Journal of Pediatric Health Care

Hypertension in a Child
A 5-year-old White boy came to the primary care office for routine follow-up of his behavior issues
(complex attention deficit disorder, oppositional defiant disorder, and possible mood disorder) and sleep
disturbance. At this office visit, the nurse practitioner (NP) noted that the child's blood pressure (BP) was
124/76 mmHg, which exceeded the 95th percentile for age and gender.
This child's BP measurements had been normal (i.e., 90/50 to 90/60 mmHg) at previous office visits. At
the request of the NP, the child's school nurse monitored his BP for 2 weeks following this office visit. The
BP measurements taken at school also were elevated (121/58, 131/68, and 117/64 mmHg). At the followup office visit, the child's BP remained hypertensive (120/72 mmHg). All BP measurements were made
with appropriate-sized cuffs in the same extremity while the child was sitting.
The child's growth has consistently followed the 90th percentile for height and weight. Besides his
behavior issues, the child is healthy, he has not had any surgeries, and his immunizations are up to date.
He has no history of a heart murmur. He was diagnosed with a speech delay at 17 months and was noted
to have anger issues (i.e., tantrums and violence toward others) and was sleeping only 4 to 5 hours per
night at 2 years of age.
The child's family history is significant for hypertension in both parents and both grandmothers. The
child's mom is 25 years old and his dad is 27 years old, and they currently are taking antihypertensive
medications for primary hypertension. The age at which the parents started taking antihypertensive
medications is unknown. The child's maternal grandfather had a myocardial infarction at the age of 42
years, and his maternal grandmother had a cerebral vascular accident at the age of 46 years.
The child lives at home with his parents and does not have any siblings. Both parents are employed and
have health insurance. The parents describe their child as a very picky eater, consuming several diet
sodas each day and refusing fruits and vegetables. His diet consisted of ready-to-serve foods (e.g., fast
foods, canned soups, and pasta). Review of systems was negative for headaches, dizziness, fainting, and
chest pain.
The child takes Clonidine, 0.1 mg at bedtime, to improve his sleep onset. He had been taking this
medication for 2 years when the hypertension was detected (3 years old).
The child's height was 120.6 cm, his weight was 24 kg, and his body mass index (BMI) was 17.6 (85th
percentile). His heart sounds were normal, and upper and lower extremity pulses were equal bilaterally.
No hepatosplenomegaly or abdominal masses were palpated.

After the school nurse monitored the child's BP for 2 weeks, he returned to his primary care provider for a
follow-up visit. At that visit, the NP obtained four extremity BP readings to rule out coarctation of the aorta.
These measurements were as follows: left arm, 120/72 mmHg; right arm, 120/68 mmHg; left leg, 124/76
mmHg; and right leg, 122/84 mmHg. A basic metabolic profile and complete blood cell count were
obtained, and results were normal. A urinalysis was normal and a urine culture had no growth. Results of
a renal ultrasound were normal. A thyroid profile was normal with a thyroid-stimulating hormone level of
0.99 U/mL (0.55 U/mL) and free T4 of 1.7 ng/dL (12.6 ng/dL).
Question

1.

What is considered hypertension in children?

2.

What are the differential diagnoses for new-onset hypertension in children?

3.

How is elevated BP in children evaluated?

4.

What dietary factors should be assessed in the evaluation and management of childhood
hypertension?