Indian Academy of Pediatrics (IAP)

STANDARD
TREATMENT
GUIDELINES 2022

Hypertension
Lead Author
Santosh Soans
Co-Authors
Mritunjay Pao, Gaurav Garg

Under the Auspices of the IAP Action Plan 2022

Remesh Kumar R
IAP President 2022
Upendra Kinjawadekar Piyush Gupta
IAP President-Elect 2022 IAP President 2021
Vineet Saxena
IAP HSG 2022–2023
© Indian Academy of Pediatrics

IAP Standard Treatment Guidelines Committee

Chairperson
Remesh Kumar R
IAP Coordinator
Vineet Saxena
National Coordinators
SS Kamath, Vinod H Ratageri
Member Secretaries
Krishna Mohan R, Vishnu Mohan PT
Members
Santanu Deb, Surender Singh Bisht, Prashant Kariya,
Narmada Ashok, Pawan Kalyan
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Hypertension

Classification of hypertension is presented in Table 1.

TABLE 1:  Classification of hypertension.

Children aged 1–12 years
Classification (percentile based) Adolescents ≥13 years (mm Hg based)
Normotensive <90th percentile <120/<80 mm Hg
Definition

Elevated BP (previously ≥ 90th percentile to <95th 120/<80 to 129/<80 mm Hg

called prehypertension) percentile or 120/80 mm Hg to
<95th percentile (whichever is
lower)
Stage 1 hypertension ≥ 90th percentile to <95th 130/80 to 139/89 mm Hg
percentile
+12 mm Hg or 130/80 to 139/89
mm Hg (whichever is lower)
Stage 2 hypertension ≥ 95th percentile + 12 mm Hg, ≥ 95th percentile + 12 mm Hg, or
or ≥ 140/90 mm Hg (whichever ≥ 140/90 mm Hg (whichever is lower)
is lower)
(BP: blood pressure)
 Hypertension

;; Prevalence is 7% for hypertension (HTN), 4% for sustained HTN and 10% for elevated HTN
in a recent study of the Indian school children. However, as per the data from large studies,
the overall prevalence of HTN in children and adolescents is around 3.5% with a higher
Incidence

prevalence in overweight and obese.

;; The incidence of pediatric primary HTN is increasing and it should be identified early in
primary care settings. If left untreated, HTN in children and adolescents can have significant
implications for cardiovascular and renal health into adulthood, including metabolic
syndrome, stroke, coronary artery disease, chronic kidney disease, and heart failure. Both
elevated blood pressure (BP) and HTN affect boys more than girls, with rates among
adolescents higher than those for younger children.

;; In a patient with abnormal BP, measurements should be taken twice during the same
visit. While oscillometric measurements are good for screening, hypertension should

Confirm Hypertension
always be confirmed with auscultatory method. A diagnosis of hypertension should be
made with three separate BP recordings at least a week apart (hypertensive emergency
being an exception). If the elevation persists at repeat measurement, recommend lifestyle
interventions and repeat BP measurements at 6 and 12 months. If BP remains elevated
after 12 months, order “ambulatory BP monitoring (ABPM)”. Hypertension should only
then be diagnosed if the patient’s BP is elevated at three separate visits.
;; Increased stress on importance of ABPM in diagnosis and management of childhood
hypertension.
;; ABPM has been strongly recommended for confirming a diagnosis of HTN in children and
adolescents if they have office BP measurements in the elevated BP category for 1 year or
more or with stage 1 HTN over three clinic visits.
;; ABPM should be done for suspected white-coat HTN or masked HTN.
;; Its use was particularly recommended in special group of populations such as chronic
kidney disease and post transplantation.

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 Hypertension

Frequency of Monitoring
;; The guidelines recommend annual BP measurement for children above 3 years and has
identified sub-groups (obese, on medications known to increase BP, especially steroids,
renal disease, history of coarctation, or diabetes) for more frequent checks.
;; Children younger than 3 years warrant regular measurements if they have any of the followings:
congenital heart disease, recurrent urinary tract infection, urological malformation, solid-
organ transplant, bone marrow transplant, malignancy, neurofibromatosis, tuberous
sclerosis, or sickle cell disease. Small for gestational age newborns, premature (<32 weeks),
or very low birth weight babies and those with umbilical arterial catheterization also require
regular checks.
Elevated Hypertension

Prehypertension is now labeled as elevated BP.

Primary Hypertension
;; Primary or essential HTN is the predominant form of HTN in 6–12-year-olds and
adolescents, especially in those with a family history of HTN or who are overweight and/
or obese.
;; Children with primary HTN are mostly overweight and with a family history positive for
HTN. In obese patients, screening should include hemoglobin A1C, lipid panel, serum
creatinine, and liver enzymes.
;; Children age 6 years and older do not require an extensive evaluation for secondary
causes of HTN if they have a positive family history of HTN, are overweight or obese, and/
or do not have history or physical examination findings suggestive of a secondary cause
of HTN. Echocardiography is recommended to assess for cardiac target organ damage,
especially left ventricular hypertrophy at the time that pharmacologic treatment of HTN
is considered in any child.

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 Hypertension
Secondary Hypertension

;; Secondary HTN is more common in pediatric age group (especially children <6 years of
age) except for adolescents and obese.
;; Secondary HTN is primarily caused by renal and/or renovascular disorders, which account
for 63–74% of the cases.
;; Factors causing secondary HTN in children commonly are renal parenchymal disease, renal
artery stenosis, coarctation of the aorta, environmental exposures, neurofibromatosis,
hormonal causes, sleep apnea, and medications.
;; Based on patient history and physical examination findings, a urinalysis, urine chemistry
panel, thyroid function tests, sleep study, complete blood cell (CBC) count, and/or a
drug screen may be warranted. An elevated diastolic BP is more predictive of secondary
HTN (specifically renovascular disease), which requires renal ultrasound. Subsequent
laboratory abnormalities may prompt further workup of renal, cardiac, or endocrine
disorders as secondary causes of HTN.

Hypertensive Crisis
Hypertensive crisis is defined as a severe elevation in BP, classified as hypertensive
emergencies and urgency.
Hypertensive urgency, in which there are no signs of end-organ damage, and hypertensive
emergency, in which signs of end-organ damage are present, such as distinct signs of
hypertensive encephalopathy, acute left ventricular failure and acute myocardial ischemia,
papilledema, and elevated liver function tests.
Echocardiography

Echocardiography is strongly recommended to assess for target organ damage at the time of
consideration of pharmacologic treatment of HTN.

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 Hypertension

Treatment
;; Diet: Dietary approaches to stop hypertension (DASH) diet that includes increased
fruits, vegetables, and grains and low in sodium and fats
Lifestyle

;; Exercise: 40 minutes of moderate aerobic activity 3 days per week

;; Motivational interviewing and counseling pharmacologic.
Target BP: Reduction in systolic and diastolic BP to <90th percentile.
Normotensive

No additional action needed. Measure the BP at the next routine Well-child Care Visit.
Stepwise Approach to Hypertension

Elevated Blood Pressure

;; Step 1: Lifestyle modification; repeat BP after 6 months.

(Previously called
Prehypertension)
;; Step 2: If still elevated, check all four-limb BP [upper limb/lower limb (UL/LL)].
If these are normal—lifestyle modification continued and BP rechecked again
after 6 months.
;; Step 3: If BP still elevated, ABPM should be ordered (if available), and consider
diagnostic evaluation. If BP normalizes at any point, return to annual BP
screening at Well-child Care Visits.

;; Step 1: If asymptomatic, provide lifestyle counseling and recheck the BP in 1–2

Stage 1 Hypertension

weeks by auscultation.
;; Step 2: If the BP reading is still at the stage 1 level, UL/LL BP should be checked and if
normal nutrition and/or weight management initiated and BP rechecked in months.
;; Step 3: If BP continues to be at stage 1 HTN level after three visits, ABPM should be
ordered (if available), diagnostic evaluation should be conducted, and treatment
should be initiated. Subspecialty referral should be considered. If symptomatic,
early initiation/referral should be considered.
Hypertension

Patients with stage 2 HTN or with target organ damage should be started on
Stage 2

antihypertensives immediately and all efforts should be made to identify an

underlying cause and the patient should be referred to subspecialty care within
a week.
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 Hypertension

First-line Agent

If patient has chronic kidney disease, proteinuria, or diabetes, angiotensin-converting

enzyme (ACE) inhibitors (captopril, enalapril, fosinopril, lisinopril, ramipril, or quinapril)
Choice of Medications

or angiotensin II receptor blockers (candesartan, irbesartan, losartan, olmesartan,

and valsartan) or long-acting calcium channel blockers (amlodipine, felodipine, and
isradipine) are recommended. Nifedipine is used only for short-term control of BP.

;; If second-line agent needed (also can be first-line): thiazide diuretic (chlorthalidone,

Second-line Agent
chlorothiazide, and hydrochlorothiazide).
;; If the patient has heart failure, if first-line treatments fail to work, or if the patient
has a specific diagnosis for which beta-blockers are indicated, prescribe beta-
blockers (atenolol and metoprolol). If the HTN is not controlled on maximum
doses of these drugs consider peripheral alpha receptor blocker like prazosin or
central adrenergic agonist like clonidine.

Management of Hypertensive Crisis

;; Pediatric patients with hypertensive crisis require immediate and appropriate reduction
in BP levels, whereas patients with hypertensive urgency require a slower rate of
reduction in BP levels over 24–48 hours. However, rapidly decreasing BP levels may result
in decreasing the blood flow of organs, causing ischemia and infarction.
;; The treatment goal with pharmacologic therapy should be a reduction in systolic blood
pressure (SBP) and diastolic blood pressure (DBP) to <90th percentile and <130/80 mm
Hg in adolescents ≥13 years of age. The rate of BP reduction should be 25% over a period
of 6–8 hours, which is gradually reduced to normal over 24–72 hours since sudden, drastic
reductions in BP can itself contribute to organ damage secondary to ischemia.
;; In patients with hypertensive encephalopathy combined with chronic HTN, it is important
to reduce the mean arterial pressure gradually during the first hour. The preferred
agents include infusion of labetalol, esmolol, and nicardipine. Intravenous (IV) sodium
nitroprusside infusion can also be used for hypertensive emergency (Table 2).

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 Hypertension

TABLE 2:  Medicines for hypertensive crisis.

Onset
Drug Class (minutes) Duration Route Dose
Labetalol α + β blocker 2–5 2–12 IV bolus 0.2–1 mg/kg/dose, up to 40 mg/
dose; infusion 0.25–3 mg/kg/h
Nicardipine Calcium 10 <8 IV bolus Bolus: 30 µg/kg up to 2 mg/dose;
channel or infusion: 0.5–4 µg/kg/min
infusion

Management of Hypertensive Crisis

Hydralazine Arterial 5–20 1–4 IV/IM IV: 0.2–0.6 mg/kg
vasodilator bolus
Esmolol Beta-1 blocker 2–10 10–30 IV 100–500 µg/kg/min, up
(minutes) infusion
Sodium Vasodilator 2–10 1–10 IV 0.5–10 µg/kg/min
nitroprusside (minutes) infusion
Fenoldopam Dopamine 10 1 IV 0.2–0.8 µg/kg/min
receptor infusion
agonist
Enalapril ACE inhibitor 15–30 6–12 IV bolus 5–10 µg/kg/dose up to
(ACE: angiotensin-converting enzyme; IM: intramuscular; IV: intravenous)

Nephrology or cardiology, pending laboratory results and after a diagnosis of HTN has
been confirmed.
Drug classes that can be used in children with hypertension are presented in Table 3.

TABLE 3:  Drug classes used in children with hypertension.

No. dose/
Referral

Class Drug Initial dose Dose per 24 hours 24 hours

Calcium Amlodipine 0.1–0.2 mg/kg 0.6 mg/kg/d 1
channel Maximum 5 mg Maximum 10 mg/d
blockers Nicardipine 0.25–0.5 mg/kg/d 1–3 mg/kg/d 2
LP Maximum
120 mg/d
Felodipine 5 mg 10 mg 1
Contd...

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 Hypertension

Contd...
No. dose/
Class Drug Initial dose Dose per 24 hours 24 hours
ACE Captopril ;; Liquid formulation: 5 mg/ 6 mg/kg/d 1 to 3
inhibitors 5 mL and 25 mg/5 mL Maximum 150 mg
;; Newborns: 0.01–0.03 mg/kg/dose
;; Infants: 0.1 mg/kg/dose
;; Older children: 0.3–0.5 mg/kg/dose
Enalapril ;; Newborns: 0.05 mg/kg/dose 0.8 mg/kg/d 1
;; Infants: 0.05 mg/kg/dose Maximum 40 mg/d
;; Older children: 0.08 mg/kg/dose
;; Maximum 5 mg
Management of Hypertensive Crisis

Lisinopril 0.08 mg/kg 0.6 mg/kg/d 1

Maximum 5 mg/d Maximum 40 mg/d
ARBs Losartan* 0.7 mg/kg/d 1.4 mg/kg/d 1
Maximum 50 mg/d Maximum 100 mg/d
Irbesartan 2 mg/kg/d 6–12 years <35 kg: 1
75–150 mg/d
≥13 years
>35 kg: 150–300 mg/d
Valsartan 3 mg/mL drug with liquid 1–6 years: 1 mg/kg/d
formulation and <4 mg/kg/d
Referral

6–18 years: <35 kg:

20 mg/d and
<40 mg/d
>35 kg: 40 mg/d
and <80 mg/d
Beta- Acebutolol 1.5–3 mg/kg/d 5–15 mg/kg/d 1 to 2
blockers Propranolol 1 mg/kg/d 4 mg/kg/d 2 to 3
Maximum 640 mg/d
Atenolol 0.1–1 mg/kg/d 2 mg/kg/d 1 to 2
Maximum 100 mg/d
Alpha- Labetalol 1–3 mg/kg/d 10–15 mg/kg/d 2
and beta- Maximum
blocker 1,200 mg/d
Alpha- Prazosin 0.05–0.1 mg/kg/d 0.5 mg/kg/d 2 to 3
blockers Maximum 0.5 mg × 2 per day Maximum 20 mg/d
Clonidine 5 µg/kg/d 30 µg/kg/d 2 to 3
Maximum 1.05 mg/d
Diuretics Hydrochloro- 0.5–1 mg/kg/d 3 mg/kg/d 1
thiazide Maximum 50 mg/d
Furosemide 0.5–2 mg/kg/dose 6 mg/kg/d 1 to 2
Spirono­ 1 mg/kg/d 3.3 mg/kg/d 1 to 2
lactone* Maximum 100 mg/d
(ACE: angiotensin-converting enzyme; ARBs: angiotensin receptor blockers)

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 Hypertension

Further Reading
;; Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice
guideline for screening and management of high blood pressure in children and adolescents.
Pediatrics. 2017;140(3):e20171904.
;; Garvick S, Ballen E, Brasher D, St Amand E, Ray O, Vera N, et al. Guidelines for screening and managing
hypertension in children. JAAPA. 2021;34(1):114-19.
;; Meena J, Singh M, Agarwal A, Chauhan A, Jaiswal N. Prevalence of hypertension among children
and adolescents in India: a systematic review and meta-analysis. Indian J Pediatr. 2021;88:1107-14.
;; Raina R, Mahajan Z, Sharma A, Chakraborty R, Mahajan S, Sethi SK, et al. Hypertensive crisis in
pediatric patients: an overview. Front Pediatr. 2020;8:588911.

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