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Research on managing pediatric hypertension is sparse, and securing an accurate diagnosis is challenging, according to experts. Recent studies suggest that many families are underinformed about hypertension risk factors and treatment options.

Pediatric hypertension is a significant concern because it can persist into adulthood and contribute to cardiovascular complications and shorter life expectancy, said Catherine Haut, DNP, CPNP-AC/PC, FAANP, FAAN, director of nursing research and evidence based practice at Nemours Children's Health in Delaware. With a lack of evidence to support treatment of hypertension in children, providers may base treatment on adult recommendations, said Haut.

Clinical Considerations

The two biggest barriers to effective management of pediatric hypertension are limited clinic time and inaccurate blood pressure (BP) measurement, said Sarah Henson, MD, assistant professor and clinical director of pediatric preventive cardiology at Cincinnati Children’s Medical Center, Cincinnati.

Pediatric BP is often measured incorrectly, usually because of the wrong cuff size, no rest period, or single oscillometric readings without auscultatory confirmation, said Henson. A 15-minute well-child visit can’t include a proper BP measurement, history, family counseling, and follow-up planning, she said. Electronic health record-embedded percentile calculators with auto-flagging of children at risk have been shown to help, as have BP-focused provider visits for confirmation and team-based care with coordinator support.

Attention to healthy lifestyle is not a delay tactic before “real” treatment and is not optional once a child is on medication for hypertension, Henson emphasized. “Effective interventions require practical, individualized counseling and collaborative discussions with both the patient and caregivers regarding achievable strategies to reduce blood pressure through sustainable lifestyle changes,” she said.

Limited evidence exists to guide initial pharmacologic therapy for pediatric hypertension, which leads to variation in clinical practice, said Megan McLaughlin, MD, assistant professor of pediatrics at the University of Rochester Medicine in Rochester, New York. Current guidelines for hypertension medication in children recommend initial pharmacologic therapy with an angiotensin-converting enzyme inhibitor (ACEi), angiotensin II receptor blocker (ARB), calcium channel blocker, or a diuretic for pediatric patients as well as adults.

To determine what medications are currently being prescribed in practice, McLaughlin and colleagues reviewed data from the Epic Cosmos database for patients diagnosed with hypertension between January 1, 2020, and December 31, 2024. The study population included 107,884 pediatric patients who were prescribed antihypertensive medications; pediatric patients were defined as those aged 18 years or younger.

McLaughlin presented the findings at the Pediatric Academic Societies (PAS) 2026 Meeting. Significantly fewer children than adults received an ARB (12.5% vs 42.0%). Children also were less likely than adults to be prescribed a beta-blocker (26.8% vs 55.0%), a diuretic (28.3% vs 48.1%), or a calcium channel blocker (46.4% vs 50.5%). Children were more likely than adults to receive an ACEi (46.0% vs 38.5%).

In addition, just 4.2% of children were on a combination antihypertensive medication compared to 19.3% of adults. “Very few pediatric patients were prescribed combination drugs, although this is a strategy that can improve adherence,” the researchers wrote.

In a subgroup analysis of medications within each class, most of the 49,601 pediatric patients on an ACEi (82.0%) were on lisinopril. The most often prescribed ARB was losartan (87% of 16,151 pediatric patients on an ARB). Among the 49,727 pediatric patients on a calcium channel blocker, amlodipine was the most common medication (83.7%).

The findings were limited by the retrospective design and potential for database errors. However, the data highlight the need for additional pharmacologic studies to optimize treatment of pediatric hypertension, the researchers concluded.

“I was surprised by the low numbers of angiotensin II receptor blockers being used in the pediatric population, since they have a favorable side effect profile and are FDA approved for hypertension,” McLaughlin said.

Possible drivers of some of the prescribing trends include provider experience and comfort with certain drugs, available formulations (such as liquids for younger patients), insurance coverage, and patient-specific factors such as comorbidities, she said. The study findings are preliminary and come from a large patient database, McLaughlin noted. Surveying providers to understand the prescribing trends would be useful, as would more clinical trials to assess pharmacotherapy in pediatric hypertension, she added.

The American Academy of Pediatrics Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, most recently published in 2017, was designed to assist providers in diagnosing children who have hypertension, but the guideline notes that referral to cardiology or nephrology is usually warranted for medication, said Haut.

When considering immediate hypertension medication in children, make sure the diagnosis is real, Henson said. “A single elevated BP is not hypertension,” she said. Confirmation means repeat measurements at separate visits, and ideally a 24-hour BP monitor, she added.

Once hypertension is confirmed, Henson said that she would start medication in addition to lifestyle changes for children who meet any of the following criteria: stage 2 hypertension; any confirmed hypertension with target organ damage; secondary hypertension, alongside treatment of the underlying cause; hypertension in chronic kidney disease, diabetes, or in posttransplant patients, in whom condition-specific BP targets apply, and persistent stage 1 hypertension despite about 6 months of lifestyle intervention.

Varying Views on Risk

In a separate study presented at the PAS meeting, Melissa Goulding, PhD, MS, an assistant professor at the University of Massachusetts Medical School in Worcester, and colleagues interviewed 32 caregivers of children aged 3-17 years about their perspectives on BP screening and hypertension. Nearly all caregivers said that their children underwent BP screening at their yearly physical or at every primary care visit.

Some thought this frequency was sufficient, others did not, based on their sense of hypertension risk. This perception of risk was not necessarily tied to family history, the researchers wrote. Caregivers both with and without a family history of hypertension reported they had not thought about BP screening for their children and were unsure of its importance, the researchers added.

Although most did not see hypertension as a risk for their children or children in general, most caregivers correctly identified risk factors including diet, stress, and family history. Discussions of BP management in children mainly involved monitoring and lifestyle, rather than medication, they noted.

In practice, clinician awareness of and adherence to current pediatric screening and assessment guidelines, including repeated BP analysis, referrals for ambulatory BP monitoring and imaging, and continued counseling on nutrition, exercise, and weight control are essential components of care, Haut said.

“Simplified treatment plans, family involvement, practical lifestyle counseling, and close follow-up can improve adherence and outcomes,” Henson said. Given the limited access to ambulatory BP monitoring, validated home BP devices, and pediatric subspecialty care in many areas, collaboration between primary care and subspecialty programs, telehealth support, and community-based approaches to care are important, she added.

However, “true symptomatic hypertension, meaning encephalopathy, acute heart failure, AKI [acute kidney injury], or hypertensive retinopathy, is uncommon and almost always reflects severe secondary disease,” Henson emphasized. Most symptoms blamed on high BP in children, such as headache, dizziness, epistaxis, and chest pain, are nonspecific, and may be more likely the cause of an elevated BP reading than the result of it, she said.

The studies received no outside funding. The researchers and Haut had no financial conflicts to disclose. Henson disclosed a consulting agreement with AstraZeneca.