Hypertension in children — structured clinical encounter

Structured encounter testing the approach to a six-year-old referred after a school health check found a stage 2 blood pressure: the confirmation and classification, the secondary-cause work-up driven by proteinuria and a small scarred kidney, the target-organ screen with echocardiography, and the shared decision with the family about an ACE inhibitor and long-term renal follow-up.

structured clinical encounter

Prompt

A six-year-old boy is referred to your general paediatric clinic after a school entry health check recorded a blood pressure of 124/84 mmHg, above the 95th percentile for his age, sex and height. He is asymptomatic, plays football twice a week, and is on the 50th centile for weight and height. He has no relevant family history. On your measurement, seated and rested with the correct cuff, his right-arm blood pressure is 122/82 mmHg, equal in both arms, and his leg pressures are 120/80 mmHg with palpable femoral pulses and no radio-femoral delay. His urinalysis shows 2+ protein and 1+ blood. His urea and electrolytes are normal and his creatinine is 62 micromoles per litre, at the upper limit of normal for his age. A renal ultrasound shows a small left kidney of seven centimetres with cortical thinning and scarring, and a normal right kidney of nine centimetres. You are the paediatric registrar working through the assessment, investigation and management with the family.

Task 1 — Confirm and classify (3 minutes)

Classify this child's blood pressure according to the AAP 2017 categories, and state the confirmation rule that applies before you label him hypertensive. Explain why the equal arm and leg pressures, with palpable femoral pulses, are an important negative finding. [1]

Task 2 — The secondary-cause work-up (4 minutes)

Given his age (under six years), his stage 2 blood pressure, his proteinuria and haematuria, and the small scarred left kidney on ultrasound, what is the most likely underlying renal diagnosis? Name the likely preceding clinical event in his history that you would now ask about, and outline the further investigations you would request to confirm the renal diagnosis and to assess his target-organ status. [1] [4]

Task 3 — Target-organ assessment (3 minutes)

Explain why an echocardiogram is the single most important target-organ investigation in any confirmed hypertensive child. State the finding that would convert this child from lifestyle-only management to drug therapy, and describe the neurocognitive consequences of untreated hypertension that the family should understand. [1] [10]

Task 4 — Management and the family conversation (5 minutes)

Outline your management plan, naming the first-line drug class and explaining why it is particularly appropriate for renal-parenchymal hypertension. State the blood-pressure target you will aim for and the monitoring you will arrange once therapy starts. Explain to the parents, in language they can use, what reflux nephropathy is, why controlling the blood pressure protects the remaining kidney function, and what the long-term follow-up will involve. [1] [8]

References

[1]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.PMID 28827377
[2]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.PMID 15286277
[3]Lurbe E; Agabiti-Rosei E; Cruickshank JK; et al 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens, 2016.PMID 27467768
[4]Hansen ML; Gunn PW; Kaelber DC Underdiagnosis of hypertension in children and adolescents. JAMA, 2007.PMID 17712071
[5]Kollias A; Dafni M; Poulidakis E; et al Out-of-office blood pressure and target organ damage in children and adolescents: a systematic review and meta-analysis. J Hypertens, 2014.PMID 25304469
[6]Mitsnefes MM; Laskin BL; Dahhou M; et al Mortality risk among children initially treated with dialysis for end-stage kidney disease, 1990-2010. JAMA, 2013.PMID 23645144
[7]Lurbe E; Litwin M; Pall D; et al Insights and implications of new blood pressure guidelines in children and adolescents. J Hypertens, 2018.PMID 29677052
[8]Flynn JT; Kruger R; Brady TM; et al Practical approach to evaluate and manage hypertension in youth: an International Society of Hypertension position paper. J Hypertens, 2026.PMID 41674374
[9]Lurbe E; Mancia G; Calpe J; et al Joint statement for assessing and managing high blood pressure in children and adolescents: Chapter 1. How to correctly measure blood pressure in children and adolescents. Front Pediatr, 2023.PMID 37138561
[10]Hooper SR; Johnson RJ; Gerson AC; et al Overview of the findings and advances in the neurocognitive and psychosocial functioning of mild to moderate pediatric CKD: perspectives from the Chronic Kidney Disease in Children (CKiD) cohort study. Pediatr Nephrol, 2022.PMID 34110493
[11]Miyashita Y; Peterson D; Rees JM; et al Isradipine for treatment of acute hypertension in hospitalized children and adolescents. J Clin Hypertens (Greenwich), 2010.PMID 21054771
[12]Flynn JT Neonatal hypertension. J Med Liban, 2010.PMID 21462844

Hypertension in children — structured clinical encounter

structured clinical encounter

Task 2 — The secondary-cause work-up (4 minutes)

Task 3 — Target-organ assessment (3 minutes)

Task 4 — Management and the family conversation (5 minutes)

References

[1]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.PMID 28827377
[2]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.PMID 15286277
[3]Lurbe E; Agabiti-Rosei E; Cruickshank JK; et al 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens, 2016.PMID 27467768
[4]Hansen ML; Gunn PW; Kaelber DC Underdiagnosis of hypertension in children and adolescents. JAMA, 2007.PMID 17712071
[5]Kollias A; Dafni M; Poulidakis E; et al Out-of-office blood pressure and target organ damage in children and adolescents: a systematic review and meta-analysis. J Hypertens, 2014.PMID 25304469
[6]Mitsnefes MM; Laskin BL; Dahhou M; et al Mortality risk among children initially treated with dialysis for end-stage kidney disease, 1990-2010. JAMA, 2013.PMID 23645144
[7]Lurbe E; Litwin M; Pall D; et al Insights and implications of new blood pressure guidelines in children and adolescents. J Hypertens, 2018.PMID 29677052
[8]Flynn JT; Kruger R; Brady TM; et al Practical approach to evaluate and manage hypertension in youth: an International Society of Hypertension position paper. J Hypertens, 2026.PMID 41674374
[9]Lurbe E; Mancia G; Calpe J; et al Joint statement for assessing and managing high blood pressure in children and adolescents: Chapter 1. How to correctly measure blood pressure in children and adolescents. Front Pediatr, 2023.PMID 37138561
[10]Hooper SR; Johnson RJ; Gerson AC; et al Overview of the findings and advances in the neurocognitive and psychosocial functioning of mild to moderate pediatric CKD: perspectives from the Chronic Kidney Disease in Children (CKiD) cohort study. Pediatr Nephrol, 2022.PMID 34110493
[11]Miyashita Y; Peterson D; Rees JM; et al Isradipine for treatment of acute hypertension in hospitalized children and adolescents. J Clin Hypertens (Greenwich), 2010.PMID 21054771
[12]Flynn JT Neonatal hypertension. J Med Liban, 2010.PMID 21462844