Childhood hypertension is a growing global health threat, especially for children with obesity, results of an updated systematic review and meta-analysis reveal.

The review determined that the global pooled prevalence of hypertension among children and adolescents is 4.28% when using only in-office blood pressure measurements, but 6.67% when combining in-office with out-of-office measurements.

The findings highlight the limitations of relying solely on in-office blood pressure measurements in young patients, study investigator Kazem Rahimi, MD, professor of cardiovascular medicine and population health, University of Oxford, UK, told Medscape Medical News.

The study also showed the prevalence of childhood hypertension nearly doubled between 2000 and 2020, which "underscores an urgent need for action," another study investigator, Peige Song, PhD, School of Public Health, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, told Medscape Medical News.

"For clinicians, the priority should be to enhance screening practices, ensure accurate diagnosis through appropriate use of tools like ambulatory blood pressure monitoring [ABPM], and focus on prevention by addressing modifiable risk factors such as obesity, poor diet, and physical inactivity," she said.

The findings were published online November 12 in The Lancet.

Increased CVD and Renal Risk 

Childhood hypertension is a key early-life risk factor for both cardiovascular and renal morbidity. It is associated with persistent hypertension and cardiovascular disease in adulthood, as well as early organ damage.

Estimating the true prevalence of childhood hypertension has been challenging, in part, because diagnostic approaches vary widely across studies, said Song. A 2019 meta-analysis by her group reported a prevalence of 4.00%, and a more recent meta-analysis that included studies through mid-2024 found a prevalence of 3.89%.

However, neither analysis included out-of-office blood pressure measurements. Reliance on clinic readings alone cannot capture white-coat hypertension — elevated blood pressure in the office but normal elsewhere — or masked hypertension, in which office readings appear normal despite elevated levels outside the clinic.

Because of these limitations, pediatric guidelines — including those by the American Academy of Pediatrics — emphasize the need to identify sustained, white-coat, and masked hypertension using out-of-office monitoring, said Song. ABPM is recognized as the gold standard for this purpose, she added.

Following a comprehensive literature search for studies of childhood hypertension published between January 1, 2000, and April 19, 2025, researchers included 96 papers in the analysis. Most (84%) reported prevalence using an in-office approach (blood pressure measured on at least three separate occasions), 14% used a combination of in-office and out-of-office measurements, and 2% applied both methods. 

Compared to previous reviews, the new analysis included more studies from typically underrepresented countries including in Asia, Africa, and Latin America, providing "a more accurate picture of what's happening in the contemporary setting," said Rahimi.

Researchers classified childhood hypertension both by severity and phenotype. Severity categories were defined as follows: prehypertension (systolic or diastolic blood pressure in the 90th percentile to below the 95th percentile); stage 1 (systolic or diastolic blood pressure in the 95th to 99th percentile plus 5 mm Hg); and stage 2 (systolic or diastolic blood pressure above the 99th percentile plus 5 mm Hg). Hypertension was also categorized by phenotype: systolic, diastolic, isolated systolic, isolated diastolic, or combined systolic–diastolic.

Using these definitions, researchers then examined prevalence estimates based on the method of blood pressure assessment. For the in-office approach, 83 articles included 443,914 youth across 21 countries. The most commonly used devices were validated oscillometric monitors (37%) and mercury sphygmomanometers (36%).

An Upward Trend

The combination approach included 15 articles from nine countries for a total of 12,597 participants. ABPM was used in 80% of these studies and home blood pressure monitoring was used in 20%. The authors noted that although ABPM is considered the reference standard for out-of-office assessment, its use may be limited by cost, availability, tolerability, and other practical factors.

With the in-office approach, the pooled prevalence of childhood hypertension was 4.28% (95% CI, 3.71-4.90) based on 81 articles. This updated estimate, which is a slight increase from the 2019 estimate of 4.00%, represents an upward trend and "is more easily accepted and interpreted, and better reflects the more recent situation," said Song.

The prevalence of hypertension was almost eight times higher among children and adolescents with obesity (18.77%; 95% CI, 14.49-23.46) than normal weight children (2.44; 95% CI, 1.38-3.77).

Subgroup analyses revealed no statistically significant differences in prevalence by age (< 13 years vs 13-19 years), sex, or setting (urban vs rural). Rates also did not differ by blood pressure measurement device (aneroid, mercury, or oscillometric), investigation period (before 2009 vs 2010-25), World Health Organization region (Africa, the Americas, Eastern Mediterranean, Europe, South-East Asia, or Western Pacific), or World Bank income group (high-income countries vs low- and middle-income countries).

Hypertension rates did vary by severity, with a pooled prevalence of prehypertension of 8.15% (95% CI, 6.36-10.13) based on 28 studies. This, said Song, indicates "a substantial pool of children are at risk for progression."

Prehypertension was nearly twice as common in children with obesity (19.53%) as in those with normal weight (9.48%). This, said the authors, "reinforces the well-established association between adiposity and elevated blood pressure in childhood" through mechanisms such as insulin resistance, endothelial dysfunction, and elevated free fatty acids and angiotensinogen.

These high prevalence rates reinforce the importance of integrating blood pressure screening into pediatric obesity prevention and management programs. However, Rahimi emphasized that hypertension is reversible with lifestyle changes such as weight reduction, lower salt intake, and being more active.

The pooled prevalence of stage 1 hypertension was 4.02% and that of stage 2 hypertension was 0.83% based on nine articles each. For stage 2 hypertension, a higher prevalence was observed among adolescents (age 13-19 years) than children (under age 13 years).

Looking at phenotypes, the pooled prevalence of isolated systolic hypertension was 1.78%, that of isolated diastolic hypertension was 0.88%, and that of systolic–diastolic hypertension was 1.39%.

Prevalence Has Doubled 

Prevalence generally increased with age for both boys and girls up to age 14 years, followed by a decline. This pattern is consistent with established pubertal physiology, including hormonal and body weight changes, which contribute to elevated blood pressure, said Rahimi.

Song noted the prevalence was consistently higher in boys than in girls, likely due to the differential effects of sex steroids on vascular function and the more pronounced transient insulin resistance during puberty in boys.

In both sexes, the prevalence of childhood hypertension nearly doubled between 2000 and 2020, increasing from 3.40% to 6.53% in boys and from 3.02% to 5.82% in girls. The authors speculate this reflects global shifts in modifiable risk factors.

Prevalence estimates also varied by measurement device. Studies using mercury sphygmomanometers consistently reported higher rates than those using oscillometric devices, aligning with evidence that oscillometric monitors tend to underestimate blood pressure.

"This variability underscores the need for standardized blood pressure measurement protocols across settings to improve comparability and support global trend monitoring," the authors write.

Researchers rated all articles using a quality score of at least five on a scale of zero to nine, with a higher score indicating better quality. This, they said, signals potential bias in certain areas.

With the combination approach, the pooled prevalence of hypertension was 6.67% (95% CI, 1.66-14.53) based on five articles. 

The pooled prevalence of white-coat hypertension was 5.17% (95% CI, 3.23-7.52) based on 11 studies. And from 12 articles, the analysis found masked hypertension was the most common phenotype (9.22%), a rate Rahimi said is particularly concerning, given its association with target organ damage and elevated cardiovascular risk in children.

These results "clearly flag" that white-coat and masked hypertension occur in children as well as adults, he said.

There was substantial heterogeneity in pooled estimates, likely due to differences in study design, applied hypertension guidelines, and measurement protocols (for example, cuff size and number of readings), and population characteristics. 

Another study limitation was that data for certain subgroups came from a small number of articles, which might reduce the robustness of the findings.

In addition, subgroup analyses didn't explore dietary exposures, physical activity, socioeconomic status, or pubertal stage. And some regions, including the Eastern Mediterranean, South-East Asia, and Africa, were not well represented.

'Most Comprehensive Picture' to Date

In an accompanying editorial, Rahul Chanchlani, MD, associate professor of pediatrics in the Division of Nephrology at McMaster Children's Hospital in Hamilton, Ontario, Canada, and colleagues write that the new analysis provides "the most comprehensive picture yet of childhood hypertension" and confirms the condition "is both common and substantial, and the prevalence is rising."

Key strengths of the new analysis include its substantially larger sample size compared with previous reviews and its more detailed breakdown of prevalence. In addition to age, sex, and body mass index, it disaggregates rates by hypertension phenotype, revealing "meaningful patterns," explain Chanchlani and colleagues. 

They describe the nearly twofold increase in childhood hypertension between 2000 and 2020 as "striking," and note that the inclusion of white-coat and masked hypertension "adds nuance to our understanding of the heterogeneity of childhood hypertension."

However, the "very high" between-study heterogeneity limits how these findings can be interpreted, they write. "These figures should not be mistaken for precise global estimates; rather, they are weighted summaries across diverse contexts." 

The editorial highlights the uneven geographic distribution of studies, with in-office data drawn largely from low- and middle-income countries and out-of-office assessments coming almost exclusively from high-income countries.

"This imbalance means that the regions where obesity, urbanization, and health system constraints converge to heighten risk are those least represented in the more accurate diagnostic approach. Without deliberate investment, this diagnostic gap will widen, leaving the children with the highest risk invisible to both research and policy," they write.

The editorialists also point out that studies relied on different guidelines, used a range of devices, and applied varying thresholds to confirm hypertension. These methodological differences influence prevalence estimates and make comparisons across regions challenging.

All included studies scored at least five on the assessment of methodological quality, but "the discussion could have interrogated more deeply the specific domains of bias," they note.

They called for the harmonization of diagnostic criteria for childhood hypertension and emphasize the urgent need to integrate childhood hypertension into national noncommunicable disease surveillance platforms.

The study received funding from the National Natural Science Foundation of China. Rahimi, Song, and the editorialists have reported no relevant disclosures.