These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

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Left ventricular hypertrophy (LVH) associates with increased risk for cardiovascular disease. Hypertension leads to LVH in adults, but its role in the pathogenesis of LVH in children is not as well established. To examine left ventricular mass and evaluate factors associated with LVH in children with stages 2 through 4 chronic kidney disease (CKD), we analyzed cross-sectional data from children who had baseline echocardiography (n ϭ 366) and underwent ambulatory BP monitoring (n ϭ 226) as a part of the observational Chronic Kidney Disease in Children (CKiD) cohort study. At baseline, 17% of children had LVH (11% eccentric and 6% concentric) and 9% had concentric remodeling of the left ventricle. On the basis of a combination of ambulatory and casual BP assessment (n ϭ 198), 38% of children had masked hypertension (normal casual but elevated ambulatory BP) and 18% had confirmed hypertension (both elevated casual and ambulatory BP). There was no significant association between LVH and kidney function. LVH was more common in children with either confirmed (34%) or masked (20%) hypertension compared with children with normal casual and ambulatory BP (8%). In multivariable analysis, masked (odds ratio 4.1) and confirmed (odds ratio 4.3) hypertension were the strongest independent predictors of LVH. In conclusion, casual BP measurements alone are insufficient to predict the presence of LVH in children with CKD. The high prevalence of masked hypertension and its association with LVH supports early echocardiography and ambulatory BP monitoring to evaluate cardiovascular risk in children with CKD. Left ventricular hypertrophy (LVH), a frequent finding in adults with chronic kidney disease (CKD), poses an increased risk for cardiovascular disease. 1 Similarly, LVH has been detected in approximately one third of children with stages 2 through 4 CKD. [2][3][4][5] Whereas hypertension is directly linked to the development of LVH in adults with CKD, 1 the relationship between elevated BP and the development of LVH in pediatric CKD remains unclear. In a multicenter study from Europe, 4 no significant associations were found between casual or ambulatory BP and LVH in children with stages 2 through 4 CKD, suggesting only a minor role of hypertension in the pathogenesis of LVH in mild to moderate pediatric CKD.

Background Few studies have prospectively evaluated the progression of chronic kidney disease (CKD) in children and factors associated with progression. Study Design Prospective assessment of risk factors for the composite event of renal replacement therapy (RRT) or 50% glomerular filtration rate (GFR) decline. Setting and Participants 496 children with CKD enrolled in the Chronic Kidney Disease in Children (CKiD) study. Outcomes Parametric failure time models were used to characterize adjusted associations between baseline levels and changes of predictors and the time to composite event. Results The cohort consisted of 398 children with non-glomerular and 98 children with glomerular disease, of whom 29% and 41%, respectively progressed to the composite event after a median follow-up of 5.2 and 3.7 years. Demographic, clinical characteristics and outcomes differed substantially according to underlying diagnosis, hence risk factors for progression were assessed in stratified analyses and formal interactions by diagnosis were performed. Among non-glomerular patients and after adjusting for baseline GFR, times to the composite event were significantly reduced with Up/c > 2 mg/mg, hypoalbuminemia, elevated blood pressure, dyslipidemia, male gender and anemia by 79%, 69%, 38%, 40%, 38% and 45%, respectively. Among patients with glomerular disease, Up/c > 0.5 mg/mg, hypoalbuminemia and elevated blood pressure significantly reduced times to the composite event by 94%, 71% and 67%, respectively. Variables expressing change in patient clinical status over the initial year of the study contributed significantly to the model which was cross validated internally. Limitations small number of events in glomerular patients and use of internal cross validation. Conclusions Characterization and modeling of risk factors for CKD progression can be used to predict the extent to which these factors, either alone or in combination, would shorten the time to RRT/50% decline of GFR in children with CKD.

To characterize the distribution of blood pressure (BP), prevalence and risk factors for hypertension in pediatric chronic kidney disease (CKD), we conducted a cross-sectional analysis of baseline BP's in 432 children (mean age 11y; 60% male; mean glomerular filtration rate [GFR] 44 ml/min/1.73m2) enrolled in the Chronic Kidney Disease in Children cohort study. BP's were obtained using an aneroid sphygmomanometer. GFR was measured by iohexol disappearance. Elevated BP was defined as BP≥90th percentile for age, gender and height. Hypertension was defined as BP≥95th percentile or as self-reported hypertension plus current treatment with antihypertensive medications. For systolic BP, 14% were hypertensive and 11% were pre-hypertensive (BP 90-95th percentile); 68% of subjects with elevated SBP were taking antihypertensive medications. For diastolic BP, 14% were hypertensive, and 9% were pre-hypertensive; 53% of subjects with elevated DBP were taking antihypertensive medications. 54% of subjects had either systolic or diastolic BP≥95th percentile or a history of hypertension plus current antihypertensive use. Characteristics associated with elevated BP included black race, shorter duration of CKD, absence of antihypertensive medication use, and elevated serum potassium. Among subjects receiving antihypertensive treatment, uncontrolled BP was associated with male sex, shorter CKD duration and absence of ACE inhibitor or ARB use. 37% of children with CKD had either elevated systolic or diastolic BP, and 39% of these were not receiving antihypertensives, indicating that hypertension in pediatric CKD may be frequently under- or even un-treated. Treatment with ACE inhibitors or ARB's may improve BP control in these patients.

Use of ambulatory blood pressure monitoring in children and adolescents has markedly increased since publication of the last American Heart Association scientific statement on pediatric ambulatory blood pressure monitoring in 2014. In addition, there has also been significant expansion of the evidence base for use of ambulatory blood pressure monitoring in the pediatric population, including new data linking ambulatory blood pressure levels with the development of blood pressure–related target organ damage. Last, additional data have recently been published that enable simplification of the classification of pediatric ambulatory monitoring studies. This scientific statement presents a succinct review of this new evidence, guidance on optimal application of ambulatory blood pressure monitoring in the clinical setting, and an updated classification scheme for the interpretation of ambulatory blood pressure monitoring in children and adolescents. We also highlight areas of uncertainty where additional research is needed.