Hypertension during childhood is more common than previously thought and it is important to recognize, confirm, and appropriately manage it.

Children have elevated blood pressure during exercise, crying, and anxiety. The procedure for measuring blood pressure was explained and demonstrated beforehand. Most children are cooperative with blood pressure measurement. If the blood pressure is initially elevated you can perform blood pressure readings again at the end of the examination. Leave the cuff on the arm (deflated) and repeat the reading later. Elevated readings must always be confirmed by subsequent measurements.

A proper cuff size is essential for accurate determinations of blood pressure in children. Select the blood pressure cuff as you would for adults; it should be wide enough to cover two thirds of the upper arm or leg (Fig. 1). A narrower cuff falsely elevates the blood pressure reading, whereas a wider cuff lowers it and may interfere with proper placement of the stethoscope diaphragm over the artery.

FIGURE 1. Blood pressure monitoring in childhood can be challenging.

With children, as with adults, the first Korotkoff sound indicates systolic pressure and the point at which the Korotkoff sounds disappear constitutes the diastolic pressure. At times, especially among chubby young children, the Korotkoff sounds are not easily heard. In such instances, you can use palpation to determine the systolic blood pressure, remembering that the systolic pressure obtained is approximately 10 mm Hg lower by palpation than by auscultation.

A relatively inaccurate method is "inspection." If unable to obtain the blood pressure by auscultation/palpation, watch for the needle to bounce by about 10 mm Hg. The systolic blood pressure obtained by "inspection" is about 1 mm Hg higher than that obtained by auscultation.

In 2004, the National Heart, Lung, and Blood Institute's National High Blood Pressure Working Group on Hypertension Control in Children and Adolescents defined normal, high-normal, and high blood pressure as follows, with measurements on at least three separate occasions.

Children who have hypertension should be evaluated extensively to determine the cause. For infants and young children, a specific cause can often be found. An increasing proportion of older children and adolescents, however, have essential or primary hypertension. In all cases it is important to repeat measurements to reduce the possibility that the elevation reflects anxiety. Sometimes, repeating measurements in school is a way to obtain readings in a more relaxed environment. Hypertension and obesity often coexist in children.

It is important not to falsely label a child or adolescent as having hypertension because of the stigma of labeling, potential limitations to activities, and possible side effects of treatment.

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