Additional Consensus Opinion Recommendations and Text Locations

RecommendationCPG Section(s)
1. Follow the revised classification scheme in Table 3 for childhood BP levels, including the use of the term “elevated BP,” the new definition of stage 2 HTN, and the use of similar BP levels as adults for adolescents ≥13 y of age.3.1
2. Use simplified BP tables (Table 4) to screen for BP values that may require further evaluation by a clinician.3.2a
3. Use reference data on neonatal BP from ref 80 to identify elevated BP values in neonates up to 44 wk postmenstrual age and BP curves from the 1987 Second Task Force report to identify elevated BP values in infants 1–12 mo of age.3.3
4. Use the standardized technique for measuring BP by auscultation described in Table 7 and Fig 2 (including appropriate cuff size, extremity, and patient positioning) to obtain accurate BP values.4.1
5. If the initial BP at an office visit is elevated, as described in Fig 3, obtain 2 additional BP measurements at the same visit and average them; use the averaged auscultatory BP measurement to determine the patient’s BP category.4.1
6. Oscillometric devices are used to measure BP in infants and toddlers until they are able to cooperate with auscultatory BP. Follow the same rules for BP measurement technique and cuff size as for older children.4.1a
7. Measure BP at every health care encounter in children <3 y of age if they have an underlying condition listed in Table 9 that increases their risk for HTN.4.2
8. After a patient’s BP has been categorized, follow Table 11 for when to obtain repeat BP readings, institute lifestyle changes, or proceed to a workup for HTN.4.3
9. When an oscillometric BP reading is elevated, obtain repeat readings, discard the first reading, and average subsequent readings to approximate auscultatory BP.4.5
10. Wrist and forearm BP measurements should not be used in children and adolescents for the diagnosis or management of HTN.4.6
11. Use ABPM to evaluate high-risk patients (those with obesity, CKD, or repaired aortic coarctation) for potential MH.4.7a, 4.8
12. Routine use of BP readings obtained in the school setting is not recommended for diagnosis of HTN in children and adolescents.4.10
13. Use the history and physical examination to identify possible underlying causes of HTN, such as heart disease, kidney disease, renovascular disease, endocrine HTN (Table 15), drug-induced HTN (Table 8), and OSAS-associated HTN (Table 18).5.2–5.4, 5.7, 9.2
14. Suspect monogenic HTN in patients with a family history of early-onset HTN, hypokalemia, suppressed plasma renin, or an elevated ARR.5.8
15. Obtain laboratory studies listed in Table 10 to evaluate for underlying secondary causes of HTN when indicated.6.4
16. Routine use of vascular imaging, such as carotid intimal-media measurements or PWV measurements, is not recommended in the evaluation of HTN in children and adolescents.6.7
17. Suspect renovascular HTN in selected children and adolescents with stage 2 HTN, significant diastolic HTN, discrepant kidney sizes on ultrasound, hypokalemia on screening laboratories, or an epigastric and/or upper abdominal bruit on physical examination.6.8a
18. Routine measurement of serum UA is not recommended for children and adolescents with elevated BP.6.9
19. Offer intensive weight-loss programs to hypertensive children and adolescents with obesity; consider using MI as an adjunct to the treatment of obesity.7.2c
20. Follow-up children and adolescents treated with antihypertensive medications every 4–6 wk until BP is controlled, then extend the interval. Follow-up every 3–6 mo is appropriate for patients treated with lifestyle modification only.7.3c
21. Evaluate and treat children and adolescents with apparent treatment-resistant HTN in a similar manner to that recommended for adults with resistant HTN.7.4
22. Treat hypertensive children and adolescents with dyslipidemia according to current, existing pediatric lipid guidelines.9.1
23. Use ABPM to evaluate for potential HTN in children and adolescents with known or suspected OSAS.9.2
24. Racial, ethnic, and sex differences need not be considered in the evaluation and management of children and adolescents with HTN.10
25. Use ABPM to evaluate BP in pediatric heart- and kidney-transplant recipients.11.3
26. Reasonable strategies for HTN prevention include the maintenance of a normal BMI, consuming a DASH-type diet, avoidance of excessive sodium consumption, and regular vigorous physical activity.13.2
27. Provide education about HTN to patients and their parents to improve patient involvement in their care and better achieve therapeutic goals.15.2, 15.3
  • Based on the expert opinion of the subcommittee members (level of evidence = D; strength of recommendations = weak). CPG, clinical practice guideline.