US Pharm. 2014;39(2):57-60.
ABSTRACT: The prevalence of hypertension in
pediatrics is a serious topic that has continued to gain exposure among
the healthcare community. Many conversations about the health status of
the American population, particularly the growing concern surrounding
trends in obesity, have brought new focus to the prevalence of
hypertension in children. As a result, healthcare practitioners,
principally pharmacists, must be adequately prepared to engage with and
assist other members of the healthcare team in this realm. The article
summarizes information pertinent to facilitating clinical
recommendations regarding the safe and effective use of the treatment
options available for this special population.
Pediatric hypertension (HTN) has become a growing problem
over the past decade. It is estimated that 3% to 5% of the pediatric
population is currently affected.1 The steady increase in the
occurrence of HTN within pediatric patients has been associated with
childhood obesity, the advancement in diagnosing childhood HTN, and the
implementation of a national databank established by the National High
Blood Pressure Education Program (NHBPEP) Working Group on Children and
Adolescents.1-4 The development of HTN among pediatric
patients raises several concerns for healthcare providers. These
concerns focus on an increased risk of developing cardiovascular disease
(CVD) as well as on risk associated with developing sustained HTN in
early adulthood patients.4,5 The following summarizes
recommendations for consideration by pharmacy practitioners as they
engage in the treatment of children who may be battling HTN.
There are two types of HTN—primary and secondary. Primary HTN may be due to family history of HTN or cardiovascular disease.4
Secondary HTN, however, is caused by another medical condition, such as
renal disease, heart disease, or an endocrine system disorder. In the
pediatric population, primary HTN is more commonly linked to adolescent
patients (>12 years of age) and is often associated with obesity and
family history of HTN or cardiovascular disease. The normal blood
pressure (BP) range associated with HTN in pediatric patients varies
based on age, sex, and height. Secondary HTN is more common in
preadolescent children and is caused by an underlying disorder.4
Screening, Diagnostics, and Symptoms
Children 3 years of age and older should have their BP
measured each time they present for a healthcare visit. It is
recommended that children younger than 3 years have their BP measured if
they have a previous history of certain conditions, such as prematurity
or other neonatal complications, congenital heart disease, recurrent
urinary tract infections, renal disease, a solid organ or bone marrow
transplant, or elevated intracranial pressure.4
BP Measurement Techniques
The recommended method of BP measurement in children is auscultation (listening to the internal sounds of the body, usually using a stethoscope).4
However, a standard clinical sphygmomanometer with stethoscope should
be used to confirm HTN when readings are ≥95th percentile.2
Children and adolescents awaiting a BP measurement should avoid
stimulant drug use and food and drink containing caffeine, sugar, and
chocolate for 30 minutes prior to the measurement. Sitting quietly for 5
minutes with feet flat on the floor, back supported, and right arm
supported with cubital fossa at heart level prior to the reading is
An appropriately sized cuff should have an inflatable
bladder width of at least 40% of the arm circumference at a point midway
between the elbow and shoulder.4 BP cuff sizes are listed in TABLE 1. If a cuff is too small, BP measurements may be incorrect and overestimated.4 In this case, the next largest cuff size should be used so as to minimize the cuff-size effect on the BP measurement.4
Normal BP for children and adolescents is defined as systolic (SBP) and
diastolic (DBP) blood pressure <90th percentile for sex, age, and
height (e.g., refer to the
Blood Pressure Levels for Boys and Girls by Age and Height Percentile) because it provides a more precise reading according to body size.4,6
It is important to distinguish pediatric HTN from other types of HTN. Pediatric hypertension is diagnosed based on average SBP and/or DBP that is ≥95th percentile for sex, age, and height on three or more office visits.4 An average SBP or DBP level ≥90th percentile, but <95th percentile, is classified as prehypertensive.4 An adolescent with a BP of ≥120/80 mmHg is also considered prehypertensive, despite a DBP reading <90th percentile.4
Pulmonary arterial hypertension (PAH) is a disorder
in which the pulmonary arteries constrict, causing an increase in
resistance to blood flow that results in abnormally high blood pressure
in the pulmonary arteries. PAH is defined as a mean pulmonary arterial
pressure >25 mmHg at rest or >30 mmHg during exercise.6
Symptoms, which include dyspnea, fatigue, chest pain, and peripheral
edema, appear gradually. While HTN refers to the systemic pressure
throughout the body, it is not to be assumed that PAH and HTN will
coexist in a patient.
White-coat hypertension, defined as elevated blood
pressure in a clinical setting, is caused by general anxiety associated
with an office visit. Patients who have BP readings >95th percentile
in a physician’s office but whose average BP in a nonclinical setting is
<90th percentile, are considered to have white-coat HTN.6
As with adult classification of HTN, pediatric HTN is
divided into two stages—stage I and stage II. Patient symptoms such as
headache, dizziness, and altered vision are not stage-specific. Stage I
HTN is defined as BP levels ranging from the 95th percentile to 5 mmHg
above the 99th percentile.6 Stage II HTN represents BP levels >5 mmHg above the 99th percentile.6
Lifestyle modifications may result in decreased blood pressure and an overall decrease in the cardiovascular risk factors.7 The
Dietary Approach to Stop Hypertension (DASH) diet is often initiated in
patients with an increased risk of cardiovascular events, and it should
be considered in symptomatic pediatric patients starting at 12 months
of age.8 The diet promotes a nutrition plan high in fruits
and vegetables, nonfat dairy products, fiber, and low amounts of daily
sodium consumption (1.2 g/day for 4 to 8 years of age and 1.5 g/day for
In addition to dietary modifications, weight loss in
overweight patients and an increase in daily physical exercise are also
beneficial.4 The NHBPEP suggests limiting sedentary activity
throughout the day and conducting 30 to 60 minutes of physical exercise
on 3 to 4 days during the week.9 Scheduled physical exercise
can be achieved by participating in sports or family-based activities
such as walking, biking, and household chores.4
Antihypertensive medication in children and adolescents
should be initiated in the presence of symptomatic HTN, end-organ damage
(e.g., left ventricular hypertrophy, retinopathy, proteinuria),
secondary HTN, stage I HTN that does not respond to lifestyle changes,
and stage II HTN.4 The treatment goal for pediatric HTN is to reduce the DBP to at least the 90th percentile for age and sex.10
In accordance with NHBPEP recommendations, pharmacologic therapy should
be initiated in a stepwise approach. Initiation on a single
antihypertensive agent should begin at the lowest effective dose.11
All of the major classes of antihypertensive medications
can be used in children to some degree. Legislation such as the FDA
Modernization Act of 1997 (FDAMA) and the Best Pharmaceuticals for
Children Act (BPCA) of 2002 have led to the study and approval of
antihypertensive medications for use in the pediatric population (TABLE 2).11-13
Angiotensin-Converting Enzyme Inhibitors (ACEIs): In
comparison with other classes of antihypertensive agents, ACEIs have
the most evidence supporting their use in the pediatric population when
treating HTN.14 Several studies have been conducted with lisinopril in the pediatric population.15
The drug has FDA approval for pediatric HTN patients aged 6 to 16
years. Adverse effects associated with the use of lisinopril include dry
cough, hypotension, hyperkalemia, acute renal failure, and increased
Angiotensin Receptor Blockers (ARBs): Several
studies have demonstrated the efficacy of ARBs in the treatment of HTN
in children. Irbesartan has been studied by von Vigier et al and
Franscini et al with 20 and 44 patients, respectively.16,17
Both studies found a significant decrease in arterial BP with
irbesartan. In general, ARBs tend to be well tolerated by patients, with
cough, headache, dizziness, and hyperkalemia reported as the most
common adverse effects.
Calcium Channel Blockers: Amlodipine and
felodipine have been studied in children aged 6 to 18 years. Amlodipine
was found to significantly lower SBP by 6.9 mmHg with the 2.5-mg dose
and by 8.7 mmHg with the 5-mg dose.18 The once-daily dosing
and low adverse-effect profile make amlodipine an appealing choice.
Felodipine was found to be not as efficacious on reducing SBP.19 The most common adverse effects of calcium channel blockers include headache, flushing, dizziness, and peripheral edema.20
Beta-Blockers: Propranolol, the first beta-blocker to be used in the U.S., is the most common beta-blocker used in children.21 In one study, mean SBP declined by 26 mmHg and mean DBP decreased by 20 mmHg using an average dose of 2.5 mg/kg daily.21 Fatigue is most frequently seen at the beginning of therapy and usually resolves in 4 to 6 weeks postinitiation.14
Diuretics: Despite the fact that diuretics
are commonly recommended for use in pediatric HTN, to date no large
controlled studies have been performed. Hydrochlorothiazide and
chlorthalidone have been reported as successful therapies within the
pediatric community.11 The adverse effects associated with diuretic use include hyperkalemia, hypernatremia, and gynecomastia in males.22
Role of the Pharmacist
Pharmacists can assist patients by aiding in monitoring
BP, promoting lifestyle modifications, verifying therapeutic doses, and
working collaboratively with physicians to identify treatment plans that
befit each patient. Ultimately, pharmacists serve as a resource to
patients through effective counseling, medication therapy management,
and their efforts to promote, improve, and monitor successful patient
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