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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 Age, y BP Percentile SBP, mm Hg DBP, mm Hg Percentile of Height Percentile of Height 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th 1 50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39 90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54 95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58 99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66 2 50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44 90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59 95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63 99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71 3 50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48 90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63 95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67 99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75 4 50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52 90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67 95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71 99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79 5 50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55 90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70 95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74 99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82 6 50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57 90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72 95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76 99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84 7 50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59 90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74 95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78 99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86 8 50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61 90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76 95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80 99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88 9 50th 95 96 98 100 102 103 104 57 58 59 60 61 61 62 90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77 95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81 99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89 10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63 90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78 95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82 99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90 11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63 90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78 95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82 99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90 12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64 90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79 95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83 99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91 13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64 90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79 95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83 99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91 14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65 90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80 95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84 99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92 15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66 90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81 95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85 99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93 16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67 90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82 95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87 99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94 17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70 90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84 95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89 99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97 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.
Age, y BP Percentile SBP, mm Hg DBP, mm Hg Percentile of Height Percentile of Height 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th 1 50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42 90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56 95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60 99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67 2 50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47 90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61 95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65 99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72 3 50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51 90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65 95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69 99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76 4 50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54 90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68 95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72 99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79 5 50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56 90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70 95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74 99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81 6 50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58 90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72 95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76 99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83 7 50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59 90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73 95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77 99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84 8 50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60 90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74 95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78 99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86 9 50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61 90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75 95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79 99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87 10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62 90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76 95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80 99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88 11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63 90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77 95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81 99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89 12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64 90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78 95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82 99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90 13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65 90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79 95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83 99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91 14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66 90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80 95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84 99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92 15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67 90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81 95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85 99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93 16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68 90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82 95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86 99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93 17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68 90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82 95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86 99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93 * 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.
- TABLE 5.
Classification of Hypertension in Children and Adolescents, With Measurement Frequency and Therapy Recommendations
SBP or DBP Percentile* Frequency of BP Measurement Therapeutic Lifestyle Changes Pharmacologic Therapy Normal <90th Recheck at next scheduled physical examination Encourage healthy diet, sleep, and physical activity — Prehypertension 90th to <95th or if BP exceeds 120/80 even if <90th percentile up to <95th percentile† Recheck in 6 mo Weight-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 hypertension 95th–99th percentile plus 5 mm Hg Recheck 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 mo Weight-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 Hg Evaluate or refer to source of care within 1 wk or immediately if the patient is symptomatic Weight-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.
Symptomatic hypertension Secondary hypertension Hypertensive target-organ damage Diabetes (types 1 and 2) Persistent hypertension despite nonpharmacologic measures Study or Procedure Purpose Target Population Evaluation for identifiable causes History, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking alcohol; physical examination History and physical examination help focus subsequent evaluation All children with persistent BP ≥95th percentile BUN, creatinine, electrolytes, urinalysis, and urine culture R/O renal disease and chronic pyelonephritis All children with persistent BP ≥95th percentile CBC R/O anemia, consistent with chronic renal disease All children with persistent BP ≥95th percentile Renal U/S R/O renal scar, congenital anomaly, or disparate renal size All children with persistent BP ≥95th percentile Evaluation for comorbidity Fasting lipid panel, fasting glucose Identify hyperlipidemia, identify metabolic abnormalities Overweight 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 screen Identify substances that might cause hypertension History suggestive of possible contribution by substances or drugs. Polysomnography Identify sleep disorder in association with hypertension History of loud, frequent snoring Evaluation for target-organ damage Echocardiogram Identify LVH and other indications of cardiac involvement Patients with comorbid risk factors* and BP 90th–94th percentile; all patients with BP ≥95th percentile Retinal exam Identify retinal vascular changes Patients with comorbid risk factors and BP 90th–94th percentile; all patients with BP ≥95th percentile Additional evaluation as indicated ABPM Identify white-coat hypertension, abnormal diurnal BP pattern, BP load Patients in whom white-coat hypertension is suspected, and when other information on BP pattern is needed Plasma renin determination Identify low renin, suggesting mineralocorticoid-related disease Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension Positive family history of severe hypertension Renovascular imaging Identify renovascular disease Young 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 levels Identify steroid-mediated hypertension Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension Plasma and urine catecholamines Identify catecholamine-mediated hypertension Young 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.
Finding* Possible Etiology Vital signs Tachycardia Hyperthyroidism, pheochromocytoma, neuroblastoma, primary hypertension Decreased lower extremity pulses; drop in BP from upper to lower extremities Coarctation of the aorta Eyes Retinal changes Severe hypertension, more likely to be associated with secondary hypertension Ear, nose, and throat Adenotonsillar hypertrophy Suggests association with sleep-disordered breathing (sleep apnea), snoring Height/weight Growth retardation Chronic renal failure Obesity (high BMI) Primary hypertension Truncal obesity Cushing syndrome, insulin resistance syndrome Head and neck Moon facies Cushing syndrome Elfin facies Williams syndrome Webbed neck Turner syndrome Thyromegaly Hyperthyroidism Skin Pallor, flushing, diaphoresis Pheochromocytoma Acne, hirsutism, striae Cushing syndrome, anabolic steroid abuse Café-au-lait spots Neurofibromatosis Adenoma sebaceum Tuberous sclerosis Malar rash Systemic lupus erythematosus Acanthrosis nigricans Type 2 diabetes Chest Widely spaced nipples Turner syndrome Heart murmur Coarctation of the aorta Friction rub Systemic lupus erythematosus (pericarditis), collagen-vascular disease, end stage renal disease with uremia Apical heave LVH/chronic hypertension Abdomen Mass Wilms tumor, neuroblastoma, pheochromocytoma Epigastric/flank bruit Renal artery stenosis Palpable kidneys Polycystic kidney disease, hydronephrosis, multicystic-dysplastic kidney, mass (see above) Genitalia Ambiguous/virilization Adrenal hyperplasia Extremities Joint swelling Systemic lupus erythematosus, collagen vascular disease Muscle weakness Hyperaldosteronism, 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.
- TABLE 9.
Antihypertensive Drugs for Outpatient Management of Hypertension in Children 1–17 Years Old*
Class Drug Dose† Dosing Interval Evidence‡ FDA Labeling§ Comments‖Verbar; ACE inhibitor Benazepril Initial: 0.2 mg/kg per d up to 10 mg/d qd RCT Yes All ACE inhibitors are contraindicated in pregnancy; females of childbearing age should use reliable contraception.
Check serum potassium and creatinine periodically to monitor for hyperkalemia and azotemia.
Cough and angioedema are reportedly less common with newer members of this class than with captopril.
Benazepril, enalapril, and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension.
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 Captopril Initial: 0.3–0.5 mg/kg/dose tid RCT, CS No Maximum: 6 mg/kg per d Enalapril Initial: 0.08 mg/kg per d up to 5 mg/d qd-bid RCT Yes Maximum: 0.6 mg/kg per d up to 40 mg/d Fosinopril Children >50 kg: qd RCT Yes Initial: 5–10 mg/d Maximum: 40 mg/d Lisinopril Initial: 0.07 mg/kg per d up to 5 mg/d qd RCT Yes Maximum: 0.6 mg/kg per d up to 40 mg/d Quinapril Initial: 5–10 mg/d qd RCT, EO No Maximum: 80 mg/d Angiotensin-receptor blocker Irbesartan 6–12 years: 75–150 mg/d qd CS Yes All ARBs are contraindicated in pregnancy; females of childbearing age should use reliable contraception.
Check serum potassium, creatinine periodically to monitor for hyperkalemia and azotemia.
Losartan label contains information on the preparation of a suspension.
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 Losartan Initial: 0.7 mg/kg per d up to 50 mg/d qd RCT Yes Maximum: 1.4 mg/kg per d up to 100 mg/d α- and β-Blocker Labetalol Initial: 1–3 mg/kg per d bid CS, EO No Asthma and overt heart failure are contraindications.
Heart rate is dose-limiting.
May impair athletic performance.
Should not be used in insulin-dependent diabetics.
Maximum: 10–12 mg/kg per d up to 1200 mg/d β-Blocker Atenolol Initial: 0.5–1 mg/kg per d qd-bid CS No Noncardioselective agents (propranolol) are contraindicated in asthma and heart failure.
Heart rate is dose-limiting.
May impair athletic performance.
Should not be used in insulin-dependent diabetics.
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/HCTZ Initial: 2.5/6.25 mg/d qd RCT No Maximum: 10/6.25 mg/d Metoprolol Initial: 1–2 mg/kg per d bid CS No Maximum: 6 mg/kg per d up to 200 mg/d Propranolol Initial: 1–2 mg/kg per d bid-tid RCT, EO Yes Maximum: 4 mg/kg per d up to 640 mg/d Calcium channel blocker Amlodipine Children 6–17 years: 2.5–5 mg once daily qd RCT Yes Amlodipine and isradipine can be compounded into stable extemporaneous suspensions.
Felodipine and extended-release nifedipine tablets must be swallowed whole.
Isradipine is available in both immediate-release and sustained-release formulations; sustained-release form is dosed qd or bid.
May cause tachycardia.
Felodipine Initial: 2.5 mg/d qd RCT, EO No Maximum: 10 mg/d Isradipine Initial: 0.15–0.2 mg/kg per d tid-qid CS, EO No Maximum: 0.8 mg/kg per d up to 20 mg/d Extended-release nifedipine Initial: 0.25–0.5 mg/kg per d qd-bid CS, EO No Maximum: 3 mg/kg per d up to 120 mg/d Central α-agonist Clonidine Children ≥12 years: bid EO Yes May cause dry mouth and/or sedation.
Transdermal preparation also available.
Sudden cessation of therapy can lead to severe rebound hypertension.
Initial: 0.2 mg/d Maximum: 2.4 mg/d Diuretic HCTZ Initial: 1 mg/kg per d qd EO Yes All patients treated with diuretics should have electrolytes monitored shortly after initiating therapy and periodically thereafter.
Useful as add-on therapy in patients being treated with drugs from other drug classes.
Potassium-sparing diuretics (spironolactone, triamterene, amiloride) may cause severe hyperkalemia, especially if given with ACE inhibitor or ARB.
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.
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 Chlorthalidone Initial: 0.3 mg/kg per d qd EO No Maximum: 2 mg/kg per d up to 50 mg/d Furosemide Initial: 0.5–2.0 mg/kg per dose qd-bid EO No Maximum: 6 mg/kg per d Spironolactone Initial: 1 mg/kg per d qd-bid EO No Maximum: 3.3 mg/kg per d up to 100 mg/d Triamterene Initial: 1–2 mg/kg per d bid EO No Maximum: 3–4 mg/kg per d up to 300 mg/d Amiloride Initial: 0.4–0.625 mg/kg per d qd EO No Maximum: 20 mg/d Peripheral α-antagonist Doxazosin Initial: 1 mg/d qd EO No May cause hypotension and syncope, especially after first dose. Maximum: 4 mg/d Prazosin Initial: 0.05–0.1 mg/kg per d tid EO No Maximum: 0.5 mg/kg per d Terazosin Initial: 1 mg/d qd EO No Maximum: 20 mg/d Vasodilator Hydralazine Initial: 0.75 mg/kg per d qid EO Yes Tachycardia and fluid retention are common side effects.
Hydralazine can cause a lupus-like syndrome in slow acetylators.
Prolonged use of minoxidil can cause hypertrichosis.
Minoxidil is usually reserved for patients with hypertension resistant to multiple drugs.
Maximum: 7.5 mg/kg per d up to 200 mg/d Minoxidil Children <12 years: qd-tid CS, EO Yes 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.
- TABLE 10.
Antihypertensive Drugs for Management of Severe Hypertension in Children 1–17 Years Old
Drug Class Dose* Route Comments Most useful† Esmolol β-Blocker 100–500 μg/kg per min IV infusion Very short-acting; constant infusion preferred. May cause profound bradycardia. Produced modest reductions in BP in a pediatric clinical trial. Hydralazine Vasodilator 0.2–0.6 mg/kg per dose IV, IM Should be given every 4 h when given IV bolus. Recommended dose is lower than FDA label. Labetalol α- and β-Blocker Bolus: 0.2–1.0 mg/kg per dose up to 40 mg/dose Infusion: 0.25–3.0 mg/kg per h IV bolus or infusion Asthma and overt heart failure are relative contraindications. Nicardipine Calcium channel blocker 1–3 μg/kg per min IV infusion May cause reflex tachycardia. Sodium nitroprusside Vasodilator 0.53–10 μg/kg per min IV infusion Monitor cyanide levels with prolonged (>72 h) use or in renal failure; or coadminister with sodium thiosulfate. Occasionally useful‡ Clonidine Central α-agonist 0.05–0.1 mg/dose, may be repeated up to 0.8 mg total dose po Side effects include dry mouth and sedation. Enalaprilat ACE inhibitor 0.05–0.1 mg/kg per dose up to 1.25 mg/dose IV bolus May cause prolonged hypotension and acute renal failure, especially in neonates. Fenoldopam Dopamine receptor agonist 0.2–0.8 μg/kg per min IV infusion Produced modest reductions in BP in a pediatric clinical trial in patients up to 12 years Isradipine Calcium channel blocker 0.05–0.1 mg/kg per dose po Stable suspension can be compounded. Minoxidil Vasodilator 0.1–0.2 mg/kg per dose po Most 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.
- APPENDIX A.
Demographic Data on Height/Blood Pressure Distribution Curves by Study Population
Source Age, y Gender Ethnic Group Persons Visits SBP Available Persons Visits DBP.5 Available Total No. of Persons Visits Male Female Black Hispanic White Asian Native American Other Missing National Institutes of Health 6–17 1896 1751 600 0 2963 0 0 84 0 3647 3609 3647 3647 3609 3647 Pittsburgh 1–5 148 137 108 0 176 0 0 0 1 285 0 285 893 0 893 Dallas 13–17 5916 5649 5266 1570 4729 0 0 0 0 11 565 11 565 11 565 21 860 21 852 21 860 Bogalusa 1–17 3751 3607 2480 0 4878 0 0 0 0 7358 0 7358 15 882 0 15 882 Houston 3–17 1457 1377 637 1341 748 23 0 0 85 2834 0 2834 2834 0 2834 South Carolina 4–17 3167 3263 3110 0 3320 0 0 0 0 6430 6368 6430 6430 6368 6430 Iowa 5–17 2099 1993 0 0 4092 0 0 0 0 4092 0 4092 4092 0 4092 Providence 1–3 230 231 24 4 431 0 0 2 0 461 371 461 898 560 898 Minnesota 9–17 9991 9418 3422 555 11 311 1677 644 1800 0 19 409 19 207 19 409 19 409 19 207 19 409 NHANES III 5–17 2465 2577 1770 1830 1324 64 10 12 32 5042 4304 5042 5042 4304 5042 NHANES 1999–2000 8–17 1041 1063 605 988 437 0 0 74 0 2104 2076 2104 2104 2076 2104 Total (percent of total) 1–17 32 161 31 066 18 022 6288 34 409 1764 654 1972 118 63 227 47 500 63 227 (51) (49) (29) (10) (54) (3) (1) (3) (0) 83 091 57 976 83 091 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.
Variable Name Symbol Systolic BP Diastolic BP5 Male Female Male Female Intercept α 102.19768 102.01027 61.01217 60.50510 Age Age-10 β1 1.82416 1.94397 0.68314 1.01301 (Age-10)2 β2 0.12776 0.00598 −0.09835 0.01157 (Age-10)3 β3 0.00249 −0.00789 0.01711 0.00424 (Age-10)4 β4 −0.00135 −0.00059 0.00045 −0.00137 Normalized height Zht γ1 2.73157 2.03526 1.46993 1.16641 Zht2 γ2 −0.19618 0.02534 −0.07849 0.12795 Zht3 γ3 −0.04659 −0.01884 −0.03144 −0.03869 Zht4 γ4 0.00947 0.00121 0.00967 −0.00079 Standard deviation σ 10.7128 10.4855 11.6032 10.9573 ρ* 0.4100 0.3824 0.2436 0.2598 n (persons) 32 161 31 066 24 057 23 443 n (visits) 42 074 41 017 29 182 28 794 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.
In this issue
Jump to section
- 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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- Physical Examination Findings Among Children and Adolescents With Obesity: An Evidence-Based Review
- Follow-Up Renal Assessment of Injury Long-Term After Acute Kidney Injury (FRAIL-AKI)
- Pravastatin Therapy and Biomarker Changes in Children and Young Adults with Autosomal Dominant Polycystic Kidney Disease
- Low Serum Vitamin D Levels Are Associated With Increased Arterial Stiffness in Youth With Type 2 Diabetes
- PRES in Children Undergoing Hematopoietic Stem Cell or Solid Organ Transplantation
- Progression of Pediatric CKD of Nonglomerular Origin in the CKiD Cohort
- CKD and Hypertension during Long-Term Follow-Up in Children and Adolescents Previously Treated with Extracorporeal Membrane Oxygenation
- Cardiovascular Risk Factors in Adolescents Born Preterm
- A Randomized, Open-Label, Dose-Response Study of Losartan in Hypertensive Children
- Assessment and Management of Hypertension in Patients on Dialysis
- Clinical Characteristics and Outcome of 467 Patients With a Clinically Recognized Eating Disorder Identified Among 52,215 Patients With Type 1 Diabetes: A Multicenter German/Austrian Study
- Effect of Pravastatin on Total Kidney Volume, Left Ventricular Mass Index, and Microalbuminuria in Pediatric Autosomal Dominant Polycystic Kidney Disease
- Predictors of Metabolically Healthy Obesity in Children
- A Predictive Model of Progression of CKD to ESRD in a Predialysis Pediatric Interdisciplinary Program
- Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT): Urinary Screening and Baseline Biochemical and Cardiovascular Assessments
- Arterial Hypertension and Posterior Reversible Cerebral Edema Syndrome Induced by Risperidone
- Dietary Phthalates and Low-Grade Albuminuria in US Children and Adolescents
- Left Ventricular Hypertrophy Diagnosis by Echo: Is it Reliable?
- Patterns of Care and Persistence After Incident Elevated Blood Pressure
- Usefulness of the High Triglyceride-to-HDL Cholesterol Ratio to Identify Cardiometabolic Risk Factors and Preclinical Signs of Organ Damage in Outpatient Children
- Cardiac Geometry and Function in Diabetic or Prediabetic Adolescents and Young Adults: The Strong Heart Study