Has the child ever had their blood pressure checked before?

The American Academy of Pediatrics suggests blood pressure monitoring starting at age 3 years. By this time one can start tracking children’s blood pressures. That is, a blood pressure observed in a child at the 50% for age will tend to be observed on repeat blood pressure observations in the same child.

Does the child have any symptoms of headache, vomiting, or blurred vision?

Often hypertension of gradual onset will be asymptomatic, but if the onset is rapid the child may be symptomatic. Remember hypertension in infants is associated with very non-specific symptoms such as irritability or poor feeding.

How was the child’s blood pressure obtained? Was the situation stressful? Was the child in a quiet environment? Was an appropriate sized cuff used i.e. 2/3 of the upper arm? Was an upper extremity used and was the child in the sitting position?

Remember standard blood pressures were determined in the upper arm in the sitting position. Blood pressures observed in the leg may be higher that in the arm.

Does the child have a history of any skin lesions?

Such diseases as neurofibromatosis can be associated with café-au-lait spots. Lupus erythematosis is associated with a malar rash. Henoch-Schönlein purpura is associated with a petechial rash over the lower extremities, buttock and extensor surfaces of the arms. These diseases may be associated with hypertension. Acanthosis nigricans is associated with insulin resistance, obesity, hyperlipidemia and hypertension (syndrome X).

Does the child have a history of joint pain, swelling and/or erythema?

Lupus and Henoch-Schönlein purpura both present with joint symptoms.

Does the child have a history of a urinary tract infection, pyelonephritis, urgency, frequency, burning on urination?

Typically urinary tract infections are not associated with hypertension, but if present usually represents a structural renal abnormality.

Does the child have a history of polyuria and/or polydypsia?

Renal tubular defects often present with an increased urine output and an increased requirement for water. Hypertension may accompany some forms of renal tubular disease, especially as renal function decreases. An example would be congenital cystinosis. Children with hypoplastic/dysplastic kidneys may present with polyuria and exhibit hypertension.

Has the child had a recent weight gain? Does the child consume "fast foods"? How much exercise does the child get?

We are seeing an explosion of obesity, hypertension, insulin resistance, and hyperlipidemia in our adolescent population associated with lack of exercise and "fast food" consumption.

Has the child had sudden episodes of pallor, sweating, heart racing, or nervousness?

Catecholamine secreting tumors could produce such symptoms.

Has the child exhibited any weakness of the lower extremities?

Guillain-Barré syndrome may be associated with hypertension.