Hypertension gets less attention in kids than in adults, but according to anephrologist, it’s vitally important to treat because it can set children on a path to poor healthfor their lifetime.
Research has shown that pediatric hypertension is linked to increased coronary artery lesionsand fibrous plaques in childhood, said Shoba Narayan, MD, division chief of nephrology at Rady Children’s Health of Orange County in Orange, California, in a presentation at the American Academy of Pediatrics (AAP) 2026 National Conference.
“Organ damage starts early,” said Narayan, who is also an associate clinical professor at UCIrvine School of Medicine. “We also know from subsequent multiple studies that hypertensionis associated with poor school performance and learning disabilities. We have the opportunityto affect long-term prognoses and outcomes in these children by improving their blood pressure control.”
Still, pediatric hypertension often goes unnoticed, she said, even though 3%-5% of children have it. It’s probably underdiagnosed because it’s usually asymptomatic, she said.
• Pediatric HTN affects ~3%-5% of children; often asymptomatic and underdiagnosed.
• Organ damage can begin early; linked to coronary lesions, fibrous plaques, poor school performance.
• AAP: BP annually from age 3; every visit if obesity, CKD, DM, BP-raising meds, coarctation.
• Accurate measurement needs 3-5 min rest, right arm at heart level, proper cuff size, auscultation.
• ABPM helps distinguish white-coat vs masked HTN; renal disease common secondary cause <6 years.
Routine Blood-Pressure Measurement Is Recommended
Narayan highlighted the 2017 AAP hypertension screening and management guidelines, which call for annual blood pressure checks in children from the age of 3 years. The recommendations also suggest checks at every visit for higher-risk children, such as thosetaking medications known to increase blood pressure and those with obesity, kidney disease,diabetes, or a history of aortic arch obstruction or coarctation.
There’s a long list of indications for blood-pressure monitoring in babies younger than 3 years,including prematurity, neonatal complications, congenital heart disease, and systemicillnesses or genetic conditions, such as sickle cell disease, that are linked to hypertension.
Take Care When Measuring Pediatric Blood Pressure
“We all know about the family and the child who barely make their appointment time,”Narayan said. “They’re rushed in, put in a room, and sat down. Then their vitals are taken. That initial blood pressure is probably not accurate.”
The guidelines recommend that patients stay quiet for 3-5 minutes. The right arm should be supported at the heart level and uncovered above the cuff, she said. “You should position the blood pressure cuff about 2-3 cm above the antecubital fossa. Auscultation is the preferred method, but we all know that the oscillometric one is the most common.”
The width of the cuff’s bladder should be at least 40% of the arm circumference, Narayan said. “One of the most common reasons I see elevated blood pressure that is falsely high,other than the use of an oscillometric method, is using a small cuff.”
Blood pressure tables can be cumbersome, she said. The 2017 AAP hypertension guidelinesinclude a simplified screening table that notes which patients should be rescreened. According to her, the charts can be placed in intake stations or carts and documentation areas.
24-Hour Monitoring Can Be Helpful
Ambulatory 24-hour blood pressure monitoring is underappreciated and under-reimbursed, Narayan said, even though it has huge potential to save patients from unnecessary treatment.
This form of monitoring, which is recommended in certain situations after apparent hypertension is detected, can separate white-coat hypertension from the real thing, she said.
It can also detect so-called “masked” hypertension, in which office readings are normal butturn out to be elevated when measured over a 24-hour period.
“We use monitors that are validated for the pediatric population,” she said. “The patient wears the cuff for 24 hours. In our practice, we have them start wearing it on a Friday and turn it in on Saturday or the next week. The blood pressure is measured every 15-30 minutes and during different activities, during the daytime, and while asleep.”
Kidneys Might Be at Fault
In most cases, pediatric hypertension is a primary condition, but it can be secondary to renal disease, especially in kids younger than 6 years, Narayan said. She often explains to families that this is why patients are seeing a nephrologist for blood pressure, which is not a common practice in adults.
In older pediatric patients, hypertension can be linked to cannabinoid hyperemesis syndrome,she said. “If I’m getting calls from the ER [emergency room] about a previously healthy patientwith stage 2 hypertension and emesis, usually, a [toxicology test] will tell us if there’s cannabis involved.”
Emphasize Diet, Exercise, and Education
Medications may be appropriate to treat pediatric hypertension, Narayan said, but diet and exercise play roles too.
Nutrition education is especially important to empower patients to look for low-sodium foods. Ramen noodles, which have high levels of sodium, are a huge culprit in adding salt to diets, she said.
But children may have limited access to food at home. In this kind of situation, providing the family with tools as to where to access healthier foods is important instead of just counseling them on a low-sodium diet.
Similarly, she said, kids may not be able to easily exercise outdoors if their neighborhood isn’t safe. Dancing to videos at home may be an alternative.
More Pediatric Hypertension Tips
In an interview, Elaine M. Urbina, MD, professor emerita of preventive cardiology at CincinnatiChildren’s Hospital Medical Center in Cincinnati, supported Narayan’s suggestions. Urbinaco-authored the 2017 AAP hypertension guidelines.
Like Narayan, Urbina noted that pediatric blood pressure tables can be hard to use. Electronicrecords could potentially be programmed to alert clinicians if a reading is too high, she said,and phone apps are available to serve the same purpose.
Urbina also noted that children with hypertension can be referred to a pediatric nephrologist orcardiologist.
These specialists can order 24-hour ambulatory monitoring, she said, which can be especiallyhelpful in patients with obesity who have high readings in the clinic. About a third of the time,she said, these patients turn out to have white-coat hypertension.
Narayan reported no disclosures. Urbina disclosed having a relationship with the National Institutes of Health.
