Treatment options for children and adolescents with hypertension (high blood pressure) are similar to those available for adults. Because children typically have better general health, more physical reserve, and fewer formed habits than adults, considerable effort is spent on modifying lifestyle factors that can contribute to elevated blood pressure.
Initial Evaluation
The first step in treating children with hypertension is to determine whether the hypertension is primary (no obvious cause)or secondary (due to some underlying cause). This first step is vital because, in many cases, treating an underlying disorder can return the blood pressure to normal without the need for additional treatment.
Figuring out if high blood pressure is the result of some underlying medical condition is somewhat complicated, and will likely require a full medical workup, including blood tests and, possibly, imaging studies (CT Scan, MRI). Some general guidelines are:
- Disturbances in attention or energy level may indicate secondary hypertension
- Elevated creatinine could be a sign of hypertension caused by kidney problems
- Very young children are more likely to have secondary hypertension, while older children and adolescents are more likely to have primary hypertension
- Children with a family history of hypertension and/or obesity are more likely to have primary hypertension
Lifestyle Changes
In children with mild to moderate hypertension, treatment almost always begins by focusing on modifiable lifestyle factors. The NHBPEP (National High Blood Pressure Education Program), a respected consortium of doctors and scientists, specifies a set of “therapeutic lifestyle changes,” which are the recommended focus of initial therapy in children. These changes include:
Each of these lifestyle changes carries special importance. Weight reduction – the most important factor – helps to reduce blood pressure and avoid future resistance to drug therapy. Regular exercise is effective for weight control, and also helps improve the general health of the cardiovascular system. Diet modification, including salt restriction (<100 meq/day) and decreased fat consumption (through increased consumption of fresh fruits and vegetables), encourages healthy eating habits that will last a lifetime. Avoiding smoking and excessive alcohol intake are two steps that not only improve blood pressure, but also reduce the risk of many other, serious diseases.For female adolescents, it may be necessary to avoid oral contraceptives. Newer oral contraceptives have lower hormone levels than older formulations, but still have a tendency to raise blood pressure.
Drug Therapy
NHBPEP guidelines state that one of the following criteria should be present before drug therapy is initiated in children:
- Symptomatic hypertension (Headaches, changes in mental processes or consciousness, increased urination, irritability)
- Evidence that the high blood pressure is causing damage to other organ systems. In children, this typically shows up as an enlarged heart chamber (left ventricular hypertrophy) or changes in the blood vessels of the retina
- Coexisting diabetes – All children with high blood pressure and diabetes should receive drug therapy to avoid long-term kidney damage and prevent early death
- Additional cardiovascular risks – Children with high cholesterol, known heart problems, or severe obesity should be started on drug therapy
Recent evidence has questioned the effectiveness of beta blockers in children, but they remain a standard therapeutic tool at this time. Very good results have been reported with calcium channel blockers and, more recently, angiotensin receptor blockers (ARBs). As in all patients, treatments with the least number of side effects are preferred.
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Treatment Goals
Whether the treatment of choice is lifestyle modification or drug therapy, the goal of treatment is the same – to reduce blood pressure back down to safe levels. The NHBPEP recommends that target blood pressure in children be:
- Less than the 95th percentile in children with no other existing diseases
- Less than the 90th percentile in children with diabetes, organ damage, or coexisting cardiovascular risk factors
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