Hypertension in children: review of current challenges and state of knowledge

INTRODUCTION

Hypertension in children and adolescents is an increasingly recognized global health issue that demands attention from both healthcare professionals and policymakers. This article explores various aspects of pediatric hypertension, beginning with an examination of its epidemiology and the significant influence of socioeconomic factors on its prevalence. It also explores the pathophysiology underlying this condition, distinguishing between primary and secondary hypertension and highlighting the various contributing mechanisms. Furthermore, this article addresses the role of the escalating obesity pandemic in the rise of hypertension in young individuals. We also discuss the challenges in accurately diagnosing hypertension in children and treatment methods. Finally, the article underscores the importance of public health and policy interventions in the primary prevention and early detection of this significant health concern in the pediatric population.

METHODOLOGY

A comprehensive literature search was performed via PubMed to identify peer-reviewed articles published from 2006 onward, with a focus on the most recent findings (predominantly from 2010 and later) to reflect the current state of knowledge.
The inclusion criteria were as follows: 1) studies published in English, 2) studies involving children or adolescents aged 0-18 years, 3) original research articles, reviews, or meta-analyses, and 4) studies addressing one or more of the following domains: prevalence, pathophysiology, monitoring methods, socioeconomic influences, lifestyle-based interventions, and public health strategies related to pediatric hypertension.

EPIDEMIOLOGY AND SOCIOECONOMIC IMPACT

High blood pressure (BP) in children and adolescents is a growing concern for health professionals worldwide. A 2018 large-scale analysis of 47 studies conducted by Song et al. estimated that its prevalence was approximately 4%. The number of children with hypertension has increased over the last two decades and appears to be linked to increased body weight. Interestingly, the prevalence of hypertension varies among pediatric age groups, ranging from 4.3% in 6-year-olds to 8% in 14-year-olds and approximately 3.3% in 19-year-olds [1]. These values, however, can differ in certain regions of the world, and prehypertension is likely much more widespread. A study by Koebnick et al. carried out on 237,248 southern California youths revealed that 31.4% had prehypertension and that 2.1% were hypertensive [2]. Notably, some patients with abnormal BP measurements do not have a follow-up visit, thus possibly lowering the real-world prevalence of hypertension [3]. Those figures are even higher for obese children. According to a study by Cho et al., the rate of hypertension among obese children in Korea increased from 14.9% in the 2007-2009 timeframe to 27.7% in the 2013-2015 period (Fig. 1) [4].
The impact of socioeconomic status (SES) on childhood hypertension is crucial to its spread. According to one study, families with low annual income were 1.35 times more likely to develop hypertension than those with higher annual income [5]. Lower education, often a sign of lower SES, might mean less health knowledge, less awareness of healthy habits, and poorer access to information about preventing and managing hypertension. In high-income countries, these inequalities could present as unequal access to healthy food or quality healthcare across different socioeconomic levels. A study by Kaczmarek et al. conducted in Poland further clarified how socioeconomic factors affect blood pressure in adolescents, with more cases of high BP in rural areas and among adolescents from lower-income families. Specific socioeconomic factors, such as lower maternal education, fathers’ unemployment, and low income, are linked to a greater risk of hypertension in this group [6].

PATHOPHYSIOLOGY OF HYPERTENSION IN CHILDREN

The main determinants of blood pressure are the relationships among stroke volume, heart rate, peripheral resistance, and arterial stiffness [7]. Primary hypertension (PH) is characterized by elevated BP with the absence of an identifiable cause of secondary hypertension [8]. Hypertensive remodeling of the arteries, which is initially a physiological response to increased arterial wall tension, over time leads to increased arterial stiffness and becomes the main factor behind the isolated increase in systolic blood pressure (SBP), which is 3-4 times more likely to affect boys [7]. The main determinants of PH in children are listed in Table 1 [8-17].
Secondary hypertension is the predominant type of hypertension in infants and preschool children [18] and is defined as elevated blood pressure secondary to an identifiable cause [19]. Secondary hypertension is diagnosed on the basis of obvious findings on physical examination and laboratory evaluation [20]. The most common causes among children between 6 and 10 years of age are renal disorders, coarctation of the aorta, and renal parenchymal disease [21]. Other causes are listed in Table 2. Williams syndrome, Turner syndrome, and Leigh syndrome are also associated with hypertension [8, 18].

PANDEMIC OF OBESITY AND ITS RELATIONSHIP WITH PEDIATRIC HYPERTENSION

The increasing global prevalence of obesity in children and adolescents has emerged as a significant public health crisis, with rates increasing nearly eightfold in girls and even more so in boys between 1975 and 2016 [22]. This negative trend further worsened during the COVID-19 pandemic, when many people’s eating habits worsened [23].
Compared with children who are not obese, obese children are much more likely to develop hypertension. Moreover, the risk of increased blood pressure in children seems to increase across the entire range of BMI values, indicating a continuous connection rather than a simple cutoff point [24].
Obesity is strongly linked to hypertension through several interconnected mechanisms. Excess visceral adiposity leads to sympathetic nervous system (SNS) overactivation, resulting in, for example, increased heart rate. Obesity also stimulates the renin-angiotensin-aldosterone system (RAAS), leading to vasoconstriction and increased sodium and water retention. Adipose tissue produces various adipokines, such as leptin, which can contribute to hypertension by affecting the SNS and acting as a pressor. Insulin resistance, which often presents with obesity, can also increase blood pressure by promoting renal sodium retention and increasing sympathetic activity. Finally, excess visceral fat might physically compress the kidneys, affecting their function [25].

CLINICAL FEATURES AND DIAGNOSTIC CHALLENGES

Hypertension in children represents a major public health concern, affecting 4-8% of the pediatric population worldwide. It is a significant risk factor for the development of cardiovascular disease in adulthood [26, 27]. Despite the availability of established guidelines for diagnosis and treatment, the detection of hypertension in children remains inadequate [26, 28]. Population-based studies indicate that approximately 85% of children meeting the diagnostic criteria for elevated blood pressure remain undiagnosed, primarily owing to the asymptomatic nature of the condition and challenges associated with its diagnosis [26, 29].
In most cases, pediatric hypertension does not cause overt clinical symptoms. However, some patients may present with nonspecific complaints such as morning headaches, chronic fatigue, dizziness, difficulty concentrating, nosebleeds, or reduced exercise tolerance [30]. These symptoms are relatively uncommon and are more frequently associated with secondary hypertension, which may result from underlying conditions such as kidney disease, endocrine disorders, or congenital heart defects. Given the typically silent progression of the disease, systematic blood pressure screening is crucial for early detection and timely intervention [31].
Children with hypertension often exhibit a characteristic metabolic phenotype. This condition is strongly associated with visceral obesity, insulin resistance, dyslipidemia, and elevated serum uric acid levels. Studies have demonstrated that approximately 15-20% of children with hypertension meet the criteria for metabolic syndrome at the time of diagnosis, compared with only 2% in the general pediatric population [32, 33]. Additionally, these patients frequently exhibit accelerated biological maturation, immunological abnormalities, and increased adrenergic activity, which may contribute to an elevated long-term risk of cardiovascular complications. In addition to metabolic dysfunction, hypertension in children is associated with progressive target organ damage, underscoring the importance of early identification and management [32].
Elevated blood pressure leads to adaptive and pathological changes in the structure and function of target organs, including the heart, kidneys, and blood vessels. Left ventricular hypertrophy (LVH) is observed in 30-40% of children with primary hypertension, with severe cases occurring in 10-15% of affected individuals. Hypertension is further linked to increased albuminuria and thickening of the carotid intima–media complex (cIMT), an established marker of early atherosclerosis. Adequate blood pressure management may reverse LVH, reduce albuminuria, and improve vascular function, highlighting the necessity of early intervention to prevent long-term complications [34, 35].
The diagnosis of pediatric hypertension requires multiple blood pressure measurements and comparisons with reference values adjusted for age, sex, and height. According to current guidelines, hypertension is diagnosed when blood pressure values exceed the 95th percentile in at least three independent measurements [28, 34, 36]. However, diagnostic criteria differ among professional organizations. The American Academy of Pediatrics (AAP) defines hypertension in children aged 13 years and older as blood pressure levels ≥ 130/80 mm Hg, whereas the European Society of Hypertension (ESH) applies a threshold of 140/90 mm Hg from the age of 16 years [28, 34]. Hypertension Canada defines normal blood pressure values as 120/80 mm Hg for children aged 6-11 years and 130/85 mm Hg for adolescents aged 12-17 years [35]. These differences reflect varying preventive strategies and approaches for assessing long-term cardiovascular risk, which influence the selection of diagnostic thresholds and therapeutic targets [8]. Table 3 presents a comparison of the diagnostic criteria for arterial hypertension according to different scientific societies.
According to the AAP and ESH recommendations, blood pressure should be measured at least once annually in children over the age of three during routine check-ups, as well as in those presenting with medical concerns. In children under three years of age, blood pressure measurement is advised only in selected cases, such as preterm birth, congenital heart disease, or chronic kidney disease [9, 34]. Routine screening in infants is not recommended because of the high likelihood of inaccurate measurements – up to 41% of readings are unreliable in one-year-old children, 20% in three-year-olds, and approximately 9% of measurements fail in the 3-6-year age group [32].
Despite these well-defined diagnostic criteria, the accurate assessment of BP in children presents multiple challenges. BP values fluctuate considerably depending on measurement conditions, which may lead to false-positive or false-negative results. Improper cuff selection can further compromise accuracy, and some children exhibit the white coat effect, characterized by an artificially elevated BP reading in clinical settings. To improve diagnostic precision, ambulatory blood pressure monitoring (ABPM) is recommended [37]. This method enables the assessment of diurnal blood pressure patterns and facilitates the detection of masked hypertension, which may not be apparent in standard clinical measurements [8, 37].

MANAGEMENT OF HYPERTENSION IN CHILDREN

Hypertension in children requires a comprehensive therapeutic approach that focuses on both normalizing blood pressure and reducing the long-term risk of cardiovascular complications. The foundation of management lies in lifestyle modifications, whereas pharmacological treatment is reserved for cases where nonpharmacological measures fail. Early intervention is crucial for preventing target organ damage and improving patient outcomes [28, 38].
According to the 2017 guidelines of the AAP, the first step in managing pediatric hypertension is educating patients and their families on lifestyle modifications, particularly dietary changes [28]. The DASH (dietary approaches to stop hypertension) diet is widely recommended, emphasizing a high intake of vegetables, fruits, whole grains, and low-fat dairy products while limiting sodium, saturated fats, and simple sugars. Studies have demonstrated its effectiveness in lowering blood pressure and improving metabolic health [38, 39].
Regular physical activity is another essential component of blood pressure regulation. The AAP recommends engaging in moderate-to-vigorous exercise for 30-60 minutes at least three times per week. Emerging evidence suggests that high-intensity interval training (HIIT) may offer a more time-efficient and potentially superior alternative to traditional aerobic exercises in reducing blood pressure among children and adolescents [40, 41].
Pharmacological intervention is considered when lifestyle modifications fail to achieve adequate blood pressure control or when hypertension is classified as severe. The AAP guidelines recommend angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), long-acting calcium channel blockers, and thiazide diuretics as first-line agents [28].
A systematic review of randomized controlled trials in children with an average age of 12 years revealed that ACE inhibitors and ARBs significantly lowered systolic blood pressure (SBP) and diastolic blood pressure (DBP) compared with placebo, whereas calcium channel blockers and thiazide diuretics showed no statistically significant advantages [38, 42]. Furthermore, ACE inhibitors demonstrated greater efficacy in reducing DBP than eplerenone, a mineralocorticoid receptor antagonist [42].
Both ACE inhibitors and ARBs are particularly recommended for children with chronic kidney disease (CKD) and diabetic nephropathy because of their nephroprotective properties. Current data suggest that these two drug classes are among the most effective in managing pediatric hypertension, simplifying treatment selection for clinicians [28, 38]. However, their use in postmenarchal girls requires caution, as they carry potential teratogenic risks in the event of unintended pregnancy [43].
Despite strong evidence supporting the effectiveness of ACE inhibitors and ARBs, there is no universally preferred antihypertensive agent for all pediatric patients. Recent research underscores the importance of personalized treatment strategies, taking into account the underlying cause of hypertension, coexisting conditions, and individual responses to therapy [38].

PUBLIC HEALTH AND POLICY INTERVENTIONS

Primary prevention of hypertension in the pediatric population represents a key objective in public health, as it contributes to a reduced incidence of cardiovascular disease later in life. Effective strategies include initiatives aimed at preventing obesity, promoting physical activity, and encouraging healthy dietary patterns such as the DASH diet [8, 44].
Primary care providers hold a strategic position in the early detection and monitoring of elevated blood pressure in children. However, their efforts may be limited by insufficient training, the complexity of existing guidelines, a lack of appropriately sized equipment, and a low awareness of pediatric hypertension. Targeted educational initiatives, along with the development of supportive digital tools, have been proposed to enhance clinical management in this area [45].
Integrating routine blood pressure screening into national school health programs, along with lifestyle modification initiatives, could enhance the early identification of children at risk [45]. Establishing healthy heart behaviors early in life has potential for long-term cardiovascular health and effective prevention of chronic disease in adulthood [8].

CONCLUSIONS

To conclude, hypertension among children is a rising problem with exponential growth in prevalence due to lifestyle and socioeconomic changes. The risk of obesity is considered to be an important factor in the pathophysiology of PH in children. Nonspecific symptoms in combination with challenging diagnostic processes lead to inadequate detection of the disease in the population. Early intervention consisting of education, lifestyle modifications, dietary changes, regular physical activity, and personalized pharmacotherapy is crucial for preventing organ damage and improving patient outcomes. Healthcare professionals and policymakers should consider hypertension in children and its consequences as one of the primary challenges in public health. In particular, general practitioners should be vigilant, as they are often the first to identify affected children.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References