THE FOURTH REPORT ON THE 

Diagnosis, Evaluation, and

Treatment of High Blood Pressure

in Children and Adolescents

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Heart, Lung, and Blood Institute

THE FOURTH REPORT ON THE 

Diagnosis, Evaluation, and

Treatment of High Blood Pressure

in Children and Adolescents

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication No. 05-5267

Originally printed September 1996 (96-3790)

Revised May 2005

THE FOURTH REPORT ON 

THE DIAGNOSIS, EVALUATION, 

AND TREATMENT OF HIGH

BLOOD PRESSURE IN

CHILDREN AND ADOLESCENTS

CHAIR

Bonita Falkner, M.D. (Thomas Jefferson

University, Philadelphia, PA)

MEMBERS

Stephen R. Daniels, M.D., Ph.D.

(Cincinnati Children’s Hospital Medical

Center, Cincinnati, OH); Joseph T. Flynn,

M.D., M.S. (Montefiore Medical Center,

Bronx, NY); Samuel Gidding, M.D.

(DuPont Hospital for Children,

Wilmington, DE); Lee A. Green, M.D.,

M.P.H. (University of Michigan, Ann

Arbor, MI); Julie R. Ingelfinger, M.D.

(MassGeneral Hospital for Children,

Boston, MA); Ronald M. Lauer, M.D.

(University of Iowa, Iowa City, IA); 

Bruce Z. Morgenstern, M.D. (Mayo

Clinic, Rochester, MN); Ronald J.

Portman, M.D. (The University of Texas

Health Science Center at Houston,

Houston, TX); Ronald J. Prineas, M.D.,

Ph.D. (Wake Forest University School 

of Medicine, Winston-Salem, NC); Albert

P. Rocchini, M.D. (University of Michigan,

C.S. Mott Children’s Hospital, Ann Arbor,

MI); Bernard Rosner, Ph.D. (Harvard

School of Public Health, Boston, MA);

Alan Robert Sinaiko, M.D. (University of

Minnesota Medical School, Minneapolis,

MN); Nicolas Stettler, M.D., M.S.C.E.

(The Children’s Hospital of Philadelphia,

Philadelphia, PA); Elaine Urbina, M.D.

(Cincinnati Children’s Hospital Medical

Center, Cincinnati, OH)

NATIONAL INSTITUTES OF

HEALTH STAFF

Edward J. Roccella, Ph.D., M.P.H.

(National Heart, Lung, and Blood

Institute, Bethesda, MD); Tracey Hoke,

M.D., M.Sc. (National Heart, Lung, and

Blood Institute, Bethesda, MD); Carl E.

Hunt, M.D. (National Center on Sleep

Disorders Research, National Heart,

Lung, and Blood Institute, Bethesda,

MD); Gail Pearson, M.D., Sc.D.

(National Heart, Lung, and Blood

Institute, Bethesda, MD)

STAFF

Joanne Karimbakas, M.S., R.D., and 

Ann Horton, M.S. (American Institutes

for Research Health Program, Silver

Spring, MD)

FINANCIAL DISCLOSURES

Dr. Flynn has served as a consultant/

advisor for Pfizer Inc., AstraZeneca LP,

ESP-Pharma, and Novartis Pharmaceuticals;

he received funding/grant support for

research projects from Pfizer, AstraZeneca,

and Novartis.

ACKNOWLEDGMENTS

We would like to thank the American

Academy of Pediatrics for its help in disseminating this report. We appreciate the

assistance by: Carol Creech, M.I.L.S.,

Heather Banks, M.A., and Angela Jehle

(American Institutes for Research Health

Program, Silver Spring, MD).

Acknowledgments iii

Acknowledgments
THE NATIONAL HIGH BLOOD

PRESSURE EDUCATION

PROGRAM COORDINATING

COMMITTEE MEMBER

ORGANIZATIONS

American Academy of Family Physicians

American Academy of Insurance Medicine

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Physician Assistants

American Association of Occupational 

Health Nurses

American College of Cardiology

American College of Chest Physicians

American College of Occupational 

and Environmental Medicine

American College of Physicians–

American Society of Internal Medicine

American College of Preventive Medicine

American Dental Association

American Diabetes Association

American Dietetic Association

American Heart Association

American Hospital Association

American Medical Association

American Nurses Association

American Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Public Health Association

American Red Cross

American Society of Health-System

Pharmacists

American Society of Hypertension

American Society of Nephrology

Association of Black Cardiologists

Citizens for Public Action on High Blood 

Pressure and Cholesterol, Inc.

Hypertension Education Foundation, Inc.

International Society on Hypertension 

in Blacks

National Black Nurses Association, Inc.

National Heart, Lung, and Blood Institute

Ad Hoc Committee on Minority 

Populations

National Hypertension Association, Inc.

National Kidney Foundation, Inc.

National Medical Association

National Optometric Association

National Stroke Association

Society for Nutrition Education

The Society of Geriatric Cardiology

Federal Agencies:

Agency for Healthcare Research and Quality

Centers for Medicare and Medicaid Services

Department of Veterans Affairs

Health Resources and Services Administration

National Center for Health Statistics

National Heart, Lung, and Blood Institute

National Institute of Diabetes and Digestive 

and Kidney Diseases

iv The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
Contents v

Contents

FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .VII

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

DEFINITION OF HYPERTENSION . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

MEASUREMENT OF BLOOD PRESSURE IN CHILDREN . . . . . . . . . . .5

Ambulatory Blood Pressure Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

BLOOD PRESSURE TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Using the Blood Pressure Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

PRIMARY HYPERTENSION AND EVALUATION 

FOR COMORBIDITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 6

EVALUATION FOR SECONDARY HYPERTENSION . . . . . . . . . . .1 8

Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Additional Diagnostic Studies for Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Renin Profiling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Evaluation for Possible Renovascular Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Invasive Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

TARGET-ORGAN ABNORMAL IT IES 

IN CHILDHOOD HYPERTENSION . . . . . . . . . . . . . . . . . . . . . . . . . . .2 2

Clinical Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

THERAPEUTIC LIFESTYLE CHANGES . . . . . . . . . . . . . . . . . . . . . . .2 4

PHARMACOLOGIC THERAPY 

OF CHILDHOOD HYPERTENSION . . . . . . . . . . . . . . . . . . . . . . . . . . .2 6

APPENDIX A. DEMOGRAPHIC DATA . . . . . . . . . . . . . . . . . . . . . . . .3 4

APPENDIX B. COMPUTATION OF BLOOD 

PRESSURE PERCENTILES FOR ARBITRARY 

SEX, AGE, AND HEIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 6

SCHEME USED FOR CLASSIFICATION 

OF THE EVIDENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 9

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 0
vi The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

List of Tables

TABLE 1. Conditions Under Which Children <3 Years Old Should Have . . . . . . . . . . . . . . .5

Blood Pressure Measured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TABLE 2. Recommended Dimensions for Blood Pressure Cuff Bladders . . . . . . . . . . . . . . . .6

TABLE 3. Blood Pressure Levels for Boys by Age and Height Percentile . . . . . . . . . . .10

TABLE 4. Blood Pressure Levels for Girls by Age and Height Percentile . . . . . . . . . . .12

TABLE 5. Classification of Hypertension in Children and Adolescents, . . . . . . . . . . . .14

With Measurement Frequency and Therapy Recommendations . . . . . . .

TABLE 6. Indications for Antihypertensive Drug Therapy in Children . . . . . . . . . . . . .14

TABLE 7. Clinical Evaluation of Confirmed Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . .15

TABLE 8. Examples of Physical Examination Findings Suggestive . . . . . . . . . . . . . . . . .20

of Definable Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TABLE 9. Antihypertensive Drugs for Outpatient Management . . . . . . . . . . . . . . . . . . . . .28

of Hypertension in Children 1–17 Years Old . . . . . . . . . . . . . . . . . . . . .

TABLE 10. Antihypertensive Drugs for Management of Severe Hypertension . . . . . . .33

in Children 1–17 Years Old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TABLE A–1. Demographic Data on Height/Blood Pressure Distribution Curves . . . . . .35

by Study Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TABLE B–1. Regression Coefficients From Blood Pressure Regression Models . . . . . . .38

List of Figures

FIGURE 1. Management Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
This is the fourth report from the National

High Blood Pressure Education Program

(NHBPEP) Working Group on Children 

and Adolescents; it updates the previous publication, Update on the Task Force Report

(1987) on High Blood Pressure in Children

and Adolescents (Pediatrics. 1996;98:649–58).

The purpose of this report is to update clinicians on the latest recommendations

concerning the diagnosis, evaluation, and

treatment of hypertension in children; recommendations are based on English-language,

peer-reviewed, scientific evidence (from 1997

to 2004) and the consensus expert opinion of

the NHBPEP Working Group.

This report includes new data from the

1999–2000 National Health and Nutrition

Examination Survey (NHANES), as well as

revised blood pressure (BP) tables that include

the 50th, 90th, 95th, and 99th percentiles by

sex, age, and height. Hypertension in children

and adolescents continues to be defined as

systolic BP (SBP) and/or diastolic BP (DBP)

that is, on repeated measurement, at or above

the 95th percentile for sex, age, and height.

BP between the 90th and 95th percentile in

childhood is now termed “prehypertension”

and is an indication for lifestyle modifications.

New guidelines are provided for the staging of

hypertension in children and adolescents, as

well as updated recommendations for diagnostic evaluation of hypertensive children.

In addition, the report evaluates the evidence

of early target-organ damage in children and

adolescents with hypertension; provides the

rationale for early identification and treatment; and provides revised recommendations,

based on recent studies, for the use of antihypertensive drug therapy. Treatment recommendations also include updated evaluation

of nonpharmacologic therapies to reduce

additional cardiovascular risk factors. The

report describes how to identify hypertensive

children who need additional evaluation for

sleep disorders that may be associated with

BP elevation.

Dr. Bonita Falkner has our deep appreciation

for leading the members of the NHBPEP

Working Group in developing this new report.

Dr. Falkner and the Working Group performed diligently and brilliantly to assemble

this document in a timely manner. Applying

these recommendations to clinical practice will

address the important public health issue of

improving inadequate BP control.

Barbara M. Alving, M.D.

Acting Director

National Heart, Lung, and Blood Institute

and

Chair

National High Blood Pressure Education Program

Coordinating Committee

Foreword vii

Foreword

Introduction 1

Introduction

Considerable advances have been made in

detection, evaluation, and management of

high blood pressure, or hypertension, in children and adolescents. Because of the

development of a large national database 

on normative blood pressure (BP) levels

throughout childhood, the ability to identify

children who have abnormally elevated BP

has improved. On the basis of developing 

evidence, it is now apparent that primary

hypertension is detectable in the young and

occurs commonly. The long-term health risks

for hypertensive children and adolescents can

be substantial; therefore, it is important that

clinical measures be taken to reduce these

risks and optimize health outcomes.

The purpose of this report is to update clinicians on the latest scientific evidence

regarding BP in children and to provide recommendations for diagnosis, evaluation, and

treatment of hypertension based on available

evidence and consensus expert opinion of the

Working Group when evidence was lacking.

This publication is the fourth report from the

National High Blood Pressure Education

Program (NHBPEP) Working Group on

Children and Adolescents and updates the

previous 1996 publication, Update on the

Task Force Report (1987) on High Blood

Pressure in Children and Adolescents.1

This report includes the following information:

■ New data, from the 1999–2000 National

Health and Nutrition Examination Survey

(NHANES), have been added to the childhood BP database, and the BP data have

been reexamined. The revised BP tables

now include the 50th, 90th, 95th, and

99th percentiles by sex, age, and height.

■ Hypertension in children and adolescents

continues to be defined as systolic BP (SBP)

and/or diastolic BP (DBP) that is, on

repeated measurement, at or above the 95th

percentile. BP between the 90th and 95th

percentile in childhood had been designated

“high normal.” To be consistent with the

Seventh Report of the Joint National

Committee on the Prevention, Detection,

Evaluation, and Treatment of High Blood

Pressure (JNC 7), this level of BP will now

be termed “prehypertensive” and is an indication for lifestyle modifications.2

■ The evidence of early target-organ damage

in children and adolescents with hypertension is evaluated, and the rationale for early

identification and treatment is provided.

■ Based on recent studies, revised recommendations for use of antihypertensive drug

therapy are provided.

■ Treatment recommendations include

updated evaluation of nonpharmacologic

therapies to reduce additional cardiovascular risk factors.

■ Information is included on the identification

of hypertensive children who need additional evaluation for sleep disorders.

Methods 3

Methods

In response to the request of the NHBPEP

Chair and Director of the National Heart,

Lung, and Blood Institute (NHLBI) regarding

the need to update the JNC 7 report,2 some

NHBPEP Coordinating Committee members

suggested that the NHBPEP Working Group

Report on Hypertension in Children and

Adolescents should be revisited. Thereafter,

the NHLBI Director directed the NHLBI staff

to examine issues that might warrant a new

report on children. Several prominent clinicians and scholars were asked to develop

background manuscripts on selected issues

related to hypertension in children and adolescents. Their manuscripts synthesized the

available scientific evidence. During the

spring and summer of 2002, NHLBI staff and

the chair of the 1996 NHBPEP Working

Group report on hypertension in children and

adolescents reviewed the scientific issues

addressed in the background manuscripts as

well as contemporary policy issues. Subsequently, the staff noted that a critical mass

of new information had been identified, thus

warranting the appointment of a panel to

update the earlier NHBPEP Working Group

Report. The NHLBI Director appointed the

authors of the background papers and other

national experts to serve on the new panel.

The chair and NHLBI staff developed a

report outline and timeline to complete the

work in 5 months.

The background papers served as focal points

for review of the scientific evidence at the first

meeting. The members of the Working Group

were assembled into teams, and each team

prepared specific sections of the report. In

developing the focus of each section, the

Working Group was asked to consider the

peer-reviewed scientific literature published in

English since 1997. The scientific evidence

was classified by the system used in the

JNC 7.2 The chair assembled the sections

submitted by each team into the first draft of

the report. The draft report was distributed

to the Working Group for review and comment. These comments were assembled and

used to create the second draft. A subsequent

onsite meeting of the Working Group was

conducted to discuss further revisions and the

development of the third draft document.

Amended sections were reviewed, critiqued,

and incorporated into the third draft. After

editing by the chair for internal consistency,

the fourth draft was created. The Working

Group reviewed this draft, and conference

calls were conducted to resolve any remaining

issues that were identified. When the Working

Group approved the final document, it was

distributed to the Coordinating Committee

for review.

3
4 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Definition of Hypertension

The definition of hypertension in children and

adolescents is based on the normative distribution of BP in healthy children. Normal BP

is defined as SBP and DBP that is less than the

90th percentile for sex, age, and height.

Hypertension is defined as average SBP or

DBP that is greater than or equal to the

95th percentile for sex, age, and height on at

least three separate occasions. Average SBP or

DBP levels that are greater than or equal to

the 90th percentile, but less than the 95th percentile, had been designated as “high normal”

and were considered to be an indication of

heightened risk for developing hypertension.

This designation is consistent with the

description of “prehypertension” in adults.

The JNC 7 Committee now defines prehypertension as a BP level that is equal to or greater

than 120/80 mmHg and recommends the

application of preventive health-related

behaviors, or therapeutic lifestyle changes, 

for individuals having SBP levels that exceed

120 mmHg.2 It is now recommended that, 

as with adults, children and adolescents with

BP levels at 120/80 mmHg or above, but less

than the 95th percentile, should be considered

prehypertensive.

The term white-coat hypertension defines a

clinical condition in which the patient has BP

levels that are above the 95th percentile when

measured in a physician’s office or clinic,

whereas the patient’s average BP is below the

90th percentile outside of a clinical setting.

■ Hypertension is defined as average SBP and/or DBP that is greater than or equal 

to the 95th percentile for sex, age, and height on three or more occasions.

■ Prehypertension in children is defined as average SBP or DBP levels that are greater 

than or equal to the 90th percentile, but less than the 95th percentile.

■ As with adults, adolescents with BP levels greater than or equal to 120/80 mmHg 

should be considered prehypertensive.

■ A patient with BP levels above the 95th percentile in a physician’s office or clinic, 

who is normotensive outside a clinical setting, has white-coat hypertension.

Ambulatory BP monitoring (ABPM) is usually required to make this diagnosis.
Measurement of Blood Pressure in Children 5

Measurement of 

Blood Pressure in Children

Children over the age of 3 years who are seen

in medical care settings should have their BP

measured at least once during every health

care episode. Children under age 3 should

have their BP measured in special circumstances. (See table 1.)

The BP tables are based on auscultatory

measurements; therefore, the preferred

method of measurement is auscultation.

As discussed below, oscillometric devices are

convenient and minimize observer error, but

they do not provide measures that are identical to auscultation. To confirm hypertension,

the BP in children should be measured with a

standard clinical sphygmomanometer, using a

stethoscope placed over the brachial artery

pulse, proximal and medial to the cubital

fossa, and below the bottom edge of the cuff

(i.e., about 2 cm above the cubital fossa). The

use of the bell of the stethoscope may allow

softer Korotkoff sounds to be heard better.3,4

The use of an appropriately sized cuff may

preclude the placement of the stethoscope 

in this precise location, but there is little 

evidence that significant inaccuracy is introduced, either if the head of the stethoscope 

is slightly out of position or if there is contact

between the cuff and the stethoscope. Preparation of the child for standard measurement

can affect the BP level just as much as 

technique.5 Ideally, the child whose BP is to

be measured should have avoided stimulant

drugs or foods, have been sitting quietly for

5 minutes, and seated with his or her back

supported, feet on the floor and right arm

supported, cubital fossa at heart level.6,7 The

right arm is preferred in repeated measures of

BP for consistency and comparison to standard tables and because of the possibility of

■ Children >3 years old who are seen in a medical setting should have their BP 

measured.

■ The preferred method of BP measurement is auscultation.

■ Correct measurement requires a cuff that is appropriate to the size of the child’s

upper arm.

■ Elevated BP must be confirmed on repeated visits before characterizing a child 

as having hypertension.

■ Measures obtained by oscillometric devices that exceed the 90th percentile should 

be repeated by auscultation.

Conditions Under Which Children 

<3 Years Old Should Have Blood 

Pressure Measured

■ History of prematurity, very low 

birthweight, or other neonatal complication

requiring intensive care

■ Congenital heart disease (repaired or 

nonrepaired)

■ Recurrent urinary tract infections, 

hematuria, or proteinuria

■ Known renal disease or urologic 

malformations

■ Family history of congenital renal disease

■ Solid organ transplant

■ Malignancy or bone marrow transplant

■ Treatment with drugs known to raise BP

■ Other systemic illnesses associated with 

hypertension (neurofibromatosis, tuberous 

sclerosis, etc.)

■ Evidence of elevated intracranial pressure

T ABLE 1
coarctation of the aorta, which might lead to

false (low) readings in the left arm.8

Correct measurement of BP in children

requires use of a cuff that is appropriate to

the size of the child’s upper right arm. The

equipment necessary to measure BP in children, ages 3 through adolescence, includes

child cuffs of different sizes and must also

include a standard adult cuff, a large adult

cuff, and a thigh cuff. The latter two cuffs

may be needed for use in adolescents.

By convention, an appropriate cuff size is a

cuff with an inflatable bladder width that is at

least 40 percent of the arm circumference at a

point midway between the olecranon and the

acromion. (See www.americanheart.org/presenter.jhtml?identifier=576.)9,10 For such a

cuff to be optimal for an arm, the cuff

bladder length should cover 80–100 percent

of the circumference of the arm.1,11 Such a

requirement demands that the bladder widthto-length ratio be at least 1:2. Not all

commercially available cuffs are manufactured with this ratio. Additionally, cuffs

labeled for certain age populations (e.g.,

infant cuffs, child cuffs) are constructed with

widely disparate dimensions. Accordingly, the

Working Group recommends that standard

cuff dimensions for children be adopted. (See

table 2.) BP measurements are overestimated

to a greater degree with a cuff that is too

small than they are underestimated by a cuff

that is too large. If a cuff is too small, the

next largest cuff should be used, even if it

appears large. If the appropriate cuffs are

used, the cuff size effect is obviated.12

SBP is determined by the onset of the “tapping” Korotkoff sounds (K1). Population

data in children1 and risk-associated epidemiological data in adults13 have established the

fifth Korotkoff sound (K5), or the disappearance of Korotkoff sounds, as the definition of

DBP. In some children, Korotkoff sounds can

be heard to 0 mmHg. Under these circumstances, the BP measurement should be

repeated with less pressure on the head of the

stethoscope.4 Only if the very low K5 persists

should K4 (muffling of the sounds) be

recorded as the DBP.

The standard device for BP measurements has

been the mercury manometer.14 Because of its

environmental toxicity, mercury has been

increasingly removed from health care settings. Aneroid manometers are quite accurate

when calibrated on a semiannual basis15 and

are recommended when mercury-column

devices cannot be obtained.

Auscultation remains the recommended

method of BP measurement in children, under

most circumstances. Oscillometric devices

measure mean arterial BP and then calculate

systolic and diastolic values.16 The algorithms

used by companies are proprietary and differ

from company to company and device to

device. These devices can yield results that

6 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Recommended Dimensions for Blood Pressure Cuff Bladders

Age Range

Newborn 

Infant 

Child 

Small adult 

Adult

Large adult 

Thigh 

Width (cm)

4

6

9

10

13

16

20

Length (cm)

8

12

18

24

30

38

42

Maximum Arm

Circumference (cm)*

10

15

22

26

34

44

52

* Calculated so that the largest arm would still allow bladder to encircle arm by at least 80 percent.

T ABLE 2
vary widely when one is compared with

another,17 and they do not always closely

match BP values obtained by auscultation.18

Oscillometric devices must be validated on a

regular basis. Protocols for validation have

been developed,19,20 but the validation process

is very difficult.

Two advantages of automatic devices are their

ease of use and the minimization of observer

bias or digit preference.16 Use of the automated devices is preferred for BP measurement

in newborns and young infants, in whom 

auscultation is difficult, and in the intensive

care setting where frequent BP measurement

is needed. An elevated BP reading obtained

with an oscillometric device should be

repeated using auscultation.

Elevated BP must be confirmed on repeated

visits before characterizing a child as having

hypertension. Confirming an elevated BP

measurement is important, because BP at high

levels tends to fall on subsequent measurement as the result of (1) an accommodation

effect (i.e., reduction of anxiety by the patient

from one visit to the next), and (2) regression

to the mean. BP level is not static but varies

even under standard resting conditions.

Therefore, except in the presence of severe

hypertension, a more precise characterization

of a person’s BP level is an average of multiple

BP measurements taken over weeks to months.

AMBULATORY BLOOD

PRESSURE MONITORING

Ambulatory BP monitoring (ABPM) refers to

a procedure in which a portable BP device,

worn by the patient, records BP over a specified period, usually 24 hours. ABPM is very

useful in the evaluation of hypertension in

children.21–23 By frequent measurement and

recording of BP, ABPM enables computation

of the mean BP during the day, night, and

over 24 hours as well as various measures to

determine the degree to which BP exceeds the

upper limit of normal over a given time

period (i.e., the BP load). ABPM is especially

helpful in the evaluation of white-coat hypertension, as well as the risk for hypertensive

organ injury, apparent drug resistance, and

hypotensive symptoms with antihypertensive

drugs. ABPM is also useful for evaluating

patients for whom more information on BP

patterns is needed, such as those with episodic

hypertension, chronic kidney disease, diabetes,

and autonomic dysfunction. Conducting

ABPM requires specific equipment and trained

staff. Therefore, ABPM in children and adolescents should be used by experts in the field

of pediatric hypertension who are experienced

in its use and interpretation.

Measurement of Blood Pressure in Children 7
8 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Blood Pressure Tables

In children and adolescents, the normal range

of BP is determined by body size and age.

BP standards that are based on sex, age, and

height provide a more precise classification 

of BP according to body size. This approach

avoids misclassifying children who are very

tall or very short.

The BP tables are revised to include the 

new height percentile data (www.cdc.gov/

growthcharts/)24 as well as the addition of BP

data from the NHANES 1999–2000. Demographic information on the source of the BP

data is provided in appendix A. The 50th,

90th, 95th, and 99th percentiles of SBP and

DBP (using K5) for height by sex and age are

given for boys and girls in tables 3 and 4.

Although new data have been added, the sex,

age, and height BP levels for the 90th and

95th percentiles have changed minimally from

the last report. The 50th percentile has been

added to the tables to provide the clinician

with the BP level at the midpoint of the

normal range. Although the 95th percentile

provides a BP level that defines hypertension,

management decisions about children with

hypertension should be determined by the

degree or severity of hypertension. Therefore,

the 99th percentile has been added to facilitate clinical decisionmaking in the plan for

evaluation. Standards for SBP and DBP for

infants younger than 1 year are available.25

In children younger than 1 year, SBP has been

used to define hypertension.

To use the tables in a clinical setting, the

height percentile is determined by using the

newly revised CDC Growth Charts

(www.cdc.gov/growthcharts/). The child’s

measured SBP and DBP are compared with

the numbers provided in the table (boys or

girls) according to the child’s age and height

percentile. The child is normotensive if the 

BP is below the 90th percentile. If the BP is

equal to or above the 90th percentile, the BP

measurement should be repeated at that visit

to verify an elevated BP. BP measurements

between the 90th and 95th percentiles indicate prehypertension and warrant reassessment

and consideration of other risk factors. (See

table 5.) In addition, if an adolescent’s BP is

greater than 120/80 mmHg, the patient

should be considered to be prehypertensive

even if this value is less than the 90th percentile. This BP level typically occurs for SBP

at age 12 years and for DBP at age 16 years.

If the child’s BP (systolic or diastolic) is at or

above the 95th percentile, the child may be

hypertensive, and the measurement must be

repeated on at least two additional occasions

to confirm the diagnosis. Staging of BP,

according to the extent to which a child’s BP

exceeds the 95th percentile, is helpful in developing a management plan for evaluation and

treatment that is most appropriate for an individual patient. On repeated measurement,

hypertensive children may have BP levels that

are only a few mmHg above the 95th percentile; these children would be managed

differently from hypertensive children who

have BP levels that are 15–20 mmHg above

the 95th percentile. An important clinical

decision is to determine which hypertensive

■ BP standards based on sex, age, and height provide a precise classification 

of BP according to body size.

■ The revised BP tables now include the 50th, 90th, 95th, and 99th percentiles 

(with standard deviations) by sex, age, and height.
children require more immediate attention for

elevated BP. The difference between the 95th

and 99th percentiles is only 7–10 mmHg and

is not large enough, particularly in view of the

variability in BP measurements, to adequately

distinguish mild hypertension—where limited

evaluation is most appropriate—from more

severe hypertension where more immediate

and extensive intervention is indicated.

Therefore, Stage 1 hypertension is the designation for BP levels that range from the 95th

percentile to 5 mmHg above the 99th percentile. Stage 2 hypertension is the designation

for BP levels that are higher than 5 mmHg

above the 99th percentile. Once confirmed 

on repeated measures, Stage 1 hypertension

allows time for evaluation before initiating

treatment unless the patient is symptomatic.

Patients with Stage 2 hypertension may need

more prompt evaluation and pharmacologic

therapy. Symptomatic patients with Stage 2

hypertension require immediate treatment and

consultation with experts in pediatric hypertension. These categories are parallel to the

staging of hypertension in adults, as noted in

JNC 7.2

USING THE BLOOD

PRESSURE TABLES

1. Use the standard height charts to determine

the height percentile.

2. Measure and record the child’s SBP 

and DBP.

3. Use the correct gender table for SBP 

and DBP.

4. Find the child’s age on the left side of the

table. Follow the age row horizontally

across the table to the intersection of the

line for the height percentile (vertical

column).

5. There, find the 50th, 90th, 95th, and 99th

percentiles for SBP in the left columns and

for DBP in the right columns.

■ BP less than the 90th percentile is normal.

■ BP between the 90th and 95th percentile 

is prehypertension. In adolescents, BP 

equal to or exceeding 120/80 mmHg is 

prehypertension, even if this figure is less 

than the 90th percentile.

■ BP greater than the 95th percentile may 

be hypertension.

6. If the BP is greater than the 90th percentile,

the BP should be repeated twice at the

same office visit, and an average SBP and

DBP should be used.

7. If the BP is greater than the 95th percentile,

BP should be staged. If Stage 1 (95th 

percentile to the 99th percentile plus

5 mmHg), BP measurements should be

repeated on two more occasions. If hypertension is confirmed, evaluation should

proceed as described in table 7. If BP is

Stage 2 (>99th percentile plus 5 mmHg),

prompt referral should be made for 

evaluation and therapy. If the patient is

symptomatic, immediate referral and treatment are indicated. Those patients with a

compelling indication, as noted in table 6,

would be treated as the next higher category of hypertension.

Blood Pressure Tables 9
10 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Systolic BP (mmHg)

← Percentile of Height →

Blood Pressure Levels for Boys by Age and Height Percentile*

T ABLE 3

Age BP

(Year) Percentile

↓

Diastolic BP (mmHg)

← Percentile of Height →

5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

1 50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39

90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54

95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58

99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66

2 50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44

90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59

95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63

99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71

3 50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48

90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63

95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67

99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75

4 50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52

90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67

95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71

99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79

5 50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55

90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70

95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74

99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82

6 50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57

90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72

95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76

99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84

7 50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59

90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74

95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78

99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86

8 50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61

90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76

95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80

99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88

9 50th 95 96 98 100 102 103 104 57 58 59 60 61 61 62

90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77

95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81

99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89

10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63

90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78

95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82

99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90
Blood Pressure Tables 11

Systolic BP (mmHg)

← Percentile of Height →

Age BP

(Year) Percentile

↓

Diastolic BP (mmHg)

← Percentile of Height →

5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63

90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78

95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82

99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90

12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64

90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79

95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83

99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64

90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79

95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83

99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91

14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65

90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80

95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84

99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92

15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66

90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81

95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85

99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93

16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67

90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82

95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87

99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94

17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70

90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84

95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89

99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97

BP, blood pressure

* The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean. For research purposes,

the standard deviations in appendix table B–1 allow one to compute BP Z-scores and percentiles for boys with height percentiles given

in table 3 (i.e., the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles). These height percentiles must be converted to height 

Z-scores given by (5% = -1.645; 10% = -1.28; 25% = -0.68; 50% = 0; 75% = 0.68; 90% = 1.28; 95% = 1.645) and then computed

according to the methodology in steps 2–4 described in appendix B. For children with height percentiles other than these, follow steps

1–4 as described in appendix B.
12 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Systolic BP (mmHg)

← Percentile of Height →

Blood Pressure Levels for Girls by Age and Height Percentile*

T ABLE 4

Age BP

(Year) Percentile

↓

Diastolic BP (mmHg)

← Percentile of Height →

5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

1 50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42

90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56

95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60

99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67

2 50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47

90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61

95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65

99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72

3 50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51

90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65

95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69

99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76

4 50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54

90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68

95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72

99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79

5 50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56

90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70

95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74

99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81

6 50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58

90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72

95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76

99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83

7 50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59

90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73

95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77

99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84

8 50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60

90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74

95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78

99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86

9 50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61

90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75

95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79

99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87

10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62

90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76

95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80

99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88
Blood Pressure Tables 13

Systolic BP (mmHg)

← Percentile of Height →

Age BP

(Year) Percentile

↓

Diastolic BP (mmHg)

← Percentile of Height →

5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63

90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77

95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81

99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89

12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64

90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78

95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82

99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90

13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65

90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79

95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83

99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91

14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66

90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80

95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84

99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92

15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67

90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81

95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85

99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93

16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68

90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82

95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86

99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93

17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68

90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82

95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86

99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93

BP, blood pressure

* The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean. For research purposes,

the standard deviations in appendix table B–1 allow one to compute BP Z-scores and percentiles for girls with height percentiles given in

table 4 (i.e., the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles). These height percentiles must be converted to height Z-scores

given by (5% = -1.645; 10% = -1.28; 25% = -0.68; 50% = 0; 75% = 0.68; 90% = 1.28; 95% = 1.645) and then computed according to

the methodology in steps 2–4 described in appendix B. For children with height percentiles other than these, follow steps 1–4 as

described in appendix B.
14 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Classification of Hypertension in Children and Adolescents, 

With Measurement Frequency and Therapy Recommendations

SBP or DBP

Percentile*

Frequency of BP

Measurement

Therapeutic

Lifestyle Changes

Pharmacologic

Therapy

T ABLE 5

Normal 

Prehypertension

Stage 1 

hypertension

Stage 2 

hypertension

<90th

90th to <95th 

or if BP exceeds

120/80 mmHg

even if below 90th 

percentile up to

<95th percentile†

95th percentile to

the 99th percentile

plus 5 mmHg

>99th percentile

plus 5 mmHg

Recheck at next

scheduled physical

examination.

Recheck in 6

months.

Recheck in 1–2

weeks or sooner 

if the patient is

symptomatic; 

if persistently 

elevated on two

additional occasions, evaluate 

or refer to source

of care within

1 month.

Evaluate or refer

to source of care

within 1 week 

or immediately 

if the patient is

symptomatic.

Encourage healthy

diet, sleep, and

physical activity.

Weight-management counseling 

if overweight,

introduce physical

activity and diet

management.‡

Weight-management counseling 

if overweight,

introduce physical

activity and diet

management.‡

Weight-management counseling 

if overweight,

introduce physical

activity and diet

management.‡

— 

None unless 

compelling 

indications such 

as CKD, diabetes

mellitus, heart failure, or LVH exist

Initiate therapy

based on indications in Table 6 

or if compelling

indications as

above.

Initiate therapy.§

BP, blood pressure; CKD, chronic kidney disease; DBP, diastolic blood pressure; LVH, left ventricular hypertrophy; SBP, 

systolic blood pressure

* For sex, age, and height measured on at least three separate occasions; if systolic and diastolic categories are different, 

categorize by the higher value.

† This occurs typically at 12 years old for SBP and at 16 years old for DBP.

‡ Parents and children trying to modify the eating plan to the Dietary Approaches to Stop Hypertension (DASH) eating plan

could benefit from consultation with a registered or licensed nutritionist to get them started.

§ More than one drug may be required.

Indications for Antihypertensive Drug

Therapy in Children

■ Symptomatic hypertension

■ Secondary hypertension

■ Hypertensive target-organ damage

■ Diabetes (types 1 and 2)

■ Persistent hypertension despite 

nonpharmacologic measures

T ABLE 6
Blood Pressure Tables 15

Clinical Evaluation of Confirmed Hypertension

Evaluation for identifiable causes

History, including sleep history, family history, risk factors, diet, and habits such as

smoking and drinking alcohol; physical

examination

BUN, creatinine, electrolytes, urinalysis, 

and urine culture 

CBC

Renal U/S

Evaluation for comorbidity

Fasting lipid panel, fasting glucose

Drug screen

Polysomnography

Evaluation for target-organ damage

Echocardiogram

Retinal exam

Further evaluation as indicated

Ambulatory BP monitoring

Plasma renin determination

Renovascular imaging

• Isotopic scintigraphy (renal scan)

• Magnetic resonance angiography

• Duplex Doppler flow studies

• 3-Dimensional CT

• Arteriography: DSA or classic

Plasma and urine steroid levels

Plasma and urine catecholamines

History and physical examination help

focus subsequent evaluation

R/O renal disease and chronic pyelonephritis

R/O anemia, consistent with chronic renal

disease

R/O renal scar, congenital anomaly, or 

disparate renal size

Identify hyperlipidemia, identify metabolic 

abnormalities

Identify substances that might cause 

hypertension

Identify sleep disorder in association with 

hypertension

Identify LVH and other indications of 

cardiac involvement

Identify retinal vascular changes

Identify white-coat hypertension, 

abnormal diurnal BP pattern, BP load

Identify low renin, suggesting mineralocorticoid-related disease

Identify renovascular disease

Identify steroid-mediated hypertension

Identify catecholamine-mediated hypertension

All children with persistent BP ≥95th 

percentile

All children with persistent BP ≥95th 

percentile

All children with persistent BP ≥95th 

percentile

All children with persistent BP ≥95th 

percentile

Overweight patients with BP at 90th–94th

percentile; all patients with BP ≥95th 

percentile. Family history of hypertension

or cardiovascular disease. Child with 

chronic renal disease

History suggestive of possible contribution

by substances or drugs

History of loud, frequent snoring

Patients with comorbid risk factors* and BP

90th–94th percentile; all patients with BP

≥95th percentile 

Patients with comorbid risk factors* and BP

90th–94th percentile; all patients with BP

≥95th percentile

Patients in whom white-coat hypertension is

suspected, and when other information on

BP pattern is needed

Young children with Stage 1 hypertension

and any child or adolescent with Stage 2

hypertension

Positive family history of severe hypertension

Young children with Stage 1 hypertension

and any child or adolescent with Stage 2

hypertension

Young children with Stage 1 hypertension

and any child or adolescent with Stage 2

hypertension

Young children with Stage 1 hypertension

and any child or adolescent with Stage 2

hypertension

T ABLE 7

BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood count; CT, computerized tomography; DSA, digital subtraction angiography; 

LVH, left ventricular hypertrophy; R/O, rule out; U/S, ultrasound

* Comorbid risk factors also include diabetes mellitus and kidney disease.

Study or Procedure Purpose Target Population
16 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Primary Hypertension 

and Evaluation for Comorbidities

High BP in childhood had been considered 

a risk factor for hypertension in early adulthood. However, primary (essential)

hypertension is now identifiable in children

and adolescents. Primary hypertension in

childhood is usually characterized by mild 

or Stage 1 hypertension and is often associated with a positive family history of

hypertension or cardiovascular disease (CVD).

Children and adolescents with primary hypertension are frequently overweight. Data on

healthy adolescents obtained in school healthscreening programs demonstrate that the

prevalence of hypertension increases progressively with increasing body mass index (BMI),

and hypertension is detectable in approximately 30 percent of overweight children

(BMI >95th percentile).26 The strong association of high BP with obesity and the marked

increase in the prevalence of childhood obesity27 indicate that both hypertension and

prehypertension are becoming a significant

health issue in the young. Overweight children

frequently have some degree of insulin resistance—a prediabetic condition. Overweight

and high BP are also components of the

insulin-resistance syndrome or metabolic syndrome, a condition of multiple metabolic risk

factors for CVD as well as for type 2

diabetes.28,29 The clustering of other CVD

risk factors that are included in the insulinresistance syndrome (high triglycerides, low

high-density lipoprotein cholesterol [HDL-C],

truncal obesity, hyperinsulinemia) is significantly greater among children with high BP

than in children with normal BP.30 Recent

reports from studies that examined childhood

data estimate that the insulin-resistance syndrome is present in 30 percent of overweight

children with BMI greater than the 95th

percentile.31 Historically, hypertension in

childhood was considered a simple independent risk factor for CVD, but its link to

the other risk factors in the insulin-resistance

syndrome indicates that a broader approach 

is more appropriate in affected children.

Primary hypertension often clusters with other

risk factors.31,32 Therefore, the medical history, physical examination, and laboratory

evaluation of hypertensive children and adolescents should include a comprehensive

assessment for additional cardiovascular risk.

These risk factors, in addition to high BP and

overweight, include low plasma HDL-C, 

elevated plasma triglyceride, and abnormal

glucose tolerance. Fasting plasma insulin 

concentration is generally elevated, but an elevated insulin concentration may be reflective

only of obesity and is not diagnostic of the

insulin-resistance syndrome. To identify other

cardiovascular risk factors, a fasting lipid

panel and fasting glucose level should be

obtained in children who are overweight and

■ Primary hypertension is identifiable in children and adolescents.

■ Both hypertension and prehypertension have become a significant health issue 

in the young due to the strong association of high BP with overweight and the 

marked increase in the prevalence of overweight children.

■ The evaluation of hypertensive children should include assessment for additional 

risk factors.

■ Due to an association of sleep apnea with overweight and high BP, a sleep history 

should be obtained.
have BP between the 90th and 94th percentile

and in all children with BP greater than the

95th percentile. If there is a strong family history of type 2 diabetes, a hemoglobin A1c or

glucose tolerance test may also be considered.

These metabolic risk factors should be

repeated periodically to detect changes in the

level of cardiovascular risk over time. Fewer

data are available on the utility of other tests

in children (e.g., plasma uric acid, or homocysteine and lp(a) levels), and the use of these

measures should depend on family history.

Sleep disorders, including sleep apnea, are

associated with hypertension, coronary artery

disease, heart failure, and stroke in adults.33,34

Although limited data are available, they suggest an association of sleep-disordered

breathing and higher BP in children.35,36

Approximately 15 percent of children snore,

and at least 1–3 percent have sleep-disordered

breathing.35 Because of the associations with

hypertension and the frequency of occurrence

of sleep disorders, particularly among 

overweight children, a history of sleeping 

patterns should be obtained in a child with

hypertension. One practical strategy for 

identifying children with a sleep problem or

sleep disorder is to obtain a brief sleep history,

using an instrument called BEARS.37(table 1.1)

BEARS addresses five major sleep domains

that provide a simple but comprehensive

screen for the major sleep disorders affecting

children ages 2–18. The components of

BEARS include: Bedtime problems, Excessive

daytime sleepiness, Awakenings during the

night, Regularity and duration of sleep, and

Sleep-disordered breathing (snoring). Each 

of these domains has an age-appropriate

trigger question and includes responses of

both parent and child, as appropriate. This

brief screening for sleep history can be completed in about 5 minutes.

In a child with primary hypertension, the presence of any comorbidity that is associated with

hypertension carries the potential to increase

the risk for CVD and can have an adverse

effect on health outcome. Consideration of

these associated risk factors and appropriate

evaluation in those children in whom the

hypertension is verified are important in planning and implementing therapies that reduce

the comorbidity risk as well as control BP.

Primary Hypertension and Evaluation for Comorbidities 17
18 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Evaluation for Secondary Hypertension

Secondary hypertension is more common in

children than in adults. The possibility that

some underlying disorder may be the cause of

the hypertension should be considered in

every child or adolescent who has elevated BP.

However, the extent of an evaluation for

detection of a possible underlying cause

should be individualized for each child. Very

young children, children with Stage 2 hypertension, and children or adolescents with

clinical signs that suggest the presence of systemic conditions associated with hypertension

should be evaluated more extensively as compared to those with Stage 1 hypertension.38

Present technologies may facilitate less invasive evaluation than in the past, although

experience in using newer modalities with

children is still limited.

A thorough history and physical examination

are the first steps in the evaluation of any

child with persistently elevated BP. Elicited

information should aim to identify not only

signs and symptoms due to high BP but also

clinical findings that might uncover an underlying systemic disorder. Thus, it is important

to seek signs and symptoms suggesting renal

disease (gross hematuria, edema, fatigue),

heart disease (chest pain, exertional dyspnea,

palpitations), and diseases of other organ systems (e.g., endocrinologic, rheumatologic).

Past medical history should elicit information

to focus the subsequent evaluation and to

uncover definable causes of hypertension.

Questions should be asked about prior hospitalizations, trauma, urinary tract infections,

snoring and other sleep problems. Questions

should address family history of hypertension,

diabetes, obesity, sleep apnea, renal disease,

other CVD (hyperlipidemia, stroke), and

familial endocrinopathies. Many drugs can

increase BP, so it is important to inquire

directly about use of over-the-counter, prescription, and illicit drugs. Equally important

are specific questions aimed at identifying the

use of nutritional supplements, especially

preparations aimed at enhancing athletic performance.

PHYSICAL EXAMINATION

The child’s height, weight, and percentiles for

age should be determined at the start of the

physical examination. Because obesity is

strongly linked to hypertension, BMI should

be calculated from the height and weight, and

the BMI percentile should be calculated. Poor

growth may indicate an underlying chronic

illness. When hypertension is confirmed, BP

should be measured in both arms and in a leg.

Normally, BP is 10–20 mmHg higher in the

legs than the arms. If the leg BP is lower than

the arm BP, or if femoral pulses are weak 

or absent, coarctation of the aorta may be

present. Obesity alone is an insufficient explanation for diminished femoral pulses in the

■ Secondary hypertension is more common in children than in adults.

■ Because overweight is strongly linked to hypertension, BMI should be calculated 

as part of the physical examination.

■ Once hypertension is confirmed, BP should be measured in both arms and in a leg.

■ Very young children, children with Stage 2 hypertension, and children or adolescents

with clinical signs that suggest systemic conditions associated with hypertension 

should be evaluated more completely than in those with Stage 1 hypertension.
presence of high BP. The remainder of the

physical examination should pursue clues

found on history and should focus on findings

that may indicate the cause and severity of

hypertension. Table 8 lists important physical

exam findings in hypertensive children.39

The physical examination in hypertensive 

children is frequently normal except for the

BP elevation. The extent of the laboratory

evaluation is based on the child’s age, history,

physical examination findings, and level of BP

elevation. The majority of children with 

secondary hypertension will have renal or 

renovascular causes for the BP elevation.

Therefore, screening tests are designed to have

a high likelihood of detecting children and

adolescents who are so affected. These tests

are easily obtained in most primary care

offices and community hospitals. Additional

evaluation must be tailored to the specific

child and situation. The risk factors, or

comorbid conditions, associated with primary

hypertension should be included in the evaluation of hypertension in all children, as well

as efforts to determine any evidence of targetorgan damage.

ADDITIONAL DIAGNOSTIC

STUDIES FOR

HYPERTENSION

Additional diagnostic studies may be appropriate in the evaluation of hypertension in a

child or adolescent, particularly if there is a

high degree of suspicion that an underlying

disorder is present. Such procedures are listed

in table 7. ABPM, discussed previously, has

application in evaluating both primary and

secondary hypertension. ABPM is also used

to detect white-coat hypertension.

RENIN PROFILING

Plasma renin level or plasma renin activity

(PRA) is a useful screening test for mineralocorticoid-related diseases. With these

disorders, the PRA is very low or unmeasurable by the laboratory and may be associated

with relative hypokalemia. PRA levels are

higher in patients who have renal artery

stenosis. However, approximately 15 percent

of children with arteriographically evident

renal artery stenosis have normal PRA

values.40–42 Assays for direct measurement 

of renin, a different technique than PRA, are

commonly used, although extensive normative data in children and adolescents are

unavailable.

EVALUATION FOR POSSIBLE

RENOVASCULAR

HYPERTENSION

Renovascular hypertension is a consequence

of an arterial lesion or lesions impeding blood

flow to one or both kidneys or to one or

more intrarenal segments.43,44 Affected children usually, but not invariably, have

markedly elevated BP.40,44 Evaluation for renovascular disease also should be considered in

infants or children with other known predisposing factors, such as prior umbilical artery

catheter placements or neurofibromatosis.44,45

A number of newer diagnostic techniques are

presently available for evaluation of renovascular disease, but experience in their use in

pediatric patients is limited. Consequently, the

recommended approaches generally use older

techniques, such as standard intra-arterial

angiography, digital-subtraction angiography

(DSA), and scintigraphy (with or without

angiotensin-converting enzyme [ACE] inhibition).44 As technologies evolve, children

should be referred for imaging studies to centers that have expertise in the radiological

evaluation of childhood hypertension.

INVASIVE STUDIES

Intra-arterial DSA with contrast is used more

frequently than standard angiography, but,

because of intra-arterial injection, this method

remains invasive. DSA also can be accomplished by using a rapid injection of contrast

into a peripheral vein, but quality of views

and the size of pediatric veins make this technique useful only for older children. DSA and

formal arteriography are still considered the

“gold standard,” but these studies should be

undertaken only when surgical or invasive

interventional radiologic techniques are being

contemplated for anatomic correction.46

Evaluation for Secondary Hypertension 19
20 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Examples of Physical Examination Findings Suggestive of Definable Hypertension*

Vital signs

Eyes

Ear, nose, and throat

(ENT)

Height/weight

Head and neck

Skin

Chest

Abdomen

Genitalia

Extremities

Tachycardia

Decreased lower

extremity pulses; 

drop in BP from upper

to lower extremities

Retinal changes

Adenotonsillar 

hypertrophy

Growth retardation 

Obesity (high BMI)

Truncal obesity

Moon facies

Elfin facies

Webbed neck

Thyromegaly

Pallor, flushing,

diaphoresis

Acne, hirsutism, striae

Café-au-lait spots

Adenoma sebaceum

Malar rash

Acanthrosis nigricans

Widely spaced nipples

Heart murmur

Friction rub

Apical heave

Mass

Epigastric/flank bruit

Palpable kidneys

Ambiguous/virilization

Joint swelling

Muscle weakness

Hyperthyroidism, pheochromocytoma, 

neuroblastoma, primary hypertension

Coarctation of the aorta

Severe hypertension, more likely to be associated

with secondary hypertension

Suggests association with sleep-disordered 

breathing (sleep apnea), snoring

Chronic renal failure

Primary hypertension

Cushing syndrome, insulin resistance syndrome

Cushing syndrome

Williams syndrome

Turner syndrome

Hyperthyroidism

Pheochromocytoma

Cushing syndrome, anabolic steroid abuse

Neurofibromatosis

Tuberous sclerosis

Systemic lupus erythematosus

Type 2 diabetes

Turner syndrome

Coarctation of the aorta

Systemic lupus erythematosus (pericarditis), 

collagen-vascular disease, end stage renal disease

with uremia

Left ventricular hypertrophy/chronic hypertension

Wilms tumor, neuroblastoma, pheochromocytoma

Renal artery stenosis

Polycystic kidney disease, hydronephrosis, multicystic-dysplastic kidney, mass (see above)

Adrenal hyperplasia

Systemic lupus erythematosus, collagen vascular

disease

Hyperaldosteronism, Liddle syndrome

T ABLE 8

BMI, body mass index; BP, blood pressure

* Adapted from Flynn, JT. Evaluation and management of hypertension in childhood. Prog Pediatr Cardiol 2001;12:177–88.

† Findings listed are examples of physical findings and do not represent all possible physical findings.

Finding† Possible Etiology
Evaluation for Secondary Hypertension 21

Newer imaging techniques may be used in

children with vascular lesions. Magnetic 

resonance angiography (MRA) is increasingly

feasible for the evaluation of pediatric 

renovascular disease, but it is still best for

detecting abnormalities in the main renal

artery and its primary branches.47–49 Imaging

with magnetic resonance requires that the

patient be relatively immobile for extended

periods—a significant difficulty for small children. At present, studies are needed to assess

the effectiveness of MRA in the diagnosis of

children with renovascular disease. Newer

methods, including 3-dimensional (3-D)

reconstructions of computerized tomography

(CT) images, or spiral CT with contrast,

appear promising in evaluating children who

may have renovascular disease.50
22 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Target-Organ Abnormalities 

in Childhood Hypertension

Hypertension is associated with increased risk

of myocardial infarction, stroke, and cardiovascular mortality in adults,2,51 and treatment

of elevated BP results in a reduction in the

risk for cardiovascular events.

Children and adolescents with severe elevation

of BP are also at increased risk of adverse outcomes, including hypertensive encephalopathy,

seizures, and even cerebrovascular accidents

and congestive heart failure.52,53 Even hypertension that is less severe contributes to

target-organ damage when it occurs with

other chronic conditions, such as chronic

kidney disease.54–56 Two autopsy studies,57,58

that evaluated tissue from adolescents and

young adults who had sudden deaths due to

trauma, demonstrated significant relationships

between the level of BP, or hypertension, and

the presence of atherosclerotic lesions in the

aorta and coronary arteries. The exact level

and duration of BP elevation that causes

target-organ damage in the young has not

been established.

One difficulty in the assessment of these 

relationships is that, until recently, few noninvasive methods could evaluate the effect of

hypertension on the cardiovascular system.

Noninvasive techniques that use ultrasound

can demonstrate structural and functional

changes in the vasculature related to BP.

Recent clinical studies using these techniques

demonstrate that childhood levels of BP are

associated with carotid intimal-medial thickness59 and large artery compliance60 in young

adults. Even healthy adolescents with clustering of cardiovascular risk factors

demonstrate elevated carotid thickness,61,62

and those with BP levels at the higher end of

the normal distribution show decreased

brachial artery flow-mediated vasodilatation.

Overall, evidence is increasing that even mild

BP elevation can have an adverse effect on

vascular structure and function63 in asymptomatic young persons.

LVH is the most prominent clinical evidence of

target-organ damage caused by hypertension

in children and adolescents. With the use of

echocardiography to measure left ventricular

mass, LVH has been reported in 34–38 percent of children and adolescents with mild,

untreated BP elevation.64–66 Daniels et al. evaluated 130 children and adolescents with

persistent BP elevation.67 They reported that

55 percent of patients had a left ventricular

mass index greater than the 90th percentile,

and 14 percent had left ventricular mass index

above 51 g/m2.7, a value in adults with hypertension that has been associated with a

fourfold greater risk of adverse cardiovascular

outcomes. When left ventricular geometry

was examined in hypertensive children,

■ Target-organ abnormalities are commonly associated with hypertension in children 

and adolescents.

■ Left ventricular hypertrophy (LVH) is the most prominent evidence of target-organ 

damage.

■ Pediatric patients with established hypertension should have echocardiographic 

assessment of left ventricular mass at diagnosis and periodically thereafter.

■ The presence of LVH is an indication to initiate or intensify antihypertensive 

therapy.
17 percent had concentric hypertrophy, a pattern that is associated with higher risk for

cardiovascular outcomes in adults, and

30 percent had eccentric hypertrophy, which

is associated with intermediate risk for cardiovascular outcomes.67

In addition, abnormalities of the retinal vasculature have been reported in adults with

hypertension.68 Few studies of retinal abnormalities have been conducted in children with

hypertension. Skalina et al. evaluated newborns with hypertension69 and reported the

presence of hypertensive retinal abnormalities

in approximately 50 percent of their patients.

On repeat examination, after the resolution of

hypertension, these abnormalities had disappeared.

CLINICAL RECOMMENDATION

Echocardiography is recommended as a 

primary tool for evaluating patients for targetorgan abnormalities by assessing the presence

or absence of LVH. Left ventricular mass is

determined from standard echocardiographic

measurements of the left ventricular end-diastolic dimension (LVED), the intraventricular

septal thickness (IVS), and the thickness of the

left ventricular posterior wall (LVPW) and can

be calculated as: LV Mass (g) = 0.80 [1.04

(IVS + LVED + LVPW)3 – (LVED)3] + 0.6

(with echocardiographic measurements in centimeters). From these measures, the left

ventricular mass can be calculated by using

the equation of Devereux et al.70 when measurements are made according to the criteria of

the American Society of Echocardiography.71

Heart size is closely associated with body

size.72 Left ventricular mass index is calculated to standardize measurements of left

ventricular mass. Several methods for

indexing left ventricular mass have been

reported, but it is recommended that height

(m2.7) be used to index left ventricular mass,

as described by de Simone et al.73 This

method accounts for close to the equivalent of

the effect of lean body mass and excludes the

effect of obesity and BP elevation on left ventricular mass. Some echo laboratories use

height as the indexing variable. This calculation is also acceptable and is somewhat easier

to use, as fewer calculations are needed.

Children and adolescents with established

hypertension should have an echocardiogram

to determine if LVH is present. A conservative cutpoint that determines the presence of

LVH is 51 g/m2.7. This cutpoint is above the

99th percentile for children and adolescents

and is associated with increased morbidity in

adults with hypertension.73 Other references

exist for normal children,74 but, unlike adults,

outcome-based standards for left ventricular

mass index are not available for children. In

interpreting the left ventricular mass index, it

should be remembered that some factors, such

as obesity and hypertension, have pathologic

effects on the heart, whereas others—such as

physical activity, particularly in highly conditioned athletes—may be adaptive.

Ascertainment of left ventricular mass index 

is very helpful in clinical decisionmaking.

The presence of LVH can be an indication for

initiating or intensifying pharmacologic

therapy to lower BP. For patients who have

LVH, the echocardiographic determination of

left ventricular mass index should be repeated

periodically.

At the present time, additional testing for other

target-organ abnormalities (such as determination of carotid intimal-medial thickness and

evaluation of urine for microalbuminuria) is

not recommended for routine clinical use.

Further research will be needed to evaluate the

clinical utility of these tests.

Target-Organ Abnormalities in Childhood Hypertension 23
24 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Therapeutic 

Lifestyle Changes

Evidence is limited that supports the efficacy

of nonpharmacological interventions for BP

reduction in the treatment of hypertension in

children and adolescents. Data that demonstrate a relationship of lifestyle with BP can be

used as the basis for recommendations. On

the basis of large randomized controlled trials,

the following lifestyle modifications are recommended in adults:2 weight reduction in

overweight or obese individuals;75 increased

intake of fresh vegetables, fruits, and lowfat

dairy (the Dietary Approaches to Stop

Hypertension Study [DASH] eating plan);76

dietary sodium reduction;76,77 increased physical activity;78 and moderation of alcohol

consumption.79 Smoking cessation has significant cardiovascular benefits.32 As information

on chronic sleep problems evolves, interventions to improve sleep quality may also have a

beneficial effect on BP.80

The potential for control of BP in children

through weight reduction is supported by BP

tracking and weight-reduction studies. BP

levels track from childhood through adolescence and into adulthood81–83 in association

with weight.84,85 Because of the strong correlation between weight and BP, excessive

weight gain is likely to be associated with elevated BP over time. Therefore, maintenance

of normal weight gain in childhood should

lead to less hypertension in adulthood.

Weight loss in overweight adolescents is associated with a decrease in BP.30,86–90 Weight

control not only decreases BP, it also

decreases BP sensitivity to salt88 and decreases

other cardiovascular risk factors, such as dyslipidemia and insulin resistance.32 In studies

that achieve a reduction in BMI of about

10 percent, short-term reductions in BP were

in the range of 8–12 mmHg. Although difficult, weight loss, if successful, is extremely

effective.32,91–93 Identifying a complication of

overweight, such as hypertension, can be a

helpful motivator for patients and families to

make changes. Weight control can render

pharmacological treatment unnecessary but

should not delay drug use when indicated.

Emphasis on the management of complications rather than on overweight shifts the aim

of weight management from an aesthetic to a

health goal. In motivated families, education

or simple behavior modification can be successful in achieving moderate weight loss or

preventing further weight gain. Steps can be

implemented in the primary care setting even

with limited staff and time resources.32,91 The

patient should be encouraged to self-monitor

time spent in sedentary activity, including

watching television and playing video or computer games, and to set goals to progressively

decrease these activities to less than 2 hours

per day.94 The family and patient should

identify physical activities that the child enjoys,

■ Weight reduction is the primary therapy for obesity-related hypertension.

Prevention of excess or abnormal weight gain will limit future increases in BP.

■ Regular physical activity and restriction of sedentary activity will improve efforts 

at weight management and may prevent an excess increase in BP over time.

■ Dietary modification should be strongly encouraged in children and adolescents who

have BP levels in the prehypertensive range as well as in those with hypertension.

■ Family-based intervention improves success.
engage in them regularly, and self-monitor time

spent in physical activities (30–60 minutes per

day should be achieved).94–96 Dietary changes

can involve portion-size control, decrease in

consumption of sugar-containing beverages and

energy-dense snacks, increase in consumption

of fresh fruits and vegetables, and regular

meals including a healthy breakfast.32,91,93,97,98

Consultation with a nutritionist can be useful

and provide customized recommendations.

During regular office visits, the primary care

provider can supervise the child’s progress in

self-monitoring and accomplishing goals and

can provide support and positive feedback to

the family. Some patients will benefit from a

more intense and comprehensive approach to

weight management from a multidisciplinary

and specialized team if available.91–93

Despite the lack of firm evidence about

dietary intervention in children, it is generally

accepted that hypertensive individuals can

benefit from a dietary increase in fresh vegetables, fresh fruits, fiber, and nonfat dairy, as

well as a reduction of sodium. Despite some

suggestion that calcium supplements may

decrease BP in children,99,100 so far the evidence is too limited to support a clinical

recommendation.101 Lower BP has been associated in children and adolescents with an

increased intake of potassium,100–103 magnesium,100,101 folic acid,101,104 unsaturated

fat,100,105,106 and fiber,100,101,104 and lower

dietary intake of total fat.100,101 However,

these associations are small and insufficient to

support dietary recommendations for specific,

individual nutrients.

Sodium reduction in children and adolescents

has been associated with small reductions in

BP, in the range of 1–3 mmHg.101,103,107–110

Data from one randomized trial suggest that

sodium intake in infancy may affect BP in

adolescence.111 Similarly, some evidence indicates that breastfeeding may be associated

with lower BP in childhood.112,113 The current

recommendation for adequate daily sodium

intake is only 1.2 g/day for 4- to 8-year-old

children and 1.5 g/day for older children.114

Since this amount of sodium is substantially

lower than current dietary intakes, lowering

dietary sodium from the current usual intake

may have future benefit. Reduced sodium

intake, with calorie restriction, may account

for some of the BP improvement associated

with weight loss.

Regular physical activity has cardiovascular

benefits. A recent meta-analysis that combined 12 randomized trials, for a total of

1,266 children and adolescents, concluded

that physical activity leads to a small, but not

statistically significant, decrease in BP.115

However, both regular physical activity and

decreasing sedentary activity—such as

watching television and playing video or electronic games—are important components of

pediatric obesity treatment and prevention.32,91–93 Weight-reduction trials

consistently report better results when physical activity and/or prevention of sedentary

activity are included in the treatment protocol. Therefore, regular aerobic physical

activity (30–60 minutes of moderate physical

activity on most days) and limitation of

sedentary activities to less than 2 hours per

day are recommended for the prevention of

obesity, hypertension, and other cardiovascular risk factors.94–96 With the exception of

power lifting, resistance training is also

helpful. Competitive sports participation

should be limited only in the presence of

uncontrolled Stage 2 hypertension.116

The scope of hypertension as a public health

problem in adults is substantial. Poor healthrelated behaviors such as physical inactivity,

unfavorable dietary patterns, and excessive

weight gain raise the risk for future hypertension. The therapeutic lifestyle changes

discussed above may have benefit for all children in prevention of future disease, including

primary hypertension. Accordingly, appropriate health recommendations for all children

and adolescents are regular physical activity; a

diet with limited sodium but rich in fresh

fruits, fresh vegetables, fiber, and lowfat dairy;

and avoiding excess weight gain.

Therapeutic Lifestyle Changes 25
26 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Pharmacologic Therapy 

of Childhood Hypertension

In adults, hypertension is typically a lifelong

condition. Most hypertensive patients will

need to remain on medications for the rest of

their lives. Usually, adults readily accept this

fact, given the known long-term adverse consequences of untreated or undertreated

hypertension.117 In children, however, the

long-term consequences of untreated hypertension are unknown. Additionally, no data are

available on the long-term effects of antihypertensive drugs on growth and development.

Therefore, a definite indication for initiating

pharmacologic therapy should be ascertained

before a drug is prescribed.

Table 6 summarizes the indications for use of

antihypertensive drugs in children. These

indications include symptomatic hypertension,

secondary hypertension, established hypertensive target-organ damage, and failure of

nonpharmacologic measures. Other indications for use of antihypertensive drugs can be

considered, depending on the clinical situation. For example, because the presence of

multiple cardiovascular risk factors (elevated

BP, dyslipidemia, tobacco use, etc.) increases

cardiovascular risk in an exponential rather

than additive fashion,118,119 antihypertensive

therapy could be considered if the child or

adolescent is known to have dyslipidemia.

The number of antihypertensive drugs has

increased since the publication of the Report

of the Task Force on Blood Pressure Control

in Children.120 The number of drugs that

have been studied systematically in children

has also increased, largely because of incentives provided to the pharmaceutical industry

under the auspices of the 1997 Food and

Drug Administration Modernization Act

(FDAMA) and the 2002 Best Pharmaceuticals

for Children Act (BPCA).121–123 These developments have had both negative and positive

consequences. Chief among the negative consequences is the lack of reliable pediatric data

for older, commonly used compounds with

expired patent protection. Currently, no

incentives exist for industry-sponsored trials

of such drugs, and alternative methods of

stimulating pediatric studies, such as those

contained in the BPCA,123–125 have yet to

come to fruition. On the other hand, publication of the results of industry-sponsored

clinical trials and single-center case series will

■ Indications for antihypertensive drug therapy in children include secondary 

hypertension and insufficient response to lifestyle modifications.

■ Recent clinical trials have expanded the number of drugs that have pediatric dosing 

information. Dosing recommendations for many of the newer drugs are provided.

■ Pharmacologic therapy, when indicated, should be initiated with a single drug.

Acceptable drug classes for use in children include ACE inhibitors, angiotensinreceptor blockers, beta-blockers, calcium channel blockers, and diuretics.

■ The goal for antihypertensive treatment in children should be reduction of BP 

to <95th percentile, unless concurrent conditions are present. In that case, 

BP should be lowered to <90th percentile.

■ Severe, symptomatic hypertension should be treated with intravenous 

antihypertensive drugs.
provide additional data that can be combined

with prior recommendations based on expert

opinion and collective clinical experience to

guide the use of antihypertensive drugs in

children and adolescents who require pharmacologic treatment.

Table 9 contains dosing recommendations for

antihypertensive drugs in children 1–17 years

old. It should be noted that many other drugs

are available in addition to those listed in table

9. Those drugs are not included in the table,

however, because few or no pediatric data were

available at the time this report was prepared.

Long-term, clinical endpoint data from randomized trials, such as the Antihypertensive

and Lipid-Lowering Treatment to Prevent

Heart Attack Trial (ALLHAT), support the

preferential use of specific antihypertensive

drugs in adults.2,126 However, pediatric clinical trials of antihypertensive drugs have

focused only on their ability to lower BP and

have not compared the effects of these drugs

on clinical endpoints. Therefore, because all

classes of antihypertensive drugs have been

shown to lower BP in children, the choice of

drug for initial antihypertensive therapy

resides in the preference of the responsible

physician. Some diuretics and beta-adrenergic

blockers, which were recommended as initial

therapy in the first and second Task Force

Reports,25,120 have a long history of safety

and efficacy based on clinical experience in

hypertensive children, and these drugs remain

appropriate for pediatric use. Similarly, some

members of the newer classes of antihypertensive drugs, including ACE inhibitors, calcium

channel blockers, and angiotensin-receptor

blockers,127–130 have been studied in children

and, based on short-term use, shown to be

safe and well-tolerated with satisfactory BP

reductions in hypertensive children.

Specific classes of antihypertensive drugs

should be used preferentially in certain hypertensive children with specific underlying or

concurrent medical conditions. Examples

include the use of ACE inhibitors or

angiotensin-receptor blockers in children with

diabetes and microalbuminuria or proteinuric

renal diseases, and the use of beta-adrenergic

blockers or calcium channel blockers in hypertensive children with migraine headaches.

This approach is similar to that outlined in 

the recent JNC 7 report, which recommends

specific classes of antihypertensive drugs for

use in adults in certain high-risk categories.2

All antihypertensive drugs should be prescribed in a similar fashion: The child is

initially started on the lowest recommended

dose listed in table 9. The dose can be

increased until the desired BP goal is achieved.

Once the highest recommended dose is

reached, or if the child experiences side effects

from the drug, a second drug from a different

class should be added. Consideration should

be given to combining drugs with complementary mechanisms of action, such as an

ACE inhibitor with a diuretic, or a vasodilator

with a diuretic or beta-adrenergic blocker.

Because little pediatric experience is available

in using fixed-dose combination products,

except for bisoprolol/HCTZ,131 routine use of

these products in children cannot be recommended at this time.

For children with uncomplicated primary

hypertension and no hypertensive targetorgan damage, the goal BP should be less

than the 95th percentile for sex, age, and

height, whereas for children with chronic

renal disease, diabetes, or hypertensive targetorgan damage, the goal BP should be less

than the 90th percentile for sex, age, and

height. Again, this approach is similar to the

recommended treatment of hypertension in

adults with additional cardiovascular risk 

factors or comorbid conditions.2

Important adjunctive aspects to the drug

therapy of childhood hypertension include

ongoing monitoring of target-organ damage as

well as BP monitoring, surveillance for drug

side effects, periodic monitoring of electrolytes

in children treated with ACE inhibitors or

diuretics, counseling regarding other cardiovascular risk factors, and continued emphasis

on nonpharmacologic measures. It may also

be appropriate to consider “step-down”

therapy in selected patients. This approach

attempts a gradual reduction in the drug after

an extended course of good BP control, with

Pharmacologic Therapy of Childhood Hypertension 27
28 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Antihypertensive Drugs for Outpatient Management of Hypertension in Children 1–17 Years Old*

Initial: 0.2 mg/kg/day up to 10 mg/day

Maximum: 0.6 mg/kg/day up to 40 mg/day

Initial: 0.3–0.5 mg/kg/dose 

Maximum: 6 mg/kg/day

Initial: 0.08 mg/kg/day up to 5 mg/day

Maximum: 0.6 mg/kg/day up to 40 mg/day

Children >50 kg: 

Initial: 5–10 mg/day

Maximum: 40 mg/day

Initial: 0.07 mg/kg/day up to 5 mg/day

Maximum: 0.6 mg/kg/day up to 40 mg/day

Initial: 5–10 mg/day

Maximum: 80 mg/day

6–12 years: 75–150 mg/day

≥13 years: 150–300 mg/day

Initial: 0.7 mg/kg/day up to 50 mg/day

Maximum: 1.4 mg/kg/day up to 100 mg/day

Initial: 1–3 mg/kg/day

Maximum: 10–12 mg/kg/day up to 1,200 mg/day

Initial: 0.5–1 mg/kg/day

Maximum: 2 mg/kg/day up to 100 mg/day

Initial: 2.5/6.25 mg/day

Maximum: 10/6.25 mg/day

Initial: 1–2 mg/kg/day

Maximum: 6 mg/kg/day up to 200 mg/day

Initial: 1–2 mg/kg/day

Maximum: 4 mg/kg/day up to 640 mg/day

Children 6–17 years:

2.5–5 mg once daily

Initial: 2.5 mg/day

Maximum: 10 mg/day 

Initial: 0.15–0.2 mg/kg/day

Maximum: 0.8 mg/kg/day up to 20 mg/day

Initial: 0.25–0.5 mg/kg/day

Maximum: 3 mg/kg/day up to 120 mg/day 

T ABLE 9

Angiotensin-converting

enzyme (ACE) inhibitor

Angiotensin-receptor blocker

α- and β-blocker

β-blocker

Calcium channel blocker

Benazepril

Captopril

Enalapril

Fosinopril

Lisinopril

Quinapril

Irbesartan

Losartan

Labetalol

Atenolol

Bisoprolol/HCTZ

Metoprolol

Propranolol

Amlodipine

Felodipine

Isradipine

Extended-release 

nifedipine

Class Drug Dose†
Pharmacologic Therapy of Childhood Hypertension 29

qd

tid

qd–bid

qd

qd

qd

qd

qd

bid

qd–bid

qd

bid

bid–tid

qd

qd

tid–qid

qd–bid

RCT

RCT, CS

RCT

RCT

RCT

RCT, EO

CS

RCT

CS, EO

CS

RCT

CS

RCT, EO

RCT

RCT, EO

CS, EO

CS, EO

Yes

No

Yes

Yes

Yes

No

Yes

Yes

No

No

No

No

Yes

Yes

No

No

No

1. All ACE inhibitors are contraindicated in pregnancy—females of 

childbearing age should use reliable contraception.

2. Check serum potassium and creatinine periodically to monitor for 

hyperkalemia and azotemia.

3. Cough and angioedema are reportedly less common with newer members 

of this class than with captopril.

4. Benazepril, enalapril, and lisinopril labels contain information on the 

preparation of a suspension; captopril may also be compounded into a 

suspension.

5. FDA approval for ACE inhibitors with pediatric labeling is limited to 

children ≥6 years of age and to children with creatinine clearance 

≥30 ml/min/1.73m2.

1. All ARBs are contraindicated in pregnancy—females of childbearing age 

should use reliable contraception.

2. Check serum potassium, creatinine periodically to monitor for 

hyperkalemia and azotemia.

3. Losartan label contains information on the preparation of a suspension.

4. FDA approval for ARBs is limited to children ≥6 years of age and to 

children with creatinine clearance ≥30 ml/min/1.73m2.

1. Asthma and overt heart failure are contraindications.

2. Heart rate is dose-limiting.

3. May impair athletic performance.

4. Should not be used in insulin-dependent diabetics.

1. Noncardioselective agents (propranolol) are contraindicated in asthma 

and heart failure.

2. Heart rate is dose-limiting.

3. May impair athletic performance.

4. Should not be used in insulin-dependent diabetics.

5. A sustained-release formulation of propranolol is available that is dosed 

once-daily.

1. Amlodipine and isradipine can be compounded into stable extemporaneous suspensions.

2. Felodipine and extended-release nifedipine tablets must be swallowed 

whole.

3. Isradipine is available in both immediate-release and sustained-release 

formulations; sustained release form is dosed qd or bid.

4. May cause tachycardia.

Dosing Interval Evidence‡ FDA Labelings§ Comments††
30 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Clonidine

HCTZ

Chlorthalidone

Furosemide

Spironolactone

Triamterene

Amiloride

Doxazosin

Prazosin

Terazosin

Hydralazine

Minoxidil

Children ≥12 years:

Initial: 0.2 mg/day

Maximum: 2.4 mg/day

Initial: 1 mg/kg/day

Maximum: 3 mg/kg/day up to 50 mg/day 

Initial: 0.3 mg/kg/day

Maximum: 2 mg/kg/day up to 50 mg/day

Initial: 0.5–2.0 mg/kg/dose

Maximum: 6 mg/kg/day 

Initial: 1 mg/kg/day

Maximum: 3.3 mg/kg/day up to 100 mg/day

Initial: 1–2 mg/kg/day

Maximum: 3–4 mg/kg/day up to 300 mg/day

Initial: 0.4–0.625 mg/kg/day

Maximum: 20 mg/day

Initial: 1 mg/day

Maximum: 4 mg/day 

Initial: 0.05–0.1 mg/kg/day

Maximum: 0.5 mg/kg/day

Initial: 1 mg/day

Maximum: 20 mg/day

Initial: 0.75 mg/kg/day

Maximum: 7.5 mg/kg/day up to 200 mg/day

Children <12 years: 

Initial: 0.2 mg/kg/day 

Maximum: 50 mg/day

Children ≥12 years:

Initial: 5 mg/day

Maximum: 100 mg/day 

T ABLE 9

Central α-agonist 

Diuretic

Peripheral α-antagonist

Vasodilator

Antihypertensive Drugs for Outpatient Management of Hypertension in Children 1–17 Years Old* 

(continued)

Class Drug Dose†
Pharmacologic Therapy of Childhood Hypertension 31

bid

qd

qd

qd–bid

qd–bid

bid

qd

qd

tid

qd

qid

qd–tid

EO

EO

EO

EO

EO

EO

EO

EO

EO

EO

EO

CS, EO

Yes

Yes

No

No

No

No

No

No

No

No

Yes

Yes

1. May cause dry mouth and/or sedation.

2. Transdermal preparation also available.

3. Sudden cessation of therapy can lead to severe rebound hypertension.

1. All patients treated with diuretics should have electrolytes monitored 

shortly after initiating therapy and periodically thereafter.

2. Useful as add-on therapy in patients being treated with drugs from other 

drug classes.

3. Potassium-sparing diuretics (spironolactone, triamterene, amiloride) may

cause severe hyperkalemia, especially if given with ACE inhibitor or ARB.

4. Furosemide is labeled only for treatment of edema but may be useful as 

add-on therapy in children with resistant hypertension, particularly in 

children with renal disease.

5. Chlorthalidone may precipitate azotemia in patients with renal diseases 

and should be used with caution in those with severe renal impairment.

1. May cause hypotension and syncope, especially after first dose.

1. Tachycardia and fluid retention are common side effects.

2. Hydralazine can cause a lupus-like syndrome in slow acetylators.

3. Prolonged use of minoxidil can cause hypertrichosis.

4. Minoxidil is usually reserved for patients with hypertension resistant 

to multiple drugs.

ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; bid, twice-daily; HCTZ, hydrochlorothiazide; qd, once-daily; qid, four times daily; tid, 

three times daily

* Includes drugs with prior pediatric experience or recently completed clinical trials.

† The maximum recommended adult dose should not be exceeded in routine clinical practice.

‡ Level of evidence upon which dosing recommendations are based (CS, case series; EO, expert opinion; RCT, randomized controlled trial)

§ FDA-approved pediatric labeling information is available. Recommended doses for agents with FDA-approved pediatric labels are the doses contained in 

the approved labels. Even when pediatric labeling information is not available, the FDA-approved label should be consulted for additional safety information.

†† Comments apply to all members of each drug class except where otherwise stated.

Dosing Interval Evidence‡ FDA Labelings§ Comments††
the eventual goal of completely discontinuing

drug therapy. Children with uncomplicated

primary hypertension, especially overweight

children who successfully lose weight, are the

best candidates for the step-down approach.

Such patients require ongoing BP monitoring

after the cessation of drug therapy, as well as

continued nonpharmacologic treatment,

because hypertension may recur.

Severe, symptomatic hypertension with BP

well above the 99th percentile occurs in some

children, usually those with underlying renal

disease, and requires prompt treatment.

Hypertensive emergencies in children are usually accompanied by signs of hypertensive

encephalopathy, typically causing seizures.

Hypertensive emergencies should be treated

by an intravenous antihypertensive that can

produce a controlled reduction in BP, aiming

to decrease the pressure by 25 percent or less

over the first 8 hours after presentation and

then gradually normalizing the BP over 26–48

hours.132,133 Hypertensive urgencies are

accompanied by less serious symptoms, such

as severe headache or vomiting. Hypertensive

urgencies can be treated by either intravenous

or oral antihypertensives, depending on the

child’s symptomatology. Table 10 provides

dosing recommendations for treatment of

severe hypertension in children when prompt

reduction in BP is indicated.

Figure 1 is a management algorithm that presents guidelines for evaluation and treatment

of Stage 1 and Stage 2 hypertension in children and adolescents. The algorithm

summarizes monitoring and intervention recommendations for children and adolescents

with prehypertension and hypertension.

Included in the algorithm are points at which

the presence of overweight is considered in

clinical decisionmaking. The algorithm also

emphasizes the inclusion of evaluation for

target-organ damage in children with established Stage 1 and Stage 2 hypertension.

32 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

BMI, body mass index; BP, blood pressure; Rx, prescription; Q, every.

*See tables 3, 4, and 5.

†Diet modification and physical activity.

‡Especially if younger, very high BP, little or no family history, diabetic, or other risk factors.

Measure BP and Height and Calculate BMI

Determine BP category for sex, age, and height*

Repeat BP

Over 3 visits

Therapeutic

Lifestyle

Changes†

Rx Specific 

for Cause

Weight Reduction

and Drug Rx

Drug Rx Drug Rx‡ Weight Reduction Weight Reduction

Educate on

Heart Health

Lifestyle†

For the Family

Stage 2 Hypertension*

Diagnostic Workup

Include Evaluation for

Target-Organ Damage‡

Diagnostic Workup

Include Evaluation for

Target-Organ Damage‡

Consider Referral

To provider with expertise in

pediatric hypertension

Stage 1 Hypertension* Normotensive*

90–<95%

or 120/80 mmHg

Secondary 

Hypertension

Normal 

BMI

Overweight Overweight Normal 

BMI

or Primary

Hypertension

Secondary 

Hypertension

or Primary

Hypertension

≥95%

≥95%

Still ≥95%

Therapeutic

Lifestyle

Changes†

Monitor Q 6 Mo

Repeat BP

In 6 months

Consider Diagnostic Workup

and Evaluation for TargetOrgan Damage‡

If overweight or comorbidity exists

Prehypertensive*

<90%

Normal Overweight

BMI

90–<95% or 120/80 mmHg

FIGURE 1

Management Algorithm
Pharmacologic Therapy of Childhood Hypertension 33

Antihypertensive Drugs for Management of Severe Hypertension 

in Children 1–17 Years Old

ß-blocker

Vasodilator

α- and ßblocker

Calcium 

channel 

blocker

Vasodilator

iv infusion

iv, im

iv bolus or

infusion

iv infusion

iv infusion 

T ABLE 10

Esmolol

Hydralazine

Labetalol

Nicardipine

Sodium

nitroprusside

Very short-acting—constant

infusion preferred. May

cause profound bradycardia.

Produced modest reductions

in BP in a pediatric clinical

trial.

Should be given every 4 hours

when given iv bolus.

Recommended dose is lower

than FDA label.

Asthma and overt heart 

failure are relative contraindications.

May cause reflex tachycardia.

Monitor cyanide levels with

prolonged (>72 hr) use or in

renal failure; or coadminister

with sodium thiosulfate.

Most Useful*

Occasionally Useful‡

100–500 mcg/kg/min

0.2–0.6 mg/kg/dose

bolus: 0.2–1.0

mg/kg/dose up to 40

mg/dose

infusion: 0.25–3.0

mg/kg/hr

1–3 mcg/kg/min

0.53–10 mcg/kg/min

Central 

α-agonist

ACE inhibitor

Dopamine

receptor 

agonist

Calcium channel blocker

Vasodilator

po

iv bolus

iv infusion

po

po

Clonidine

Enalaprilat

Fenoldopam

Isradipine

Minoxidil

Side effects include dry

mouth and sedation.

May cause prolonged

hypotension and acute renal

failure, especially in neonates.

Produced modest reductions

in BP in a pediatric clinical

trial in patients up to 12

years.

Stable suspension can be

compounded.

Most potent oral vasodilator;

long-acting.

0.05–0.1 mg/dose

may be repeated up

to 0.8 mg total dose

0.05–0.1 mg/kg/dose

up to 1.25 mg/dose

0.2–0.8 mcg/kg/min

0.05–0.1 mg/kg/dose

0.1–0.2 mg/kg/dose

ACE, angiotensin-converting enzyme; im, intramuscular; iv, intravenous; po, oral.

* Useful for hypertensive emergencies and some hypertensive urgencies.

† All dosing recommendations are based upon expert opinion or case series data except as otherwise noted.

‡ Useful for hypertensive urgencies and some hypertensive emergencies.

Drug Class Dose† Route Comments

Drug Class Dose* Route Comments
34 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

APPENDIX A.

Demographic Data
Appendix A. Demographic Data 35

Gender

Demographic Data on Height/Blood Pressure Distribution Curves by Study Population*

T ABLE A–1

Ethnic Group

NIH 6–17 1,896 1,751 600 0 2,963 0 0 84 0 3,647 3,609 3,647

3,647 3,609 3,647

Pittsburgh 1–5 148 137 108 0 176 0 0 0 1 285 0 285

893 0 893

Dallas 13–17 5,916 5,649 5,266 1,570 4,729 0 0 0 0 11,565 11,565 11,565

21,860 21,852 21,860

Bogalusa 1–17 3,751 3,607 2,480 0 4,878 0 0 0 0 7,358 0 7,358 

15,882 0 15,882

Houston 3–17 1,457 1,377 637 1,341 748 23 0 0 85 2,834 0 2,834

2,834 0 2,834

South 4–17 3,167 3,263 3,110 0 3,320 0 0 0 0 6,430 6,368 6,430Carolina 6,430 6,368 6,430Iowa 5–17 2,099 1,993 0 0 4,092 0 0 0 0 4,092 0 4,092

4,092 0 4,092

Providence 1–3 230 231 24 4 431 0 0 2 0 461 371 461

898 560 898

Minnesota 9–17 9,991 9,418 3,422 555 11,311 1,677 644 1,800 0 19,409 19,207 19,409

19,409 19,207 19,409

NHANES III 5–17 2,465 2,577 1,770 1,830 1,324 64 10 12 32 5,042 4,304 5,042

5,042 4,304 5,042

NHANES 8–17 1,041 1,063 605 988 437 0 0 74 0 2,104 2,076 2,10499–00 2,104 2,076 2,104Total 1–17 32,161 31,066 18,022 6,288 34,409 1,764 654 1,972 118 63,227 47,500 63,227(Percent (51) (49) (29) (10) (54) (3) (1) (3) (0) 83,091 57,976 83,091of Total)

Person’s

Visits

SBP

Available 

Person’s

Visits

DBP.5

Available 

Total

No. of

Person’s 

Visits

Age NativeSource (Years) Boys Girls Black Hispanic White Asian American Other Missing

DBP.5, diastolic blood pressure (Korotkoff 5); NHANES, National Health and Nutrition Examination Survey; NIH, National Institutes of Health; SBP, systolic blood pressure.* Table differs from 1997 report: updated height percentile used; subjects whose height Z-score was less than –6 or greater than +6 were excluded.
36 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

APPENDIX B.

Computation of Blood Pressure

Percentiles for Arbitrary Sex, Age, 

and Height
Appendix B. Computation of Blood Pressure Percentiles for Arbitrary Sex, Age, and Height 37

1. Refer to the most recent CDC growth charts, which are available online, and convert the

height of h inches to a height Z-score relative to boys of the same age; this is denoted by Zht.

2. Compute the expected SBP (μ) for boys of age y years and height h inches given by 

μ = α + Σ βj (y-10)j

+ Σ γ k (Zht)

k

where α, β1..., β4 and γ1..., γ4 are given in the 3rd column of appendix table B–1.

3. Then convert the boy’s observed SBP to a Z-score (Zbp) given by

Zbp = (x – μ)/σ

where σ is given in the 3rd column of appendix table B–1.

4. To convert the bp Z-score to a percentile (P), compute P = Φ (Zbp) x 100%

where Φ (Z) = area under a standard normal distribution to the left of Z.

Thus, if Zbp = 1.28, then Φ (Zbp) = .90 and the bp percentile = .90 x 100% = 90%.

5. To compute percentiles for SBP for girls, diastolic blood pressure (DBP) (K5) for boys, 

and DBP (K5) for girls, use the regression coefficients from the 4th, 5th, and 6th columns 

of appendix table B–1.

For example, a 12-year-old boy, with height at the 90th percentile for his age-sex group, 

has a height Z-score = 1.28, and his expected SBP (μ) is 

μ = 102.19768 + 1.82416 (2) + 0.12776 (22) + 0.00249 (23) –0.00135 (24) + 2.73157 

(1.28) –0.19618 (1.28)2 –0.04659 (1.28)3 + 0.00947 (1.28)4 = 109.46 mmHg.

Suppose his actual SBP is 120 mmHg (x); his SBP Z-score is then: 

SBP Z-score = (x – μ)/σ = (120–109.46)/10.7128 = 0.984

The corresponding SBP percentile = Φ (0.984) x 100% = 83.7th percentile.

■ To compute the systolic blood pressure (SBP) percentile of a boy who is age y years 

and height h inches with SBP = x mmHg:

4

j=1

4

k=1

Computation of Blood Pressure

Percentiles for Arbitrary Sex, Age, 

and Height
38 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

Regression Coefficients From Blood Pressure Regression Models*

102.01027

1.94397

0.00598

-0.00789

-0.00059

2.03526

0.02534

-0.01884

0.00121

10.4855

0.3824

31,066

41,017

T ABLE B–1

Intercept

Age

Age–10

(Age–10)2

(Age–10)3

(Age–10)4

Normalized height

Zht

Zht2

Zht3

Zht4

Standard deviation

ρ†

n (persons) 

n (visits)

102.19768

1.82416

0.12776

0.00249

-0.00135

2.73157

-0.19618

-0.04659

0.00947

10.7128

0.4100

32,161

42,074

60.50510

1.01301

0.01157

0.00424

-0.00137

1.16641

0.12795

-0.03869

-0.00079

10.9573

0.2598

23,443

28,794

61.01217

0.68314

-0.09835

0.01711

0.00045

1.46993

-0.07849

-0.03144 

0.00967

11.6032

0.2436

24,057

29,182

BP, blood pressure; Diastolic BP5, diastolic measurement at Korotkoff 5.

* The coefficients were obtained from mixed-effects linear regression models.

† The value of ρ represents the correlation between BP measurements at different ages for the same child after correcting for age 

and Zht. This computation was necessary because some studies contributing to the childhood BP database provided BP at more

than one age.

Systolic BP Diastolic BP5

α

β1

β2

β3

β 4

γ1

γ2

γ3

γ4

σ

Variable Name Symbol Male Female Male Female
Scheme Used for Classification of the Evidence 39

Scheme Used for 

Classification of the Evidence

M Meta-analysis; use of statistical 

methods to combine the results from

clinical trials

RA Randomized controlled trials; 

also known as experimental studies

RE Retrospective analyses; also known 

as case-control studies

F Prospective study; also known as cohort

studies, including historical 

or prospective followup studies

X Cross-sectional survey; also known 

as prevalence studies

PR Previous review or position 

statements

C Clinical interventions 

(nonrandomized)

These symbols are appended to the citations

in the reference list. The studies that provided

evidence supporting the recommendations 

of this report were classified and reviewed 

by the staff and the executive committee.

The classification scheme is from the JNC 7

report and other NHBPEP Working Group

Reports (www.nhlbi.nih.gov/about/nhbpep/

index.htm).2,134–138
40 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

References

1. National High Blood Pressure Education

Program Working Group on Hypertension

Control in Children and Adolescents. Update

on the 1987 Task Force Report on High

Blood Pressure in Children and Adolescents:

A working group report from the National

High Blood Pressure Education Program.

Pediatrics 1996;98:649–58. PR

2. Chobanian AV, Bakris GL, Black HR,

Cushman WC, Green LA, Izzo JL, Jr., et al.

The Seventh Report of the Joint National

Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood

Pressure: The JNC 7 report. JAMA

2003;289:2560–72. PR

3. Prineas RJ, Jacobs D. Quality of Korotkoff

sounds: Bell vs diaphragm, cubital fossa vs

brachial artery. Prev Med 1983;12:715–9.

4. Londe S, Klitzner TS. Auscultatory blood

pressure measurement—effect of pressure on

the head of the stethoscope. West J Med

1984;141:193–5.

5. Prineas RJ. Blood pressure in children and

adolescents. In: Bulpitt CJ, ed. Epidemiology

of hypertension. New York: Elsevier; 2000,

86–105. Birkenhager WH and Reid JL, eds.

Handbook of hypertension, v. 20.

6. Mourad A, Carney S, Gillies A, Jones B,

Nanra R, Trevillian P. Arm position and

blood pressure: A risk factor for hypertension? J Hum Hypertens 2003;17:389–95.

7. Netea RT, Lenders JW, Smits P, Thien T.

Both body and arm position significantly

influence blood pressure measurement.

J Hum Hypertens 2003;17:459–62.

8. Rocchini AP. Coarctation of the aorta and

interrupted aortic arch. In: Moller JH,

Hoffmann U, eds. Pediatric cardiovascular

medicine. New York: Churchill Livingstone;

2000, p. 570.

9. Gomez-Marin O, Prineas RJ, Rastam L. Cuff

bladder width and blood pressure measurement in children and adolescents. J Hypertens

1992;10:1235–41.

10. American Heart Association. Home monitoring of high blood pressure. Available at:

www.americanheart.org/presenter.jhtml?identifier=576. Verified July 12, 2004.

11. Prineas RJ. Measurement of blood pressure

in the obese. Ann Epidemiol

1991;1:321–36. PR

12. Ostchega Y, Prineas RJ, Paulose-Ram R,

Grim CM, Willard G, Collins D. National

Health and Nutrition Examination Survey

1999–2000: Effect of observer training and

protocol standardization on reducing blood

pressure measurement error. J Clin

Epidemiol 2003;56:768–74.

13. Lewington S, Clarke R, Qizilbash N, Peto R,

Collins R. Age-specific relevance of usual

blood pressure to vascular mortality: A

meta-analysis of individual data for one million adults in 61 prospective studies. Lancet

2002;360:1903–13. M

14. Jones DW, Appel LJ, Sheps SG, Roccella EJ,

Lenfant C. Measuring blood pressure accurately: New and persistent challenges. JAMA

2003;289:1027–30. PR

15. Canzanello VJ, Jensen PL, Schwartz GL. Are

aneroid sphygmomanometers accurate in

hospital and clinic settings? Arch Intern

Med 2001;161:729–31. PR
16. Butani L, Morgenstern BZ. Are pitfalls of

oxcillometric blood pressure measurements

preventable in children? Pediatr Nephrol

2003;18:313–8. PR

17. Kaufmann MA, Pargger H, Drop LJ.

Oscillometric blood pressure measurements

by different devices are not interchangeable.

Anesth Analg 1996;82:377–81.

18. Park MK, Menard SW, Yuan C. Comparison

of auscultatory and oscillometric blood pressures. Arch Pediatr Adolesc Med

2001;155:50–3. RA

19. O'Brien E, Pickering T, Asmar R, Myers M,

Parati G, Staessen J, et al. Working Group

on Blood Pressure Monitoring of the

European Society of Hypertension

International Protocol for validation of blood

pressure measuring devices in adults. Blood

Press Monit 2002;7:3–17. PR

20. O'Brien E, Coats A, Owens P, Petrie J,

Padfield PL, Littler WA, et al. Use and 

interpretation of ambulatory blood 

pressure monitoring: Recommendations 

of the British hypertension society. BMJ

2000;320:1128–34. PR

21. Sorof JM, Portman RJ. Ambulatory blood

pressure measurements. Curr Opin Pediatr

2001;13:133–7.

22. Simckes AM, Srivastava T, Alon US.

Ambulatory blood pressure monitoring in

children and adolescents. Clin Pediatr (Phila)

2002;41:549–64. PR

23. Lurbe E, Sorof JM, Daniels SR. Clinical and

research aspects of ambulatory blood pressure monitoring in children. J Pediatr

2004;144:7–16. PR

24. Centers for Disease Control and Prevention,

National Center for Health Statistics. 2000

CDC Growth Charts: United States.

Available at: www.cdc.gov/growthcharts/.

Verified July 12, 2004.

25. Task Force on Blood Pressure Control in

Children. Report of the Second Task Force

on Blood Pressure Control in Children—

1987. National Heart, Lung, and Blood

Institute, Bethesda, Maryland. Pediatrics

1987;79:1–25. PR

26. Sorof J, Daniels S. Obesity hypertension 

in children: A problem of epidemic proportions. Hypertension 2002;40:441–7. PR

27. Ogden CL, Flegal KM, Carroll MD, Johnson

CL. Prevalence and trends in overweight

among US children and adolescents,

1999–2000. JAMA 2002;288:1728–32. X

28. Reaven GM. Insulin resistance/compensatory

hyperinsulinemia, essential hypertension, and

cardiovascular disease. J Clin Endocrinol

Metab 2003;88:2399–403.

29. U.S. Department of Health and Human

Services, National Institutes of Health,

National Heart, Lung, and Blood Insitute,

National Cholesterol Education Program.

Third Report of the Expert Panel on

Detection, Evaluation, and Treatment of

High Blood Cholesterol in Adults (Adult

Treatment Panel III) final report. NIH

Publication No. 02-5215. Bethesda, MD:

National Heart, Lung, and Blood Institute.

September 2002. PR

30. Sinaiko AR, Steinberger J, Moran A, Prineas

RJ, Jacobs DR, Jr. Relation of insulin resistance to blood pressure in childhood. J

Hypertens 2002;20:509–17. RA

31. Cook S, Weitzman M, Auinger P, Nguyen M,

Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: Findings

from the third National Health and Nutrition

Examination Survey, 1988–1994. Arch

Pediatr Adolesc Med 2003;157:821–7. X

References 41
32. Williams CL, Hayman LL, Daniels SR,

Robinson TN, Steinberger J, Paridon S, et al.

Cardiovascular health in childhood: A statement for health professionals from the

Committee on Atherosclerosis, Hypertension,

and Obesity in the Young (AHOY) of the

Council on Cardiovascular Disease in the

Young, American Heart Association.

Circulation 2002;106:143–60. PR

33. Quan SF, Gersh BJ. Cardiovascular consequences of sleep-disordered breathing: Past,

present and future: Report of a workshop

from the National Center on Sleep Disorders

Research and the National Heart, Lung, and

Blood Institute. Circulation 2004;109:951–7.

34. Strohl KP. Invited commentary: To sleep,

perchance to discover. Am J Epidemiol

2002;155:394–5.

35. Marcus CL, Greene MG, Carroll JL. Blood

pressure in children with obstructive sleep

apnea. Am J Respir Crit Care Med

1998;157:1098–103. X

36. Enright PL, Goodwin JL, Sherrill DL, Quan

JR, Quan SF. Blood pressure elevation associated with sleep-related breathing disorder in

a community sample of white and Hispanic

children: The Tucson Children's Assessment

of Sleep Apnea study. Arch Pediatr Adolesc

Med 2003;157:901–4. F

37. Mindell JA, Owens JA. A clinical guide to

pediatric sleep: Diagnosis and management

of sleep problems. Philadelphia, PA:

Lippincott Williams & Wilkins; 2003, p. 10,

Table 1.1.

38. Sinaiko AR. Hypertension in children.

N Engl J Med 1996;335:1968–73. PR

39. Flynn JT. Evaluation and management of

hypertension in childhood. Prog Pediatr

Cardiol 2001;12:177–88. PR

40. Hiner LB, Falkner B. Renovascular hypertension in children. Pediatr Clin North Am

1993;40:123–40. PR

41. Dillon MJ, Ryness JM. Plasma renin activity

and aldosterone concentration in children.

Br Med J 1975;4:316–9. X

42. Guzzetta PC, Potter BM, Ruley EJ, Majd M,

Bock GH. Renovascular hypertension in children: Current concepts in evaluation and

treatment. J Pediatr Surg 1989;24:1236–40. C

43. Watson AR, Balfe JW, Hardy BE.

Renovascular hypertension in childhood: 

A changing perspective in management.

J Pediatr 1985;106:366–72.

44. Dillon MJ. The diagnosis of renovascular

disease. Pediatr Nephrol 1997;11:366–72. PR

45. Mena E, Bookstein JJ, Holt JF, Fry WJ.

Neurofibromatosis and renovascular hypertension in children. Am J Roentgenol

Radium Ther Nucl Med 1973;118:39–45. RE

46. Shahdadpuri J, Frank R, Gauthier BG, Siegel

DN, Trachtman H. Yield of renal arteriography in the evaluation of pediatric hypertension. Pediatr Nephrol 2000;14:816–9. RE

47. Binkert CA, Debatin JF, Schneider E, Hodler

J, Ruehm SG, Schmidt M, et al. Can MR

measurement of renal artery flow and renal

volume predict the outcome of percutaneous

transluminal renal angioplasty? Cardiovasc

Intervent Radiol 2001;24:233–9. F

48. Marcos HB, Choyke PL. Magnetic resonance

angiography of the kidney. Semin Nephrol

2000;20:450–5. PR

49. Debatin JF, Spritzer CE, Grist TM, Beam C,

Svetkey LP, Newman GE, et al. Imaging of

the renal arteries: Value of MR angiography.

AJR Am J Roentgenol 1991;157:981–90. F

50. Vade A, Agrawal R, Lim-Dunham J, Hartoin

D. Utility of computed tomographic renal

angiogram in the management of childhood

hypertension. Pediatr Nephrol

2002;17:741–7. RE

42 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
51. MacMahon S, Peto R, Cutler J, Collins R,

Sorlie P, Neaton J, et al. Blood pressure,

stroke, and coronary heart disease. Part 1,

Prolonged differences in blood pressure:

Prospective observational studies corrected

for the regression dilution bias. Lancet

1990;335:765–74. F

52. Still JL, Cottom D. Severe hypertension in

childhood. Arch Dis Child 1967;42:34–9.

PR

53. Gill DG, Mendes de Costa B, Cameron JS,

Joseph MC, Ogg CS, Chantler C. Analysis 

of 100 children with severe and persistent

hypertension. Arch Dis Child

1976;51:951–6. F

54. Johnstone LM, Jones CL, Grigg LE,

Wilkinson JL, Walker RG, Powell HR. Left

ventricular abnormalities in children, adolescents and young adults with renal disease.

Kidney Int 1996;50:998–1006. X

55. Mitsnefes MM, Daniels SR, Schwartz SM,

Khoury P, Strife CF. Changes in left ventricular mass in children and adolescents during

chronic dialysis. Pediatr Nephrol

2001;16:318–23. F

56. Mitsnefes MM, Kimball TR, Witt SA,

Glascock BJ, Khoury PR, Daniels SR. Left

ventricular mass and systolic performance in

pediatric patients with chronic renal failure.

Circulation 2003;107:864–8. X

57. Berenson GS, Srinivasan SR, Bao W,

Newman WP, III, Tracy RE, Wattigney WA.

Association between multiple cardiovascular

risk factors and atherosclerosis in children

and young adults. The Bogalusa Heart Study.

N Engl J Med 1998;338:1650–6. F

58. McGill HC, Jr., McMahan CA, Zieske AW,

Malcom GT, Tracy RE, Strong JP. Effects of

nonlipid risk factors on atherosclerosis in

youth with a favorable lipoprotein profile.

Circulation 2001;103:1546–50.

59. Davis PH, Dawson JD, Riley WA, Lauer RM.

Carotid intimal-medial thickness is related to

cardiovascular risk factors measured from

childhood through middle age: The

Muscatine Study. Circulation

2001;104:2815–9. F

60. Arnett DK, Glasser SP, McVeigh G, Prineas

R, Finklestein S, Donahue R, et al. Blood

pressure and arterial compliance in young

adults: The Minnesota Children's Blood

Pressure Study. Am J Hypertens

2001;14:200–5. F

61. Knoflach M, Kiechl S, Kind M, Said M, Sief

R, Gisinger M, et al. Cardiovascular risk factors and atherosclerosis in young males:

ARMY study (Atherosclerosis Risk-Factors in

Male Youngsters). Circulation

2003;108:1064–9. X

62. Sanchez A, Barth JD, Zhang L. The carotid

artery wall thickness in teenagers is related to

their diet and the typical risk factors of heart

disease among adults. Atherosclerosis

2000;152:265–6.

63. Barnes VA, Treiber FA, Davis H. Impact of

Transcendental Meditation on cardiovascular

function at rest and during acute stress in

adolescents with high normal blood pressure.

J Psychosom Res 2001;51:597–605. RA

64. Belsha CW, Wells TG, McNiece KL, Seib

PM, Plummer JK, Berry PL. Influence of

diurnal blood pressure variations on target

organ abnormalities in adolescents with mild

essential hypertension. Am J Hypertens

1998;11:410–7. F

65. Sorof JM, Alexandrov AV, Cardwell G,

Portman RJ. Carotid artery intimal-medial

thickness and left ventricular hypertrophy in

children with elevated blood pressure.

Pediatrics 2003;111:61–6.

References 43
66. Hanevold C, Waller J, Daniels S, Portman R,

Sorof J. The effects of obesity, gender, and

ethnic group on left ventricular hypertrophy

and geometry in hypertensive children: A

collaborative study of the International

Pediatric Hypertension Association.

Pediatrics 2004;113:328–33. X

67. Daniels SR, Loggie JM, Khoury P, Kimball

TR. Left ventricular geometry and severe left

ventricular hypertrophy in children and 

adolescents with essential hypertension.

Circulation 1998;97:1907–11. X

68. Svardsudd K, Wedel H, Aurell E, Tibblin G.

Hypertensive eye ground changes.

Prevalence, relation to blood pressure and

prognostic importance. The study of men

born in 1913. Acta Med Scand

1978;204:159–67. F

69. Skalina ME, Annable WL, Kliegman RM,

Fanaroff AA. Hypertensive retinopathy in

the newborn infant. J Pediatr

1983;103:781–6. X

70. Devereux RB, Alonso DR, Lutas EM,

Gottlieb GJ, Campo E, Sachs I, et al.

Echocardiographic assessment of left ventricular hypertrophy: Comparison to necropsy

findings. Am J Cardiol 1986;57:450–8. RE

71. Sahn DJ, DeMaria A, Kisslo J, Weyman A.

Recommendations regarding quantitation in

M-mode echocardiography: Results of a survey of echocardiographic measurements.

Circulation 1978;58:1072–83.

72. Daniels SR, Kimball TR, Morrison JA,

Khoury P, Witt S, Meyer RA. Effect of lean

body mass, fat mass, blood pressure, and sexual maturation on left ventricular mass in

children and adolescents. Statistical, biological, and clinical significance. Circulation

1995;92:3249–54. X

73. de Simone G, Daniels SR, Devereux RB,

Meyer RA, Roman MJ, de Divitiis O, et al.

Left ventricular mass and body size in normotensive children and adults: Assessment 

of allometric relations and impact of overweight. J Am Coll Cardiol

1992;20:1251–60. F

74. Daniels SR, Kimball TR, Morrison JA,

Khoury P, Meyer RA. Indexing left ventricular mass to account for differences in body

size in children and adolescents without cardiovascular disease. Am J Cardiol

1995;76:699–701. X

75. He J, Whelton PK, Appel LJ, Charleston J,

Klag MJ. Long-term effects of weight loss

and dietary sodium reduction on incidence of

hypertension. Hypertension 2000;35:544–9. F

76. Sacks FM, Svetkey LP, Vollmer WM, Appel

LJ, Bray GA, Harsha D, et al. Effects on

blood pressure of reduced dietary sodium and

the Dietary Approaches to Stop Hypertension

(DASH) diet. DASH-Sodium Collaborative

Research Group. N Engl J Med

2001;344:3–10. RA

77. Vollmer WM, Sacks FM, Ard J, Appel LJ,

Bray GA, Simons-Morton DG, et al. Effects

of diet and sodium intake on blood pressure:

Subgroup analysis of the DASH-sodium trial.

Ann Intern Med 2001;135:1019–28. RA

78. Whelton SP, Chin A, Xin X, He J. Effect of

aerobic exercise on blood pressure: A metaanalysis of randomized, controlled trials.

Ann Intern Med 2002;136:493–503. M

79. Xin X, He J, Frontini MG, Ogden LG,

Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: A metaanalysis of randomized controlled trials.

Hypertension 2001;38:1112–7. M

80. Ayas NT, White DP, Manson JE, Stampfer

MJ, Speizer FE, Malhotra A, et al. A

prospective study of sleep duration and coronary heart disease in women. Arch Intern

Med 2003;163:205–9. X

44 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
81. Cook NR, Gillman MW, Rosner BA, Taylor

JO, Hennekens CH. Combining annual

blood pressure measurements in childhood to

improve prediction of young adult blood

pressure. Stat Med 2000;19:2625–40. F

82. Lauer RM, Mahoney LT, Clarke WR.

Tracking of blood pressure during childhood:

The Muscatine Study. Clin Exp Hypertens A

1986;8:515–37. F

83. Lauer RM, Clarke WR. Childhood risk 

factors for high adult blood pressure: 

The Muscatine Study. Pediatrics

1989;84:633–41. F

84. Clarke WR, Woolson RF, Lauer RM.

Changes in ponderosity and blood pressure

in childhood: The Muscatine Study. Am J

Epidemiol 1986;124:195–206. F

85. Burke V, Beilin LJ, Dunbar D. Tracking of

blood pressure in Australian children.

J Hypertens 2001;19:1185–92. F

86. Figueroa-Colon R, Franklin FA, Lee JY, von

Almen TK, Suskind RM. Feasibility of a 

clinic-based hypocaloric dietary intervention

implemented in a school setting for obese

children. Obes Res 1996;4:419–29. RA

87. Wabitsch M, Hauner H, Heinze E, Muche R,

Bockmann A, Parthon W, et al. Body-fat distribution and changes in the atherogenic riskfactor profile in obese adolescent girls during

weight reduction. Am J Clin Nutr

1994;60:54–60. C

88. Rocchini AP, Key J, Bondie D, Chico R,

Moorehead C, Katch V, et al. The effect of

weight loss on the sensitivity of blood pressure to sodium in obese adolescents. N Engl

J Med 1989;321:580–5. C

89. Rocchini AP, Katch V, Anderson J,

Hinderliter J, Becque D, Martin M, et al.

Blood pressure in obese adolescents: Effect

of weight loss. Pediatrics 1988;82:16–23.

RA

90. Sinaiko AR, Gomez-Marin O, Prineas RJ.

Relation of fasting insulin to blood pressure

and lipids in adolescents and parents.

Hypertension 1997;30:1554–9. X

91. Robinson TN. Behavioural treatment of

childhood and adolescent obesity. Int J Obes

Relat Metab Disord

1999;23 Suppl 2:S52–S57. PR

92. Epstein LH, Myers MD, Raynor HA, Saelens

BE. Treatment of pediatric obesity. Pediatrics

1998;101:554–70. PR

93. Barlow SE, Dietz WH. Obesity evaluation

and treatment: Expert Committee recommendations. The Maternal and Child Health

Bureau, Health Resources and Services

Administration and the Department of

Health and Human Services. Pediatrics

1998;102:e29. Available at: 

www.pediatrics.org/cgi/content/full/102/3/e29.

Verified July 12, 2004. PR

94. Krebs NF, Jacobson MS. Prevention of pediatric overweight and obesity. Pediatrics

2003;112:424–30. PR

95. U.S. Department of Health and Human

Services. The Surgeon General's call to action

to prevent and decrease overweight and 

obesity. Rockville, MD: U.S. Department 

of Health and Human Services, Public Health

Service, Office of the Surgeon General. 2001.

PR

96. Gutin B, Owens S. Role of exercise intervention in improving body fat distribution and

risk profile in children. Am J Human Biol

1999;11:237–47. RA

97. Siega-Riz AM, Popkin BM, Carson T. Trends

in breakfast consumption for children in the

United States from 1965–1991. Am J Clin

Nutr 1998;67:748S–756S.

98. Warren JM, Henry CJ, Simonite V. Low

glycemic index breakfasts and reduced food

intake in preadolescent children. Pediatrics

2003;112:e414. Available at: 

www.pediatrics.org/cgi/content/full/112/

5/e414. Verified July 12, 2004. RA

References 45
99. Gillman MW, Hood MY, Moore LL, Nguyen

US, Singer MR, Andon MB. Effect of calcium supplementation on blood pressure in

children. J Pediatr 1995;127:186–92. RA

100. Simons-Morton DG, Hunsberger SA, Van

Horn L, Barton BA, Robson AM, McMahon

RP, et al. Nutrient intake and blood pressure

in the Dietary Intervention Study in Children.

Hypertension 1997;29:930–6. RA

101. Simons-Morton DG, Obarzanek E. Diet and

blood pressure in children and adolescents.

Pediatr Nephrol 1997;11:244–9. PR

102. Miller JZ, Weinberger MH, Christian JC.

Blood pressure response to potassium supplementation in normotensive adults and children. Hypertension 1987;10:437–42. C

103. Sinaiko AR, Gomez-Marin O, Prineas RJ.

Effect of low sodium diet or potassium supplementation on adolescent blood pressure.

Hypertension 1993;21:989–94. RA

104. Falkner B, Sherif K, Michel S, Kushner H.

Dietary nutrients and blood pressure in 

urban minority adolescents at risk for 

hypertension. Arch Pediatr Adolesc Med

2000;154:918–22. X

105. Stern B, Heyden S, Miller D, Latham G,

Klimas A, Pilkington K. Intervention study 

in high school students with elevated blood

pressures. Dietary experiment with polyunsaturated fatty acids. Nutr Metab

1980;24:137–47. C

106. Goldberg RJ, Ellison RC, Hosmer DW, Jr.,

Capper AL, Puleo E, Gamble WJ, et al.

Effects of alterations in fatty acid intake on

the blood pressure of adolescents: The

Exeter-Andover Project. Am J Clin Nutr

1992;56:71–6. F

107. Cooper R, Van Horn L, Liu K, Trevisan M,

Nanas S, Ueshima H, et al. A randomized

trial on the effect of decreased dietary sodium

intake on blood pressure in adolescents.

J Hypertens 1984;2:361–6. RA

108. Falkner B, Michel S. Blood pressure response

to sodium in children and adolescents. Am J

Clin Nutr 1997;65:618S–621S. PR

109. Gillum RF, Elmer PJ, Prineas RJ. Changing

sodium intake in children. The Minneapolis

Children's Blood Pressure Study.

Hypertension 1981;3:698–703. RA

110. Howe PR, Cobiac L, Smith RM. Lack of

effect of short-term changes in sodium intake

on blood pressure in adolescent schoolchildren. J Hypertens 1991;9:181–6. RA

111. Geleijnse JM, Hofman A, Witteman JC,

Hazebroek AA, Valkenburg HA, Grobbee

DE. Long-term effects of neonatal sodium

restriction on blood pressure. Hypertension

1997;29:913–7. RA

112. Martin RM, Ness AR, Gunnell D, Emmett P,

Smith GD. Does breast-feeding in infancy

lower blood pressure in childhood? The Avon

Longitudinal Study of Parents and Children

(ALSPAC). Circulation 2004;109:1259–66. F

113. Wilson AC, Forsyth JS, Greene SA, Irvine L,

Hau C, Howie PW. Relation of infant diet to

childhood health: Seven year follow up of

cohort of children in Dundee infant feeding

study. BMJ 1998;316:21–5. F

114. Panel of Dietary Intakes for Electrolytes and

Water, Standing Committee on the Scientific

Evaluation of Dietary Reference Intakes,

Food and Nutrition Board, Institute of

Medicine. Dietary reference intakes for

water, potassium, sodium, chloride, and 

sulfate. Washington, DC: National

Academies Press. 2004. Available at:

www.nap.edu/books/0309091691/html/.

Verified July 12, 2004. PR

115. Kelley GA, Kelley KS, Tran ZV. The effects

of exercise on resting blood pressure in children and adolescents: A meta-analysis of

randomized controlled trials. Prev Cardiol

2003;6:8–16. M

46 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
116. American Academy of Pediatrics. American

Academy of Pediatrics Committee on Sports

Medicine and Fitness. Athletic participation

by children and adolescents who have systemic hypertension. Pediatrics

1997;99:637–8. PR

117. Klag MJ, Whelton PK, Randall BL, Neaton

JD, Brancati FL, Ford CE, et al. Blood pressure and end-stage renal disease in men.

N Engl J Med 1996;334:13–8. F

118. Yusuf HR, Giles WH, Croft JB, Anda RF,

Casper ML. Impact of multiple risk factor

profiles on determining cardiovascular 

disease risk. Prev Med 1998;27:1–9. X

119. Kavey RE, Daniels SR, Lauer RM, Atkins

DL, Hayman LL, Taubert K. American

Heart Association guidelines for primary prevention of atherosclerotic cardiovascular 

disease beginning in childhood. Circulation

2003;107:1562–6. PR

120. Blumenthal S, Epps RP, Heavenrich R, Lauer

RM, Lieberman E, Mirkin B, et al. Report of

the task force on blood pressure control in

children. Pediatrics 1977;59:797–820. PR

121. The Food and Drug Administration

Modernization Act of 1997. Public Law 105-

115. Enacted November 21, 1997.

122. Wells TG. Trials of antihypertensive therapies in children. Blood Press Monit

1999;4:189–92. PR

123. Flynn JT. Successes and shortcomings of the

Food and Drug Modernization Act. Am J

Hypertens 2003;16:889–91. PR

124. Best Pharmaceuticals for Children Act of

2002. Public Law 107-109. Enacted

January 4, 2002.

125. U.S. Department of Health and Human

Services, National Institutes of Health. List

of drugs for which pediatric studies are 

needed. Federal Register 2003;68:2789–90.

126. ALLHAT Officers and Coordinators for the

ALLHAT Collaborative Research Group.

Major outcomes in high-risk hypertensive

patients randomized to angiotensinconverting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive

and Lipid-Lowering Treatment to Prevent

Heart Attack Trial (ALLHAT). JAMA

2002;288:2981–97. RA

127. Wells T, Frame V, Soffer B, Shaw W, Zhang

Z, Herrera P, et al. A double-blind, placebocontrolled, dose-response study of the effectiveness and safety of enalapril for children

with hypertension. J Clin Pharmacol

2002;42:870–80. F

128. Soffer B, Zhang Z, Miller K, Vogt BA,

Shahinfar S. A double-blind, placebocontrolled, dose-response study of the effectiveness and safety of lisinopril for children

with hypertension. Am J Hypertens

2003;16:795–800. RA

129. Sakarcan A, Tenney F, Wilson JT, Stewart JJ,

Adcock KG, Wells TG, et al. The pharmacokinetics of irbesartan in hypertensive children

and adolescents. J Clin Pharmacol

2001;41:742–9.

130. Trachtman H, Frank R, Mahan JD, Portman

R, Restaino I, Matoo TK, et al. Clinical trial

of extended-release felodipine in pediatric

essential hypertension. Pediatr Nephrol

2003;18:548–53. RA

131. Sorof JM, Cargo P, Graepel J, Humphrey D,

King E, Rolf C, et al. Beta-blocker/thiazide

combination for treatment of hypertensive

children: A randomized double-blind, 

placebo-controlled trial. Pediatr Nephrol

2002;17:345–50. RA

132. Adelman RD, Coppo R, Dillon MJ. The

emergency management of severe hypertension. Pediatr Nephrol 2000;14:422–7. PR

133. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000;356:411–7. PR

References 47
134. Sheps SG, Roccella EJ. Reflections on the

sixth report of the Joint National Committee

on Prevention, Detection, Evaluation, and

Treatment of High Blood Pressure. Curr

Hypertens Rep 1999;1:342–5. PR

135. Ingelfinger JR. Renovascular disease in children. Kidney Int 1993;43:493–505. PR

136. World Health Organization. World Health

Report 2002: Reducing risks, promoting

healthy life. Geneva, Switzerland: 2002.

Available at: www.who.int/whr/2002/.

Verified July 12, 2004.

137. U.S. Department of Health and Human

Services, National Institutes of Health,

National Heart, Lung, and Blood Institute.

National High Blood Pressure Education

Program. Available at: www.nhlbi.nih.gov/

about/nhbpep/index.htm. Verified July 12,

2004.

138. JNC 6. National High Blood Pressure

Education Program. The Sixth Report of 

the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of

High Blood Pressure. Arch Intern Med

1997;157:2413–46. PR

48 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
For More Information

The NHLBI Health Information Center 

is a service of the National Heart, Lung, 

and Blood Institute (NHLBI) of the National

Institutes of Health. The NHLBI Health

Information Center provides information 

to health professionals, patients, and the

public about the treatment, diagnosis, 

and prevention of heart, lung, and blood 

diseases and sleep disorders. For more 

information, contact:

NHLBI Health Information Center 

P.O. Box 30105

Bethesda, MD 20824-0105

Phone: 301-592-8573

TTY: 240-629-3255

Fax: 301-592-8563

Web site: http://www.nhlbi.nih.gov

Discrimination Prohibited: Under provisions of applicable

public laws enacted by Congress since 1964, no person 

in the United States shall, on the grounds of race, color,

national origin, handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to

discrimination under any program or activity (or, on the

basis of sex, with respect to any education program or

activity) receiving Federal financial assistance. In addition,

Executive Order 11141 prohibits discrimination on the

basis of age by contractors and subcontractors in the 

performance of Federal contracts, and Executive Order

11246 states that no federally funded contractor may

discriminate against any employee or applicant for

employment because of race, color, religion, sex, or

national origin. Therefore, the National Heart, Lung, 

and Blood Institute must be operated in compliance 

with these laws and Executive Orders.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Heart, Lung, and Blood Institute

National High Blood Pressure Education Program

NIH Publication No. 05-5267

Originally printed September 1996 (96-3790)

Revised May 2005