥12 years:
    Initial: 5 mg/d
    Maximum: 100 mg/d
    • FDA indicates Federal Drug Administration; ARB indicates angiotensin-receptor blocker; bid, twice daily; HCTZ, hydrochlorothiazide; qd, once daily; qid, four times daily; tid, three times daily.

    • ↵* Includes drugs with prior pediatric experience or recently completed clinical trials.

    • ↵† The maximum recommended adult dose should not be exceeded in routine clinical practice.

    • ↵‡ Level of evidence upon which dosing recommendations are based. CS indicates case series; EO, expert opinion; RCT, randomized controlled trial.

    • ↵§ FDA-approved pediatric labeling information is available. Recommended doses for agents with FDA-approved pediatric labels are the doses contained in the approved labels. Even when pediatric labeling information is not available, the FDA-approved label should be consulted for additional safety information.

    • ↵‖Verbar; Comments apply to all members of each drug class except where otherwise stated.

    • View popup
    TABLE 10.

    Antihypertensive Drugs for Management of Severe Hypertension in Children 1–17 Years Old

    DrugClassDose*RouteComments
    Most useful†
        Esmololβ-Blocker100–500 μg/kg per minIV infusionVery short-acting; constant infusion preferred. May cause profound bradycardia. Produced modest reductions in BP in a pediatric clinical trial.
        HydralazineVasodilator0.2–0.6 mg/kg per doseIV, IMShould be given every 4 h when given IV bolus. Recommended dose is lower than FDA label.
        Labetalolα- and β-BlockerBolus: 0.2–1.0 mg/kg per dose up to 40 mg/dose Infusion: 0.25–3.0 mg/kg per hIV bolus or infusionAsthma and overt heart failure are relative contraindications.
        NicardipineCalcium channel blocker1–3 μg/kg per minIV infusionMay cause reflex tachycardia.
        Sodium nitroprussideVasodilator0.53–10 μg/kg per minIV infusionMonitor cyanide levels with prolonged (>72 h) use or in renal failure; or coadminister with sodium thiosulfate.
    Occasionally useful‡
        ClonidineCentral α-agonist0.05–0.1 mg/dose, may be repeated up to 0.8 mg total dosepoSide effects include dry mouth and sedation.
        EnalaprilatACE inhibitor0.05–0.1 mg/kg per dose up to 1.25 mg/doseIV bolusMay cause prolonged hypotension and acute renal failure, especially in neonates.
        FenoldopamDopamine receptor agonist0.2–0.8 μg/kg per minIV infusionProduced modest reductions in BP in a pediatric clinical trial in patients up to 12 years
        IsradipineCalcium channel blocker0.05–0.1 mg/kg per dosepoStable suspension can be compounded.
        MinoxidilVasodilator0.1–0.2 mg/kg per dosepoMost potent oral vasodilator, long-acting.
    • FDA indicates Food and Drug Administration; IM, intramuscular; IV, intravenous; po, oral.

    • ↵* All dosing recommendations are based on expert opinion or case series data except as otherwise noted.

    • ↵† Useful for hypertensive emergencies and some hypertensive urgencies.

    • ↵‡ Useful for hypertensive urgencies and some hypertensive emergencies.

    • View popup
    APPENDIX A.

    Demographic Data on Height/Blood Pressure Distribution Curves by Study Population

    SourceAge, yGenderEthnic GroupPersons Visits SBP AvailablePersons Visits DBP.5 AvailableTotal No. of Persons Visits
    MaleFemaleBlackHispanicWhiteAsianNative AmericanOtherMissing
    National Institutes of Health6–17189617516000296300840364736093647
    364736093647
    Pittsburgh1–5148137108017600012850285
    8930893
    Dallas13–1759165649526615704729000011 56511 56511 565
    21 86021 85221 860
    Bogalusa1–17375136072480048780000735807358
    15 882015 882
    Houston3–17145713776371341748230085283402834
    283402834
    South Carolina4–17316732633110033200000643063686430
    643063686430
    Iowa5–17209919930040920000409204092
    409204092
    Providence1–32302312444310020461371461
    898560898
    Minnesota9–1799919418342255511 31116776441800019 40919 20719 409
    19 40919 20719 409
    NHANES III5–172465257717701830132464101232504243045042
    504243045042
    NHANES 1999–20008–171041106360598843700740210420762104
    210420762104
    Total (percent of total)1–1732 16131 06618 022628834 4091764654197211863 22747 50063 227
    (51)(49)(29)(10)(54)(3)(1)(3)(0)83 09157 97683 091
    • DBP .5, DBP (Korotkoff 5).

    • Table differs from the 1997 report: updated height percentile used; subjects whose height Z score was less than −6 or greater than 6 were excluded.

    • View popup
    TABLE B1.

    Regression Coefficients From Blood Pressure Regression Models

    Variable NameSymbolSystolic BPDiastolic BP5
    MaleFemaleMaleFemale
    Interceptα102.19768102.0102761.0121760.50510
    Age
        Age-10β11.824161.943970.683141.01301
        (Age-10)2β20.127760.00598−0.098350.01157
        (Age-10)3β30.00249−0.007890.017110.00424
        (Age-10)4β4−0.00135−0.000590.00045−0.00137
    Normalized height
        Zhtγ12.731572.035261.469931.16641
        Zht2γ2−0.196180.02534−0.078490.12795
        Zht3γ3−0.04659−0.01884−0.03144−0.03869
        Zht4γ40.009470.001210.00967−0.00079
    Standard deviationσ10.712810.485511.603210.9573
    ρ*0.41000.38240.24360.2598
    n (persons)32 16131 06624 05723 443
    n (visits)42 07441 01729 18228 794
    • The coefficients were obtained from mixed-effects linear regression models. Diastolic BP5 indicates diastolic measurement at Korotkoff 5.

    • ↵* The value of ρ represents the correlation between BP measurements at different ages for the same child after correcting for age and Zht. This computation was necessary because some studies contributing to the childhood BP database provided BP at more than 1 age.

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Pediatrics
Vol. 114, Issue Supplement 2
1 Aug 2004
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  • Table of Contents

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  • Article
    • INTRODUCTION
    • METHODS
    • DEFINITION OF HYPERTENSION
    • MEASUREMENT OF BP IN CHILDREN
    • BP TABLES
    • PRIMARY HYPERTENSION AND EVALUATION FOR COMORBIDITIES
    • EVALUATION FOR SECONDARY HYPERTENSION
    • TARGET-ORGAN ABNORMALITIES IN CHILDHOOD HYPERTENSION
    • THERAPEUTIC LIFESTYLE CHANGES
    • PHARMACOLOGIC THERAPY OF CHILDHOOD HYPERTENSION
    • APPENDIX A. DEMOGRAPHIC DATA
    • APPENDIX B. COMPUTATION OF BLOOD PRESSURE PERCENTILES FOR ARBITRARY GENDER, AGE, AND HEIGHT
    • REFERENCES
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • Comments

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