Highlights
Blood pressure (BP) levels track consistently from the moment of birth through preschool and early school age, suggesting that cardiovascular risk profiles are established much earlier than previously confirmed.
For every 1-standard deviation (SD) increase in initial mean arterial pressure (MAP) at birth, the hazard ratio for developing hypertension by age 11 is 3.75, representing a nearly fourfold increase in risk.
The findings advocate for a paradigm shift in pediatric care, suggesting that blood pressure monitoring should be considered a vital component of health assessments starting from the neonatal period to mitigate long-term cardiovascular disease (CVD) burden.
Introduction: The Life-Course Perspective of Hypertension
Hypertension remains the leading modifiable risk factor for cardiovascular disease and premature mortality globally. While traditionally viewed as a condition of adulthood, emerging evidence suggests that the physiological foundations for elevated blood pressure are laid during early development. The concept of “tracking”—the tendency for individuals to maintain their relative rank in a distribution over time—is central to understanding the progression of cardiovascular risk. However, until recently, most longitudinal studies began tracking blood pressure in late childhood or adolescence, leaving a critical gap in our understanding of the neonatal and preschool years.
The ENVIRONAGE (ENVironmental influence on early AGEing) birth cohort study addresses this gap by providing longitudinal data from birth through to the age of 11. By identifying the trajectories of blood pressure in early life, clinicians can better understand when the risk for adult hypertension begins and identify high-risk children who may benefit from early intervention strategies.
Study Design: The ENVIRONAGE Birth Cohort
The ENVIRONAGE study is a prospective, ongoing birth cohort initiated in February 2010 in Belgium. This specific analysis included 500 healthy children with a mean gestational age of 39.2 weeks. The study design focused on longitudinal follow-up at two distinct stages: First Follow-Up (FU1) between ages 4 and 6 years, and Second Follow-Up (FU2) between ages 9 and 11 years.
Blood pressure measurements were taken at birth and during both follow-up visits. To ensure clinical relevance, elevated blood pressure and hypertension were defined according to the 2017 American Academy of Pediatrics (AAP) guidelines, which provide age-, sex-, and height-specific percentiles. The primary exposure variable was initial blood pressure (at birth or FU1), and the primary outcomes were the incidences of elevated BP and hypertension at the final follow-up. Statistical analysis utilized multivariable-adjusted linear, mixed, and Cox proportional hazards regression models to account for potential confounders such as birth weight, maternal characteristics, and socio-economic factors.
Key Findings: Tracking Blood Pressure from Birth
The study provides robust evidence that blood pressure does not fluctuate randomly but follows a predictable trajectory. The mean systolic blood pressure (SBP) rose from 67.3 mm Hg at birth to 100.2 mm Hg at FU1 and 107.7 mm Hg at FU2. Similarly, diastolic blood pressure (DBP) and mean arterial pressure (MAP) showed consistent upward trajectories as children aged.
Statistical Significance of Blood Pressure Persistence
The researchers found that for every 1-SD increase in initial BP (either at birth or at age 4-6), the BP at the final follow-up increased significantly: 2.66 mm Hg for SBP, 1.37 mm Hg for DBP, and 1.97 mm Hg for MAP. These increases were independent of common covariates, reinforcing the idea that a child born with a higher relative blood pressure is likely to remain on a higher trajectory throughout their childhood.
The Risk of Hypertension
The most striking results were found in the Cox proportional hazards models. For each 1-SD increase in the initial MAP, the hazard ratio (HR) for elevated blood pressure was 2.84 (95% CI, 1.50-5.38). More alarmingly, the HR for clinical hypertension was 3.75 (95% CI, 1.79-7.86). This suggests that neonatal blood pressure is a potent predictor of clinical hypertensive status just one decade later.
Clinical Significance and Expert Commentary
The clinical implications of the ENVIRONAGE study are profound. Traditionally, routine blood pressure screening does not begin until age 3 in most healthy-child visit protocols. However, if BP tracking begins at birth, we may be missing a decade-long window of opportunity for identifying children at the highest risk for future cardiovascular events.
Experts in pediatric nephrology and cardiology note that while we cannot change a child’s birth BP, we can influence the environmental and lifestyle factors that exacerbate an upward trajectory. These factors include sodium intake, physical activity, and exposure to environmental pollutants—factors that the ENVIRONAGE study continues to investigate. The early identification of “high-trackers” allows for more personalized pediatric care and more aggressive lifestyle counseling for families.
Biological Plausibility: The Fetal Programming Hypothesis
The persistence of blood pressure levels from birth suggests a degree of biological programming. This aligns with the Barker Hypothesis, which posits that environmental insults during critical windows of development (prenatal and early postnatal) can permanently program the body’s structure and function. Potential mechanisms include alterations in nephron number, changes in the sympathetic nervous system’s reactivity, or epigenetic modifications of the renin-angiotensin-aldosterone system. By observing tracking from birth, this study provides empirical support for the idea that the cardiovascular “set point” is established very early in life.
Conclusion: A Call for Early Pediatric Screening
The ENVIRONAGE birth cohort study demonstrates that blood pressure trajectories are established at birth and remain consistent through school age. The high hazard ratios for hypertension associated with neonatal MAP suggest that early life blood pressure is not merely a transient physiological state but a significant marker of future health.
For clinicians and health policy experts, these findings suggest that the current practice of waiting until age 3 to begin routine BP monitoring might be reconsidered, particularly for children at the higher end of the neonatal distribution. Future research should focus on whether early intervention in these high-risk “trackers” can successfully alter their trajectory and reduce the incidence of cardiovascular disease in adulthood. Monitoring and managing BP from birth may represent one of the most effective long-term strategies for public health in the 21st century.
References
Yu YL, Renaers E, Martens DS, et al. Blood Pressure Trajectory From Birth to Preschool and School Age in the ENVIRONAGE Birth Cohort. JAMA Netw Open. 2026;9(1):e2551361. doi:10.1001/jamanetworkopen.2025.51361
Flynn JT, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904.
