8. High Blood Pressure
INTRODUCTION
This section of the Guidelines provides recommendations to pediatric care providers
on the evaluation and treatment of high blood pressure (BP) in their child and adolescent
patients. Because a recent National Heart, Lung, and Blood Institute (NHLBI) task
force report addresses this subject,[1] this section differs from the rest
of the sections in the Guidelines in that the evidence review was limited to the
past 6 years, as described below. The results of this limited evidence review are
summarized by the Expert Panel in this section, with detailed information from each
study extracted into the evidence tables, which will be available at
http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm. The conclusions of
the Expert Panel's review of the evidence are summarized, and the section ends with
age-specific recommendations for BP measurement and diagnosis and treatment of hypertension.
BACKGROUND
In 2004, an NHLBI Task Force published The Fourth Report on the Diagnosis, Evaluation,
and Treatment of High Blood Pressure in Children and Adolescents (Fourth Report).[1]
This report was based on a complete review of the current evidence on BP management
up to that time and included detailed recommendations for diagnosing and managing
high BP throughout childhood. Those expert consensus recommendations were used as
the basis for the recommendations for this section of these Guidelines. The review
of the science was considered complete until 2003, when the review of the Fourth
Report ended. Therefore, the evidence review on high BP for these Guidelines
was limited to studies published between January 1, 2003, and June 30, 2007,with
the addition of selected studies through June 30, 2008, identified by the Expert
Panel that met all the criteria for inclusion. Repeating the review performed by
the Fourth Report Task Force was not believed to be either necessary, given
the relatively short time since publication of the Fourth Report, or to
be a judicious use of the resources available for the development of these Guidelines.
The randomized controlled trials (RCTs) identified from 2003 to 2008 for this evidence
review were graded individually and can be viewed in the evidence tables, which
will be available at
http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm.
OVERVIEW OF THE EVIDENCE ON TREATMENT OF HIGH BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS
The evidence review for the defined period identified 9 observational studies, 13
RCTs, and 3 meta-analyses. Eight RCTs evaluated medications for hypertension control
that had not previously been studied in childhood: amlodipine, felodipine,
fosinopril, lisinopril, losartan, metoprolol, and valsartan.[2],[3],[4],[5],[6],[7],[8],[9]
Each of these medications was found to be well-tolerated for relatively short periods
in children from ages 6 to 17 years, but primarily in adolescents. Most of the trials
lasted 38 weeks; 1 trial for adolescents lasted 52 weeks. One trial evaluated
valsartan in children ages 15 years, but data on the use of other drugs in
younger children are lacking. All studies tended to determine tolerability and efficacy
on reducing BP levels. In one study, African American children were found to require
greater doses of fosinopril to obtain the same BP control as Caucasian children.[4]
Several studies addressed the roles of diet and lifestyle as they relate to BP.
A meta-analysis of RCTs testing reduction of salt intake on BP in children and adolescents
found that a modest reduction in salt intake did decrease BP, with a significant
effect size of -1.17 millimeters of mercury (mmHg) for systolic BP and -2.47 mmHg
for diastolic BP in children ages 816 years who were normotensive or had high
normal BP. The meta-analysis included three trials in infants; results for this
age group indicated that salt reduction decreased systolic BP by 2.47 mmHg.[10]
In the Coronary Artery Risk Development in Young Adults study, higher intake of
plant foods (whole grains, fruits, vegetables) and lower intake of meat products
were associated with lower BP on a population basis among individuals ages 1830
years.[11]
An RCT of the Dietary Approaches to Stop Hypertension (DASH) diet was conducted
in 57 adolescents with prehypertension or hypertension. At 3-month follow up, the
DASH group had a significantly greater decrease in systolic BP, associated with
higher intake of fruits and vegetables and low-fat dairy products and lower intake
of total fat, than did the usual-care group. In the intervention group, intake of
potassium and magnesium was significantly higher than in usual-care controls, but
there was no difference in sodium intake.[12] Another RCT found that a 4-month
transcendental meditation intervention was effective in lowering BP assessed by
ambulatory BP monitoring of African American adolescents with high-normal baseline
BP measurements at 8-month followup.[13]
Four studies evaluated the late effects of feeding style in infants. A 6-year followup
of an RCT in infants showed that increased intake of polyunsaturated fatty acids
(PUFA) in infant formula was associated with a significantly lower BP than a standard
formula-fed control group; in a breast-fed reference group, diastolic BP was significantly
lower than in the nonsupplemented group but did not differ from the PUFA-supplemented
group.[14]
Maternal fish oil supplementation in lactating mothers was not associated with any
difference in BP or pulse wave velocity at 2.5-year followup compared
with either a control group whose mothers received olive oil or a breast-fed reference
group.[15]
In small-for-gestational-age babies, a nutrient-enriched diet that promoted more
rapid weight gain in infancy was associated with higher BP in childhood 68
years later.[16]
In a meta-analysis of 15 studies, breastfeeding in infancy was found to be associated
with lower BP at followup 360 years later, with a small but significant effect
size for both systolic and diastolic BP.[17]
A series of epidemiologic studies provide important information. Long-term followup
studies suggest that low birth weight is inversely associated with BP later in adult
life[18]
and that differences in birth weight may explain the origin of "Black/White" differences
in BP.[19]
A weighted analysis of BP data from national surveys in 8- to 17-year-olds obtained
from 1963 to 2002 demonstrated that BP, prehypertension, and hypertension trended
downward from 1963 to 1988 but upward thereafter.[20] At least part
of this increase was explained by the rise in obesity, with the upward shift in
BP occurring approximately 10 years after the upward trend in the prevalence of
obesity. There were racial/ethnic differences, with non-Hispanic Blacks and Mexican
Americans showing a greater prevalence of hypertension and prehypertension than
non-Hispanic Whites and males showing a greater prevalence than females. BP variability
was assessed in an analysis of longitudinal data from the National Childhood Blood
Pressure database.[21]
Among subjects designated as having prehypertension at baseline, 14 percent of boys
and 12 percent of girls had hypertension 2 years later. Among subjects classified
as hypertensive at baseline, 31 percent of boys and 26 percent of girls were still
hypertensive after 2 years, and 47 percent of boys and 26 percent of girls were
in the prehypertension category. Baseline BP z-score, baseline body mass index (BMI),
and change in BMI were significant independent determinants of subsequent BP. Finally,
a meta-analysis of 50 cohort studies confirmed that BP consistently tracks from
childhood into adulthood, with the strength of tracking increasing with baseline
age and decreasing with followup length.[22]
CONCLUSIONS OF THE EVIDENCE REVIEW UPDATE: 20032008
- The evidence review for the defined time period resulted in no major changes in
the approach to BP evaluation and management.
- In epidemiologic surveys of children and adolescents over the past 20 years, BP
levels are increasing, and the prevalences of hypertension and prehypertension are
increasing; these findings are explained partially by the rise in obesity.
- Prehypertension progresses to hypertension at the rate of approximately 7 percent
per year; hypertension persists in almost one-third of boys and one-fourth of girls
on 2-year longitudinal followup.
- From the evidence review, both breastfeeding and supplementation of formula with
PUFA in infancy are associated with lower BP at followup.
- A DASH-style dietwhich is rich in fruits, vegetables, low-fat or fat-free
dairy products, whole grains, fish, poultry, beans, seeds, and nuts and lower in
sweets and added sugars, fats, and red meats than the typical American dietis
associated with lower BP, as in adults. The Cardiovascular Health Integrated Lifestyle
Diet (CHILD 1) combined with the DASH eating plan (described in Section V. Nutrition
and Diet) is an appropriate diet for children that meets the DASH study and Dietary
Guidelines for Americans 2010 (2010 DGA) nutrient goals.
- Lower dietary sodium intake is associated with lower BP levels in infants, children,
and adolescents.
- Losartan, amlodipine, felodipine, fosinopril, lisinopril, metoprolol, and valsartan
can be added to the list of medications that are tolerated over short periods, and
can reduce BP in children from ages 6 to 17 years but predominantly is effective
in adolescents. For African American children, greater doses of fosinopril may be
needed for effective BP control. Trial durations, however, were short, and long-term
safety is still in question. Antihypertensive medications are shown in Table 85.
- In one study in small-for-gestational-age babies, a nutrient-enriched diet that
promoted rapid weight gain was associated with higher BP on followup in late childhood.
This potential risk should be considered when such diets are selected in the clinical
setting.
- In one study, transcendental meditation has been shown to effectively lower BP in
nonhypertensive adolescents.
RECOMMENDATIONS
Recommendations regarding BP are all graded as expert opinion (Grade D) since they
are based on the expert consensus conclusions of the Fourth Report.
The current recommendations focus on a developmental approach to the prevention
of cardiovascular disease (CVD) by appropriate identification and amelioration of
risk factors during routine pediatric care. For BP, the Fourth Report provided
an algorithm and flow diagram to assist clinicians in identifying hypertension in
children.[1]
For these Guidelines, these recommendations are stratified to provide age-appropriate
approaches that are congruent with the risk factor recommendations in other sections;
this is reflected in Table 81 and in revised algorithms (Figures 81
and 82). The BP norms for age, gender, and height are shown in Tables 83
and 84 and are taken directly from the Fourth Report.
For children from birth to age 3 years:
- Routine measurement of BP is not recommended. Blood pressure should be measured
when there is a suspicion of renal disease, coarctation of the aorta, or other condition
that may be associated with BP elevation. Conditions under which children younger
than age 3 years should have BP measured are listed in Table 82.
- In these young patients, auscultation of BP is often quite difficult, so measurement
with an oscillometric device using an appropriate size cuff is acceptable. The state
of the infant or young child (e.g., sleeping, quiet, fussing, crying) is very important
in the interpretation of BP measurement.
- For younger patients, treatment of high BP is often directed at the underlying cause,
since primary hypertension is uncommon.
For children, ages 311 years:
- Routine measurement of BP during health care visits is recommended. This is true
of visits for health maintenance and for visits when the child is ill.
- Auscultation should be the method of choice for confirmation of elevated BP measurements
using an oscillometric device. The BP percentiles from the Fourth Report
based on age, gender, and height percentiles should be used to categorize BP as
prehypertension or Stage 1 or Stage 2 Hypertension (Tables 83 and 84).
BP elevation must be persistent to be considered hypertension; the process for establishing
the BP category is outlined in Table 81 and in Figures 81 and 82.
- In this age group, obesity is an increasingly important cause of BP elevation. When
obesity is present, therapy should first be directed at improving diet and physical
activity behaviors. This age group offers the opportunity to intervene early in
the process of obesity development, allowing the clinician to focus on weight maintenance
while the child grows, as opposed to weight loss. It also provides an important
opportunity to introduce the DASH-style diet, which is described in Section V. Nutrition
and Diet, as an example of CHILD 1. The DASH diet focuses on increased fruits and
vegetables, low-fat dairy products, and whole-grain foods and meets all nutrient
and energy requirements for children in this age range. Dietary sodium intake should
also be limited.
- BP category-specific management is outlined in Table 81 and Figure 82.
For adolescents, ages 1217 years:
- The approach to the evaluation of BP is similar to that of children ages 3 to younger
than 12 years, but the prevalence of primary hypertension is much more common, and
obesity is a major concern as an underlying factor. As shown in Tables 83
and 84, the percentiles of the Fourth Report should be used to evaluate
BP.
- Adolescents with obesity are at risk of type 2 diabetes mellitus. Diabetes is a
condition for which more aggressive BP lowering is recommended; this is described
in Section XI. Diabetes Mellitus and Other Conditions Predisposing to the
Development of Accelerated Atherosclerosis, which addresses the management of children
with high-risk conditions.
- In this age group, the level of BP indicating prehypertension is at least 120/80,
the same as that for adults. This is because the 90th percentile for adolescents
is higher than 120/80 for most ages and height percentiles.
- For adolescents with increased BMI and elevated BP, weight loss is the cornerstone
of therapy. Both dietary and physical activity behaviors should be addressed, aiming
for appropriate energy balance, lower dietary sodium, and a DASH-like dietary pattern.
Recommendations for the management of obesity are outlined in Section X. Overweight
and Obesity.
- BP category-specific management is outlined in Figures 81 and 82 and
in Table 81.
For young adults, ages 1821 years:
- Adult cut points for BP in this age group are used to define hypertension, as per
the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7) guidelines.[23]
- In this age range, institution of the adult DASH diet is recommended for individuals
with prehypertension or hypertension, as is reduction of dietary sodium. Overweight
continues to be a major concern in this age group; weight reduction should be promoted
through enhanced energy expenditure coupled with reduced energy intake. Physical
activity should be promoted, since moderate-to-vigorous physical activity reduces
BP levels in adults.
- The management of hypertension is as described in JNC 7.[23]
For all age groups, the assessment of left ventricular mass (LVM) by echocardiography
is recommended as the best method to assess hypertensive target organ disease. Assessment
should be done for patients with stage 2 hypertension and those with persistent
stage 1 hypertension. Evaluation of LVM may be helpful in establishing the need
for pharmacologic treatment of hypertension.
Table 85 shows medications that have been used to achieve BP control in children
and adolescents. At present, no data support the use of specific antihypertensive
agents for specific age groups, and long-term safety data are not available.
Table 81 Age-Specific Recommendations for Blood Pressure (BP) Measurement
and Diagnosis of Hypertension
BP recommendations are based on The Fourth Report on the Diagnosis, Evaluation,
and Treatment of High Blood Pressure in Children and Adolescents (Fourth
Report), with the evidence review updated from 2003.
Recommendations are all graded as expert opinion (Grade D) as they are based on
the expert consensus conclusions of the Fourth Report.
Birth-3 years
|
No routine BP measurement
- Measure BP if history (+) for neonatal complications, congenital heart disease,
urinary/ renal abnormality, solid-organ transplant, malignancy, drug Rx, or condition
known to raise BP or increase intracranial pressure (Table 8-2)
- If BP > 90th %ile by oscillometry, confirm by auscultation
- →If BP confirmed ≥ 90th %ile, initiate evaluation for etiology and treatment
per algorithm.
(Figure 8-2)
|
3-11 years
|
Annual BP measurement in all, interpreted for age/sex/height per Tables 8-3 and
8-4 below
- BP < 90th %ile, repeat in 1 year
- BP ≥ 90th %ile:
- Repeat BP X 2 by auscultation
- Average replicate measurements → Re-evaluate BP category
→ If BP confirmed ≥ 90th %ile, < 95th %ile = Prehypertension (HTN)
- Recommend weight management if indicated
- Repeat BP in 6 months
→ If BP ≥ 95th %ile, < 99th %ile + 5mmHg
- Repeat BP in 1-2 weeks, average all BP measurements"
- Re-evaluate BP category
- BP confirmed ≥ 95th %ile, < 99th %ile + 5 mmHg = Stage 1 HTN
- Basic work-up per figure 8-2
→ If BP ≥ 99th %ile + 5 mmHg
- Repeat BP by auscultation X 3 at that visit, average all
BP measurements
- Re-evaluate BP category
- BP confirmed ≥ 99th %ile + 5 mmHg = Stage 2 HTN
- Refer to pediatric HTN expert within 1 week OR
- Begin BP treatment and initiate basic work-up, per Figure 8-2.
|
12-17 years
|
Annual BP measurement in all, interpreted for age/sex/height per Tables 8-3 and
8-4 below
- BP < 90th %ile, counsel on CHILD 1 diet, activity recommendations, and repeat
BP in 1 year
- BP ≥ 90th %ile or > 120/80:
- Repeat BP X 2 by auscultation
- Average replicate measurements → Re-evaluate BP category
→ If BP confirmed ≥ 90th %ile, < 95th %ile or ≥
120/80 = Pre-HTN
- CHILD 1 diet, activity recommendations, weight management if indicated
- Repeat BP in 6 months
→ If BP ≥ 95th %ile, < 99th %ile + 5mmHg
- Repeat BP in 1-2 weeks, average all BP measurements
- Re-evaluate BP category
- BP confirmed ≥ 95th %ile, < 99th %ile + 5 mmHg = Stage 1 HTN
- Basic work-up per Figure 8-2
→ If BP ≥ 99th %ile + 5 mmHg
- Repeat BP by auscultation X 3 at that visit, average all
BP measurements
- Re-evaluate BP category
- BP confirmed ≥ 99th %ile + 5 mmHg = Stage 2 HTN
- Refer to pediatric HTN expert within 1 week OR
- Begin BP treatment and initiate work-up, per Figure 8-2
|
18-21 years
|
Measure BP at all health care visits
- BP ≥ 120/80 to 139/89 = Pre-HTN
- BP ≥ 140/90 to 159/99 = Stage 1 HTN
- BP ≥ 160/100 = Stage 2 HTN
Evaluation/ Treatment per JNC recommendations[23]
|
Table 82. 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 unrepaired)
- 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 know to raise BP
- Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous
sclerosis, etc.)
- Evidence of increased intracranial pressure
Figure 8-1. Blood Pressure (BP) Measurement and Categorization
Figure 8-1 Description
The figure is a flow chart with 21 labeled boxes linked by arrows. The chart is
in one direction with all arrows pointing downward to one or more boxes.
Below the flow chart is described as lists in which the possible next steps are
listed beneath each box label.
- Select appropriate BP cuff size. Meaure BP at each well child visit over 3 years
of age* (auscultatory method preferred)
- Forward to Measure HT, WT & calculate BMI
- Measure HT, WT & calculate BMI
- Foward to Determine BP category for age, HT, gender (Tables 8-3 & 8-4)
- Determine BP category for age, HT, gender (Tables 8-3 & 8-4)
Determine BMI category for age and gender (CDC growth charts)
- Forward to <90%ile (normal)
- Forward to ≥ 90th%ile or 120/80 mmHg to < 95th% (preHTN)
- Forward to ≥ 95th%ile < 99th% + 5 mmHg (stage 1)
- Forward to ≥ 99th%ile + 5 mmHg (stage 2)
- <90th%ile (normal)
- Forward to Normotensive
- Forward to Repeat BP at next visit, plus
- Forward to Educate on CHILD-1 activity
levels**
- ≥ 90th%ile or 120/80 mmHg to < 95th% (preHTN)
- Foward to Repeat by auscultation if performed with oscillometric device
- ≥ 95th%ile < 99th% + 5 mmHg (stage 1)
- Foward to Repeat by auscultation if performed with oscillometric device
- ≥ 99th%ile + 5 mmHg (stage 2)
- Foward to Repeat by auscultation if performed with oscillometric device
- Repeat by auscultation if performed with oscillometric device
- Forward to Average replicate BP measurements at initial visit
- Average replicate BP measurements at initial visit
Re-evaluate BP category
- Forward to Pre-Hypertensive
- Forward to Stage 1 Hypertension
- Forward to Stage 2 Hypertension
- Pre-Hypertensive
- Forward to Repeat BP in 6 months
- Stage 1 Hypertension
- Forward to Repeat BP in 1-2 weeks
- Stage 2 Hypertension
- Forward to Evaluate or refer for treatment within 1 week
- Repeat BP in 6 months, plus
- Forward to CHILD-1/activity education** &/or Weight management***
- Repeat BP in 1-2 weeks
Average BP over all 3 visits, plus
- Forward to CHILD-1/activity education** &/or Weight management***
- Evaluate or refer for treatment within 1 week, plus
- Forward to CHILD-1/activity education** &/or Weight management***
- CHILD-1/activity education** &/or Weight management***
- CHILD-1/activity education** &/or Weight management***
- CHILD-1/activity education** &/or Weight management***
Figure 8-1 Legend:
* See Table 1;
Cardiovascular Health Integrated
Lifestyle Diet - Section V. Nutrition and Diet;
** Section VI. Physical Activity;
*** Section X. Overweight and Obesity
Figure 8-2. Blood Pressure (BP) Management by Category
Figure 8-2 Description
The figure is a flow chart with 29 labeled boxes linked by arrows. The chart is
in one direction with all arrows pointing downward to one or more boxes.
Below the flow chart is described as lists in which the possible next steps are
listed beneath each box label.
- Determine BP category from average of replicate readings at multiple visits (see
measurement algorithm)
- Forward to Normotensive
- Forward to Pre-Hypertension
- Forward to Stage 1 Hypertension
- Forward to Stage 2 Hypertension
- Normotensive
- Forward to Assess other CV risk factors
- Pre-Hypertension
- Forward to Assess other CV risk factors*
- Stage 1 Hypertension
- Forward to Basic Work-up: Medical/Family/Sleep Hx, PEx, CBC, renal panel, U/A, Renal/Cardiac
U/S, lipids, glucose
- Stage 2 Hypertension
- Forward to Basic Work-up: &/or refer to Ped HTN expert for extended work-up
- Assess other CV risk factors, plus
- Forward to CHILD-1/Activity Education**
- Assess other CV risk factors*, plus
- Forward to CHILD-1/activity education** &/or Weight management***
- Basic Work-up: Medical/Family/Sleep Hx, PEx, CBC, renal panel, U/A, Renal/Cardiac
U/S, lipids, glucose, plus
- Forward to CHILD-1/activity education** &/or Weight management***
- Basic Work-up: &/or refer to Ped HTN expert for extended work-up
- Primary or Secondary HTN, forward to Anti-HTN Drug +/- Rx for 20 cause
+ Weight management*** &/or CHILD-1/activity
education**
- CHILD-1/Activity Education**
- Forward to Re-evaluate at next visit
- CHILD-1/activity education** &/or Weight management***
- Forward to Monitor Q 6 Mo
- CHILD-1/activity education** &/or Weight management***
- Primary HTN No LVH, Forward to Monitor Q3 to 6 Months
- Secondary HTN or LVH, Forward to Rx for 20 cause + Anti-HTN Drug
- Anti-HTN Drug +/- Rx for 20 cause + Weight management***
&/or CHILD-1/activity education**
- Forward to Follow until BP controlled, Q 1-2 wks
- Monitor Q 6 Mo
- Forward to Re-evaluate BP cagegory**
- Monitor Q 3 to 6 Months
- Forward to Re-evaluate BP cagegory
- Rx for 20 cause + Anti-HTN Drug
- Forward to Monitor Q 3-6 Months
- Follow until BP controlled, Q 1-2 wks
- Monitor Q 1-3 Months
- Re-evaluate BP Category**
- <90th %ile, 90<95th%ile (≥95th%ile → Stage 1 W/U) ≥95th%ile,
forward to Consider basic W/U + cardiac U/S for TOD*
- Re-evaluate BP category
- Forward to Anti-HTN Drug if no improvement
- Monitor Q3-6 Months
- Forward to Consider re-evaluation of BP Category if BP well controlled, ↓BMI
or s/p Rx for 20 cause
- Monitor Q 1-3 Months
- Forward to Consider re-evaluation of BP Category if BP well controlled, ↓BMI
or s/p Rx for 20 cause
- Consider basic W/U + cardiac U/S for TOD*
- Forward to Monitor Q 6 Mo
- Anti-HTN Drug if no improvement
- Forward to Continue moderate follow-up
- Consider re-evaluation of BP Category if BP well controlled, ↓BMI or s/p Rx
for 20 cause
- Forward to Continue moderate follow-up
- Forward to Continue close follow-up
- Re-evaluate at next visit
- Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target
Organ Damage
- Monitor Q 6 Mo
- Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target
Organ Damage
- Continue moderate follow-up
- Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target
Organ Damage
- Continue close follow-up
- Forward to GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target
Organ Damage
- GOAL BP: <95th%ile for age/sex/HT, <90th %ile if CKD, DM, Target Organ Damage
Figure 8-2 Legend:
* Work up for target organ
damage (TOD)/ LVH if obese or (+) for other CV risk factors;
Cardiovascular Health Integrated
Lifestyle Diet; See Section V. Nutrition and Diet;
** Activity Education. See Section VI.
Physical Activity;
*** Weight management. See Section X. Overweight
and Obesity.
Table 8-3. Blood Pressure (BP) Norms for Boys by Age and Height Percentiles (%iles)
Age, y
|
BP %ile
|
SBP, mm Hg,
%ile of Height,
5th
|
SBP, mm Hg,
%ile of Height,
10th
|
SBP, mm Hg,
%ile of Height,
25th
|
SBP, mm Hg,
%ile of Height,
50th
|
SBP, mm Hg,
%ile of Height,
75th
|
SBP, mm Hg,
%ile of Height,
90th
|
SBP, mm Hg,
%ile of Height,
95th
|
DBP, mm Hg,
%ile of Height,
5th
|
DBP, mm Hg,
%ile of Height,
10th
|
SBP, mm Hg,
%ile of Height,
25th
|
SBP, mm Hg,
%ile of Height,
50th
|
SBP, mm Hg,
%ile of Height,
75th
|
DBP, mm Hg,
%ile of Height,
90th
|
DBP, mm Hg,
%ile of Height,
95th
|
1
|
50th
|
80
|
81
|
83
|
85
|
87
|
88
|
89
|
34
|
35
|
36
|
37
|
38
|
39
|
39
|
1
|
90th
|
94
|
95
|
97
|
99
|
100
|
102
|
103
|
49
|
50
|
51
|
52
|
53
|
53
|
54
|
1
|
95th
|
98
|
99
|
101
|
103
|
104
|
106
|
106
|
54
|
54
|
55
|
56
|
57
|
58
|
58
|
1
|
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
|
2
|
90th
|
97
|
99
|
100
|
102
|
104
|
105
|
106
|
54
|
55
|
56
|
57
|
58
|
58
|
59
|
2
|
95th
|
101
|
102
|
104
|
106
|
108
|
109
|
110
|
59
|
59
|
60
|
61
|
62
|
63
|
63
|
2
|
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
|
3
|
90th
|
100
|
101
|
103
|
105
|
107
|
108
|
109
|
59
|
59
|
60
|
61
|
62
|
63
|
63
|
3
|
95th
|
104
|
105
|
107
|
109
|
110
|
112
|
113
|
63
|
63
|
64
|
65
|
66
|
67
|
67
|
3
|
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
|
4
|
90th
|
102
|
103
|
105
|
107
|
109
|
110
|
111
|
62
|
63
|
64
|
65
|
66
|
66
|
67
|
4
|
95th
|
106
|
107
|
109
|
111
|
112
|
114
|
115
|
66
|
67
|
68
|
69
|
70
|
71
|
71
|
4
|
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
|
5
|
90th
|
104
|
105
|
106
|
108
|
110
|
111
|
112
|
65
|
66
|
67
|
68
|
69
|
69
|
70
|
5
|
95th
|
108
|
109
|
110
|
112
|
114
|
115
|
116
|
69
|
70
|
71
|
72
|
73
|
74
|
74
|
5
|
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
|
6
|
90th
|
105
|
106
|
108
|
110
|
111
|
113
|
113
|
68
|
68
|
69
|
70
|
71
|
72
|
72
|
6
|
95th
|
109
|
110
|
112
|
114
|
115
|
117
|
117
|
72
|
72
|
73
|
74
|
75
|
76
|
76
|
6
|
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
|
7
|
90th
|
106
|
107
|
109
|
111
|
113
|
114
|
115
|
70
|
70
|
71
|
72
|
73
|
74
|
74
|
7
|
95th
|
110
|
111
|
113
|
115
|
117
|
118
|
119
|
74
|
74
|
75
|
76
|
77
|
78
|
78
|
7
|
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
|
8
|
90th
|
107
|
109
|
110
|
112
|
114
|
115
|
116
|
71
|
72
|
72
|
73
|
74
|
75
|
76
|
8
|
95th
|
111
|
112
|
114
|
116
|
118
|
119
|
120
|
75
|
76
|
77
|
78
|
79
|
79
|
80
|
8
|
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
|
9
|
90th
|
109
|
110
|
112
|
114
|
115
|
117
|
118
|
72
|
73
|
74
|
75
|
76
|
76
|
77
|
9
|
95th
|
113
|
114
|
116
|
118
|
119
|
121
|
121
|
76
|
77
|
78
|
79
|
80
|
81
|
81
|
9
|
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
|
10
|
90th
|
111
|
112
|
114
|
115
|
117
|
119
|
119
|
73
|
73
|
74
|
75
|
76
|
77
|
78
|
10
|
95th
|
115
|
116
|
117
|
119
|
121
|
122
|
123
|
77
|
78
|
79
|
80
|
81
|
81
|
82
|
10
|
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
|
11
|
90th
|
113
|
114
|
115
|
117
|
119
|
120
|
121
|
74
|
74
|
75
|
76
|
77
|
78
|
78
|
11
|
95th
|
117
|
118
|
119
|
121
|
123
|
124
|
125
|
78
|
78
|
79
|
80
|
81
|
82
|
82
|
11
|
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
|
12
|
90th
|
115
|
116
|
118
|
120
|
121
|
123
|
123
|
74
|
75
|
75
|
76
|
77
|
78
|
79
|
12
|
95th
|
119
|
120
|
122
|
123
|
125
|
127
|
127
|
78
|
79
|
80
|
81
|
82
|
82
|
83
|
12
|
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
|
13
|
90th
|
117
|
118
|
120
|
122
|
124
|
125
|
126
|
75
|
75
|
76
|
77
|
78
|
79
|
79
|
13
|
95th
|
121
|
122
|
124
|
126
|
128
|
129
|
130
|
79
|
79
|
80
|
81
|
82
|
83
|
83
|
13
|
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
|
14
|
90th
|
120
|
121
|
123
|
125
|
126
|
128
|
128
|
75
|
76
|
77
|
78
|
79
|
79
|
80
|
14
|
95th
|
124
|
125
|
127
|
128
|
130
|
132
|
132
|
80
|
80
|
81
|
82
|
83
|
84
|
84
|
14
|
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
|
15
|
90th
|
122
|
124
|
125
|
127
|
129
|
130
|
131
|
76
|
77
|
78
|
79
|
80
|
80
|
81
|
15
|
95th
|
126
|
127
|
129
|
131
|
133
|
134
|
135
|
81
|
81
|
82
|
83
|
84
|
85
|
85
|
15
|
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
|
16
|
90th
|
125
|
126
|
128
|
130
|
131
|
133
|
134
|
78
|
78
|
79
|
80
|
81
|
82
|
82
|
16
|
95th
|
129
|
130
|
132
|
134
|
135
|
137
|
137
|
82
|
83
|
83
|
84
|
85
|
86
|
87
|
16
|
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
|
17
|
90th
|
127
|
128
|
130
|
132
|
134
|
135
|
136
|
80
|
80
|
81
|
82
|
83
|
84
|
84
|
17
|
95th
|
131
|
132
|
134
|
136
|
138
|
139
|
140
|
84
|
85
|
86
|
87
|
87
|
88
|
89
|
17
|
99th
|
139
|
140
|
141
|
143
|
145
|
146
|
147
|
92
|
93
|
93
|
94
|
95
|
96
|
97
|
SD = standard deviation
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.
Table 84. Blood Pressure (BP) Norms for Girls by Age and Height Percentiles
(%iles)
Age, y
|
BP %ile
|
SBP, mm Hg,
%ile of Height,
5th
|
SBP, mm Hg,
%ile of Height,
10th
|
SBP, mm Hg,
%ile of Height,
25th
|
SBP, mm Hg,
%ile of Height,
50th
|
SBP, mm Hg,
%ile of Height,
75th
|
SBP, mm Hg,
%ile of Height,
90th
|
SBP, mm Hg,
%ile of Height,
95th
|
DBP, mm Hg,
%ile of Height,
5th
|
DBP, mm Hg,
%ile of Height,
10th
|
SBP, mm Hg,
%ile of Height,
25th
|
SBP, mm Hg,
%ile of Height,
50th
|
SBP, mm Hg,
%ile of Height,
75th
|
DBP, mm Hg,
%ile of Height,
90th
|
DBP, mm Hg,
%ile of Height,
95th
|
1
|
50th
|
83
|
84
|
85
|
86
|
88
|
89
|
90
|
38
|
39
|
39
|
40
|
41
|
41
|
42
|
1
|
90th
|
97
|
97
|
98
|
100
|
101
|
102
|
103
|
52
|
53
|
53
|
54
|
55
|
55
|
56
|
1
|
95th
|
100
|
101
|
102
|
104
|
105
|
106
|
107
|
56
|
57
|
57
|
58
|
59
|
59
|
60
|
1
|
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
|
2
|
90th
|
98
|
99
|
100
|
101
|
103
|
104
|
105
|
57
|
58
|
58
|
59
|
60
|
61
|
61
|
2
|
95th
|
102
|
103
|
104
|
105
|
107
|
108
|
109
|
61
|
62
|
62
|
63
|
64
|
65
|
65
|
2
|
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
|
3
|
90th
|
100
|
100
|
102
|
103
|
104
|
106
|
106
|
61
|
62
|
62
|
63
|
64
|
64
|
65
|
3
|
95th
|
104
|
104
|
105
|
107
|
108
|
109
|
110
|
65
|
66
|
66
|
67
|
68
|
68
|
69
|
3
|
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
|
4
|
90th
|
101
|
102
|
103
|
104
|
106
|
107
|
108
|
64
|
64
|
65
|
66
|
67
|
67
|
68
|
4
|
95th
|
105
|
106
|
107
|
108
|
110
|
111
|
112
|
68
|
68
|
69
|
70
|
71
|
71
|
72
|
4
|
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
|
5
|
90th
|
103
|
103
|
105
|
106
|
107
|
109
|
109
|
66
|
67
|
67
|
68
|
69
|
69
|
70
|
5
|
95th
|
107
|
107
|
108
|
110
|
111
|
112
|
113
|
70
|
71
|
71
|
72
|
73
|
73
|
74
|
5
|
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
|
6
|
90th
|
104
|
105
|
106
|
108
|
109
|
110
|
111
|
68
|
68
|
69
|
70
|
70
|
71
|
72
|
6
|
95th
|
108
|
109
|
110
|
111
|
113
|
114
|
115
|
72
|
72
|
73
|
74
|
74
|
75
|
76
|
6
|
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
|
7
|
90th
|
106
|
107
|
108
|
109
|
111
|
112
|
113
|
69
|
70
|
70
|
71
|
72
|
72
|
73
|
7
|
95th
|
110
|
111
|
112
|
113
|
115
|
116
|
116
|
73
|
74
|
74
|
75
|
76
|
76
|
77
|
7
|
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
|
8
|
90th
|
108
|
109
|
110
|
111
|
113
|
114
|
114
|
71
|
71
|
71
|
72
|
73
|
74
|
74
|
8
|
95th
|
112
|
112
|
114
|
115
|
116
|
118
|
118
|
75
|
75
|
75
|
76
|
77
|
78
|
78
|
8
|
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
|
9
|
90th
|
110
|
110
|
112
|
113
|
114
|
116
|
116
|
72
|
72
|
72
|
73
|
74
|
75
|
75
|
9
|
95th
|
114
|
114
|
115
|
117
|
118
|
119
|
120
|
76
|
76
|
76
|
77
|
78
|
79
|
79
|
9
|
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
|
10
|
90th
|
112
|
112
|
114
|
115
|
116
|
118
|
118
|
73
|
73
|
73
|
74
|
75
|
76
|
76
|
10
|
95th
|
116
|
116
|
117
|
119
|
120
|
121
|
122
|
77
|
77
|
77
|
78
|
79
|
80
|
80
|
10
|
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
|
11
|
90th
|
114
|
114
|
116
|
117
|
118
|
119
|
120
|
74
|
74
|
74
|
75
|
76
|
77
|
77
|
11
|
95th
|
118
|
118
|
119
|
121
|
122
|
123
|
124
|
78
|
78
|
78
|
79
|
80
|
81
|
81
|
11
|
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
|
12
|
90th
|
116
|
116
|
117
|
119
|
120
|
121
|
122
|
75
|
75
|
75
|
76
|
77
|
78
|
78
|
12
|
95th
|
119
|
120
|
121
|
123
|
124
|
125
|
126
|
79
|
79
|
79
|
80
|
81
|
82
|
82
|
12
|
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
|
13
|
90th
|
117
|
118
|
119
|
121
|
122
|
123
|
124
|
76
|
76
|
76
|
77
|
78
|
79
|
79
|
13
|
95th
|
121
|
122
|
123
|
124
|
126
|
127
|
128
|
80
|
80
|
80
|
81
|
82
|
83
|
83
|
13
|
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
|
14
|
90th
|
119
|
120
|
121
|
122
|
124
|
125
|
125
|
77
|
77
|
77
|
78
|
79
|
80
|
80
|
14
|
95th
|
123
|
123
|
125
|
126
|
127
|
129
|
129
|
81
|
81
|
81
|
82
|
83
|
84
|
84
|
14
|
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
|
15
|
90th
|
120
|
121
|
122
|
123
|
125
|
126
|
127
|
78
|
78
|
78
|
79
|
80
|
81
|
81
|
15
|
95th
|
124
|
125
|
126
|
127
|
129
|
130
|
131
|
82
|
82
|
82
|
83
|
84
|
85
|
85
|
15
|
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
|
16
|
90th
|
121
|
122
|
123
|
124
|
126
|
127
|
128
|
78
|
78
|
79
|
80
|
81
|
81
|
82
|
16
|
95th
|
125
|
126
|
127
|
128
|
130
|
131
|
132
|
82
|
82
|
83
|
84
|
85
|
85
|
86
|
16
|
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
|
17
|
90th
|
122
|
122
|
123
|
125
|
126
|
127
|
128
|
78
|
79
|
79
|
80
|
81
|
81
|
82
|
17
|
95th
|
125
|
126
|
127
|
129
|
130
|
131
|
132
|
82
|
83
|
83
|
84
|
85
|
85
|
86
|
17
|
99th
|
133
|
133
|
134
|
136
|
137
|
138
|
139
|
90
|
90
|
91
|
91
|
92
|
93
|
93
|
SD = standard deviation
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.
Table 8-5. Anti-hypertensive Medications with Pediatric
Angiotensin-converting enzyme (ACE) inhibitor
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
Angiotensin-converting enzyme (ACE) inhibitor
|
Benazepril
|
0.2 mg/kg/day up to 10 mg/day
|
0.6 mg/kg/day up to 40 mg/day
|
qd
|
Randomized controlled trial
|
Yes
|
Angiotensin-converting enzyme (ACE) inhibitor
|
Captopril
|
0.3-0.5 mg/kg/dose (>12 months)
|
6 mg/kg/day
|
tid
|
Randomized controlled trial, Case series
|
No
|
Angiotensin-converting enzyme (ACE) inhibitor
|
Fosinopril**
|
Children >50 kg:
5-10 mg/day
|
40 mg/day
|
qd
|
Randomized controlled trial
|
Yes
|
Angiotensin-converting enzyme (ACE) inhibitor
|
Lisinopril**
|
0.07 mg/kg/day up to 5 mg/day
|
0.6 mg/kg/day up to 40 mg/day
|
qd
|
Randomized controlled trial
|
Yes
|
Angiotensin-converting enzyme (ACE) inhibitor
|
Quinapril
|
5-10 mg/day
|
80 mg/day
|
qd
|
Randomized controlled trial, Expert opinion
|
No
|
Comments§
- 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.
- Benezapril 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/1.73m2.
- Initial dose of fosinopril of 0.1 mg/kg/day may be effective, although African American
patients may require a higher dose.
|
Angiotensin-receptor blocker (ARB)
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
Angiotensin-receptor blocker (ARB)
|
Irbesartan
|
6-12 years: 75-150 mg/day; ≥13 years: 150-300mg/day
|
300 mg/day
|
qd
|
Case series
|
Yes
|
Angiotensin-receptor blocker (ARB)
|
Losartan**
|
0.7 mg/kg/day up to 50 mg/day
|
1.4 mg/kg/day up to 100 mg/day
|
qd-bid
|
Randomized controlled trial
|
Yes
|
Angiotensin-receptor blocker (ARB)
|
Valsartan**
|
5-10 mg/day
0.4 mg/kg/day
|
40-80 mg/day
3.4 mg/kg/day
|
qd
|
Randomized controlled trial
|
No
|
Comments§
- All ARBs are contraindicated in pregnancy; females of childbearing age should use
reliable contraception
- Check serum potassium and 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/1.73m2 .
|
Alpha- and beta-antagonist
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
alpha- and beta-antagonist
|
Labetalol
|
1-3 mg/kg/day
|
10-12 mg/kg/day up to 1,200 mg/day
|
bid
|
Case series, Expert opinion
|
No
|
Comments§
- Asthma and overt heart failure are relative contraindications.
- Heart rate is dose limiting.
- May impair athletic performance in athletes.
- Should not be used in insulin-dependent diabetics.
|
Beta-antagonist
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
beta-antagonist
|
Atenolol
|
0.5-1 mg/kg/day
|
2 mg/kg/day up to
100 mg/day
|
qd-bid
|
Case series
|
No
|
beta-antagonist
|
Bisoprolol/
HCTZ
|
2.5-6.25 mg/day
|
10/6.25 mg/day
|
qd
|
Randomized controlled trial
|
No
|
beta-antagonist
|
Metoprolol**
|
Children >6 years: 1 mg/kg/day (12.5-50 mg/day)
|
2 mg/kg/day up to
200 mg/day
|
bid
|
Case series
|
Yes***
|
beta-antagonist
|
Propranolol
|
1-2 mg/kg/day
|
4 mg/kg/day up to
640 mg/day
|
bid-tid
|
Randomized controlled trial, Expert opinion
|
Yes
|
Comments§
- Noncardioselective agents (propranolol) are contraindicated in asthma and heart
failure.
- Heart rate is dose limiting.
- May impair athletic performance in athletes.
- Should not be used in insulin-dependent diabetics.
- A sustained-release, once-daily formulation of propranolol is available.
|
Calcium channel blocker
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
Calcium channel blocker
|
Amlodipine**
|
Children 6-17 years: 2.5 mg/day
|
5 mg/day
|
qd
|
Randomized controlled trial
|
Yes
|
Calcium channel blocker
|
Felodipine
|
2.5 mg/day
|
10 mg/day
|
qd
|
Randomized controlled trial, Expert opinion
|
No
|
Calcium channel blocker
|
Isradipine
|
0.15-0.2 mg/kg/day
|
0.8 mg/kg/day up to 20 mg/day
|
tid-qid
|
Case series, Expert opinion
|
No
|
Calcium channel blocker
|
Extended-release nifedipine
|
0.25-0.5 mg/kg/day
|
3 mg/kg/day up to
120 mg/day
|
qd-bid
|
Case series, Expert opinion
|
No
|
Comments§
- 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.
- Doses up to 10 mg of amlodipine have been evaluated in children.
- Contraindicated for children <1 year of age.
|
Central alpha-agonist
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
Central alpha-agonist
|
Clonidine
|
Children ≥12 years: 0.2 mg/day
|
2.4 mg/day
|
bid
|
Expert opinion
|
Yes
|
Comments§
- May cause dry mouth and/or sedation.
- Transdermal preparation is available.
- Sudden cessation of therapy can lead to severe rebound hypertension.
|
Diuretic
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
Diuretic
|
HCTZ
|
1 mg/kg/day
|
3 mg/kg/day up to
50 mg/day
|
qd
|
Expert opinion
|
Yes
|
Diuretic
|
Chlorthalidone
|
0.3 mg/kg/day
|
2 mg/kg/day up to
50 mg/day
|
qd
|
Expert opinion
|
No
|
Diuretic
|
Furosemide
|
0.5-2.0 mg/kg/ dose
|
6 mg/kg/day
|
qd-bid
|
Expert opinion
|
`No
|
Diuretic
|
Spironolactone
|
1 mg/kg/day
|
3.3 mg/kg/day up to 100 mg/day
|
qd-bid
|
Expert opinion
|
No
|
Diuretic
|
Triamterene
|
1-2 mg/kg/day
|
3-4 mg/kg/day up to 300 mg/day
|
bid
|
Expert opinion
|
No
|
Diuretic
|
Amiloride
|
0.4-0.625 mg/kg/day
|
20 mg/day
|
qd
|
Expert opinion
|
No
|
Comments§
- 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 (spironolactione, 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.
|
Peripheral alpha-antagonist
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
Peripheral alpha-antagonist
|
Doxazosin
|
1 mg/day
|
4 mg/day
|
qd
|
Expert opinion
|
No
|
Peripheral alpha-antagonist
|
Prazosin
|
0.05-0.1 mg/kg/ day
|
0.5 mg/kg/day
|
tid
|
Expert opinion
|
No
|
Peripheral alpha-antagonist
|
Terazosin
|
1 mg/day
|
20 mg/day
|
qd
|
Expert opinion
|
No
|
Comments§
- May cause first-dose hypotension.
|
Vasodilator
Class
|
Drug
|
Initial Dose*
|
Maximal Dose
|
Dosing Interval
|
Evidence
|
FDA
|
Vasodilator
|
Hydralazine
|
0.75 mg/kg/day
|
7.5 mg/kg/day up to 200 mg/day
|
qid
|
Expert opinion
|
Yes
|
Vasodilator
|
Minoxidil
|
Children <12 years: 0.2 mg/kg/ day; children > 12 years: 5 mg/day
|
Children <12 years:
50 mg/day; children ≥12 years: 100 mg/day
|
qd-tid
|
Case series, Expert opinion
|
Yes
|
Comments§
- 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.
|
RCT = randomized controlled trial
CS = case series
EO = expert opinion
* The maximal recommended adult dose should
not be exceeded in routine clinical practice.
Level of evidence on which recommendations
are based.
U.S. Food and Drug Administration (FDA)
-approved pediatric labeling information is available for treatment of hypertension.
Recommended doses for agents with FDA-approved pediatric labels contained in this
table 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.
§ Comments apply to all members of each
drug class except where otherwise stated.
** Indicates drug added since The Fourth Report
on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and
Adolescents (2004).
*** Study did not reach primary end point
(dose response for reduction in systolic blood pressure). Some prespecified secondary
end points demonstrated effectiveness.
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