in progress

Draft Recommendation Statement

High Blood Pressure in Children and Adolescents: Screening

April 21, 2020

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This topic is being updated. Please use the link(s) below to see the latest documents available.

Recommendation Summary

Population Recommendation Grade
Children and adolescents The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents. I

Additional Information

  • Screening for High Blood Pressure in Children and Adolescents (Consumer Guide): Draft Recommendation | Link to File

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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The prevalence of hypertension (both primary and secondary) in children and adolescents in the United States ranges from 3% to 4% in most studies.1-5 Primary hypertension in children and adolescents occurs primarily in children older than age 13 years and has no known cause but is associated with several risk factors, including family history and higher body mass index.1 Secondary hypertension occurs primarily in younger children and is most commonly caused by genetic disorders, renal disease, endocrine disorders, or cardiovascular abnormalities.1 6

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The USPSTF concludes that the evidence to support screening for high blood pressure in children and adolescents is insufficient and that the balance of benefits and harms cannot be determined.

See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.7

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Patient Population Under Consideration

This recommendation applies to children and adolescents who are not known to have hypertension.

Definitions of Hypertension

Primary hypertension has no known cause. Secondary hypertension in children is most commonly caused by renal or renovascular disease. Other causes of secondary hypertension include congenital cardiovascular abnormalities, genetic disorders, and endocrine disorders.1, 6

The American Academy of Pediatrics revised its definitions of abnormal blood pressure in children and adolescents in 2017.8 For children ages 1 to 13 years, hypertension is defined as three auscultatory blood pressure measurements at three different visits that are either above the 95th percentile based on age, height, and sex or above 130/90 mm Hg (millimeters of mercury), whichever measurement is lower.1, 8 The thresholds for adolescents age 13 years or older follow the adult guidelines from the American Heart Association and American College of Cardiology, regardless of sex and height: stage 1 hypertension in children age 13 years or older is defined as a blood pressure measurement of 130/80 to 139/89 mm Hg, stage 2 hypertension in children age 13 years or older is defined as a blood pressure measurement above 140/90 mm Hg.9

Screening Tests

Best practice is to measure blood pressure in the right arm with an appropriately sized cuff1, 8 at three different visits. Some organizations suggest that the diagnosis should be confirmed by ambulatory blood pressure monitoring (ABPM). ABPM uses portable devices that record blood pressure measurements at regular intervals (usually 20 to 30 minutes) over 12 to 24 hours.8

Screening Intervals

There is no good evidence about how often blood pressure should be measured in children and adolescents.

Treatment

Hypertension in children is often treated with lifestyle and pharmacologic interventions. Lifestyle interventions for hypertension include weight loss in children who are overweight or obese, increased physical activity, and the Dietary Approaches to Stop Hypertension (DASH) diet, as well as education and counseling. Medication is generally used to treat hypertension that is unresponsive to lifestyle modification.1

Suggestions for Practice Regarding the I Statement

In deciding whether to screen for hypertension in children and adolescents, clinicians should consider the following.

Potential Preventable Burden

Important risk factors for primary hypertension in children and adolescents are higher body mass index and a family history of hypertension. Other risk factors include low birth weight, male sex, and African American or Hispanic race/ethnicity. The increasing prevalence of hypertension in children and adolescents, possibly driven by childhood obesity, suggests that identification and treatment of hypertension may become a significant health care issue. The goal of identifying and treating children and adolescents with primary hypertension can be viewed within a larger framework of adult cardiovascular risk reduction, which includes addressing other biometric risk factors such as higher body mass index and lipid profiles and hyperglycemia. However, the variables for cardiovascular risk reduction in children are less understood than in adults.

Extending the adult framework for cardiovascular risk reduction to children and adolescents is limited by several methodological challenges that complicate the determination of the potential preventable burden. There is limited evidence about the clinical and epidemiologic significance of percentile thresholds used in children in terms of their association with adult cardiovascular disease. In addition, the performance characteristics of current methods for diagnosing hypertension during childhood are limited and of concern because of possible high false-positive rates (i.e., elevated blood pressure measurements that later normalize).

One justification that has been suggested for screening is to identify secondary hypertension, a relatively rare condition. Younger children (younger than age 6 years) are more likely than older children and adolescents to have a secondary cause of hypertension. Secondary hypertension is unlikely to be the only clinical manifestation of the underlying disorder in these cases, and management is primarily targeted at treating the underlying condition, as well as controlling hypertension.1

Potential Harms

Clinic-based screening for high blood pressure could result in false-positive results. Thus, unnecessary secondary evaluations or treatments may be common, particularly with frequent blood pressure screening. Pharmacologic interventions have been shown to be well tolerated, but this has only been evaluated in studies over relatively short periods.1 Treatment of hypertension in childhood and adolescence with pharmacologic agents is done for a much longer period, and therefore, adverse effects may be more likely to occur. 

Current Practice

Current practice for blood pressure screening typically involves measurement in office-based health care settings as part of well child or sports participation examinations, often in conjunction with other vital signs and growth parameters. Several organizations recommend routine measurement of blood pressure at well child visits starting at age 3 years, based on consensus.1

Other Related USPSTF Recommendations

The USPSTF recommends that clinicians screen for obesity in children age 6 years or older and offer or refer them to a comprehensive, intensive behavioral intervention to improve weight status (B recommendation).10 The USPSTF found insufficient evidence on screening for lipid disorders in children and adolescents age 20 years or younger (I statement).11 These recommendations are available on the USPSTF website (www.uspreventiveservicestaskforce.org).

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Scope of Review

The USPSTF commissioned a systematic evidence review to update its 2013 recommendation on screening for high blood pressure in children and adolescents.1, 13 The USPSTF reviewed the evidence on the benefits of screening, test accuracy, the effectiveness and harms of treatment, and the association between hypertension and markers of cardiovascular disease in childhood and adulthood. The scope of this review is similar to that of the prior systematic review except that in the current review, the USPSTF also examined the evidence on secondary hypertension.

Accuracy of Screening Tests

One fair-quality, U.S.-based study (n=247) of participants ages 11 to 19 years assessed the sensitivity of two office-based blood pressure measurements (1 to 2 weeks apart) compared with ABPM (the reference standard). Systolic blood pressure (SBP) at the 90th percentile was used as a threshold for elevated blood pressure. The sensitivity of office-based blood pressure measurements was 81.6%, with a specificity of 70.3% (confidence intervals [CIs] not reported), compared with ABPM.1, 14

Association With Adult Hypertension and Other Intermediate Outcomes

Twenty observational studies evaluated the association between high blood pressure in childhood and hypertension or other intermediate outcomes in adulthood. Study sites included the United States, Eastern Europe, Finland, New Zealand, and Australia. The mean duration of followup was 10 to 33 years.1 The studies used different thresholds for defining elevated blood pressure and hypertension in children and different definitions of hypertension in adults. However, despite differing thresholds, studies were generally consistent in demonstrating an association between elevated blood pressure in childhood and elevated blood pressure in adulthood.

Various measures of association were reported across studies. Reported odds ratios (ORs) ranged from 1.1 to 4.5, risk ratios (RRs) ranged from 1.45 to 3.60, and hazard ratios (HRs) ranged from 2.8 to 3.2.1. Predictive accuracy measures such as sensitivity and positive predictive value varied, with sensitivity ranging from 0.0 to 0.89 and positive predictive values ranging from 0.05 to 0.97.1

Seven studies looked at the association between elevated blood pressure in childhood and other intermediate outcomes. Studies reported associations between abnormal blood pressure in childhood and carotid intima-media thickness in adulthood, with an OR of 1.24 (95% CI, 1.13 to 1.37) (mean duration of followup was 25 years); HRs ranged from 2.03 to 3.07 (duration of followup was 10 to 21 years) and correlation coefficients ranged from 0.04 to 0.16 (duration of followup was 21 to 31 years).1

Two studies reported significant associations between elevated blood pressure in childhood and left ventricular hypertrophy in adulthood (ORs ranged from 1.30 to 1.59; HRs ranged from 1.92 to 3.41).1, 15, 16 Single studies demonstrated significant associations between elevated childhood blood pressure and subclinical cardiovascular disease, higher aorta-femoral pulse wave velocity, and microalbuminuria.1, 15, 17

Benefits of Early Detection and Treatment

No studies directly assessed screening for high blood pressure in children and adolescents and reported effectiveness in delaying the onset of or reducing the risk for adverse cardiovascular health outcomes related to hypertension, either in childhood or adulthood. No studies addressed screening for secondary hypertension in asymptomatic children.1

Twenty randomized, controlled trials (RCTs) and a meta-analysis1, 18 examined treatment of high blood pressure.

Thirteen fair-quality placebo-controlled RCTs and one meta-analysis evaluated the efficacy of various pharmacologic treatments on lowering blood pressure.1, 18 Most of the studies excluded children or adolescents with known secondary hypertension or severe hypertension. Trial duration was limited to 2 to 4 weeks. All studies reported greater reductions in systolic and diastolic blood pressure measurements in participants who received pharmacologic treatments compared with placebo. Not all differences reached statistical significance. Beta blockers, calcium channel blockers, and mineralocorticoid receptor antagonists did not achieve significant reductions over 2 to 4 weeks. Pooled reductions of SBP were -4.38 mm Hg (95% CI, -2.16 to -7.27 mm Hg) for angiotensin-converting enzyme inhibitors, -3.07 mm Hg (95% CI, -1.44 to -4.99 mm Hg) for angiotensin receptor blockers, -3.20 mm Hg (95% CI, +2.23 to -8.69 mm Hg) for beta blockers, -3.10 mm Hg (95% CI, +0.45 to -6.52 mm Hg) for calcium channel blockers, and -0.12 mm Hg (95% CI, +3.46 to -3.69 mm Hg) for mineralocorticoid receptor antagonists.1

SBP was significantly reduced by physical exercise in two fair-quality RCTs over 3 months (-8.3 mm Hg; P<0.05; 1 RCT; N=40) and 8 months (-4.9 mm Hg; P≤0.05; 1 RCT; N=69).1, 19, 20 A DASH-type diet (high in fruits, vegetables, and low-fat dairy foods) resulted in statistically significant reductions in SBP (-2.2 mm Hg) and diastolic blood pressure (2.8 mm Hg) in a completers-only analysis of one fair-quality RCT over 3 months (-2.2 mm Hg; P<0.01; 1 RCT; N=57). However, the effect did not last beyond the intervention period.1, 21 One fair-quality RCT using a combination of a pharmacologic treatment (low-dose propranolol/chlorthalidone) and lifestyle interventions (dietary and exercise modifications for children and parents) over 6 months reported a statistically significant reduction of SBP (-7.6 mm Hg) and diastolic blood pressure (-6.9 mm Hg).1, 22, 23 Low-salt diet and progressive muscle relaxation did not achieve reductions of blood pressure.1

The USPSTF did not identify studies that reported on the effectiveness of treatment of primary childhood hypertension and the reduction of blood pressure or other intermediate or health outcomes in adulthood.

Harms of Screening and Treatment

The USPSTF did not identify studies that examined the harms of screening. Six fair-quality RCTs reported similar risks of adverse events between pharmacologic treatments and placebo.1 Trial duration was only 2 to 4 weeks. One fair-quality RCT reported similar risks for adverse events between a group receiving a combination of pharmacotherapy and lifestyle interventions and a control group without treatment over 6 months.1

How Does Evidence Fit With Biological Understanding?

The proportion of children with primary hypertension who revert to normal blood pressure over time, without any intervention, and the proportion of those who will continue to have hypertension in adulthood is unknown. Persistent elevation of blood pressure in adults is an established risk factor for cardiovascular and cerebrovascular disorders and renal impairment. However, these conditions are often distant future events for children and adolescents. Children with primary hypertension are at higher risk of developing intermediate outcomes such as increased left ventricular mass and carotid intima-media thickness.1, 5 As a result, intermediate measures of target end-organ injury, including physical alterations to the structure of vascular walls (early atherosclerosis or thickening of arteries) and the heart (increased left ventricle mass) and altered renal function (microalbuminuria), are often studied. At present, the evidence about the relationship between high blood pressure or intermediate outcomes in children and the presence of hypertension and intermediate outcomes in adults is inconsistent.

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There are several critical evidence gaps to better understanding the potential net benefit of screening for high blood pressure in childhood and adolescence.

  • Determine the test accuracy of blood pressure measurements with sphygmomanometers or oscillometric automated devices and establish thresholds for hypertension for 24-hour ambulatory monitoring. Apply the new thresholds for determining abnormal blood pressure to existing data sets and test the validity of these thresholds.
  • Conduct long-term treatment studies that assess benefits and harms of pharmacologic treatments of hypertension in children and adolescents.
  • Address the long-term natural history of hypertension in children and the spontaneous resolution of hypertension.
  • Assess the associations among childhood hypertension, adulthood hypertension, and surrogate measures of cardiovascular disease in childhood and adulthood, as well as adulthood clinical cardiovascular disease, are also needed.
  • Assess harms of medications, long-term compliance with treatment, and the effect of individual components of multifactorial interventions.
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The American Academy of Pediatrics recommends screening all patients for hypertension annually and high-risk patients at each visit beginning at age 3 years.1, 8 It also recommends using ABPM for the confirmation of hypertension in children and adolescents.8 The American Heart Association and the National Heart, Lung, and Blood Institute recommend routine screening starting at age 3 years.24, 25 The American Academy of Family Physicians states that there is insufficient evidence for or against routine screening for high blood pressure in children and adolescents.26

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1. Gartlehner G, Vander Schaaf EB, Orr C, Kennedy SM, Clark R, Viswanathan M. Screening for High Blood Pressure in Children and Adolescents: Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 193. AHRQ Publication No. 20-05261-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2020.
2. Dobson CP, Eide M, Nylund CM. Hypertension prevalence, cardiac complications, and antihypertensive medication use in children. J Pediatr. 2015;167(1):92-97.e1.
3. McNiece KL, Poffenbarger TS, Turner JL, et al. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr. 2007;150(6):640-644, 4.e1.
4. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874-9.
5. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117(25):3171-3180.
6. Flynn JT, Pierce CB, Miller ER, et al. Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr. 2012;160(3):434-440.e1.
7. U.S. Preventive Services Task Force. Procedure Manual. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual. Accessed April 3, 2020.
8. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3).
9. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138(17):e426-e483.
10. US Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.
11. US Preventive Services Task Force. Screening for lipid disorders in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(6):625-633.
12. US Preventive Services Task Force. Screening for primary hypertension in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2013;132(5):907-914.
13. Gartlehner G, Vander Schaaf EB, Orr C, Kennedy SM, Clark R, Viswanathan M. Screening for high blood pressure in children and adolescents: systematic review and evidence report for the US Preventive Services Task Force. JAMA. 2020. [In press]
14. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl 4th Report):555-576.
15. Xi B, Zhang T, Li S, et al. Can pediatric hypertension criteria be simplified? A prediction analysis of subclinical cardiovascular outcomes from the Bogalusa Heart Study. Hypertension. 2017;69(4):691-696
16. Du T, Fernandez C, Barshop R, Chen W, Urbina EM, Bazzano LA. 2017 pediatric hypertension guidelines improve prediction of adult cardiovascular outcomes. Hypertension. 2019;73(6):1217-1223.
17. Hoq S, Chen W, Srinivasan SR, Berenson GS. Childhood blood pressure predicts adult microalbuminuria in African Americans, but not in whites: the Bogalusa Heart Study. Am J Hypertens. 2002;15(12):1036-41.
18. Burrello J, Erhardt EM, Saint-Hilary G, et al. Pharmacological treatment of arterial hypertension in children and adolescents: a network meta-analysis. J Hypertens. 2019;37:e178.
19. Son WM, Sung KD, Bharath LP, Choi KJ, Park SY. Combined exercise training reduces blood pressure, arterial stiffness, and insulin resistance in obese prehypertensive adolescent girls. Clin Exp Hypertens. 2017;39(6):546-552.
20. Hansen HS, Froberg K, Hyldebrandt N, Nielsen JR. A controlled study of eight months of physical training and reduction of blood pressure in children: the Odense schoolchild study. BMJ. 1991;303(6804):682-5.
21. Couch SC, Saelens BE, Levin L, Dart K, Falciglia G, Daniels SR. The efficacy of a clinic-based behavioral nutrition intervention emphasizing a DASH-type diet for adolescents with elevated blood pressure. J Pediatr. 2008;152(4):494-501.
22. Berenson GS, Voors AW, Webber LS, et al. A model of intervention for prevention of early essential hypertension in the 1980s. Hypertension. 1983;5(1):41-54.
23. Berenson GS, Shear CL, Chiang YK, Webber LS, Voors AW. Combined low-dose medication and primary intervention over a 30-month period for sustained high blood pressure in childhood. Am J Med Sci. 1990;299(2):79-86.
24. Flynn JT, Daniels SR, Hayman LL, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63(5):1116-1135.
25. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213-256.
26. American Academy of Family Physicians. Clinical preventive service recommendation: hypertension, children and adolescents. https://www.aafp.org/patient-care/clinical-recommendations/all/hypertension.html. Accessed April 3, 2020.

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Rationale Assessment
Detection There is inadequate evidence about the accuracy of screening for high blood pressure in children and adolescents
Benefits of Early Detection and Intervention and Treatment (based on direct or indirect evidence)
  • There is no direct evidence that screening for high blood pressure in children and adolescents delays or reduces adverse health outcomes.
  • There is adequate evidence about the longitudinal association between high blood pressure in children and adolescents and high blood pressure and other intermediate outcomes in adults.
  • There is inadequate evidence on the long-term effectiveness of interventions (pharmacologic, lifestyle, or lifestyle interventions combined with pharmacotherapy) in the treatment of high blood pressure in children and adolescents resulting in reduced blood pressure or improved intermediate outcomes in children or adults.
  • There is inadequate evidence on the effectiveness of interventions in the treatment of high blood pressure in children and adolescents resulting in reduced adverse health outcomes associated with high blood pressure in adults.
Harms of Early Detection and Intervention and Treatment
  • There is inadequate evidence to assess the potential harms of screening for high blood pressure in children and adolescents.
  • There is inadequate evidence to assess the potential harms of pharmacologic, lifestyle, or lifestyle interventions combined with pharmacotherapy for treatment of high blood pressure in children and adolescents.
USPSTF Assessment The benefits and harms of screening for blood pressure in children and adolescents are uncertain, and the balance of benefits and harms cannot be determined.
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