T h e NE W E NGL A ND JOU R NA L o f M E DICINE

CLINICAL PRACTICE
version of this
article is available
at NEJM.org

This article
was last
updated on
Septem-ber
25, 2014, at
NEJM.org.
N
Eng
lJ
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6-
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DOI
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6/N
EJ
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p10
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Copyright 2014
Massachusetts
Medical Society.
Caren G.
Solomon, M.D.,
M.P.H.,
o
d
Pr
h es
e su
C re
h Juli
il e R.
Ing
d elfin
ger,
o M.D
.
r This Journal feature begins
A highlighting
with a case vignette
a common clinical
d various strategiessupporting
problem. Evidence
is then
o review presented, followed by a
of formal guidelines,
l ends when they exist. The article
with the authors clinical
e recommendations.

s A 13-year-old boy visits his

c pediatrician because his school
football team requires medical
e clearance before the start of the
season. On physical examination,
n his weight is 72 kg (above the 99th
t percentile for age and sex) and his
height is 155 cm (the 50th
wpercentile); his body-mass index
(the weight in kilograms divided by
itthe square of the height in meters)
is 30 (above the 99th percentile).
h His blood pressure is 134/77 mm
EHg (the 99th percentile for systolic
blood pressure and the 90th
l percen-tile for diastolic blood
pressure), and his heart rate is 70
e beats per minute. The serum
v creatinine level is 0.7 mg per
deciliter (62 mol per liter), and
a the urinalysis is normal. He is
otherwise healthy and does not
t report any symptoms. His father
has hyperten-sion and type 2
e diabetes. How should this case be
d further evaluated and treated?
B THE
CLINI
l CAL
PROB
o LEM
 Education Program Working
The Group on High Blood Pressure in
prevalence 4
Children and Adolescents
of elevated (hereinafter called the working
blood group), which was published in
pressure 2004. The report presented a
among reclassification of blood-pressure
children and levels and introduced the concept
adolescents of prehyperten-sion in children
has been and adolescents, just as
increasing prehypertension was added as a
worldwide category for adults in the 2003
in concert report of the Joint National
with the Committee on Prevention, Detec-
marked tion, Evaluation, and Treatment
increase in of High Blood Pressure 7 (JNC
the 5
prevalence 7). The subsequent version of
of obe-sity that report, JNC 8, which was
among the released recently, still includes
1-3 6
young. this catego-ry. A persons blood
Yet the best pressure often follows a given
way to centile over time; this phenom-
7-10
identify enon is called tracking. The
hypertensio working group thought that by
n and the changing the definition of early
youth who hypertension, awareness about
are at hypertension would increase,
greatest risk with resultant better efforts at
for intervention, prevention, or both.
4
hypertensio
n is still Blood-pressure norms for
debated. children and adolescents (and
The most associated cutoff points for
recent prehypertension and hypertension)
normative vary according to percentiles for
4,11-13
blood- age and height. U.S. norms
pressure were determined on the basis of
data on data on more than 60,000 children,
infants, including data from the most recent
children, working group update, which
and added information from the 1999
adolescents 2000 National Health and Nutrition
in the 4
United Examination Sur-vey. For each
States are year of age (through age 17), the
4
from the working group tables list the 50th,
fourth 90th, 95th, and 99th percentiles for
report of the systolic and diastolic blood
National pressure for children who are at the
High Blood 5th, 10th, 25th, 50th, 75th, 90th,
Pressure and 95th percentiles for height (see

2316
N ENGL J MED 370;24 NEJM.ORG JUNE 12, 2014

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October7,2015.
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 CLINICAL PRACTICE

KEY CLINICAL POINTS

ELEVATED BLOOD PRESSURE IN A CHILD OR ADOLESCENT

The prevalence of elevated blood pressure among children and adolescents has
increased in concert with the marked increase in obesity among the young.

Blood-pressure norms (and associated cutoff points for prehypertension and hypertension) for
children and adolescents vary according to percentiles for age and height.

The evaluation of elevated blood pressure in children and adolescents is designed to

detect secondary hypertension, which may be curable.

Management generally starts with nonpharmacologic therapy, followed by pharmacotherapy if the

for-mer approach is not successful; however, pharmacotherapy is initiated early if hypertension is
severe or if there are concomitant conditions such as diabetes mellitus.

Sustained hypertension in the young may be associated with end-organ damage.

Available data suggest that therapy to lower blood pressure can reverse end-organ damage.

the Supplementary Appendix, available with
the full text of this article at NEJM.org). Since
14,15
some studies have shown substantial
underrecog-nition of elevated blood pressure
in children in routine office practice,
simplified versions of these tables, though not
validated, have been developed to help
clinicians identify children and adoles-cents at
risk (Table 1, and www.pedhtn.org/
11-13
BPLimitsChart0112.pdf).
Hypertension is diagnosed in a child or
ado-lescent if the mean systolic blood
pressure or diastolic blood pressure is above
the 95th per-centile for sex, age, and height on
three or more occasions. Prehypertension is
defined as a mean systolic or diastolic blood
pressure at or above the 90th percentile but
below the 95th percentile (Table 2) or blood
pressure of 120/80 mm Hg or greater, even if
the blood pressure is at or below the 90th
percentile. Stage 1 hypertension is de-fined childhood and adolescence.
4
19
several countries showed rates of elevated
blood pressure as high as 17.3% in Brazil,
12.3 to 15.1% in Greece, and 13.8% in the
United States. Available data suggest that if
elevated blood pressure is defined as blood
pressure of more than 120/80 mm Hg, as
20
many as 15% of teens have this condition.
The usefulness of identifying children who
have elevated blood pressure has been
20,21
questioned. However, data suggest that end-
organ damage is present at the time of diagnosis
in a substantial number of children with this
condition. For ex-ample, studies indicate that
left ventricular hy-pertrophy is present in up to
40% of adolescents who have recently received
15,22
a diagnosis of hyper-tension. Increased
rates of death, premature heart failure, coronary
artery disease, and vascu-lar stiffness among
persons younger than 55 years of age have been
associated with elevated blood pressure in
23-26

as blood pressure between the 95th and 99th S TR ATEGIES AND EV IDENCE
percentile plus 5 mm Hg, and stage 2
hyperten-sion is defined as blood pressure EVALUATION
above the 99th percentile plus 5 mm Hg. Many pediatricians offices, clinics, and
In a study involving three blood-pressure hospi-tals use oscillometric devices rather
mea-surements in schoolchildren in Houston
than manual sphygmomanometers to measure
who were 11 to 17 years of age, 19% of the
blood pressure, yet the working group norms
children had elevated blood pressure (15.7% had
16 are derived from measurements obtained with
prehyperten-sion, and 3.2% had hypertension). the latter. Oscillo-metric devices measure
Elevated blood pressure is more common among oscillations in the arte-rial wall and then
children who are overweight or obese than
11,17,18 derive systolic and diastolic blood-pressure
among children of normal weight. A levels with the use of proprietary
study comparing blood-pressure levels in
children and adolescents in

N ENGL J MED 370;24 NEJM.ORG JUNE 12, 2014 2317

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T h e NE W E NGL A ND JOU R NA L o f M E DICINE
th
ey
Table 1. Blood-Pressure m
Thresholds Indicating ay
the Need for Further un
Evaluation, Intervention, de
or Both.* re
Years sti
of Age Boys m
SBP DBP at
e
it.
3 100 59 If
4 102 62 bl
5 104 65 oo
d-
6 105 68
pr
7 106 70 es
8 107 71 -
9 109 72 su
10 111 73
re
le
11 113 74
ve
12 115 74 ls
13 117 75 ar
14 120 75 e
fo
15 120 76
un
16 120 78 d
17 120 80 to
18 120 80 be
el
* The threshold for ev
further evaluation at
or intervention is
based on cutoff ed
points for
hypertension from wi
the fourth report th
of the National
High Blood th
Pressure
Education e
Program Working us
Group on High
Blood Pressure in e
Children and
Adolescents.
4 of
DBP denotes an
diastolic blood
pressure, and os
SBP systolic cil
blood pressure.
Data are
11 from Kaelber and lo
Pickett.
Data are from Mitchell et m
13
al.
et
ri
c
algorithm de
27 vi
s.
These ce
devices ,
tend to m
overestim an
ate the ua
systolic l
blood- m
pressure ea
level, su
although re
occa- m
sionally en
ts should th
be e
obtained ti
with an m
appropria e
te-sized (a
cuff.
n
Generally
d
three
blood- if
pressure so
measure ,
ments are th
obtained e
during m
each ag
encounter -
, and the ni
average tu
of the de
three of
measure
el
ments is
ev
calculate
d; high at
readings io
from n)
three or
separate w
encounter he
s are re- th
quired to er
confirm th
hypertens e
ion, pa
unless the ti
blood
en
pressure
t
is
extremely ha
elevated, s
in which
case w
rapid hi
evaluatio te
n is -
indicated. co
4 at
Ambu
latory h
blood- y
pressure pe
monitori rt
ng is in- en
dicated if si
it is o
unclear n
whether (e
the blood le
pressure va
is te
elevated d
most of bl
ood pres- hypertension
sure in (normal blood
the pressure in the cli-
clinician nicians office but
elevated blood
s office
pressure else-
alone) or 28
masked where). The
working group
recommends
consid-ering
ambulatory blood-
pressure monitoring
in these
circumstances, as
well as in patients
with diabetes,
chronic kidney
disease, episodic
hyper-tension, or
autonomic
4
dysfunction.
Studies con-ducted
at referral clinics for
evaluation of hyper-
tension in children
and adolescents
have indicated that
as many as 30 to
40% of children
referred for
evaluation of
elevated blood
pressure in a clinical
setting may actually
have white-coat hy-
29
pertension.
The extent of an
evaluation in a child
with hypertension
should be guided by
the severity of the
elevation in blood
pressure and the age
of the child (Table
4
2). The younger the
child, the more
likely it is that a
definable cause will
be identi-fied for the
elevation in blood
pressure. Among
children older than
10 years of age,
primary
hypertension is far
more likely than
secondary
hypertension,
particularly if the
patient is over-
weight or obese, has
a family history of
hyper-tension, or
 29 she is in recumbent
both. The evaluation
should include and standing
ascertainment of the positions, to rule out
patients medical history, postural chang-es in
prescribed medications, blood pressure.
family history, and risk Table 3 summarizes
factors, including diet, addi-tional
sleep patterns, and activ-ity evaluations
level. Stimulants for the recommended by
treatment of atten-tion- the Working Group
deficit disorder may on High Blood
increase blood pressure, Pressure Control in
although data indicate that Chil-dren and
4,26
the increase is gener-ally 5 Adolescents.
30
mm Hg or less. Clinicians
should ask about the use of Evaluation of
other agents that may hypertension in
increase blood pressure children and
(e.g., pseudoephedrine), as adolescents is
well as about substance generally phased.
abuse and smoking habits. In addition to a
Phys-ical examination careful history
should focus on signs of an taking and physical
un-derlying condition examination, a
causing hypertension and phase 1 evaluation
on evidence of target-organ to identify or rule
damage. Blood pressure
out com-mon
should be measured in the
causes of
upper and lower ex-
tremities to screen for
secondary
coarctation, and these hypertension is
measurements should be recom-mended in
obtained while the pa-tient patients with blood
is seated and while he or pressure that is

2318

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 CLINICAL PRACTICE

Table 2. Classifications of Blood Pressure and Therapeutic Approaches.*

Systolic or Diastolic
Blood Pressure Classification

Pharmacol
ogic
Therapy
<90th percentile Normal blood
pressure No
ne
90th to <95th percentile, or Prehypertension
if blood pressure exceeds
120/80 mm Hg, even if it is None
<90th or <95th percentile unless
there is
a clinical
indicatio
n
95th to 99th percentile plus Stage 1 hypertension (diabete
5 mm Hg s,
chronic
kidney
disease,
left
ventricul
ar
hypertro
>99th percentile plus 5 mm Hg Stage 2 hypertension -phy, or
heart
failure)

Initiate
accordin
g to
blood-
pressur
e level
and
presenc
e of
sympto
matic
hyper-
tension,
seconda
ry
hyperte
nsion,
evi-
dence of
target-
organ
damage
,
or
diabete
s
Initiate
;
m
or
e
th
an
on
e
ag
en
t
m
ay
be
ne
ed
ed
 * Adapted from the fourth report of the National High Blood
Pressure Education Program Working 4
Group on High Blood
Pressure in Children and Adolescents.
Percentiles listed are based on blood pressure as
measured on at least three separate occasions and
determined according to the patients age, height, and
sex.
Diet management may be facilitated by consultation with
a licensed or registered nutritionist. A DASH (Dietary
Approaches to Stop Hyper tension) diet may be useful.
in those with ambulatory
blood-pressure readings in
persistently at or above the the hypertensive and
95th percentile and in prehypertensive range than
patients with diabetes, in normotensive patients.33
cardiac disease, and other A detailed eye
chronic conditions if the examination is also
blood pressure is above the informative in the evaluation
90th percentile. This of pediatric hypertension,
evaluation includes basic since findings regarding the
laboratory tests presence or absence of
(measurement of levels of hypertensive retinopathy will
blood urea nitrogen, help in therapeutic decision
creatinine, and electrolytes; making. Arteriolar changes
a com-plete blood count; may be seen early in children
and a urinalysis and urine with hypertension. In a cross-
culture) and renal sectional study involving
ultrasonography to assess assessment of retinal diameter
for renal scarring, disparate in two population-based
kidney size, and con-genital cohorts of healthy
4
anomalies. About 80% of schoolchildren 6 to 8 years of
cases of second-ary age (one in Australia and one
hypertension in children are 34
in Singapore), children in
attributed to renal disease, the higher blood-pressure
and another 10% are quartiles had signifi-cantly
attributed to renovascular greater arteriolar narrowing
disease. than did those in lower
Left ventricular mass quartiles.
should also be assessed; the
interpretation must consider Limited data have
the patients height, body- indicated an increased prev-
surface area, and level of fit- alence of learning disabilities
15,25,31,32
ness. In a study among children with mild-to-
involving patients 5 to 18 moderate hypertension, as
33
years of age, the left- compared with
ventricular-mass index (a
height-adjusted index) was
significantly higher

N ENGL J MED 370;24 NEJM.ORG JUNE 12, 2014 2319

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 T h e NE W E NGL A ND JOU R NA L o f M E DICINE

Table 3. Continued Evaluation for Pediatric Hypertension.*

Purpose of
Procedure or Examination Target Population Test
Evaluation for coexisting condition: fasting lipid Overweight children with bloodIdentify
pressure at 90th to
panel, fasting blood glucose 94th percentile; all patients withhyperlipidemia
blood pressure
at 95th percentile; children with chronic
and kidney
metabolic
disease, family history of hypertension, or cardio-
abnormalities
vascular disease
Evaluation for target-organ damage
Echocardiography Patients with risk factors for a coexisting condition
and blood pressure at 90th94th percentile; all
patients with blood pressureIdentify
at >95thleft
percentile
ventricular
hyper trophy and
Retinal examination Patients with risk factors for a coexisting condition
other indicators of
and blood pressure at 90th94th percentile; all
patients with blood pressure at cardiac involvement
>95th percentile
Additional evaluation as indicated Identify retinal
changes
Ambulatory blood-pressure monitoring Patients in whom white-coat hypertension is sus-
pected and patients in whom detection of pat-
tern of elevation would be helpful
Determination of plasma renin activity or level Young children with stage 1 hypertension and
Identify white-coat
(and plasma aldosterone level) children and adolescents with stage 2 hyper-
hypertension or
tension
abnormal diurnal
blood-pressure
pattern
Identify low-renin
hypertension,
possible
mineralocorticoid-
mediated
hypertension; identify
high renin level that
suggests
renovascular dis-
ease; identify positive
family history of
hypertension
Renovascular imaging: isotopic Young children with stage 1 hypertension and Identify
renovascular disease
scintigraphy (renal scan), magnetic
children and adolescents with stage 2 hyper-
resonance angiography, duplex
tension
Doppler flow studies, three-
dimensional computed tomography,
digital-subtraction angiography, or
classic arteriography Young children with stage 1 hypertension and chil- Identify steroid-
mediated hyper-
Plasma and urinary steroid levels dren and adolescents with stage 2 hypertension tension
Young children with stage 1 hypertension and chil- Identify
Plasma and urinary catecholamines catecholamine-mediated
dren and adolescents with stage 2 hypertension

hypertension

* Adapted from the fourth report of the National High Blood Pressure Education Program Working
4
Group on High Blood Pressure in Children and Adolescents.
TREATMENT OPTIONS
Treatment for pediatric hypertension is guided
35 by the evaluation. Discussion of the
controls. A multicenter study is currently
36 management of various causes of secondary
ongo-ing to confirm these findings. Other hypertension is be-yond the scope of this
data have indicated increased carotid intima
37 review. If the evaluation
media thick-ness (which is considered to be
a marker of atherosclerosis in adults) in
children with hyper-tension, as compared with
controls. However, neither neurocognitive
testing nor determination of carotid intima
media thickness is included in current
guidelines for routine clinical assessment.

suggests that the patient has primary
hyperten-sion, nonpharmacologic therapy is
generally the first approach.
Nonpharmacologic Therapy
Lifestyle changes are recommended for
children with prehypertension or stage 1
4,38-42
hypertension. These approaches include
a program of dynamic exercise (i.e., exercise
that involves substantial and recurrent body
movement, such as bicycling or running); a
balanced diet with a high intake of fruits,
vegetables, and low-fat dairy products, as well
as a reduction in dietary sodium; a weight-
reduction program in patients who are
overweight; and reinforcement of adherence
to these practices.

2320 N ENGL J MED 370;24 NEJM.ORG JUNE 12, 2014

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withoutpermission.Copyright2014MassachusettsMedical
Society.Allrightsreserved.
CLINICAL PRACTICE
randomiz
ed trial
Sever comparin
al studies g 12-
involvin week
g regimens
children of
and exercise,
adoles- diet, and
cents a
have combinat
suggeste ion of
d that these
successf approach
ul weight es in
loss is preadole
effective scent
in children
decreasin who
g blood- were
pressure overweig
levels. 43
ht, all
For
the
example,
groups
a
had
randomiz
reduction
ed trial
s in
involvin
weight
g obese
and in
adolesce
diastolic
nts
blood
showed
pressure
that a
at 12
family-
weeks,
based
and there
weight-
were no
loss
significa
program
nt
(with
differenc
focused
es
family
among
meetings
the
about
groups.
weight,
Another
exercise,
controlle
and
d trial of
nutrition)
a
, as
behavior
compare
al
d with
nutrition
usual
al
care, led
program
to more
involvin
weight
g the
loss and
DASH
greater
(Dietary
improve
Approac
ments in
hes to
blood-
Stop
pressure
Hyperten
and
sion) diet
metaboli
in
c
39 hyperten
levels. sive
In a
 42 exercise
teens
showed a regimen
greater ap-pears
decrease to be
in improve
systolic d with
(althoug frequent
h not visits to
diastolic) and
blood feedbac
pressure k from a
in the clinician
DASH- ,
diet physical
group -fitness
than in coun-
controls selor, or
at the 3- nutrition
month ist, as
follow- well as
42
up. with the
Howe use of
ver, ancillary
effecting devices
such such as
changes pedomet
is often
dif- ers; in
ficult. cross-
The sectional
inclusio studies,
n of more
family steps
participa walked,
tion ap-
pears to as
be measure
useful, if d by
not pedomet
essential er, are
, correlate
particula d with
rly if the lower
child
needs to blood
lose pressure
3 45
weight. s.
9
Pharma
It is cothera
uncertai py
n how If blood
much pressure
exercise does not
should improve
be with
recomm lifestyle
ended changes,
and how or if
best to concerte
encoura d efforts
ge to
encoura
partici-
44
ge life-
pation. style
Adheren modifica
ce to an tion are
not with the
successf use of
ul, pharmac
medicati
on may othera-
be
indicate
4,46-50
d.
Medicati
on
should
be ini-
tiated if
there are
sympto
ms or
coexisti
ng
health
conditio
ns or if
there is
an
identifie
d
secondar
y cause
of
hyperten
sion or
evidence
of end-
organ
damage
in
children
or
adolesce
nts with
stage 1
hyperten
sion. In
addition,
drug
therapy
should
be
initiated
routinel
y in
young
people
with
stage 2
hyperten
4
sion.
There
is some
evidence
that
target-
organ
dam-age
may
regress
 Food
51,52 and
py.
One Drug
study Adminis
involvin tration
g
children
(FDA)
and approve
adoles- d
cents pediatric
who labeling
were has
assessed
after 1 increase
year of d mark-
therapy edly
showed since
significa passage
nt
reduction of the
s from FDA
baseline Moderni
in the zation
left- Act of
ventricul
ar-mass 1997,
index, which
the undersc
prevalen ored the
ce of left need to
ventricul
evaluate
ar
hypertro medicati
phy, and ons used
the in
carotid children
in-tima for
media
thickness which
51 there
.
Another were no
small specific
study in- pediatric
dicated indicatio
that left ns.
ventricul
ar Since
hypertro then,
phy many
regressed antihype
after a rtensive
year of agents
therapy
with an have
angioten been
sin-con- studied
verting in chil-
enzyme dren;
(ACE)
inhibitor. this has
52 led to
better
The
informat
number
ion
of
about
antihype
pharmac
rtensive
okinetic
agents
s,
that
adverse
have
events,
and than one
appropri medicati
-ate on as a
dosing. first-line
A list of 53
agent).
such 5
JNC 7
agents is
favored
provided
the use
in Table
of
4. thiazide-
There type
is no diuretics
consensu in adults,
s and JNC
regardin 6
g the 8
best suggests
initial four
therapy potential
for first-line
hyperten classes
sion in of
children antihyper
and tensive
adolesce medicati
nts; on in
comparat adults.
ive trials However
are , data to
lacking inform
in the the use
pediatric of
populatio thiazides
n. A or other
survey of medicati
pediatric on
ne- classes
phrologis for treat-
ts ing
indicated pediatric
that 47% hyperten
consider sion are
ed ACE limited,
inhibitor and
s to be agents in
first-line several
therapy, different
37% classes
chose are
calcium- consider
channel ed ac-
blockers, ceptable
15.3% 5
choices.
chose 0
diuret-
ics, and
A
6.6%
R
chose
beta-
blockers E
(some
chose A
more S
 effects
O of
F lifestyle
and
U pharmac
N ologic
C intervent
E ions in
R patients
T in this
A age
I group.
N Achievi
T ng and
maintain
Y ing
lifestyle
Longitu changes
dinal and
data adheren
regardin ce to
g medicati
outcome on are
s in chil- chal-
dren and lenging,
adolesce particula
nts with rly in
hyperten adolesce
sion are nts, and
sparse. effec-
Data tive
also are strategie
lacking s to
from improve
clinical adheren
trials ce
regardin remain
g long- un-
term certain.

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T h e NE W E NGL A ND JOU R NA L o f M E DICINE

GUID rekomendasi di
ELIN 2.004,4 Baru
ES panduan-garis
Nasional dari Masyarakat
Tekanan Darah Eropa untuk
Tinggi Hyperten-sion,
Pendidikan 54 yang
Program diterbitkan pada
Kelompok Kerja musim gugur
Darah Tinggi tahun 2009,
Pres-yakin pada mirip dengan US
Anak dan kelompok kerja
Remaja rekomen-tions.4
diperbarui Rekomendasi
terakhir hadir adalah

Table 4. Selected Oral Medications for Hypertension in Children and Adolescents.*

Class and Agent Initial Dose Maximum Dose

ACE inhibitor
Captopril 0.30.5 mg/kg/dose 6 mg/kg/day (to 450 mg/day) H

Enalapril 0.08 mg/kg/day 0.6 mg/kg/day (to 40 mg) H

Lisinopril 0.07 mg/kg/day (to 5 mg) 0.6 mg/kg/day (to 40 mg) H

Calcium-channel blocker
Amlodipine 0.06 mg/kg/day 0.3 mg/kg/day (to 10 mg/day) R
Isradipine 0.050.15 mg/kg/dose 3 or 0.8 mg/kg/day (to 20 mg/day) R
4 times/day
Extended-release nifedipine 0.250.5 mg/kg/day 3 mg/kg/day (to 120 mg/day) R
Diuretic
Amiloride 0.40.625 mg/kg/day 20 mg/day H

Chlorthalidone 0.3 mg/kg/day 2 mg/kg/day (to 50 mg/day) H

Furosemide 0.52 mg/kg/dose 1 or 2 times/day 6 mg/kg/day H

Hydrochlorothiazide 0.51 mg/kg/day 3 mg/kg/day (to 50 mg/day) H

Beta-adrenergic antagonist
Atenolol 0.51 mg/kg/day 2 mg/kg/day (to 100 mg/day) B

Metoprolol 12 mg/kg/day 6 mg/kg/day (to 200 mg/day) B

Propranolol 1 mg/kg/day 6 mg/kg/day (to 640 mg/day) B

 Vasodilator
Hydralazine 0.75 mg/kg/day in 3 or 4 divided 7.5 mg/kg/day (200 mg/day) Ta
doses
Minoxidil In children <12 yr: 0.2 mg/kg/day; In children <12 yr: 50 mg/day; Ta
in children 12 yr: 5 mg/day in children 12 yr: 100 mg/day

2322 N ENGL J MED 370;24 NEJM.ORG JUNE 12, 2014

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 CLINICAL PRACTICE

Table 4. (Continued.)

Class and Agent Initial Dose Maximum Dose Common Adverse Events

Angiotensin-receptor blocker
Losartan 0.7 mg/kg/day (to 50 mg/day) 1.4 mg/kg/day (to 100 mg/day) Hyperkalemia; cough, (though less commonly than
Valsartan
with ACE inhibitors);
contraindicated in
pregnancy
If patient <6 yr: 80 mg/day; if Hyperkalemia, cough (though
If patient <6 yr: 510 mg/day; if
patient 617 yr: 2.7 mg/kg/ less commonly than with
patient 617 yr: 1.3 mg/kg/ day up to 160 mg total ACE inhibitors);
day up to 40 mg total contraindicated in pregnancy

Alpha- and beta-adrenergic

antagonists

edilol 0.1 mg/kg/dose (to 6.25 mg/day) 0.5 mg/kg/dose (to 25 mg) twice Dizziness, depression, dry eyes,
daily wheezing, bradycardia,
gastrointestinal side effects,
lower-extremity edema
talol 13 mg/kg/day 1200 mg/day Dizziness, depression, dry eyes,
wheezing, bradycardia,
gastrointestinal side effects,
lower-extremity edema
y acting alpha agonist: 520 g/kg/day 25 g/kg/day (to 0.9 mg/day) Sedation
onidine
one receptor antagonist
enone 25 mg/day 100 mg/day Hyperkalemia, dizziness,
hypercholesterolemia
nolactone 1 mg/kg/day 3.3 mg/kg/day (to 100 mg/day) Hyperkalemia, dizziness,
gynecomastia

* Diadaptasi dari laporan keempat dan tekanan darah tinggi Nasional Pendidikan Program Kelompok Kerja Tekanan
DarahTinggi pada anak dan Adolecents. 4 Urutan penyajian kelas ini didasarkan pada survei dari nephrologist.53
pediatrik, namun, seperti pengalaman tumbuh dengan penggunaan dari angiotensin receptor blockers dan antagonis
aldosterone receptor, praktek mungkin akan berubah. Ini bukan daftar lengkap dari dosis pediatric. ACE (angiotensin-
converting Enzym) meunjukkan
+ Dosis dewasa maksimum untuk obat apapun tidak boleh melebihi
++ Informasi tentang bagaimana mempersiapkan suspense tanpa persiapan yang stabil tersedia.
+++ Obat ini tersedia sebagai larutan oral yang disediakan secara komersial yang disetujui oleh Food and Drug Administration.

ensi dengan panduan ini. Selain itu Pedoman Eropa

erikan beberapa normatif nilai untuk rawat tekanan
pemantauan ing.54 A baru-baru ini dirilis ser
gahan AS keburukan Task Force report21
mpulkan bahwa "skr menyewa bukti tidak cukup untuk
i keseimbangan manfaat dan bahaya skrining untuk
nsi primer pada anak-anak tanpa gejala dan remaja
mencegah kardiomiopati berikutnya penyakit pembuluh
di masa kecil atau dewasa. " Namun, beberapa dokter,
is, dan re-pencari mengkritik report22,55 sebagai ig-
data yang tersedia menunjukkan bahwa akhir-organ
kan dapat dibalik dengan terapi. Lebih lanjut- lebih,
pun laporan menganggap merugikan F- sociated dengan
kuran tekanan darah, anak-anak dengan hipertensi tidak
ksi mungkin memiliki komplikasi yang mencakup
nsi Krisis, yang laporan tidak consider.21

CONCLUSIONS AND
R ECOMMENDATIONS
Anak laki-laki 13 tahun digambarkan dalam
sketsa memiliki tekanan darah tinggi yang dapat
dikategorikan sebagai tahap 1 hipertensi dan dia
juga obesitas. Ia mungkin memiliki hipertensi
primer, tetapi ia harus menjalani anamnesis yang
cermat dan pemeriksaan fisik. Aminasi
( termasuk pemeriksaan retina), Ba tes
laboratorium sic, echocardiography dan ginjal
ultrasonografi untuk skrinning ginjal yang
mendasari penyakit. Saya pertama kali akan
 T h e NE W E NGL A ND JOU R NA L o f M E DICINE
melakukan upaya yang setelah 6-12 bulan
kuat untuk meminta terapi non
dukungan dari farmakologis, saya akan
keluarganya, guru dan mempertimbangkan
orang dewasa lainnya. melembagakan
Saya akan recom- farmakoterapi 4,53
memperbaiki sering Dengan tidak adanya
tidak lanjut untuk jumlah yang memadai
memantau berat badan, uji coba obat kepala
kebugaran dan tekanan yang melibatkan anak.
darahnya. dan daya No potential conflict of
interest relevant to this
akan encour usia article was reported.
program latihan yang Disclosure forms
dinamis. Jika tekanan provided by the author are
darahnya tidak menurun available with the full text
of this article at NEJM.org.
ke level non- hipertensi

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