Screening Tests for Children (Ages 2 to 12)

Childhood obesity is a growing problem in the United States. About 17% of children and adolescents in the U.S. are obese. There are many serious health consequences of being obese, including increased risk of developing type 2 diabetes, high blood pressure and high cholesterol, joint problems, sleep apnea, and social and psychological problems. Children who continue to be overweight into adulthood are at greater risk for serious health problems, including heart disease, stroke, and some cancers.

Recommendations

The American Academy of Pediatrics (AAP) recommends routine obesity screening of children starting at age 2. At least once a year, a healthcare practitioner should assess a child's weight status. This is the recommendation of a federally-convened expert committee, one that represents 15 national healthcare organizations, including AAP. The child's weight and height as well as age and sex are considered in determining the child's body mass index (BMI) percentile. BMI is a useful tool for estimating body fat.

• Overweight: An overweight child (one whose BMI is between the 85th percentile and the 94th percentile on standardized growth charts) faces additional health risks.
• Obese: An obese child (at or above the 95th percentile on standardized growth charts) faces even more serious health risks.

For children aged 2 years and older, AAP says BMI changes should be monitored by calculating and plotting BMI on the Centers for Disease Control and Prevention (CDC) growth charts at every healthcare visit so that interventions can be implemented when a child starts to cross BMI percentiles upward, even before he or she approaches the 85th or the 95th percentile.

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen children ages 6 and older for obesity and refer them to programs to promote improvements in weight status. The Task Force has found that the BMI is an acceptable measure for determining excess weight and defines "overweight" and "obese" as above. The American Academy of Family Physicians makes the same recommendation.

Being overweight is one of the most common problems seen by pediatricians. At each well-child visit, the following should be discussed: the child's dietary patterns, levels of physical activity, and sedentary behaviors. The family's history of obesity, type 2 diabetes, and high blood pressure are important considerations as are a number of other physical measurements the healthcare provider can take. The goal is to prevent and address the problems of overweight and obesity through identification and early interventions, namely, changes to diet and exercise, to achieve a healthy weight and BMI.

Children's body mass calculations need to be accurate and related to their growth charts. A visit to a healthcare practitioner will provide you with the most reliable information, but the calculator on the CDC web site (in Links below) can help you determine if your child is at risk of being overweight.

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Links
HealthyChildren.org: Obesity  
Centers for Disease Control and Prevention: BMI Percentile Calculator for Child and Teen

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Sources Used in Current Review

Centers for Disease Control and Prevention. Childhood Obesity Facts. Available online at https://www.cdc.gov/obesity/data/childhood.html. Accessed October 2016.

U.S. Preventive Services Task Force. Obesity in Children and Adolescents: Screening. Available online at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryDraft/obesity-in-children-and-adolescents-screening1?ds=1&s=child%20obesity%20screening. Accessed October 2016.

American Academy of Pediatrics. Press Room: AAP Updates Recommendations on Obesity Prevention. Available online through https://www.aap.org. Accessed October 2016.

Daniels, Stephen R. and Hassink, Sandra G. and the Committee on Nutrition. The Role of the Pediatrician in Primary Prevention of Obesity. Pediatrics. July 2015, Vol 136 / Issue 1. Available online at http://pediatrics.aappublications.org/content/136/1/e275. Accessed October 2016.

Herman, Amy Orciari. USPSTF Again Recommends Obesity Screening in Kids, Clarifies Age Group. NEJM Journal Watch. November 2, 2016. Available online at http://www.jwatch.org/fw112212/2016/11/02/uspstf-again-recommends-obesity-screening-kids-clarifies?query=pfwTOC&jwd=000020042086&jspc=. Accessed October 2016.

About 193,000 young people under 20 years of age in the United States had diabetes in 2015, according to the U.S. Centers for Disease Control and Prevention (CDC). While most cases of type 1 diabetes are diagnosed in those under the age of 18, the signs and symptoms often develop rapidly and the diagnosis is often made in an emergency room setting. Thirty percent of new-onset cases of type 1 diabetes in children present with diabetic ketoacidosis. Thus, blood glucose measurements as screening for type 1 diabetes in asymptomatic children is presently not necessary. On the other hand, some youth with type 2 diabetes will have no obvious signs or symptoms of high blood glucose, especially early in the disease, and screening can be a useful tool. While still uncommon in children under age 10, the incidence of type 2 diabetes has increased dramatically in the last decade, especially in minority populations, according to the American Diabetes Association (ADA).

Developing the disease early in life means that the patient is at increased risk for the development of diabetic complications because of the potentially prolonged duration of exposure to high blood glucose (hyperglycemia). This increases the risk of serious health problems earlier in adulthood, such as heart disease, kidney failure, blindness, and foot amputations.

Risk Factors
Overweight, obesity, and physical inactivity are all contributing factors to development of type 2 diabetes, and they too have become national health problems. As public health experts work to educate Americans on how to avoid diabetes and its serious complications, parents and children should be aware that healthy eating habits and activity choices can lower an individual's risk of developing type 2 diabetes and related complications later in life.

A youth who is overweight—defined as [1] a body mass index (BMI) greater than the 85th percentile for age and sex, [2] weight for height greater than the 85th percentile, or [3] overweight more than 120% of ideal for height— plus 2 other known risk factors faces a substantial risk of having or developing type 2 diabetes, warns the ADA. These risk factors include:

• Having a close relative with type 2 diabetes
• Being Native American, African American, Latino, Asian American, or Pacific Islander
• Having signs of or conditions associated with insulin resistance, such as acanthosis nigricans, high blood pressure (hypertension), unhealthy lipid levels (dyslipidemia), polycystic ovary syndrome, or having a reduced birth weight (small-for-gestational age)
• Having a birth mother who has diabetes or had gestational diabetes

Recommendations
The ADA makes the following screening recommendations:

• Consider screening overweight children who have 2 or more additional risk factors for diabetes every 3 years, starting at 10 years of age or at the onset of puberty if that occurs earlier.
• Screen using one of the following tests:
  • Fasting glucose (fasting blood glucose, FBG) – this test measures the level of glucose in the blood after an 8-12 hour fast.
  • Hemoglobin A1c (also called A1c or glycated hemoglobin) – this test evaluates the average amount of glucose in the blood over the last 2 to 3 months and has been recommended as another test to screen for diabetes.
  • 2-hour oral glucose tolerance test (OGTT) – this test involves drawing a fasting blood sample for glucose measurement, followed by having the person drink a solution containing 1.75 g of glucose per kilogram body weight to a maximum of 75 grams and then drawing another sample two hours after the person begins to consume the glucose solution.

If any of these results is abnormal, the test is repeated on another day. If the repeat result is also abnormal, a diagnosis of diabetes is made.

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Links
KidsHealth.org: Kids – Diabetes Center
American Diabetes Association

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Sources Used in Current Review (last reviewed 9/18/17)

(2017). National diabetes Statistics Report, 2017. Centers for Disease Control and Prevention. Available online at https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed on 8/06/17.

(2015 October). Abnormal Blood Glucose and Type 2 Diabetes Mellitis: Screening. U.S. Preventive Services Task Force. Available online at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes?ds=1&s=diabetes. Accessed on 8/06/17.

(2017 July 27, Updated). What's New in Diabetes. Centers for Disease Control and Prevention. Available online at https://www.cdc.gov/diabetes/new/index.html. Accessed on 8/06/17.

(2017 July 25, Updated). Who’s at Risk? Centers for Disease Control and Prevention. Available online at https://www.cdc.gov/diabetes/basics/risk-factors.html. Accessed on 8/06/17.

Genzen, J. et. al. (2017 July, Updated). Diabetes Mellitus. ARUP Consult. Available online at https://arupconsult.com/content/diabetes-mellitus. Accessed on 8/06/17.

(2016 November). Diabetes Tests & Diagnosis. National Institute of Diabetes and Digestive and Kidney Diseases. Available online at https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis. Accessed on 8/06/17.

(2015). Screening and Monitoring of Prediabetes. American Association of Clinical Endocrinologists. Available online at http://outpatient.aace.com/prediabetes/screening-and-monitoring-prediabetes. Accessed on 8/06/17.

Diabetes Management Guidelines, American Diabetes Association (ADA) 2016 Guidelines. National Diabetes Education Initiative. Available online at http://www.ndei.org/ADA-2013-Guidelines-Criteria-Diabetes-Diagnosis.aspx.html#children. Accessed on 8/06/17.

Beginning in childhood, the waxy substance called cholesterol and other fatty substances known as lipids begin to build up in the arteries, hardening into plaques that narrow the arterial passageways. During adulthood, plaque buildup and resulting health problems occur not only in the arteries supplying blood to the heart muscle but in arteries throughout the body (a problem known as atherosclerosis). For both men and women in the United States, the number one cause of death is heart disease, and the amount of cholesterol in the blood greatly affects a person's chances of suffering from it.

Growing evidence shows that the biological processes that precede heart attacks and cardiovascular disease begin in childhood, although they don't generally cause symptoms or lead to disease until middle age or later. Experts encourage physical activity and healthy eating in childhood and adolescence, limiting saturated fat and trans fat, to help protect against heart disease in adulthood.

Monitoring and maintaining healthy levels of cholesterol are important in staying healthy. Screening for high cholesterol, typically with a lipid profile, is important because there are usually no symptoms. A lipid profile usually includes total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides. Non-HDL-cholesterol can also be calculated by subtracting the HDL-C value from the total cholesterol result. Typically, fasting for 9-12 hours before having the blood sample drawn is required; only water is permitted. However, some laboratories offer non-fasting lipid profiles. In particular, children and teens may have testing done without fasting.

Since screening recommendations are not always consistent between healthcare organizations, it's important to work with your children's healthcare provider to develop a cholesterol-screening plan that is right for them.

Recommendations

• The American Academy of Pediatrics (AAP) recommends routine lipid testing in all youths once between the ages of 9 and 11 and again between 17 and 21. Testing at a younger age and more frequent screening with a lipid profile is recommended for youths who are at an increased risk of developing heart disease as adults. Children younger than 2 years old are too young to be tested.
• The American Heart Association (AHA) does not recommend routine screening for children and adolescents with normal heart disease risk.
• The U.S. Preventive Services Task Force (USPSTF) recommends screening for high cholesterol in youths 20 and younger only if they are at increased risk. Currently, there is not enough evidence to recommend for or against routine screening in all youths, according to the Task Force.

Risk Factors

• Family History: Youths are at increased risk if they have a parent, grandparent, aunt/uncle, or sibling who has high cholesterol or if they have a family history of cardiovascular disease (prior to age 55 in male relative and age 65 in female relative).
• Personal Health: Youths are also at higher risk if they:
  • Are overweight or obese
  • Have a diet high in fats, especially saturated or trans fat
  • Get little or no exercise
  • Have diabetes or hypertension (high blood pressure)
  • Smoke cigarettes or use other tobacco products

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Links
American Heart Association: Hey Kids, Learn About Cholesterol
KidsHealth.org: Cholesterol 

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Sources Used in Current Review (last reviewed 7/12/17)

(2016 August 9). Screening for lipid disorders in children and adolescents. U.S. Preventive Task Force recommendation statement. U.S. Preventive Services Task Force. Available online at http://jamanetwork.com/journals/jama/fullarticle/2542642. Accessed June 2017.

Swift, D. (2017 February 17). AAP updates preventive care guidelines, targets HIV, depression screening. Medscape, News and Perspective. Available online at http://www.medscape.com/viewarticle/875950?pa=gzilco%2FMqWtheZwS%2BIv9ew%2F1apM1lJZswxmtf97%2BKCThPQZnAFNU5cYUCO0MrUVvVrJxKJt4DRD8mxYr6kYfOw%3D%3D. Accessed June 2017.

(Reviewed 2017 April). Common misconceptions about cholesterol. American Heart Association. Available online at http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/Common-Misconceptions-about-Cholesterol_UCM_305638_Article.jsp#.WUsgzhPyvR0. Accessed June 2017.

(Reviewed 2017 April). How to get your cholesterol tested. American Heart Association. Available online at http://www.heart.org/HEARTORG/Conditions/Cholesterol/HowToGetYourCholesterolTested/How-To-Get-Your-Cholesterol-Tested_UCM_305595_Article.jsp#.WUrsWxPyvEY. Accessed June 2017.

@2017. Periodicity schedule. American Academy of Pediatrics. Available online at https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Periodicity-Schedule.aspx. Accessed June 2017.

Family History of Early Atherosclerotic Cardiovascular Disease. National Heart, Lung and Blood Institute. Available online at https://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/full-report-chapter-4. Accessed June 2017.

Lead is a metal that was once a common additive to household paint and leaded gasoline and was used in water pipes and as a solder in canned foods. Although these uses have been limited in the U.S., the interiors of many houses built before 1978 contain peeling lead paint chips and dust and lead-contaminated water. Soil surrounding these houses may also be contaminated with lead. Children who live, play, or spend time in these environments are at risk of exposure to this metal and can bring lead into their bodies by inhaling or ingesting contaminated dust, water, paint chips, or lead-contaminated items. Other local sources of lead may be areas near industrial or manufacturing sites.

A young child's exposure to lead can damage the brain and other organs and cause behavioral problems and developmental delays. Even at low levels, lead can cause irreversible damage without causing physical symptoms, and impaired cognitive development may not be noticed until the child enters school.

Poisoning from this environmental hazard usually occurs in early childhood and many children in the United States need to be screened for lead poisoning.

Recommendations

The American Academy of Pediatrics (AAP) recommends that a risk assessment be performed for lead exposure at well-child visits at 6 months, 9 months, 12 months, 18 months, 24 months, and at 3, 4, 5, and 6 years of age. A blood lead level test should be done only if the risk assessment comes back positive. According to the AAP and the U.S. Centers for Disease Control and Prevention (CDC), universal screening or blood lead level tests are no longer recommended, except for children in high prevalence areas with increased risk factors.

Pediatricians may also offer screening to:

• Medicaid-eligible children at age 1 and again at 2 years of age
• Children of all ages who are recent immigrants, refugees, or adoptees at the earliest opportunity
• A child whose parent, guardian, or provider requests blood lead testing due to suspected exposure

People should check with their healthcare practitioner and/or local health department regarding lead screening guidelines specific to the risks in their area.

The CDC uses a threshold blood lead level (BLL) of 5 mcg/dL (five micrograms per deciliter) to identify children living in environments that expose them to lead hazards. Any test results above this level should trigger lead management and monitoring. Any child who has an elevated blood lead level needs to have his or her home or other environment evaluated. Other people at the residence should be tested as well. Without the elimination or reduction of the source of the exposure - a lead hazard in the environment - the elevated lead level will likely recur.

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Links
Centers for Disease Control and Prevention: Lead - Prevention Tips
KidsHealth: Lead Poisoning
MayoClinic: Lead exposure: Tips to protect your child

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Sources Used in Current Review

Centers for Disease Control and Prevention. Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention. PDF available for download at http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf. Accessed 10/6/2015.

(Updated 6/19/2014) Centers for Disease Control and Prevention. What Do Parents Need to Know to Protect Their Children? Available online at http://www.cdc.gov/nceh/lead/acclpp/blood_lead_levels.htm. Accessed 10/6/2015.

(April 2015) Centers for Disease Control and Prevention. Educational Interventions for Children Affected by Lead. Available online at http://www.cdc.gov/nceh/lead/publications/educational_interventions_children_affected_by_lead.pdf. Accessed 10/6/2015.

American Academy of Pediatrics. Detection of Lead Poisoning. Available online at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-exposure/Pages/Detection-of-Lead-Poisoning.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR:+No+local+token. Accessed October 2016.

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis bacteria. TB primarily targets the lungs but may affect any area of the body. It can be spread through the air from person to person through droplets of respiratory secretions such as sputum or aerosols released by coughing, sneezing, laughing, or breathing.

Most people who become infected with M. tuberculosis manage to confine the mycobacteria to a few cells in their lungs, where they stay alive but in an inactive form. This latent TB infection does not make the person sick or infectious and, in most cases, it does not progress to active tuberculosis. However, some people - especially those with compromised immune systems - may progress directly from initial TB infection to active tuberculosis. People who have HIV are much more likely to become sick if they contract TB. Another increasing concern is drug-resistant forms of TB that are resistant to the antibiotics typically prescribed to treat the disease.

According to the U.S. Centers for Disease Control and Prevention (CDC), TB in children is a public health concern because it is a marker for recent transmission of the bacteria, and infants and young children are more likely than older children and adults to develop life-threatening forms of the disease. Among children, the most cases of TB are seen in those under 5 years of age and in adolescents older than 10 years of age.

TB is one of the world's deadliest diseases, although it is relatively uncommon in the U.S. Still, it is a large health issue among at-risk groups. Current guidelines call for targeted screening among such groups.

Recommendations

The American Academy of Pediatrics (AAP) recommends that children who are at risk of contracting TB have a tuberculin skin test, such as if:

• They have been exposed to someone with active or suspected TB (e.g., a family member or other contact)
• They are immigrants from a country where TB is endemic or have traveled to those countries for more than one week

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Links
CDC: Tuberculosis (TB) in Children in the United States
HealthyChildren.org (AAP): Tuberculosis in Children

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Sources Used in Current Review

U.S. Centers for Disease Control and Prevention. Tuberculosis (TB) in Children in the United States. Available online at http://www.cdc.gov/tb/topic/populations/tbinchildren/default.htm. Accessed October 2016.

HealthyChildren.org. Tuberculosis in Children. Available online at http://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Tuberculosis.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token. Accessed October 2016.

Children grow and develop rapidly and need iron in their diet to develop normally. If a child does not consume enough iron, there is a risk of developing iron deficiency. Iron deficiency can cause anemia, a condition that can delay a child's mental, motor, and behavioral development and create problems that last long after the iron level is raised to a healthy level. Poor motor skills, behavior problems at home and school, and poor performance in school can be the long-term consequences of not receiving enough iron as a young child (0 to 3 years of age).

Iron deficiency may also be due to a severe blood loss, a genetic disorder, or something interfering with the body's ability to absorb iron, such as a medication the child is taking or a chronic illness (e.g., celiac disease).

The prevalence of iron deficiency anemia in children 1-5 years in the U.S. is about 1-2%.

Recommendations
The American Academy of Pediatrics (AAP), like several other organizations, recommends that children be screened with a hemoglobin and hematocrit test if they have risk factors for iron deficiency or iron deficiency anemia.

Risk factors for iron deficiency anemia in young children may include:

• Exclusive breastfeeding beyond 4 months of age without supplemental iron
• Households with a low income or living in poverty
• Drinking more than 24 ounces of cow's milk per day after 12 months of age
• History of:
  • Medications that interfere with iron absorption
  • Extensive blood loss
  • Restricted diet that doesn't provide enough iron
  • Prematurity or low birth weight
  • Exposure to lead

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Link
Mayo Clinic: Iron deficiency in children - Prevention tips for parents

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Sources Used in Current Review

American Academy of Pediatrics. Policy Statement: 2014 Recommendations for Pediatric Preventive Health Care. Pediatrics. Available online at http://pediatrics.aappublications.org/content/pediatrics/133/3/568.full.pdf. Accessed October 2016.

Blood pressure is the force that your blood puts on artery walls. High blood pressure, also known as hypertension, happens when that force is consistently too high.

High blood pressure in children is rare, but it can be a serious problem. About 3.5 percent of children and teens have high blood pressure. About the same percentage of children have blood pressure that is above what is considered optimal, but not high enough to diagnose as hypertension. Among obese and overweight children, the rate of high blood pressure can reach almost 25%.

Detecting high blood pressure in children is important because over time, hypertension can damage a child’s circulatory system and contribute to heart attack, stroke, and other health problems later in life. In general, the longer a child has high blood pressure, the greater the potential for damage to the child’s heart and other organs including kidneys, brain, or eyes.

Screening children for hypertension is also important because it can be an indicator of underlying conditions like diabetes, or kidney disease.

Most people with high blood pressure aren’t aware of it because there are often no obvious symptoms. The only way to find out if a child has high blood pressure is to have it checked.

How is blood pressure measured?

Blood pressure was traditionally measured in healthcare settings using a blood pressure cuff with a pressure gauge (sphygmomanometer). This air-filled cuff wraps around the upper arm and obstructs blood flow. By releasing small amounts of air from the cuff, blood slowly flows back into the arm. The pressure measured inside the cuff is the same as the pressure inside the arteries.

There are two numbers measured for blood pressure. Systolic blood pressure is the pressure when your heart beats. Diastolic pressure is when the heart relaxes between beats and the pressure drops. Together, they are written as systolic over diastolic pressure. For instance, a blood pressure of 120/80 mm Hg (millimeters of mercury) corresponds to a systolic pressure of 120 and a diastolic pressure of 80.

Using a sphygmomanometer is still considered the best method but, more commonly, devices that combine a blood pressure cuff with electronic sensors are used to measure blood pressure. Another method is to have the child wear a device that monitors and records the blood pressure at regular intervals during the day to evaluate blood pressure over time. This is especially helpful during the diagnostic process and can help rule out "white coat" hypertension, the high measurements that can occur when the child is at the doctor's office and not at other times.

A single measurement of blood pressure is not enough to diagnose hypertension. Typically, multiple readings are taken on different days. A diagnosis of high blood pressure is made if measurements are consistently high.

A child’s blood pressure may vary greatly between healthcare visits, or even within visits. So, it is important to obtain multiple measurements over time before diagnosing and treating a child for hypertension.

What is normal blood pressure?

High blood pressure in children ages 1 to 18 is defined differently than it is in adults. The 2017 American Academy of Pediatrics Clinical Practice Guideline recommends comparing a child’s blood pressure to tables that use data from healthy children of the same sex and height class. If a child has a blood pressure higher than 90 to 95 percent of other children in their age and height class, then they may have high blood pressure.

Screening Recommendations

The 2017 American Academy of Pediatrics (AAP) Clinical Practice Guideline, endorsed by the American Heart Association, recommends starting blood pressure measurement for healthy children at age 3, then measuring it annually. Children younger than 3 should have their blood pressure measured at every healthcare visit if they are increased risk for developing hypertension. Some of these risks include:

• Congenital heart disease
• Recurring urinary tract infections
• Kidney disease
• Born prematurely
   

The AAP recommends that children with certain conditions have their blood pressure measured during every healthcare visit. The conditions include:

• Obesity
• Taking medication known to raise blood pressure
• Diabetes
• Kidney disease
• A severe narrowing in the aorta, the major blood vessel carrying oxygenated blood to the body
   

The American Heart Association and American Thoracic Society’s 2015 guidelines on hypertension in children acknowledge that the causes of hypertension in children are often different from those in adults. They focus on classifying the type of hypertension a child has and determining treatment.

Related Content

Conditions: Hypertension

Sources (Last reviewed 4/17/19)

(Reviewed 2014 July 7). Family History and Other Characteristics That Increase Risk for High Blood Pressure. Centers for Disease Control and Prevention. Available online at https://www.cdc.gov/bloodpressure/family_history.htm. Accessed February 2019.

Abman, S. et al. (2015 November 3). Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Available online at https://www.ahajournals.org/doi/10.1161/CIR.0000000000000329. Accessed February 2019.

(2015 February 15). Screening for primary hypertension in children and adolescents: recommendation statement. U.S. Preventative Services Task Force. Available online at: https://www.aafp.org/afp/2015/0215/od1.html. Accessed February 2019.

(Reviewed 2016 October 31).High blood pressure in children. The American Heart Association. Available online at https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-pressure-is-a-silent-killer/high-blood-pressure-in-children. Accessed February 2019.

(2016 October 31). What is high blood pressure? American Heart Association. Available online at https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/what-is-high-blood-pressure. Accessed February 2019.

Flynn, J.T. (2017 September). Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. American Academy of Pediatrics. Available online at: http://pediatrics.aappublications.org/content/140/3/e20171904. Accessed February 2019.

(Reviewed 2017 November 13). Monitoring your blood pressure at home. American Heart Association. Available online at https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home. Accessed February 2019.

(Reviewed 2017 November 30). Monitor your blood pressure. American Heart Association. Available online at https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure. Accessed February 2019.

(Reviewed 2017 November 30). Understanding blood pressure readings. American Heart Association. Available online at https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings. Accessed February 2019.

(Reviewed 2018 July 18). High blood pressure during childhood and adolescence. Centers for Disease Control and Prevention. Available online athttps://www.cdc.gov/bloodpressure/youth.htm#cdc. Accessed February 2019.

© 2019). High blood pressure in children and adolescents. Stanford Children’s Health. Available online at https://www.stanfordchildrens.org/en/topic/default?id=high-blood-pressure-in-children-and-adolescents-90-P01609. Accessed February 2019.

(2019 February 13). High blood pressure. Centers for Disease Control and Prevention. Available online at https://www.cdc.gov/bloodpressure/index.htm. Accessed February 2019.

Heart health screenings. American Heart Association. Available online at https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/heart-health-screenings. Accessed February 2019.

Highlights from the 2017 guideline for the prevention, detection, evaluation and management of high blood pressure in adults. American Heart Association. Available online at https://www.heart.org/-/media/data-import/downloadables/hypertension-guideline-highlights-flyer-ucm_497841.pdf. Accessed February 2019.

High blood pressure. National Heart, Lung, and Blood Institute. Available online at https://www.nhlbi.nih.gov/health-topics/high-blood-pressure. Accessed February 2019.