Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville, FL (Drs. Smith and Martin); Mayo Clinic Florida, Jacksonville (Dr. McMullan); Uniformed Services University of Health Sciences, Bethesda, MD (Dr. Smith) dustinksmith@yahoo.com
The authors reported no potential conflict of interest relevant to this article.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of the Navy, US Department of Defense, or the government of the United States.
Exercise.“Regular” physical exercise for children to reduce BP is defined as ≥ 30 to 60 minutes of active play daily.6,29 Studies have shown significant improvement not only in BP but also in other cardiovascular disease risk parameters with regular physical exercise.27 A study found that the reduction in systolic BP is, on average, approximately 6 mm Hg with physical activity alone.30
Nutrition. DASH—Dietary Approaches to Stop Hypertension—is an evidence-based program to reduce BP. This nutritional guideline focuses on a diet rich in natural foods, including fruits, vegetables, minimally processed carbohydrates and whole grains, and low-fat dairy and meats. It also emphasizes the importance of avoiding foods high in processed sugars and reducing sodium intake.31 Higher-than-recommended sodium intake, based on age and sex (and established as part of dietary recommendations for children on the US Department of Health and Human Services’ website health.gov) directly correlates with the risk of prehypertension and hypertension—especially in overweight and obese children.20,32 DASH has been shown to reliably reduce the incidence of hypertension in children; other studies have supported increased intake of fruits, vegetables, and legumes as strategies to reduce BP.33,34
The family history should include notation of first- and second-degree relatives with hypertension. Inquire about medications that can raise BP, including oral contraceptives.
Other interventions.Techniques to improve adherence to exercise and nutritional modifications for children include motivational interviewing, community programs and education, and family counseling.27,35 A recent study showed that a community-based lifestyle modification program that is focused on weight loss in obese children resulted in a significant reduction in BP values at higher stages of obesity.36 There is evidence that techniques such as controlled breathing and meditation can reduce BP.37 Last, screening and counseling to encourage tobacco and substance use discontinuation are recommended for children and adolescents to improve health outcomes.25
Proceed with pharmacotherapy when these criteria are met
Medical therapy is recommended when certain criteria are met, although this decision should be individualized and made in agreement by the treating physician, patient, and family. These criteria (FIGURE6,20,25-28) are6,29:
once a diagnosis of stage 1 hypertension has been established, failure to meet a BP goal after 3 to 6 months of attempting lifestyle modifications
stage 2 hypertension without a modifiable risk factor, such as obesity
any stage of hypertension with comorbid CKD, DM, or proteinuria
target-organ damage, such as left ventricular hypertrophy
symptomatic hypertension.6,29
There are circumstances in which one or another specific antihypertensive agent is recommended for children; however, for most patients with primary hypertension, the following classes are recommended for first-line use6,22:
