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What is hypertension?

Most people think of hypertension (high blood pressure) as something that affects adults, but children can also be affected. In fact, it’s estimated that up to 5 percent of children and adolescents now have hypertension.

While children with hypertension don’t carry the same immediate risks that adults with hypertension face, high blood pressure can still cause changes in your child’s body that put him or her at risk for complications later in life. That’s why it should be taken very seriously.

  • Hypertension can have physical, behavioral, and genetic causes.
  • Most infants are young children with hypertension have secondary hypertension, meaning that it’s the result of a known medical condition, such as kidney, heart, or endocrine disorders
  • Primary hypertension means that it seems to occur on its own, without being associated with another disease.
  • In the early stages of hypertension, children may have no symptoms.
  • If left untreated, hypertension can persist into adulthood.
  • Hypertension can often be treated with lifestyle modification, such as changing to a more healthful diet and increasing physical activity.
  • Hypertension is different than pulmonary hypertension in that hypertension is found throughout the body, while in pulmonary hypertension, hypertension is found only in the vessel that carries blood from the heart to the lungs, the pulmonary arteries.

How common is hypertension in children?

Hypertension is becoming increasingly common in children and adolescents. A recent study that looked at 15,000 adolescents found that nearly one in five had hypertension. And there’s reason to believe that hypertension is vastly underdiagnosed in children, since:

  • It can be difficult to measure in infants and young children
  • It’s sometimes challenging to identify
  • It’s often thought of as not something that really affects kids

The rise in the number of children with primary hypertension in the United States is thought to correlate with the rise of obesity.

What complications are associated with hypertension?

While kids with hypertension are unlikely to have heart attacks and strokes, it still has significant risks. Hypertension causes changes in the structures of the blood vessels and heart. Since hypertension in children has historically been understudied, there isn’t a lot of data about exactly what these changes mean. But we do know that in adults, hypertension increases the chance of complications in the heart, blood vessels, and kidneys. There’s also compelling evidence that some of these changes are seen in children with high blood pressure.

These changes affect:

  • Blood vessels: High blood pressure can damage blood vessels throughout the body, which makes it harder for organs to work efficiently.
  • Kidneys: If the blood vessels in the kidneys are damaged, they may stop removing waste and extra fluid from the body. This extra fluid can raise blood pressure even more.
  • Other organs: If left untreated, hypertension makes it harder for blood to reach many different parts of the body, including the eyes and the brain, and can lead to blindness and strokes.

How is blood pressure measured?

Blood pressure is measured in millimeters of mercury (mm Hg). A typical normal blood pressure in an adult is 120/80 mm Hg, or "120 over 80." The top number refers to the pressure when the heart is pushing blood out through the arteries (systolic). The bottom number refers to the pressure when the heart is at rest — “between beats” (diastolic).

It’s easy to tell whether an adult has hypertension, because there’s a standard set of measurements:

  • Normal blood pressure: Systolic < 120 mmHg and diastolic < 80 mm Hg
  • Pre-hypertension: Systolic 120-139 mmHg or diastolic 80-89 mmHg
  • Stage 1 hypertension: Systolic 140-159 mmHg or diastolic 90-99 mmHg
  • Stage 2 hypertension: Systolic ≥160 or diastolic ≥100 mmHg

But it’s harder with children. That’s because there are no universal cut-offs as there are for adults; instead, whether a child has hypertension depends on how his blood pressure compares to his peers (determined by gender, height, and age).

  • Pre-hypertension: 90th to 95th percentile
  • Stage 1 hypertension: 95th–99th (plus 5 mm mercury)
  • Stage 2 hypertension: Anything higher than 99th plus 5 mm mercury

Symptoms & Causes

What are the signs and symptoms of hypertension?

Often, kids and teens with pre-hypertension or stage 1 hypertension won’t show any symptoms at all. If your child has stage 2 hypertension, she might experience one or more of the following symptoms:

An infant with stage 2 hypertension may seem irritable, not be feeding properly, or vomiting. Sometimes these infants are diagnosed with “failure to thrive.”

What causes hypertension in children?

Primary hypertension

Primary hypertension means that the hypertension does not seem to be caused by some other underlyng medical condition. Many doctors think that the incidence of childhood or adolescent hypertension has been rising along with the obesity epidemic. The majority of teens and children over age 6 with hypertension have a family history of hypertension and/or are overweight.

Secondary hypertension

Secondary hypertension is caused by a known underlying medical condition. Of these, about

  • 80 percent of children have some kind of kidney disease or blood vessel abnormalities
  • 5 percent have an endocrinological disorder
  • 2 to 5 percent have heart disease

Hypertension in infants with hypertension almost always has a secondary cause. In addition, premature infants have a higher incidence of hypertension.

Among kids with hypertension, especially those who are very young, secondary hypertension is more common than primary hypertension. But among children who are older than 6 to 8 years old, the ratio of primary to secondary hypertension is approaching 50/50.

Diagnosis & Treatments

How are young children diagnosed with hypertension?

It can be challenging to diagnose hypertension in infants because most pediatricians don’t start checking blood pressure until a child is 2 years old. But if an infant has risk factors for hypertension, her doctors will monitor her blood pressure. These factors include:

  • Being born prematurely
  • Having a history of urinary tract infections or other kidney problems
  • Having a history of heart disease
  • Being small for gestational age/weight at birth

Hypertension in an infant has a much higher probability of being caused by an underlying condition, so doctors are very thorough when looking for signs of one. In addition to the diseases and conditions they’d look for in an older child, they’ll also look for blood vessel malformations of the aorta and kidney.

After we complete all necessary tests, our experts meet to review and discuss what they have learned about your child's condition. Then we will meet with you and your family to discuss the results and outline the best treatment options.

How do we treat hypertension?

Most primary hypertension can be treated with changes in diet and exercise habits, and if necessary, there are medications that can help, too.

Your child's treatment plan may depend on:

  • Whether the hypertension is primary or secondary (if secondary, treating the underlying condition may help resolve the hypertension)
  • The severity of blood pressure elevation

Infants may be treated with doses of liquid medication or with medicines given through an IV if they are hospitalized.

Premature infants sometimes have hypertension that starts right in the neonatal period or in the first couple months of life. We generally start these infants on medication to stabilize their hypertension. Some of these infants grow out of their hypertension and are able to stop medication when they are 1 to 2 years old.

How Boston Children’s Hospital approaches hypertension

In the Hypertension Program at Boston Children's, we:

  • Provide comprehensive care for children and adolescents with high blood pressure
  • Conduct a thorough evaluation based on a child’s presentation to determine if there is an underlying cause for the elevated blood pressure
  • Provide guidance to promote reductions in blood pressure reduction through lifestyle modification
  • Assess any complications of high blood pressure
  • Promote proper high blood pressure screening throughout Boston Children’s and the greater community

Our experts evaluate and care for children with hypertension in our Boston and Peabody locations.

What's the long-term outlook for my child?

Every child is different, but in general, the outlook for kids with hypertension is quite good. It can almost always be well-managed with medications and/or changes in diet and exercise.

FAQs

Frequently asked questions

Pediatricians are making great efforts to prevent obesity and stem the tide of problems that accompany it. We believe that promoting healthy lifestyle choices will help combat this trend and will go a long way toward preventing primary hypertension in children (and keep adults healthier, too).

Some things are being done — nutritional information is being made more readily available, there’s one push to provide healthy options in schools and another to remove soft drinks from them — but still, it often comes down to families making the right decisions. We are dedicated to educating families to assist with appropriate dietary and activity choices to improve overall health and reduce the risk of hypertension.

It’s hard to say. Researchers are starting to see that kids and adolescents with pre-hypertension are more likely to develop stage 1 hypertension, but we don’t know if  or when stage 1 hypertension will progress to stage 2.

In some cases, secondary hypertension can be “fixed.” For example, if:

  • It’s caused by a narrowing in a blood vessel that the doctors are able to widen
  • It’s caused by a rare endocrine tumor that doctors are able to treat successfully

There are also cases in which hypertension might be transient; for example, if it’s caused by a temporary inflammation of the filters in the kidney.

Even when hypertension can’t be “fixed,” it can almost always be well-controlled, with diet and exercise and/or medication.

Keep an eye out for:

  • Chest pains
  • Severe headaches that don’t seem to respond to at-home treatment
  • Changes in vision
  • Nausea
  • Swelling of hands and feet
  • Shortness of breath with limited exertion
  • Changes in her urine (such as lack of urine production, urine that is brown or tea-colored)

Call your child’s doctor if she experiences any of these symptoms.

Only a fraction of kids with hypertension require medication. Frequently, it’s treated with diet and exercise modification first. And if the child is overweight, every kilogram (around 2 pounds) of weight she loses, her blood pressure could bring her blood pressure down by about a point.

While children with hypertension are more likely to have it as adults, it’s not necessarily always the case. This depends on factors including the cause of the hypertension and how it responds to treatment.

For children with pre-hypertension or stage 1 hypertension, changing to a more healthful diet and exercising more is often enough to manage the hypertension. For children with more severe hypertension, medication is often necessary.

Not necessarily. If your child has primary hypertension, appropriate lifestyle modifications may allow for medications to be stopped. In addition, if a secondary cause is identified and successfully treated, medications may not be necessary.

“White coat hypertension” is when a child’s blood pressure readings are high at the doctor’s office (mostly because she’s anxious, which can cause blood pressure to rise), but normal outside of the office (for example at home or at school).

This is pretty common in kids. By some estimations, between 30 and 40 percent of kids who have high blood pressure in the office actually have white-coat hypertension.

White coat hypertension is still a risk. Everyone’s blood pressure changes from time to time — it’s lower when you’re asleep, for example — but if a child’s blood pressure continually rises when she’s anxious (such as before a test), it can be sign of high blood pressure at other times and potentially cause the same kinds of damage that standard hypertension causes.

White coat hypertension is diagnosed by taking the child’s blood pressure outside of the doctor’s office. This can be done in different ways:

  • Some parents feel comfortable doing it at home.
  • Sometimes we make arrangements for a school nurse to check the child’s blood pressure.
  • Your child’s doctor might recommend that she wear an ambulatory blood pressure monitoring device — a blood pressure cuff attached to a small device that sits on her belt and measures her blood pressure at regular intervals over the course of 24 hours. This device is about the size of a deck of cards and is usually tolerated very well.

If your child is diagnosed with white coat hypertension, her doctor may still want to follow her, since some children with white coat hypertension will develop actual hypertension in the future.

Research & Clinical Trials

Our areas of innovation for hypertension

Boston Children's Hospital is home to the world’s largest research program at a pediatric institution, and we’re known for pioneering new treatments. A large part of our success comes from our commitment to research—and to advancing the frontiers of what’s possible through our innovative approach.

Our Hypertension Program is in the process of building collaborations and partnerships with children’s hospitals and other institutions around the country, trying to understand pediatric cardiovascular risk factors such as hypertension and how they link up to adult arteriosclerotic heart disease.

Our clinicians are also involved with:

  • Adapting techniques used to research cardiovascular risk in adults for children
  • Integrating blood pressure measurement data into Children’s electronic records
  • Retraining clinical assistants, nurses and other staff members about how to measure kids’ blood pressure appropriately, compare the readings to the appropriate norms and encourage the kids to have follow-up and treatment if necessary
  • Developing a protocol to ensure that high blood pressure in children is cared for in the same way across various departments within Boston Children’s