Hypertension in kids: When to refer

high blood presssure
(Illustration: Fawn Gracey)

We typically associate hypertension with older people, but elevated blood pressure isn’t an uncommon finding in children and adolescents. According to the American Academy of Pediatrics (AAP), pediatric hypertension occurs in 2 to 5 percent of kids and is one of the top five chronic diseases in children.

Despite those numbers, the diagnosis is missed in up to 75 percent of pediatric patients in primary care settings. “We should be checking blood pressure at every routine well-child visit for kids age 3 and older, and more often in kids with cardiometabolic risk factors, such as obesity and diabetes,” says Corinna Rea, MD, MPH, a pediatrician in Boston Children’s Primary Care at Longwood.

Making a diagnosis

It’s not unusual for children to experience elevated blood pressure readings during doctor visits: The stress of the medical environment can cause pressure to rise in some kids. But that’s not a reason to discount the reading, says Rea. Instead, she recommends that providers perform two additional measurements during the same visit — if it normalizes by the third reading, no further action is needed.

If blood pressure stays elevated, you should consider testing with an ambulatory blood pressure monitor (ABPM), a portable device that records blood pressure every 20 to 30 minutes over a 24-hour period. Recent clinical practice guidelines from the AAP advise that ABPM should be performed to confirm hypertension in children and adolescents with elevated office blood pressure measurements for one year or more or with stage 1 hypertension over three clinic visits.

Seeking specialty care

Not sure when to refer to a specialist? Knowing the two main categories of hypertension can help guide your decision. The first, primary hypertension, means that the hypertension does not seem to be caused by some other underlying medical condition. Primary hypertension is more common in older children and teens and often appears to be related to obesity. Primary care physicians should feel comfortable initiating therapy for primary hypertension, typically with lifestyle measures such as diet and exercise.

Secondary hypertension is the result of an underlying medical condition. Kidney disease or blood vessel anomalies,are responsible for roughly 80 percent of cases of secondary hypertension in children. Endocrine disorders, heart problems and certain medications (such as corticosteroids) can also cause secondary hypertension. If you believe your patient’s high blood pressure may be due to an underlying condition or if you are uncomfortable prescribing antihypertensive medications, a referral to a nephrologist, preventive cardiologist or other specialist may be in order.

A collaborative effort

“Because most children with secondary hypertension have kidney involvement, we tend to see a lot of kids with high blood pressure,” says Deborah Stein, MD, co-director of the Center for Midaortic Syndrome and Renovascular Hypertension. The first step to finding a cause is evaluation with a 24-hour ABPM, followed by blood and imaging tests, based on the child’s risk factors and other symptoms. The results of these tests help determine which class of anti-hypertensive medication, if any, is recommended. Some causes of renovascular hypertension, such as midaortic syndrome, may eventually require surgery or other interventional procedure.

Regardless of the treatment, routine follow-up and close partnership with the child’s primary care physician are key, says Michael Ferguson, MD, the Center’s other co-director and director of the Renal Hypertension Program. “These families need a collaborative team of pediatricians, specialists and even school nurses that communicate well with each other,” he explains. “We want to work with primary care providers to monitor treatment and help kids stay healthy.”

Learn about the Renal Hypertension Program, the Center for Midaortic Syndrome and Renovascular Hypertension and Boston Children’s Primary Care at Longwood.