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Pediatrics. 2018 Sep;142(3). pii: e20182096. doi: 10.1542/peds.2018-2096. Epub 2018 Aug 20.

Diagnosis, Evaluation, and Management of High Blood Pressure in Children and Adolescents.

Author information

Division of Cardiology, Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland;
Consultant, Washington, District of Columbia.
Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington.
Division of General Internal Medicine, Departments of Pediatrics and Population and Quantitative Health Sciences, Case Western Reserve University and Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio.
University of Missouri-Kansas City, Children's Mercy Kansas City, Children's Mercy Integrated Care Solutions, Kansas City, Missouri.
Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana.
Department of Pediatrics, School of Medicine, University of Colorado, Children's Hospital Colorado, Aurora, Colorado.
Preventive Cardiology Clinic.
Division of Nephrology, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada.
Departments of Medicine and Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania.
Cardiology Division, Nemours Cardiac Center, A. I. duPont Hospital for Children and Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana.
Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine Information Technology Services, and Seattle Children's Hospital, Seattle, Washington.
Department of Pediatrics, Morehouse School of Medicine, Atlanta, Georgia.
Primary Care at Longwood, and.
Departments of Pediatrics and Internal Medicine, McGovern School of Medicine, University of Texas, Houston, Texas.
Department of Pediatrics, UPMC Shadyside Family Medicine Residency, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Department of Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.
Division of Molecular Genetics, Department of Pediatrics, Columbia University Irving Medical Center, Columbia University, New York, New York.
Broad Institute, Cambridge, Massachusetts; and.
Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.


Systemic hypertension is a major cause of morbidity and mortality in adulthood. High blood pressure (HBP) and repeated measures of HBP, hypertension (HTN), begin in youth. Knowledge of how best to diagnose, manage, and treat systemic HTN in children and adolescents is important for primary and subspecialty care providers.


To provide a technical summary of the methodology used to generate the 2017 "Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents," an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents."


Medline, Cochrane Central Register of Controlled Trials, and Excerpta Medica Database references published between January 2003 and July 2015 followed by an additional search between August 2015 and July 2016.


English-language observational studies and randomized trials.


Key action statements (KASs) and additional recommendations regarding the diagnosis, management, and treatment of HBP in youth were the product of a detailed systematic review of the literature. A content outline establishing the breadth and depth was followed by the generation of 4 patient, intervention, comparison, outcome, time questions. Key questions addressed: (1) diagnosis of systemic HTN, (2) recommended work-up of systemic HTN, (3) optimal blood pressure (BP) goals, and (4) impact of high BP on indirect markers of cardiovascular disease in youth. Once selected, references were subjected to a 2-person review of the abstract and title followed by a separate 2-person full-text review. Full citation information, population data, findings, benefits and harms of the findings, as well as other key reference information were archived. Selected primary references were then used for KAS generation. Level of evidence (LOE) scoring was assigned for each reference and then in aggregate. Appropriate language was used to generate each KAS based on the LOE and the balance of benefit versus harm of the findings. Topics that could not be researched via the stated approach were (1) definition of HTN in youth, and (2) definition of left ventricular hypertrophy. KASs related to these stated topics were generated via expert opinion.


Nearly 15 000 references were identified during an initial literature search. After a deduplication process, 14 382 references were available for title and abstract review, and 1379 underwent full text review. One hundred twenty-four experimental and observational studies published between 2003 and 2016 were selected as primary references for KAS generation, followed by an additional 269 primary references selected between August 2015 and July 2016. The LOE for the majority of references was C. In total, 30 KASs and 27 additional recommendations were generated; 12 were related to the diagnosis of HTN, 13 were related to management and additional diagnostic testing, 3 to treatment goals, and 2 to treatment options. Finally, special additions to the clinical practice guideline included creation of new BP tables based on BP values obtained solely from children with normal weight, creation of a simplified table to enhance screening and recognition of abnormal BP, and a revision of the criteria for diagnosing left ventricular hypertrophy.


An extensive and detailed systematic approach was used to generate evidence-based guidelines for the diagnosis, management, and treatment of youth with systemic HTN.


Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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