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Hypertension in Children

Hypertension (high blood pressure) is usually thought of as a problem of older adults. In fact, almost 90% of 80 year olds have hypertension. However, hypertension has become increasingly common in children, perhaps related to increased incidence of childhood obesity. One study estimates that approximately 20% of adolescents qualify as having hypertension.


Hypertension has long been labeled the “silent killer”, and in fact most children with high blood pressure have no symptoms. However, the increased pressure in the body’s blood vessels slowly and silently damages them. Over decades this damage, especially when combined with other risk factors for blood vessel injury (like obesity, diabetes, high cholesterol, or tobacco use) increases the risk of organ damage, especially heart attacks and strokes.

Because hypertension has no symptoms, pediatricians will routinely check blood pressure with well child evaluations, beginning at age 3 years. Most persons are aware that there are 2 blood pressure measurements, the systolic (measurement of pressure within blood vessels when the heart is pumping blood) and diastolic (measurement of pressure within blood vessels when the heart is at rest). Though persons with hypertension generally have elevation of both systolic and diastolic pressure, some children and adolescents will have elevation of one or the other, especially in early stages (usually the systolic is high).

A common question at this point is what is a normal blood pressure for children and what blood pressure qualifies as hypertension. In adults, a normal blood pressure is 120/80 or less and hypertension is 140/90 or higher. Blood pressures in between are labeled “high normal”. Normal blood pressure in children varies by age, sex, and height. Studies over time have used these factors to establish parameters for normal, high normal, and hypertension, in children.

If the systolic or diastolic blood pressure with the well child evaluation (or with measurement for any other reason) is elevated the next step generally is multiple repeat measurements. Blood pressure normally goes up and down during the day due to a variety of circumstances, such as stress. Thus, repeat testing should be done in as stress free setting as possible.  Sometimes that means checks by a nurse at school or perhaps at home. If the majority of these readings are elevated, children are usually referred for evaluation by a pediatric specialist with expertise in diagnosing and treating hypertension.


Adults with hypertension usually have “essential” hypertension, meaning that there is no underlying hormone, kidney, or other problem causing the blood pressure to be high. Most children also have essential hypertension, though some, especially younger children, will have an underlying problem. The specialist evaluating your child will decide what testing should be done to check for a “secondary” cause of hypertension. This might mean blood and urine tests, ultrasound or other x-rays. If a secondary cause for hypertension is diagnosed, the pediatric specialist doctor will discuss treatment options.



Modification of diet is important for almost all children and adolescents with hypertension. Decreasing salt (sodium) in the diet is usually advised and can lower blood pressure in some circumstances. Most salt in diet comes from processed and canned foods. We generally suggest that diet sodium be limited to 2000 or 3000 mg a day (the typical American diet has 4000-8000 mg daily). There are multiple good sodium counter apps that can be downloaded for free or $1. In terms of effectiveness of changing diet we believe that the more actively engaged your child, the more likely success. We encourage children to use technology to become familiar with the content of what they eat and how changes can be made. Similarly, we often suggest following principles of the DASH (dietary approaches to stop hypertension) diet. The DASH diet emphasizes whole grains, lean meats, low fat and no fat dairy, fruit and vegetable. There are multiple resources that can be accessed to fashion meals consistent with the DASH diet principles. Again, apps for these can be accessed for free or little cost. Involving your child and the entire family in these efforts maximizes success.

Overweight children will see many benefits of weight loss, including blood pressure lowering. We generally emphasize a diet low in simple sugars and carbohydrates with little or no fiber. This means limitation of breads, pastas, and rice. Beverages should be free of calories, except for a glass of no fat milk daily (if desired). There is also sugar (and salt) added to many processed foods and sauces. Again, we suggest engagement in technology to learn sugar content of many foods and fashioning a family plan to modify meals, as necessary.

We also advise avoidance of caffeine. Certain over the counter medications should also be avoided, particularly nasal decongestant sprays and cold remedies that contain decongestant medication (such as pseudophedrine, ephedrine, phenylephrine, naphazoline, and oxymetazoline). Supportive measures such as increasing home humidity, saline nasal sprays, and measures to sooth the throat (honey has been shown to be useful), should be attempted.


Dietary modifications alone may not be enough to lower blood pressure into a desired range. Some families find starting medication for treating hypertension in children and adolescents discouraging. Fortunately though, side effects of anti-hypertensive medication at this age are unusual. In almost all cases, the risks of long-standing high blood pressure are much greater than the risk of side effect, especially with present dosing strategies (see below).

There are four main classes of anti-hypertensive medication. No one class of medication works for everyone, but almost all patients will respond to at least one class of therapy. In the past, the medication strategy had been to try one class of medication, and if initial response not optimal at that dose, increase toward the maximum for that drug. However, studies have demonstrated that increasing the dose only improved blood pressure modestly, but increased the risk for side effect more significantly (except for ACE inhibitors and ARB medications where side effects did not increase with higher doses). Thus, present strategy generally is to start a modest dose of a particular medication. If blood pressure response not optimal a modest dose of a second drug in a different class is then started. This strategy improves blood pressure the best and minimizes side effects.

Of note, any medication that lowers blood pressure can initially cause dizziness or light-headedness. As the body adjusts to the lower blood pressure these symptoms generally improve, usually over a few days or a couple of weeks. Please note, that the potential side effects noted below are not a comprehensive list. Also note that the majority of young persons taking these medications do not have significant side effects.

The four main classes of medications are:

  1. ACE (Angiotensin Converting Enzyme) inhibitors/ARB (Angiotensin Receptor Blocker)
    These medications relax blood vessels by blocking a hormone produced by the kidney. These medicines can be particularly useful in patients with diabetes as they can reduce kidney damage in this circumstance. Most patients have few side effects. ACE but not ARB medications can cause cough or constant throat clearing. Both can increase blood potassium and in unusual circumstances temporarily decrease kidney function. Periodic blood testing may thus be necessary. In addition, these medications can be associated with birth defects, especially heart defects, in unborn children. Thus, females of child bearing age must attempt to avoid pregnancy. Of note, the most serious birth defects occur with use in the second and third trimesters.
    • Lisinopril
    • Enalapril
    • Ramipril
  2. Calcium Channel blockers
    These medications also relax blood vessels. Again, most patients have few side effects, occasionally constipation, flushing, or fluid retention.
    • Amlodipine
    • Nifedipine
    • Isradipine
  3. Diuretics
    These medications increase the urine and sodium elimination in the kidney. Side effects include low blood potassium, high blood uric acid, increased cholesterol. Thus, periodic blood tests may be required.
    • Hydrochlorothiazide
    • Chlorthalidone
    • Furosemide
  4. Beta Blockers
    These medications slow heart rate and relax blood vessels. Side effects can include fatigue (especially with exercise), cold hands, headaches, constipation.
    • Metoprolol
    • Atenolol