Pediatric hypertension generally presents to the ED in 2 forms: (1) the otherwise asymptomatic child with elevated blood pressure, and (2) the child with a true hypertensive emergency. This issue provides recommendations to ensure that asymptomatic patients with hypertension receive appropriate testing and referrals and outlines a systematic approach for the evaluation and treatment of patients with severe hypertension. You will learn:

The differences between primary hypertension and secondary hypertension

The stages of hypertension and the significance of each, as well as rough equations to determine the stage of a patient’s hypertension, based on the patient’s age

Which medications are appropriate for administration in the prehospital setting, and which should be administered in the ED

Key historical information that should be elicited

Recommendations for taking accurate blood pressure measurements and for confirming high blood pressure readings

How to determine which portion of the workup is necessary in the ED, and what is better done by outpatient clinicians or the inpatient team

Which patients need treatment in the ED, and which patients can be sent home with education and follow-up with their primary care physician

Evidence-based recommendations for administration of antihypertensive medications

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Hypertensive Emergencies
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Blood Pressure Measurements
      2. Signs of End-Organ Damage
      3. Posterior Reversible Encephalopathy Syndrome
      4. Additional Physical Examination Findings
9. Diagnostic Studies
   1. Patients With Elevated Blood Pressure
   2. Asymptomatic Patients With Blood Pressure > 95^th Percentile
   3. Patients With Hypertension Who Have Cardiac Symptoms
   4. Patients With Hypertension Who Have Neurologic Symptoms
10. Treatment
    1. Oral Medications
       1. Nifedipine
    2. Intravenous Medications
       1. Labetalol
       2. Esmolol
       3. Sodium Nitroprusside
       4. Nicardipine
11. Special Populations
    1. Infants Aged < 1 Year
    2. Patients With Sickle Cell Disease
12. Controversies and Cutting Edge
13. Disposition
    1. Asymptomatic Patients With Elevated Blood Pressure
    2. Asymptomatic Patients With Stage 1 Hypertension
    3. Asymptomatic Patients With Stage 2 Hypertension
    4. Symptomatic Patients With Stage 2 Hypertension
14. Summary
15. Risk Management Pitfalls in the Management of Pediatric Patients With Hypertension
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway for Management of Pediatric Patients With Hypertension
19. Tables
    1. Table 1. Blood Pressure Definitions
    2. Table 2. Etiologies of Secondary Pediatric Hypertension
    3. Table 3. Dosing Information for Antihypertensive Medications
20. References

Abstract

Pediatric hypertension is increasing in incidence, but remains greatly underrecognized, despite its severe long-term health consequences. Often discovered as incidental to another complaint, pediatric patients with hypertension may be asymptomatic but with markedly abnormal blood pressure, or they may have a true hypertensive emergency. This issue provides strategies to ensure that the child with asymptomatic hypertension receives appropriate screening and referrals, and outlines a systematic approach for the evaluation and treatment of the critically ill child who presents with symptoms of severe hypertension.

Case Presentations

A 5-year-old girl presents to the ED with a clavicle deformity after falling at the playground. You are almost ready to discharge her after confirmatory x-ray and sling placement when you note that her blood pressure is 150/90 mm Hg. Realizing that oscillometric devices may be inaccurate, you measure her blood pressure with a manual manometer, and it is 170/100 mm Hg. On further questioning, you learn that she has no significant medical history and no family history of hypertension. What defines hypertension in a child this age? Are additional tests needed? Do you need to treat this level of hypertension?

The following week, you are back in the ED when a medic calls ahead to say that they are on their way with a 16-year-old boy with altered mental status. She reports his vital signs, and you ask her to repeat the blood pressure, which she confirms is 140/80 mm Hg. You wonder whether this patient’s blood pressure is the cause of his altered mental status, or is there something else going on? Should you treat hypertension in this patient the same way you would in an adult? How aggressive do you need to be with lowering his blood pressure? Should you advise the medic to give medications prehospital prior to ED arrival?

Your string of shifts is almost over when you are called into a room for an infant with respiratory distress. You’ve just seen 4 kids with upper respiratory infections, and you feel confident that this is the scenario. The 4-month-old, who was born at 26 weeks’ gestation, shows mild-to-moderate respiratory distress; however, there has been no viral prodrome. A chest x-ray demonstrates moderate pulmonary edema. Back in the room, you note that her blood pressure is 110/80 mm Hg, and you begin to wonder whether that is high for an infant. What additional testing—if any—is necessary? Do you need to intervene? Is there anything specific you should be worried about?

Introduction

The prevalence of pediatric hypertension is increasing and, while the exact the number is unknown, it is estimated to affect up to 5% of children in the United States.^1,2 From the emergency clinician’s perspective, pediatric hypertension generally presents in 2 forms: (1) the otherwise asymptomatic child with elevated blood pressure, and (2) the child with a true pediatric hypertensive emergency. It can be challenging for the emergency clinician to know whether the asymptomatic patient with elevated blood pressure warrants evaluation in the acute care or the primary care setting. The combination of cumbersome tables for defining hypertension and uncertainty regarding optimal treatment hinders clinician identification and treatment of pediatric hypertension. While measurable pathology is found in many children with hypertension (left ventricular hypertrophy, increased carotid artery intimal thickness, and cognitive dysfunction), it is uncertain whether hypertension in children results in increased cardiovascular risk as adults.^3-8 The lack of data regarding long-term risks and benefits is a barrier to action for clinicians in both the emergency department (ED) and in the primary care setting. In contrast, a hypertensive emergency requires emergent management in the ED. Managing a pediatric hypertensive emergency with the associated high rate of morbidity and mortality can be a challenge for the emergency clinician, especially without pediatric subspecialty support. This issue of Pediatric Emergency Medicine Practice provides evidenced-based recommendations for managing children with elevated blood pressure who are asymptomatic upon presentation to the ED and reviews treatment options for children with hypertensive emergencies.

Critical Appraisal of the Literature

A search was performed in PubMed using the following search terms: pediatric hypertension, hypertensive emergencies, pediatric hypertensive emergencies, and posterior reversible encephalopathy syndrome. The search resulted in 166 articles from 2000 to the present. There were numerous case reports, retrospective reviews, review articles, and expert opinion pieces. The major guidelines from Europe, Canada, and the United States were reviewed, compared, and contrasted. No guidelines were found in either the National Guideline Clearinghouse or the National Institute for Health and Care Excellence databases. One Cochrane review examined the long-term use of antihypertensive medications in children.

As with much of pediatric literature, there is a paucity of strong evidence in screening, identification, or treatment for hypertension; much of the data are based on expert opinions from subspecialists. In 2004, the National Heart, Lung, and Blood Institute of the United States National Institutes of Health released their final guideline on identification and treatment of hypertension. This work was then taken over by the American Academy of Pediatrics (AAP), which released their update to the guidelines in 2017. The majority of the recommendations in that publication ranged from weak-to-moderate, with few strong recommendations.

As the incidence of pediatric hypertension increases, there is increasing effort to develop evidence-based guidelines. Current challenges include: (1) age-based definitions of the disease are cumbersome, which leads to underrecognition; (2) the consequences of pediatric hypertension are not always consistent or clear; (3) the risks and benefits of long-term treatment for hypertension are still not well understood; and (4) it is difficult to perform prospective randomized controlled trials for hypertensive emergencies, as they are relatively rare.

For this review, recommendations are based on the available evidence; when that evidence is expert opinion, it is noted.

Risk Management Pitfalls in the Management of Pediatric Patients With Hypertension

2. “This child’s blood pressure is very high! I’m worried about giving IV medications, so I think I’ll just give a small dose of oral nifedipine. That should be safe.”

While easy to give because it is an oral agent, nifedipine can cause an excessive drop in blood pressure, altered mental status, and even dysrhythmia. While there are no studies showing tissue ischemia (as has been shown in the adult literature), there are better and more predictable medications that should be used.

5. “His oscillatory blood pressure was high, but I’m sure it’s just because it was an automated blood pressure reading. The child can follow up for another blood pressure evaluation at his pediatrician’s office.”

While oscillatory blood pressure machines are not as specific for hypertension as a manual blood pressure measurement, they are sensitive enough to be used for screening purposes. Elevated blood pressure measurements should not be ignored, but should be validated with auscultatory technique, preferentially in the right upper extremity as well as a lower extremity.

9. “This child has high blood pressure. I can’t manage this chronic problem in the ED.”

For some children, hypertension is an acute issue, especially in younger children and/or in the setting of stage 2 hypertension, and it is one that requires urgent evaluation and referral. Despite increasing data regarding pediatric hypertension, it can still go underdiagnosed in primary care. It is important to recognize, evaluate, and educate about high blood pressure, even if therapy might not be instituted in the ED.

Tables

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. Koebnick C, Black MH, Wu J, et al. The prevalence of primary pediatric prehypertension and hypertension in a real-world managed care system. J Clin Hypertens. 2013;15(11):784-792. (Cross-sectional study; 237,248 patients)
2. Lo JC, Sinaiko A, Chandra M, et al. Prehypertension and hypertension in community-based pediatric practice. Pediatrics. 2013;131(2):e415-e424. (Retrospective cohort; 199,513 patients)
3. Ostrovskaya MA, Rojas M, Kupferman JC, et al. Executive function and cerebrovascular reactivity in pediatric hypertension. J Child Neurol. 2013;30(5):543-546. (Prospective; 14 patients)
4. Flynn JT. High blood pressure in the young: why should we care? Acta Paediatr. 2018;107(1):14-19. (Review article)
5. Lande MB, Adams H, Falkner B, et al. Parental assessments of internalizing and externalizing behavior and executive function in children with primary hypertension. J Pediatr. 2009;154(2):207-212. (Case control; 64 patients)
6. Kupferman JC, Lande MB, Adams HR, et al. Primary hypertension and neurocognitive and executive functioning in school-age children. Pediatr Nephrol. 2012;28(3):401-408. (Review article)
7. Jing L, Nevius CD, Friday CM, et al. Ambulatory systolic blood pressure and obesity are independently associated with left ventricular hypertrophic remodeling in children. J Cardiovasc Magn Reson. 2017;19(86):1-11. (Prospective analysis; 72 patients)
8. Urbina EM. Abnormalities of vascular structure and function in pediatric hypertension. Pediatr Nephrol. 2016;31(7):1061-1070. (Review article)
9. Guillery EN, Robillard JE. The renin-angiotensin system and blood pressure regulation during infancy and childhood. Pediatr Clin North Am. 1993;40(1):61-79. (Review article)
10. Brady TM. Obesity-related hypertension in children. Front Pediatr. 2017;5:1-7. (Review article)
11. Flynn JT, Tullus K. Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatr Nephrol. 2009;24(6):1101-1112. (Review article)
12. Shapiro DJ, Hersh AL, Cabana MD, et al. Hypertension screening during ambulatory pediatric visits in the United States, 2000-2009. Pediatrics. 2012;130(4):604-610. (Database review)
13. Bijlsma MW, Blufpand HN, Kaspers GJ, et al. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Pediatr. 2014;164(1):173-177. (Multicenter survey; 197 patients)
14. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874-879. (Observational cohort; 14,187 patients)
15. Kaelber DC, Liu W, Ross M, et al. Diagnosis and medication treatment of pediatric hypertension: a retrospective cohort study. Pediatrics. 2016;138(6). (Retrospective cohort; 1.2 million pediatric patients)
16. Ricke TL, Hendry PL, Kalynych C, et al. Incidence and recognition of elevated triage blood pressure in the pediatric emergency department. Pediatr Emerg Care. 2011;27(10):922-927. (Retrospective review; 907 patients)
17. Yang W-C, Wu H-P. Clinical analysis of hypertension in children admitted to the emergency department. Pediatr Neonatol. 2010;51(1):44-51. (Retrospective review; 99 patients)
18. Yoon EY, Davis MM, Rocchini A, et al. Medical management of children with primary hypertension by pediatric subspecialists. Pediatr Nephrol. 2008;24(1):147-153. (Retrospective review; 180 patients)
19. Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol. 2011;27(1):17-32. (Review article)
20. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3). (Clinical guidelines)
21. Semanik MG. The use of electronic health records to identify children with elevated blood pressure and hypertension. Curr Hypertens Rep. 2017;19(12):98. (Review article)
22. Kupferman JC, Zafeiriou DI, Lande MB, et al. Stroke and hypertension in children and adolescents. J Child Neurol. 2016;32(4):408-417. (Review article)
23. Lee CH, Kang KT, Hsu WC. Blood pressure changes after adenotonsillectomy in children with obstructive sleep apnea-reply. JAMA Otolaryngol Head Neck Surg. 2018;144(7):647-648. (Retrospective review; 50 patients)
24. Wiesen J, Adkins M, Fortune S, et al. Evaluation of pediatric patients with mild-to-moderate hypertension: yield of diagnostic testing. Pediatrics. 2008;122(5):e988-e993. (Retrospective chart review; 249 patients)
25. Dionne JM, Harris KC, Benoit G, et al. Hypertension Canada’s 2017 guidelines for the diagnosis, assessment, prevention, and treatment of pediatric hypertension. Can J Cardiol. 2017;33(5):577-585. (Review article)
26. Chhadia S, Cohn RA, Vural G, et al. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol. 2013;43(12):1549-1556. (Retrospective study; 62 patients)
27. Castelli PK, Dillman JR, Kershaw DB, et al. Renal sonography with Doppler for detecting suspected pediatric renin-mediated hypertension – is it adequate? Pediatr Radiol. 2013;44(1):42-49. (Retrospective study; 47 patients)
28. Rountas C, Vlychou M, Vassiou K, et al. Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography. Ren Fail. 2007;29(3):295-302. (Prospective review; 58 patients)
29. Fischer M, Schmutzhard E. Posterior reversible encephalopathy syndrome. J Neurol. 2017;264(8):1608-1616. (Review article)
30. Perez MI, Musini VM, Wright JM. Pharmacological interventions for hypertensive emergencies. Cochrane Database of Syte Rev. 2008(1):CD003653. (Review article)
31. Egger DW, Deming DD, Hamada N, et al. Evaluation of the safety of short-acting nifedipine in children with hypertension. Pediatr Nephrol. 2002;17(1):35-40. (Retrospective review; 166 patients)
32. Blaszak RT, Savage JA, Ellis EN. The use of short-acting nifedipine in pediatric patients with hypertension. J Pediatr. 2001;139(1):34-37. (Retrospective review; 117 patients)
33. Flynn JT. Nifedipine in the treatment of hypertension in children. J Pediatr. 2002;140(6):787-788. (Review article)
34. Rouine-Rapp K, Mello DM, Hanley FL, et al. Effect of enalaprilat on postoperative hypertension after surgical repair of coarctation of the aorta. Pediatr Crit Care Med. 2003;4(3):327-332. (Prospective randomized trial; 14 patients)
35. Towe E, Tobias JD. Preliminary experience with clevidipine in the pediatric population. J Intensive Care Med. 2010;25(6):349-352. (Retrospective cohort; 10 patients)
36. Tobias JD, Tulman DB, Bergese SD. Clevidipine for perioperative blood pressure control in infants and children. Pharmaceuticals (Basel). 2013;6(1):70-84. (Review article)
37. Chandar J, Zilleruelo G. Hypertensive crisis in children. Pediatr Nephrol. 2011;27(5):741-751. (Review article)
38. Bunchman TE, Lynch RE, Wood EG. Intravenously administered labetalol for treatment of hypertension in children. J Pediatr. 1992;120(1):140-144. (Retrospective review; 13 children)
39. Thomas CA, Moffett BS, Wagner JL, et al. Safety and efficacy of intravenous labetalol for hypertensive crisis in infants and small children. Pediatr Crit Care Med. 2011;12(1):28-32. (Retrospective review; 27 patients)
40. Tabbutt S, Nicolson SC, Adamson PC, et al. The safety, efficacy, and pharmacokinetics of esmolol for blood pressure control immediately after repair of coarctation of the aorta in infants and children: a multicenter, double-blind, randomized trial. J Thorac Cardiovasc Surg. 2008;136(2):321-328. (Randomized controlled multicenter trial; 116 patients)
41. Wiest DB, Garner SS, Uber WE, et al. Esmolol for the management of pediatric hypertension after cardiac operations. J Thorac Cardiovasc Surg. 1998;115(4):890-897. (Open-label prospective trial; 20 patients)
42. Hammer GB, Lewandowski A, Drover DR, et al. Safety and efficacy of sodium nitroprusside during prolonged infusion in pediatric patients. Pediatr Crit Care Med. 2015;16(5):397-403. (Prospective randomized controlled trial; 63 patients)
43. Flynn JT, Mottes TA, Brophy PD, et al. Intravenous nicardipine for treatment of severe hypertension in children. J Pediatr. 2001;139(1):38-43. (Retrospective review; 29 children)
44. Nakagawa TA, Sartori SC, Morris A, et al. Intravenous nicardipine for treatment of postcoarctectomy hypertension in children. Pediatr Cardiol. 2004;25(1):26-30. (Retrospective review; 10 patients)
45. Treluyer JM, Hubert P, Jouvet P, et al. Intravenous nicardipine in hypertensive children. Eur J Pediatr. 1993;152(9):712-714. (Retrospective review; 14 patients)
46. Dionne JM, Flynn JT. Management of severe hypertension in the newborn. Arch Dis Child. 2017;102(12):1176-1179. (Review article)
47. Batisky DL. Neonatal hypertension. Clin Perinatol. 2014;41(3):529-542. (Review article)
48. Becker AM, Goldberg JH, Henson M, et al. Blood pressure abnormalities in children with sickle cell anemia. Pediatr Blood Cancer. 2013;61(3):518-522. (Prospective analysis; 52 patients)
49. Falkner B, Gidding SS, Portman R, et al. Blood pressure variability and classification of prehypertension and hypertension in adolescence. Pediatrics. 2008;122(2):238-242. (Retrospective cohort; 8535 subjects)
50. Moore LL, Bradlee ML, Singer MR, et al. Dietary approaches to stop hypertension (DASH) eating pattern and risk of elevated blood pressure in adolescent girls. Br J Nutr. 2012;108(9):1678-1685. (Database review; > 2000 patients)
51. Couch SC, Saelens BE, Levin L, et al. The efficacy of a clinic-based behavioral nutrition intervention emphasizing a DASH-type diet for adolescents with elevated blood pressure. J Pediatr. 2008;152(4):494-501. (Prospective study; 57 patients)