1. Management of High Blood Pressure in Children and Adolescents: Recommendations of the European Society of Hypertension
Empar Lurbe – Chairperson; Renata Cifkova; J Kennedy Cruickshank; Michael J Dillon; Isabel Ferreira; Cecilia Invitti; Tatiana Kuznetsova; Stephane Laurent – Ex officio; Giuseppe Mancia – Ex officio; Francisco Morales-Olivas; Wolfgang Rascher; Josep Redon; Franz Schaefer; Tomas Seeman; George Stergiou; Elke Wühl; Alberto Zanchetti

2. Hypertension in Children and Adolescents: Recommendations of the ESH
Introduction and purpose
Definition and classification
Diagnostic evaluation
Preventive measures
Evidence for therapeutic management
Therapeutic strategies
Therapeutic approaches under special conditions
Treatment of associated risk factors
9. Screening of secondary forms
10. Long-term follow-up
11. Future research
12. Implementation of guidelines
13. Bibliography
Figures
Tables
Boxes

3. Introduction and Purpose (I)
There is growing evidence that children and adolescents with mild BP elevation are much more common than was thought in the past
Longitudinal studies have demonstrated that BP abnormalities in those age ranges do not infrequently translate into adult hypertension
Hypertension in children and adolescents has gained ground in CV medicine thanks to the progress made in several areas of pathophysiological and clinical research

4. Introduction and Purpose (II)
The remoteness of cardiovascular events from the BP values of many years before makes the relationship between those BP values and the events difficult to establish
Large intervention studies are lacking, and therefore cannot provide hints about cutoffs for evidence-based recommendations
Many of the classifications and recommendations in children are based on statistical considerations and are the result of assumptions or extrapolations from evidence obtained in adults

5. Characteristics of blood pressure
Introduction and Purpose
Characteristics of blood pressure
Blood pressure increases during growth and maturation
Adolescence is a fast growth period during which body mass and BP change rapidly
Reference BP values over the last few decades have been referred to as ones specific for sex, age and/or height

6. Definition and classification
SBP and/or DBP Percentile
Normal
<90th
High-normal
≥ 90th to <95th
≥ 120/80 even if below 90th percentile in adolescents
Stage 1 hypertension
95th percentile to the 99th percentile plus 5 mmHg
Stage 2 hypertension
>99th percentile plus 5 mmHg

7. Diagnostic algorithm of hypertension
Definition and classification
Diagnostic algorithm of hypertension
SBP and/or DBP
<P90th
>P90th
NORMOTENSION
Repeated
measurements
<P90th
P90-95th
≥P95th
NORMOTENSION
FOLLOW-UP
HYPERTENSION
Evaluation for
etiology and
organ damage
Repeated
measurements
Figure 1

8. Blood pressure measurement
Diagnostic evaluation
Blood pressure measurement
The recommended method is auscultatory
Use K1 for systolic BP and K5 for diastolic BP
If the oscillometric method is used, the monitor needs to be validated for this age group
If hypertension is detected by the oscillometric method, it needs to be confirmed using the auscultatory method
Use the appropriate cuff size according to arm width
Children above 3 years of age who are seen in a medical setting should have their BP measured
In younger children, BP should be measured under special circumstances that increase the risk for hypertension
Box 1

9. Indications for 24-hour ABPM
Diagnostic evaluation
Indications for 24-hour ABPM
During the process of diagnosis
Confirm hypertension before starting antihypertensive drug treatment
Type 1 diabetes
Chronic kidney disease
Renal, liver or heart transplant
During antihypertensive drug treatment
Evaluation of refractory hypertension
Assessment of BP control in children with organ damage
Symptoms of hypotension
Clinical trials
Other clinical conditions
Autonomic dysfunction
Suspicion of catecholamine-secreting tumours
Box 2

10. Evaluation of organ damage
Diagnostic evaluation
Evaluation of organ damage
Organ damage is common and LV hypertrophy is the most prominent type
Echocardiography should be performed. Left Ventricular Hypertrophy is an indication to initiate or intensify antihypertensive therapy
Microalbuminuria is recommended for routine clinical use
Carotid intima-media thickness, arterial stiffness, retinal and CNS assessment are not recommended for routine clinical use

11. Evaluation for Secondary Hypertension
Screening for secondary forms
Evaluation for Secondary Hypertension
Very young children with Stage 1 or Stage 2 hypertension
Children or adolescents with Stage 2 hypertension
Age-distribution of hypertension etiologies
> 10 years
Essential Hypertension
Renal Parenchymal Disease
Exogenous Hypertension (drugs)
Endocrine Disorders
Coarctation of the aorta
Mendelian Genetic Disorders
< 1 month
Renal arterial thrombosis
Congenital renal disease
Umbilical canalization
Bronchopulmonary dysplasia
>1 month to <6 years
Renal parenchymal disease
Coarctation of the aorta
Renovascular disease
> 6 years to 10 years
Renal parenchymal disease
Renovascular disease
Essential hypertension

12. Life style recommendations to reduce high BP values
Preventive measures
Life style recommendations to reduce high BP values
GOAL
Maintain or achieve BMI <85th
GENERAL RECOMMENDATIONS
Moderate to vigorous physical aerobic activity 40 minutes, 3-5 days/week and avoid more than 2 hours daily of sedentary activities
Avoid intake of excess sugar, excess soft drinks, saturated fat and salt and recommend fruits, vegetables and grain products
Implement the behavioural changes (physical activity and diet) tailored to individual and family characteristics
Involve the parents/family as partners in the behavioural change process
Provide educational support and materials
Establish realistic goals
Develop a health-promoting reward system
Competitive sports participation should be limited only in the presence of uncontrolled stage 2 hypertension
Box 6

13. When to initiate antihypertensive treatment
Evidence for therapeutic management
When to initiate antihypertensive treatment
Life threatening
hypertension
High-normal BP
Hypertension
One or more of the following conditions:
Symptomatic
Secondary
Organ damage
Diabetes NO
YES
Nonpharmacological
treatment
Pharmacological
treatment
Figure 3

14. Blood pressure targets
Evidence for therapeutic management
Blood pressure targets
In general
BP <90th age, sex and height specific percentile
Chronic kidney disease
BP <75th percentile in children without proteinuria and <50th percentile in cases of proteinuria
24-hour ABP strongly recommended.
Goals: <75th percentile in children without proteinuria and <50th percentile in cases of proteinuria

15. How to initiate antihypertensive treatment
Therapeutic strategies
How to initiate antihypertensive treatment
Particular conditions
Stage 2
Chronic kidney disease
Secondary
All hypertensives
Monotherapy
(low dose
4-8 w)
No response
Monotherapy
(full dose)
No response
Switch
drug
Side effects
No response
Combination
therapy

16. Therapeutic strategies
Antihypertensive agents with efficacy and safety studies in children and adolescents
Class
Efficacy studies
Diuretics
Clorthalidone, HCZT
b-blockers
Atenolol, Metoprolol, Propanolol
CCB
Amlodipine, Felodipne, Isradipine
ACEi
Captopril, Enalapril, Fosinopril, Lisinopril, Quinapril, Ramipril
ARB
Candesartan, Irbesartan, Losartan, Valsartan

17. Long-term follow-up Long-term follow-up
Initial frequent follow up visits to monitor
BP control, organ damage
Side effects of treatment
Other reversible risk factors
Once BP stable and in target range, frequency of visits can be reduced
Home monitoring of BP or 24 hour ABPM can facilitate follow up assessments
Dependent on the underlying cause of hypertension, further investigative procedures may be indicated to monitor success of surgical intervention or medical treatment

18. Future research Future research
Develop accurate non-mercury sphygmomanometer for auscultatory BP measurement and oscillometric BP
Reference values for office, home and ambulatory BP based on a European pediatric population
Increase knowledge in the use of out-of-office BP measurements
Collect information about early organ damage to refine risk stratification and use the information to set intermediate objectives during treatment
Box 10

19. Future research Future research
Conduct controlled studies with antihypertensive drugs in order to improve knowledge about specific benefits and disadvantages of BP lowering agents and establish adequate doses
Conduct large, long term randomized therapeutic trials using onset of organ damage to obtain information about when to initiate antihypertensive drug treatment and about BP goals
Box 10

20. Implementation of Guidelines
Implementation guidelines
Implementation of Guidelines
Joint efforts should be started so as to promptly implement the guidelines
Synergistic actions at various levels (learned societies, expert committees, GPs, pediatricians, nurses and other healthcare providers, school, parents and policy makers) should be encouraged to participate
The role of learned Societies, particularly ESH, is crucial for spreading the guidelines and the acceptance by National Hypertension Societies and Leagues
Active support of research is necessary in order to gain knowledge helpful to future developments in the field, so studies that are recommended should be promptly initiated

21. Hypertension in Children and Adolescents: Recommendations of the European Society of Hypertension
Renata Cifkova, Prague
J Kennedy Cruickshank, Manchester
Michael J Dillon, London
Isabel Ferreira, Maastricht
Cecilia Invitti, Milan
Tatiana Kuznetsova, Leuven
Stephane Laurent, Paris - Ex officio
Empar Lurbe, Valencia – Chair
Giuseppe Mancia, Milan - Ex officio
Francisco Morales-Olivas, Valencia
Wolfgang Rascher, Erlangen
Josep Redon, Valencia
Franz Schaefer, Heidelberg
Tomas Seeman, Prague
George Stergiou, Athens
Elke Wühl, Heidelberg
Alberto Zanchetti, Milan