51
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Mhanna C, Pinto M, Koechley H, Kannekanti N, Raina R, Parimi P, Shekhawat P. Postnatal glucocorticoid use impacts renal function in VLBW neonates. Pediatr Res 2022; 91:1821-1826. [PMID: 34400792 PMCID: PMC8366742 DOI: 10.1038/s41390-021-01624-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Preterm neonates often require glucocorticoids to manage refractory hypotension, prevent, and treat bronchopulmonary dysplasia. We have investigated the effect of cumulative dose and duration of glucocorticoids on blood pressure and renal function in VLBW infants. METHODS In this retrospective cohort study, medical records of infants (GA ≤ 35 weeks) born January 2015 to December 2019 were reviewed to extract demographic and clinical characteristics, dose and duration of steroids, blood pressure (BP), and creatinine at the time of discharge from the neonatal intensive care unit. RESULTS Two hundred and eighty-three neonates with average GA (28 ± 3 weeks) and birthweight (1060±381 g). Twenty-eight percent (33/116) of infants who received postnatal steroids developed hypertension versus 16% (27/167) of controls (OR = 2.0, p = 0.011). There was a correlation between the cumulative dosage of postnatal steroids and systolic BP (R2 = 0.06, p < 0.001). With increasing steroid dose and total steroid days, there was a significant increase in creatinine clearance at the time of discharge (R2 = 0.13, p < 0.001; R2 = 0.13, p < 0.001, respectively). CONCLUSIONS Cumulative dose of postnatal steroids and duration of use is associated with increased systolic BP in premature infants. Postnatal steroids should be used prudently to prevent long-term cardiovascular and renal morbidity. IMPACT Preterm neonates are exposed to a high dose of glucocorticoids during their neonatal intensive care stay. The dose and duration of use of postnatal glucocorticoids was associated with significant increase in blood pressure at the time of discharge in preterm neonates. Postnatal glucocorticoid use is associated with improved creatinine clearance likely due to a state of hyperfiltration and may lead to chronic kidney disease later in life. Postnatal glucocorticoids should be used prudently in this highly vulnerable population.
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Affiliation(s)
- Christiane Mhanna
- grid.239578.20000 0001 0675 4725Department of Pediatrics, The Cleveland Clinic Children’s Hospital, Cleveland, OH USA
| | - Merlin Pinto
- grid.411931.f0000 0001 0035 4528MetroHealth Medical Center, Department of Pediatrics, Division of Neonatology, Cleveland, OH USA
| | - Hannah Koechley
- grid.411931.f0000 0001 0035 4528MetroHealth Medical Center, Department of Pediatrics, Division of Neonatology, Cleveland, OH USA
| | - Naveen Kannekanti
- grid.411931.f0000 0001 0035 4528MetroHealth Medical Center, Department of Pediatrics, Division of Neonatology, Cleveland, OH USA
| | - Rupesh Raina
- grid.413473.60000 0000 9013 1194Akron Children’s Hospital, Department of Pediatric Nephrology, Akron, OH USA
| | - Prabhu Parimi
- grid.411931.f0000 0001 0035 4528MetroHealth Medical Center, Department of Pediatrics, Division of Neonatology, Cleveland, OH USA
| | - Prem Shekhawat
- MetroHealth Medical Center, Department of Pediatrics, Division of Neonatology, Cleveland, OH, USA.
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Branagan A, Costigan CS, Stack M, Slagle C, Molloy EJ. Management of Acute Kidney Injury in Extremely Low Birth Weight Infants. Front Pediatr 2022; 10:867715. [PMID: 35433560 PMCID: PMC9005741 DOI: 10.3389/fped.2022.867715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/22/2022] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is a common problem in the neonatal intensive care unit (NICU). Neonates born at <1,000 g (extremely low birth weight, ELBW) are at an increased risk of secondary associated comorbidities such as intrauterine growth restriction, prematurity, volume restriction, ischaemic injury, among others. Studies estimate up to 50% ELBW infants experience at least one episode of AKI during their NICU stay. Although no curative treatment for AKI currently exists, recognition is vital to reduce potential ongoing injury and mitigate long-term consequences of AKI. However, the definition of AKI is imperfect in this population and presents clinical challenges to correct identification, thus contributing to under recognition and reporting. Additionally, the absence of guidelines for the management of AKI in ELBW infants has led to variations in practice. This review summarizes AKI in the ELBW infant and includes suggestions such as close observation of daily fluid balance, review of medications to reduce nephrotoxic exposure, management of electrolytes, maximizing nutrition, and the use of diuretics and/or dialysis when appropriate.
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Affiliation(s)
- Aoife Branagan
- Paediatrics, Trinity Research in Childhood Centre (TRICC), Trinity College Dublin, Dublin, Ireland.,Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Caoimhe S Costigan
- Nephrology, Children's Health Ireland (CHI) at Crumlin & Temple Street, Dublin, Ireland
| | - Maria Stack
- Paediatrics, Trinity Research in Childhood Centre (TRICC), Trinity College Dublin, Dublin, Ireland.,Nephrology, Children's Health Ireland (CHI) at Crumlin & Temple Street, Dublin, Ireland
| | - Cara Slagle
- Division of Neonatology & Pulmonary Biology and the Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,The University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Eleanor J Molloy
- Paediatrics, Trinity Research in Childhood Centre (TRICC), Trinity College Dublin, Dublin, Ireland.,Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.,Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.,Neonatology, Children's Health Ireland (CHI) at Crumlin, Dublin, Ireland
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53
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Roeper R, Massicotte P, AlAbbas A, Law BH. A preterm infant with hematuria. Paediatr Child Health 2021; 26:388-389. [PMID: 34777653 DOI: 10.1093/pch/pxaa115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/08/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rhiana Roeper
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Patti Massicotte
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Abdullah AlAbbas
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Brenda H Law
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
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Outcomes of solitary functioning kidneys-renal agenesis is different than multicystic dysplastic kidney disease. Pediatr Nephrol 2021; 36:3673-3680. [PMID: 33954810 DOI: 10.1007/s00467-021-05064-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/16/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Multicystic dysplastic kidney (MCDK) disease and unilateral renal agenesis (URA) are well-known causes of a solitary functioning kidney (SFK) and are associated with long-term kidney injury. The aims of this study were to characterize the natural history of SFK at our center, define the risk factors associated with chronic kidney injury, and identify distinguishing features between URA and MCDK that predict outcome. METHODS This was a retrospective cohort study of 230 SFK patients. We compared MCDK (n=160) and URA (n=70) according to clinical features at diagnosis and kidney outcomes over follow-up. Univariate and multivariate binary regression analysis was used to determine independent risk factors for chronic kidney injury, defined as the composite outcome of hypertension, proteinuria, or chronic kidney disease (eGFR <60 mL/min/1.73m2). RESULTS URA had a higher prevalence of comorbid genetic syndromes (15 vs. 6%, p=0.04), non-renal anomalies (39 vs. 11%, p<0.001), and congenital anomalies of the kidney and urinary tract (CAKUT) (51 vs. 26%, p<0.001) than MCDK. Over follow-up, URA experienced more hypertension (19 vs. 3%, p=0.002), proteinuria (12 vs. 3%, p=0.03), and the composite outcome (19 vs. 6%, p=0.003) than MCDK. Independent risk factors for chronic kidney injury included CAKUT (OR 5.01, p=0.002) and URA (OR 2.71, p=0.04). CONCLUSIONS In our population, URA was more likely to have associated syndromes or anomalies, and to have worse outcomes over time than MCDK. URA diagnosis was an independent risk factor for chronic kidney injury. Our results will be used to develop a standardized clinical pathway for SFK management. A higher resolution version of the Graphical abstract is available as Supplementary information.
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55
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Harding M, Deyell RJ, Blydt-Hansen T. Catecholamines in neuroblastoma: Driver of hypertension, or solely a marker of disease? Cancer Rep (Hoboken) 2021; 5:e1569. [PMID: 34612613 PMCID: PMC9351666 DOI: 10.1002/cnr2.1569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/02/2021] [Accepted: 09/21/2021] [Indexed: 11/05/2022] Open
Abstract
Background Neuroblastoma is a common solid tumor of childhood and is often associated with hypertension. Potential etiologies contributing to hypertension include renal compression, pain, volume overload, and catecholamine secretion. Cases We completed a single center retrospective review of children with neuroblastoma and ≥stage II hypertension (per Hypertension Canada guidelines) over a 2‐year period. All patients (n = 10) had elevated urine normetanephrine levels and eight had intra‐abdominal tumors. Four patients had refractory hypertension requiring > three agents, of which three required alpha/beta blockade. Conclusion Although multifactorial, hypertension in neuroblastoma often has a neuroendocrine component. Excess normetanephrine production in neuroblastoma may be a more common hypertensive mechanism than previously appreciated. Urinary normetanephrine elevation could suggest potential neuroendocrine‐mediated hypertension.
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Affiliation(s)
- Matthew Harding
- Division of Nephrology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Rebecca J Deyell
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Tom Blydt-Hansen
- Division of Nephrology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
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Joram N, Beqiri E, Pezzato S, Andrea M, Robba C, Liet JM, Chenouard A, Bourgoin P, Czosnyka M, Léger PL, Smielewski P. Impact of Arterial Carbon Dioxide and Oxygen Content on Cerebral Autoregulation Monitoring Among Children Supported by ECMO. Neurocrit Care 2021; 35:480-490. [PMID: 33686559 DOI: 10.1007/s12028-021-01201-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cerebral autoregulation (CA) impairment is associated with neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Severe variations of arterial CO2 (PaCO2) and O2 (PaO2) tension after ECMO onset are common and associate with mortality and poor neurological outcome. The impact of gas exchange on CA among critically ill patients is poorly studied. METHODS Retrospective analysis of data collected prospectively from 30 children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France. A correlation coefficient between the variations of regional cerebral oxygen saturation (rSO2) and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). Cox-MAP plots were investigated allowing determining lower limit of autoregulation (LLA) and upper limit of autoregulation (ULA) limits of autoregulation. Age-based normal blood pressure was used to adjust the MAP, LLA, and ULA data from each patient and then reported as percentage (nMAP, nLLA, and nULA, respectively). RSO2, COx, nMAP, nLLA, and nULA values were averaged over one hour before each arterial blood gas (ABG) sample during ECMO run. RESULTS Thirty children (median age 4.8 months [Interquartile range (IQR) 0.7-39.1], median weight 5 kg [IQR 4-15]) experiencing 31 ECMO runs were included in the study. Three hundred and ninety ABGs were analyzed. The highest values of COx were observed on day 1 (D1) of ECMO. The relationship between COx and PaCO2 was nonlinear, but COx values tended to be lower in case of hypercapnia compared to normocapnia. During the whole ECMO run, a weak but significant correlation between PaCO2 and nULA was observed (R = 0.432, p = 0.02). On D1 of ECMO, this correlation was stronger (R = 0.85, p = 0.03) and a positive correlation between nLLA and PaCO2 was also found (R = 0.726, p < 0.001). A very weak negative correlation between PaO2 and nULA was observed within the whole ECMO run and on D1 of ECMO (R = -0.07 p = 0.04 and R = -0.135 p = <0.001, respectively). The difference between nULA and nLLA representing the span of the autoregulation plateau was positively correlated with PaCO2 and negatively correlated with PaO2 (R = 0.224, p = 0.01 and R = -0.051, p = 0.004, respectively). CONCLUSIONS We observed a complex relationship between PaCO2 and CA, influenced by the level of blood pressure. Hypercapnia seems to be globally protective in normotensive or hypertensive condition, while, in case of very low MAP, hypercapnia may disturb CA as it increases LLA. These data add additional arguments for very cautiously lower PaCO2, especially after ECMO start.
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Affiliation(s)
- Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France. .,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France. .,INSERM U955-ENVA, University Paris 12, Paris, France.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Physiology and Transplantation, Milan University, Milan, Italy
| | - Stefano Pezzato
- Pediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Moscatelli Andrea
- Pediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Chiara Robba
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Pierre-Louis Léger
- INSERM U955-ENVA, University Paris 12, Paris, France.,Pediatric Intensive Care Unit, Trousseau University Hospital, Paris, France
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Hundscheid T, Donders R, Onland W, Kooi EMW, Vijlbrief DC, de Vries WB, Nuytemans DHGM, van Overmeire B, Mulder AL, de Boode WP. Multi-centre, randomised non-inferiority trial of early treatment versus expectant management of patent ductus arteriosus in preterm infants (the BeNeDuctus trial): statistical analysis plan. Trials 2021; 22:627. [PMID: 34526095 PMCID: PMC8444433 DOI: 10.1186/s13063-021-05594-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Background Controversy exists about the optimal management of a patent ductus arteriosus (PDA) in preterm infants. A persistent PDA is associated with neonatal mortality and morbidity, but causality remains unproven. Although both pharmacological and/or surgical treatment are effective in PDA closure, this has not resulted in an improved neonatal outcome. In most preterm infants, a PDA will eventually close spontaneously, hence PDA treatment potentially increases the risk of iatrogenic adverse effects. Therefore, expectant management is gaining interest, even in the absence of convincing evidence to support this strategy. Methods/design The BeNeDuctus trial is a multicentre, randomised, non-inferiority trial assessing early pharmacological treatment (24–72 h postnatal age) with ibuprofen versus expectant management of PDA in preterm infants in Europe. Preterm infants with a gestational age of less than 28 weeks and an echocardiographic-confirmed PDA with a transductal diameter of > 1.5 mm are randomly allocated to early pharmacological treatment with ibuprofen or expectant management after parental informed consent. The primary outcome measure is the composite outcome of mortality, and/or necrotizing enterocolitis Bell stage ≥ IIa, and/or bronchopulmonary dysplasia, all established at a postmenstrual age of 36 weeks. Secondary short-term outcomes are comorbidity and adverse events assessed during hospitalization and long-term neurodevelopmental outcome assessed at a corrected age of 2 years. This statistical analysis plan focusses on the short-term outcome and is written and submitted without knowledge of the data. Trial registration ClinicalTrials.gov NTR5479. Registered on October 19, 2015, with the Dutch Trial Registry, sponsored by the United States National Library of Medicine Clinicaltrials.gov NCT02884219 (registered May 2016) and the European Clinical Trials Database EudraCT 2017-001376-28.
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Affiliation(s)
- Tim Hundscheid
- Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Paediatrics, Division of Neonatology, Radboud University Medical Centre Nijmegen, Internal postal code 804, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
| | - Rogier Donders
- Department for Health Evidence, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Wes Onland
- Emma Children's Hospital Amsterdam University Medical Centers, Department of Neonatology, University of Amsterdam, Vrije Universiteit Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Elisabeth M W Kooi
- Beatrix Children's Hospital, Department of Paediatrics, Division of Neonatology, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - Daniel C Vijlbrief
- Utrecht University, Wilhelmina Children's Hospital, Division of Woman and Baby, Department of Neonatology, University Medical Centre Utrecht, Lundlaan 6, 3584, EA, Utrecht, The Netherlands
| | - Willem B de Vries
- Wilhelmina Children's Hospital, Division of Woman and Baby, Department of Neonatology, University Medical Centre Utrecht, Utrecht University, Lundlaan 6, 3584, EA, Utrecht, The Netherlands
| | - Debbie H G M Nuytemans
- Neonatology Network Netherlands (N3), p/a Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | | | - Antonius L Mulder
- Department of Paediatrics, Division of Neonatology, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Willem P de Boode
- Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Paediatrics, Division of Neonatology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
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Kanic Z, Kanic V, Hojnik T. Enalapril and Acute Kidney Injury in a Hypertensive Premature Newborn - Should It Be Used or Not? J Pediatr Pharmacol Ther 2021; 26:638-642. [PMID: 34421415 DOI: 10.5863/1551-6776-26.6.638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/28/2020] [Indexed: 11/11/2022]
Abstract
Extremely low birth weight infants (birth weight ≤1000 g) have a significantly lower nephron number. The glomerular filtration rate (GFR) is usually sufficient under normal conditions but is unable to meet the needs during stress, which results in acute kidney injury (AKI). We describe the case of an extremely low birth weight infant (970 g) with a gestational age of 27 weeks (immature preterm) who was mechanically ventilated because of hyaline membrane disease. AKI with anuria and a rise in serum creatinine to 3.4 mg/dL developed in the second week. Diuresis was restored after diuretics and dopamine were administered intravenously and kidney function recovered in the next two weeks. However, he slowly became hypertensive, so intravenous enalapril was introduced in the 6th week. After the third dose, he suffered another AKI. After cessation of enalapril, kidney function recovered over the next few days. Although angiotensin-converting enzyme inhibitors (ACEi) may cause kidney injury, it can be used with great caution in the treatment of hypertension or heart failure in preterm infants. There remains a real dilemma of whether enalapril should be used in extremely low birth weight immature infants.
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59
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Cao D, Chen Y, Gao X, Zhu Y, Wu D, Liu G. Hypertension in 172 Chinese Children: An 8-Year Retrospective Study. J NIPPON MED SCH 2021; 88:178-188. [PMID: 34193741 DOI: 10.1272/jnms.jnms.2021_88-301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We evaluated children with hypertension and compared those with essential and secondary (including renal and non-renal) hypertension. METHODS This retrospective study analyzed data from hypertensive children (age, 0-18 years) referred for treatment between January 2008 and December 2015. Demographic factors, causative factors, and medical treatments were evaluated. Treatment failure was defined as a systolic or diastolic blood pressure ≥95th percentile for age, gender, and height on three separate occasions, despite treatment. All patients not meeting the failure criteria were considered to have controlled hypertension. The control rate was defined as the proportion of patients with controlled blood pressure. RESULTS Among 172 consecutive patients, 28% had essential hypertension and 72% had secondary hypertension. As compared with children with secondary hypertension, those with essential hypertension had a higher frequency of family history of hypertension (P<0.001), a higher body mass index (BMI) (P=0.001), lower frequency of proteinuria (P=0.003), lower uric acid (P=0.04), and lower triglyceride (P=0.048). The medications used in the controlled group were similar to those used in the uncontrolled group. Angiotensin-converting enzyme inhibitors (ACEIs) were only used in nephrogenic patients, and a higher rate of ACEI use seemed to increase control rates. Control rates did not significantly differ by age, number of drugs, or cause of hypertension. CONCLUSIONS As compared with children with secondary hypertension, those with essential hypertension were more likely to have a family history of hypertension and had a higher BMI, lower frequency of proteinuria, and lower uric acid and triglyceride concentrations. Treatment guidelines for essential and secondary hypertension should be established for children of all ages.
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Affiliation(s)
- Di Cao
- Medical Affairs Department, Children's Hospital of Fudan University
| | - Yewei Chen
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Xuan Gao
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Yiqing Zhu
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Dan Wu
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Gongbao Liu
- Medical Affairs Department, Children's Hospital of Fudan University
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Alvarado C, Balestracci A, Toledo I, Martin SM, Beaudoin L, Voyer LE. Transient early-childhood hyperkalemia without salt wasting, physiopathological approach of three cases. Nefrologia 2021; 42:S0211-6995(21)00068-0. [PMID: 33902940 DOI: 10.1016/j.nefro.2020.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 11/25/2022] Open
Abstract
Two types of early-childhood hyperkalemia had been recognized, according to the presence or absence of urinary salt wasting. This condition was attributed to a maturation disorder of aldosterone receptors and is characterized by sustained hyperkalemia, hyperchloremic metabolic acidosis due to reduced ammonium urinary excretion and bicarbonate loss, and normal creatinine with growth delay. We present three patients of the type without salt wasting, which we will call transient early-childhood hyperkalemia without salt wasting, and discuss its physiopathology according to new insights into sodium and potassium handling by the aldosterone in distal nephron. In three children from 30 to 120-day-old admitted with bronchiolitis and growth delay hyperkalemia was found in routine laboratory. Further studies revealed a normal creatinine with inappropriately normal or low fractional excretion of potassium, accompanied by inadequately normal serum aldosterone and plasma renin activity for their higher plasma potassium levels, but without urine salt wasting. They also presented hyperchloremic metabolic acidosis with fractional excretion of bicarbonate 0.58-2.2%, positive urinary anion gap during metabolic acidosis and normal ability to acidify the urine. Based on these findings a diagnosis of transient early-childhood hyperkalemia without salt wasting was made and they were treated sodium bicarbonate and hydrochlorothiazide with favorable response. The condition was transient in all cases leading to treatment discontinuation. Given that transient early-childhood hyperkalemia without salt wasting is a tubular disorder of transient nature with mild symptoms; it must be keep in mind in the differential diagnosis of hyperkalemia in young children.
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Affiliation(s)
- Caupolicán Alvarado
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sandra Mariel Martin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Beaudoin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Luis Eugenio Voyer
- Department of Pediatrics, Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Elimination of Intravenous Di-2-Ethylhexyl Phthalate Exposure Abrogates Most Neonatal Hypertension in Premature Infants with Bronchopulmonary Dysplasia. TOXICS 2021; 9:toxics9040075. [PMID: 33918157 PMCID: PMC8067010 DOI: 10.3390/toxics9040075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022]
Abstract
(1) Background: The incidence of hypertension in very low birthweight (VLBW) infants in a single neonatal intensive care unit (NICU) dropped markedly during a 2-year period when the IV fluid (IVF) in both the antenatal unit and the NICU temporarily changed to a di-2-ethylhexyl phthalate (DEHP)-free formulation. The objective of the current report is to document this observation and demonstrate the changes in incidence of hypertension were not associated with the variation in risk factors for hypertension; (2) Methods: The charts of all VLBW infants born in a single NICU during a 7-year span were reviewed. This time includes 32 months of baseline, 20 months of DEHP-free IVF, 20 months of IVF DEHP re-exposure, and two 4-month washout intervals. The group of interest was limited to VLBW infants with bronchopulmonary dysplasia (BPD). Chi-square analysis was used to compare incidence of hypertension among periods. Vermont Oxford NICU Registry data were examined for variation in maternal and neonatal risk factors for hypertension; Results: Incidence of hypertension in VLBW infants with BPD decreased from 7.7% (baseline) to 1.4% when IVF was DEHP-free, rising back to 10.1% when DEHP-containing IVF returned to use. Risk factors for neonatal hypertension were stable across the 3 study periods in the NICU’s group of VLBW infants; (3) Conclusions: Serendipitous removal of IVF containing DEHP resulted in near elimination of hypertension in one NICU—an effect entirely reversed after the same brand of DEHP-containing IVF returned to clinical use. These results suggest that DEHP exposure from IVF plays a major role in neonatal hypertension.
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Abstract
The blood pressure (BP) of neonates, especially those born premature, changes rapidly over the first days and weeks of life. Neonatal BPs may be affected by maternal factors, perinatal factors or events, and intrinsic or extrinsic infant factors. Unfortunately, the effect of many maternal health and disease states has only been studied in small numbers or has shown conflicting results. Many events around the time of delivery have the potential to influence the neonatal BP, and while definitive studies are often lacking, some observational data support physiological expectations. The strongest determinants of neonatal BP are the infant factors of gestational age at birth, birth weight, and postmenstrual age. Understanding the expected pattern of BP changes, identifying the potential influencing factors, and accurately measuring the BP are all essential to determine whether there is a BP abnormality present but are also more complex in the neonatal population. This review describes the evidence for maternal conditions, perinatal events, and infant factors to affect neonatal BP. It also explains what is currently known about the changing BP patterns in neonates including those born preterm. In addition, by examining the physiological process of hemodynamic adaptation to the extrauterine environment and compensatory cardiovascular responses, we can gain insight into the expected and unexpected vascular responses, making the variability of neonatal BP seem a little more predictable.
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Affiliation(s)
- Janis M Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
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63
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Infantile arterial hypertension: A diagnostic challenge in paediatrics. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.anpede.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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GarcÍa-Otero L, LÓpez M, GoncÉ A, Fortuny C, Salazar L, Valenzuela-Alcaraz B, Guirado L, CÉsar S, GratacÓs E, Crispi F. Cardiac remodeling and hypertension in HIV uninfected infants exposed in utero to antiretroviral therapy. Clin Infect Dis 2021; 73:586-593. [PMID: 33471090 DOI: 10.1093/cid/ciab030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We aimed to assess the postnatal pattern of cardiovascular remodeling associated with intrauterine exposure to maternal HIV and antiretroviral treatment (ART). METHODS Prospective cohort including 34 HIV-exposed uninfected (HEU) infants and 53 non-HIV-exposed infants evaluated from fetal life up to 6 months postnatally. A cardiovascular evaluation was performed including echocardiography, blood pressure and carotid intima media thickness (cIMT) measurement. RESULTS ART regimens during pregnancy included two nucleoside reverse transcriptase inhibitors (Abacavir+Lamivudine (32.4%), Emtricitabine+Tenofovir (41.2%) and Zidovudine+Lamivudine (20.6%)). At 6 months of age, HIV-exposed uninfected infants showed thicker myocardial walls (septal wall thickness mean 5.02 mm (SD 0.85) vs 3.98 mm (0.86); p<0.001) and relative systolic dysfunction with decreased mitral ring displacement (8.57 mm (2.03) vs 10.34 mm (1.84); p=0.002) and decreased tricuspid S' (9.71 cm/s (1.94) vs 11.54 cm/s (2.07); p=0.003) together with relative diastolic dysfunction showed by prolonged left isovolumic relaxation time (58.57 ms (13.79) vs 47.94 (7.39); p<0.001). Vascular assessment showed significantly higher systolic and diastolic blood pressure (102 mmHg (16.1) vs 80 mmHg (13.9); p<0.001 and 64 mmHg (14.4) vs 55 mmHg (10.2); p=0.045 respectively), with 50% of HIV-exposed children meeting criteria for hypertension vs 3.77% of the non-HIV-exposed group (p<0.001) and thicker mean cIMT in the HIV-exposed group (0.62 µm (0.09) vs 0.51 µm (0.09); p=0.015). CONCLUSIONS Subclinical cardiac impairment together with higher blood pressure and thicker cIMT were observed in HIV-exposed infants at 6 months of age. Half of them presented hypertension. Our findings support a possible increased cardiovascular risk in HIV uninfected infants exposed in utero to ART.
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Affiliation(s)
- Laura GarcÍa-Otero
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Marta LÓpez
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Anna GoncÉ
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Claudia Fortuny
- Pediatric Infectious Diseases Department, Hospital Sant Joan de Déu Barcelona, University of Barcelona, Barcelona, Spain
| | - Laura Salazar
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Brenda Valenzuela-Alcaraz
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Laura Guirado
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Sergi CÉsar
- Department of Pediatric Cardiology, Hospital Sant Joan de Déu Barcelona, University of Barcelona, Barcelona, Spain
| | - Eduard GratacÓs
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Fátima Crispi
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clinic de Ginecologia, Obstetricia i Neonatologia (ICGON), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Díaz Anadón LR, González López C, Ordóñez Álvarez FA, Santos Rodríguez F. [Infantile arterial hypertension: A diagnostic challenge in paediatrics]. An Pediatr (Barc) 2020; 94:117.e1-117.e8. [PMID: 33358354 DOI: 10.1016/j.anpedi.2020.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/28/2020] [Accepted: 10/29/2020] [Indexed: 10/22/2022] Open
Abstract
Arterial Hypertension prevalence (HTN) has significantly increased in paediatric patients, mainly in older children and teenagers. In these subjects the most common type is essential or primary HTN. However, in infants HTN prevalence is significantly lower and is almost always due to secondary causes, which can be potentially severe. Hence the importance of its detection, in order to establish an etiological diagnosis and provide an appropriate treatment, which usually requires a specialist physician. In addition to the technical difficulties of blood pressure measurement in infants, the lack of recommendations to perform a systematic screening in this age range and the absence of well-established normal values turns infancy-onset HTN into a diagnostic and therapeutic challenge for the physician. By means of the exposition of three infancy-onset HTN cases, the aim is to increase the paediatrician's awareness of this pathology and also to provide information about its diagnostic and therapeutic approach, dealing also with pharmacological measures of treatment.
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Affiliation(s)
- Lucas R Díaz Anadón
- Unidad de Nefrología Pediátrica, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Clara González López
- Unidad de Nefrología Pediátrica, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Flor A Ordóñez Álvarez
- Unidad de Nefrología Pediátrica, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Fernando Santos Rodríguez
- Unidad de Nefrología Pediátrica, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Departamento de Medicina, Área de Pediatría, Universidad de Oviedo, Oviedo, Asturias, España.
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66
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Janson JA, Wasylewicz ATM, Eijkemans M, Kerskes M. Citalopram intoxication in four week old infant. BMC Pediatr 2020; 20:552. [PMID: 33287753 PMCID: PMC7722423 DOI: 10.1186/s12887-020-02439-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 11/19/2020] [Indexed: 11/16/2022] Open
Abstract
Background In contrast to intoxications in toddlers which can be due to accidental ingestions, many intoxications in infants are due to medication errors. To our knowledge, this is the first case report of a citalopram intoxication in an infant, and may offer new insight on possible screening methods for intoxication as well as pharmacokinetics of citalopram in small infants. Case presentation This case report describes an unintentional citalopram intoxication in a 4 week old infant due to a vitamin D drops ‘look alike’ error. The infant showed extreme jitteriness and opisthotonus at presentation, as well as prolonged signs of gastro-oesophageal reflux. No cardiac rhythm disturbances or convulsions were seen. The clinical course combined with Finnegan scores was correlated to and supported by pharmacokinetic and pharmacokinetic data of citalopram in the patient. Conclusions Using Finnegan scores in general pediatric practice could help objectify follow-up of acute intoxications in young infants with neurological symptoms. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-020-02439-5.
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Affiliation(s)
- Jo-Anne Janson
- Pediatrics, Maastricht UMC+, Maastricht, The Netherlands
| | | | - Marianne Eijkemans
- Pediatrics, Catharina Hospital, Michelangelolaan 2, 5623, EJ Eindhoven, The Netherlands.
| | - Marieke Kerskes
- Pharmacology, Catharina Hospital, Eindhoven, The Netherlands
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Kim J, Lee JW, Kim DY. Analysis of Characteristics of Peripheral Arterial Ischemia in Premature Babies and Effects of Nitroglycerin Patch Application. CHILD HEALTH NURSING RESEARCH 2020; 26:434-444. [PMID: 35004487 PMCID: PMC8650864 DOI: 10.4094/chnr.2020.26.4.434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 11/06/2022] Open
Abstract
Purpose: The aim of this retrospective study was to analyze the characteristics of peripheral arterial ischemia and tissue necrosis in premature babies, as well as the effects of nitroglycerin.Methods: In total, 513 newborns were enrolled who were admitted to the neonatal intensive care unit with a gestational age of 34 weeks or younger. Data were collected on general personal and clinical information, peripheral arterial ischemia, and nitroglycerin patch application in the premature infants. The collected data were analyzed using the x<sup>2</sup> test, t-test, Mann-Whitney U test, logistic regression.Results: Thirty-six (7.0%) infants had peripheral arterial ischemia, while 477 (93.0%) infants did not. Lower gestational age (x<sup>2</sup>=35.97, p<.001), lower birth weight (x<sup>2</sup>=29.40, p<.001), lower blood pressure (x<sup>2</sup>=23.10, p<.001), and insertion of an umbilical artery catheter (p<.001) were significantly associated with the occurrence of peripheral arterial ischemia. Among the preterm infants in whom nitroglycerin patches were applied, 30 (83.3%) premature infants without necrosis improved without complications, 4 (11.1%) showed hypotension, and 2 (5.6%) showed skin damage.Conclusion: Based on a review of our experiences with nitroglycerin patches, we recommend closely observing skin color and using nitroglycerin patches on the skin to help improve flow in premature infants with peripheral arterial ischemia.
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Affiliation(s)
- Jeongeun Kim
- Registered Nurse, Neonatal Intensive Care Unit, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jin Won Lee
- Registered Nurse, Neonatal Intensive Care Unit, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dong Yeon Kim
- Unit Manager, Hematology Intensive Care Unit, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
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68
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Pediatric hypertension: Review of the definition, diagnosis, and initial management. Int J Pediatr Adolesc Med 2020; 9:1-6. [PMID: 35573063 PMCID: PMC9072228 DOI: 10.1016/j.ijpam.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/11/2020] [Accepted: 09/27/2020] [Indexed: 11/23/2022]
Abstract
Pediatric hypertension (HTN) is a significant and growing health concern. While previously thought to be an uncommon condition in the pediatric population, recent studies have shown an increase in incidence, which is largely due to the obesity epidemic. Accordingly, primary or idiopathic HTN has become more prevalent compared to secondary causes of HTN. The incidence of hypertension is about 3.5%; however, it may be higher as HTN can be missed during routine pediatric well visits. Since childhood HTN frequently tracks into adulthood and is a risk factor for both cardiovascular disease and progression of renal disease; early diagnosis and management of this condition is essential. In this review, we will discuss the approach of a pediatric nephrologist for evaluation and management of pediatric HTN.
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69
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Abstract
Hypertension in neonates is increasingly recognized because of improvements in neonatal intensive care that have led to improved survival of premature infants. Although normative data on neonatal blood pressure remain limited, several factors appear to be important in determining blood pressure levels in neonates, especially gestational age, birth weight and maternal factors. Incidence is around 1% in most studies and identification depends on careful blood pressure measurement. Common causes of neonatal hypertension include umbilical catheter associated thrombosis, renal parenchymal disease, and chronic lung disease, and can usually be identified with careful diagnostic evaluation. Given limited data on long-term outcomes and use of antihypertensive medications in these infants, clinical expertise may need to be relied upon to decide the best approach to treatment. This review will discuss these concepts and identify evidence gaps that should be addressed.
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Affiliation(s)
- Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, And Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA.
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Jakamy R, Séguéla PE, Jalal Z, de Guillebon M, Thambo JB. An Unusual Cause of Neonatal Heart Failure. Can J Cardiol 2020; 36:1831.e5-1831.e6. [PMID: 32497582 DOI: 10.1016/j.cjca.2020.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/11/2020] [Accepted: 05/28/2020] [Indexed: 11/17/2022] Open
Abstract
Hypertension is an important and under-recognized cause of acquired cardiomyopathy in newborns. Half the etiologies of neonatal hypertension are undetermined. We present a rare case of severe neonatal hypertension with ventricular dysfunction secondary to substance exposure during pregnancy. This case report emphasizes the importance of a well-focused prenatal history on maternal medications and substance use.
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Affiliation(s)
- Réda Jakamy
- Pediatric and Congenital Cardiology Department, Hôpital Cardiologique du Haut-Lévêque, Bordeaux, France.
| | - Pierre-Emmanuel Séguéla
- Pediatric and Congenital Cardiology Department, Hôpital Cardiologique du Haut-Lévêque, Bordeaux, France
| | - Zakaria Jalal
- Pediatric and Congenital Cardiology Department, Hôpital Cardiologique du Haut-Lévêque, Bordeaux, France
| | | | - Jean-Benoit Thambo
- Pediatric and Congenital Cardiology Department, Hôpital Cardiologique du Haut-Lévêque, Bordeaux, France
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71
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Lee Y, Choi JH, Oh A, Kim GH, Park SH, Moon JE, Ko CW, Cheon CK, Yoo HW. Clinical, endocrinological, and molecular features of four Korean cases of cytochrome P450 oxidoreductase deficiency. Ann Pediatr Endocrinol Metab 2020; 25:97-103. [PMID: 32615689 PMCID: PMC7336261 DOI: 10.6065/apem.1938152.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/16/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cytochrome P450 oxidoreductase (POR) deficiency is a rare autosomal recessive disorder caused by mutations in the POR gene encoding an electron donor for all microsomal P450 enzymes. It is characterized by adrenal insufficiency, ambiguous genitalia, maternal virilization during pregnancy, and skeletal dysplasia. In this study, we investigated the clinical, hormonal, and molecular characteristics of patients with POR deficiency in Korea. METHODS This study included four patients with POR deficiency confirmed by biochemical and molecular analysis of POR. Clinical and biochemical findings were reviewed retrospectively. Mutation analysis of POR was performed by Sanger sequencing after polymerase chain reaction amplification of all coding exons and the exon-intron boundaries. RESULTS All patients presented with adrenal insufficiency and ambiguous genitalia regardless of their genetic sex. Two patients harbored homozygous p.R457H mutations in POR and presented with adrenal insufficiency and genital ambiguity without skeletal phenotypes. The other two patients with compound heterozygous mutations of c.[1329_1330insC];[1370G>A] (p.[I444Hfs*6];[R457H]) manifested skeletal abnormalities, such as craniosynostosis and radiohumeral synostosis, suggesting Antley-Bixler syndrome. They also had multiple congenital anomalies involving heart, kidney, and hearing ability. All patients were treated with physiologic doses of oral hydrocortisone. CONCLUSION We report the cases of 4 patients with POR deficiency identified by mutation analysis of POR. Although the study involved a small number of patients, the POR p.R457H mutation was the most common, suggesting founder effect in Korea. POR deficiency is rare and can be misdiagnosed as 21-hydroxylase or 17α-hydroxylase/17,20-lyase deficiency. Therefore, molecular analysis is critical for confirmatory diagnosis.
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Affiliation(s)
- Yena Lee
- Depar tment of Pediatrics, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Depar tment of Pediatrics, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Arum Oh
- Depar tment of Pediatrics, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Gu-Hwan Kim
- Medical Genetics Center, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Sook-Hyun Park
- Department of Pediatrics, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Eun Moon
- Department of Pediatrics, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Cheol Woo Ko
- Department of Pediatrics, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chong-Kun Cheon
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Han-Wook Yoo
- Depar tment of Pediatrics, Asan Medical Center, Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea,Address for correspondence: Han-Wook Yoo, MD, PhD Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul 05505, Korea Tel: +82-2-3010-3374 Fax: +82-2-473-3725 E-mail:
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Kullberg SA, Rheault MN, Haggstrom A, Maguiness SM. Segmental infantile hemangioma and concomitant hypertension in three African American neonates. Pediatr Dermatol 2020; 37:524-526. [PMID: 32053242 DOI: 10.1111/pde.14119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present three African American infants with segmental, ulcerated infantile hemangiomas and concomitant, persistent hypertension. When treated with beta-blocker therapy, the hemangiomas decreased in size and the ulcerations resolved, but there was no impact on the elevated blood pressure in one of our patients. We failed to identify any associations between infantile hemangioma and hypertension in the literature.
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Affiliation(s)
- Sara A Kullberg
- University of Minnesota Medical School, Minneapolis, Minnesota
| | - Michelle N Rheault
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Anita Haggstrom
- Department of Dermatology and Pediatrics, Indiana University, Indianapolis, Indiana
| | - Sheilagh M Maguiness
- Department of Dermatology and Pediatrics, University of Minnesota, Minneapolis, Minnesota
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Psara E, Pentieva K, Ward M, McNulty H. Critical review of nutrition, blood pressure and risk of hypertension through the lifecycle: do B vitamins play a role? Biochimie 2020; 173:76-90. [PMID: 32289470 DOI: 10.1016/j.biochi.2020.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 12/17/2022]
Abstract
Hypertension is the leading cause of preventable mortality worldwide, contributing to over 9 million deaths per annum, predominantly owing to cardiovascular disease. The association of obesity, physical inactivity and alcohol with elevated blood pressure (BP) is firmly established. Weight loss or other dietary strategies, such as the Dietary Approaches to Stop Hypertension (DASH) diet, have been shown to be effective in lowering BP. Additionally, specific nutrients are recognised to contribute to BP, with higher sodium intake linked with an increased risk of hypertension, while potassium is associated with a reduced risk of hypertension. Of note, emerging evidence has identified a novel role for one-carbon metabolism and the related B vitamins, particularly riboflavin, in BP. Specifically in adults genetically at risk of developing hypertension, owing to the common C677T polymorphism in MTHFR, supplemental riboflavin (co-factor for MTHFR) was shown in randomised trials to lower systolic BP by up to 13 mmHg. A BP response to intervention of this magnitude could have important clinical impacts, given that a reduction in systolic BP of 10 mmHg is estimated to decrease stroke risk by 40%. This review aims to explore the factors contributing to hypertension across the lifecycle and to critically evaluate the evidence supporting a role for nutrition, particularly folate-related B vitamins, in BP and risk of hypertension. In addition, gaps in our current knowledge that warrant future research in this area, will be identified.
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Affiliation(s)
- Elina Psara
- Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, Northern Ireland, BT52 1SA, United Kingdom
| | - Kristina Pentieva
- Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, Northern Ireland, BT52 1SA, United Kingdom
| | - Mary Ward
- Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, Northern Ireland, BT52 1SA, United Kingdom
| | - Helene McNulty
- Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, Northern Ireland, BT52 1SA, United Kingdom.
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Freeman AD, Fitzgerald CA, Baxter KJ, Neff LP, McCracken CE, Bryan LN, Morsberger JL, Zahid AM, Santore MT. Does hypertension at initial presentation adversely affect outcomes in pediatric traumatic brain injury? J Pediatr Surg 2020; 55:702-706. [PMID: 31277980 PMCID: PMC6925357 DOI: 10.1016/j.jpedsurg.2019.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 06/04/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Adults with traumatic brain injury (TBI) who present hypertensive suffer worse outcomes and increased mortality compared to normotensive patients. The purpose of this study is to determine if age-adjusted hypertension on presentation is associated with worsened outcomes in pediatric TBI. METHODS A retrospective chart review was conducted on pediatric patients with severe TBI admitted to a single system pediatric tertiary care center. The primary outcome was mortality. Secondary outcomes included length of stay, need for neurosurgical intervention, duration of mechanical ventilation, and the need for inpatient rehabilitation. RESULTS Of 150 patients, 70% were hypertensive and 30% were normotensive on presentation. Comparing both groups, no statistically significant differences were noted in mortality (13.3% for both groups), need for neurosurgical intervention (51.4% vs 48.8%, p = 0.776), length of stay (6 vs 8 days, p = 0.732), duration of mechanical ventilation (2 vs 3 days, p = 0.912), or inpatient rehabilitation rates (48.6% vs 48.9%, p = 0.972). In comparing just the hypertensive patients, there was a trend toward increased mortality in the 95th and 99th percentile groups at 15.8% and 14.1%, versus the 90th percentile group at 6.7% but the difference was not statistically significant (p = 0.701). CONCLUSIONS Contrary to the adult literature, pediatric patients with severe TBI and hypertension on presentation do not appear to have worsened outcomes compared to those who are normotensive. However, a trend toward increased mortality did exist at extremes of age adjusted hypertension. Larger scale studies are needed to validate these findings. STUDY TYPE Retrospective cohort study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Ashley D. Freeman
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States,Corresponding author at: 1405 Clifton Rd NE, Division of Critical Care Medicine, 4 Floor Tower 1, Atlanta, GA 30322. Tel.: +1 404 785 4751; fax: +1 404 785 6233. (A.D. Freeman)
| | - Caitlin A. Fitzgerald
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Katherine J. Baxter
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Lucas P. Neff
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
| | - Courtney E. McCracken
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
| | - Leah N. Bryan
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
| | - Jill L. Morsberger
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Arslan M. Zahid
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States
| | - Matthew T. Santore
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States,Children’s Healthcare of Atlanta, Egleston Campus, 1405 Clifton Rd NE, Atlanta, GA 30322, Unites States
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75
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Göknar N, Çalışkan S. New guidelines for the diagnosis, evaluation, and treatment of pediatric hypertension. TURK PEDIATRI ARSIVI 2020; 55:11-22. [PMID: 32231445 PMCID: PMC7096568 DOI: 10.14744/turkpediatriars.2020.92679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/02/2019] [Indexed: 12/14/2022]
Abstract
Childhood hypertension has become a significant public health problem due to increased prevalence in recent decades. High blood pressure causes increased mortality and morbidity in childhood, precedes adult hypertension, and causes increased cardiovascular events in adulthood. These concerns have led to an update of guidelines about childhood hypertension by the European Society of Hypertension in 2016 and the American Academy of Hypertension in 2017. This review highlights the important developments in these guidelines and recent literature about childhood hypertension in terms of diagnosis, prevalence, risk factors, diagnostic tools, prevention and management.
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Affiliation(s)
- Nilüfer Göknar
- Division of Pediatric Nephrology, Department of Pediatrics, İstanbul Medeniyet University, Faculty of Medicine, İstanbul, Turkey
| | - Salim Çalışkan
- Division of Pediatric Nephrology, Department of Pediatrics, İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, İstanbul, Turkey
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76
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Göpel W, Müller M, Rabe H, Borgmann J, Rausch TK, Faust K, Kribs A, Dötsch J, Ellinghaus D, Härtel C, Roll C, Szabo M, Nürnberg P, Franke A, König IR, Turner MA, Herting E. Genetic background of high blood pressure is associated with reduced mortality in premature neonates. Arch Dis Child Fetal Neonatal Ed 2020; 105:184-189. [PMID: 31201254 PMCID: PMC7063394 DOI: 10.1136/archdischild-2019-317131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/07/2019] [Accepted: 05/28/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of our study was to determine if a genetic background of high blood pressure is a survival factor in preterm infants. DESIGN Prospective cohort study. SETTING Patients were enrolled in 53 neonatal intensive care units. PATIENTS Preterm infants with a birth weight below 1500 g. EXPOSURES Genetic score blood pressure estimates were calculated based on adult data. We compared infants with high genetic blood pressure estimates (>75th percentile of the genetic score) to infants with low genetic blood pressure estimates (<25th percentile of the genetic score). MAIN OUTCOME MEASURES Lowest blood pressure on the first day of life and mortality. RESULTS 5580 preterm infants with a mean gestational age of 28.1±2.2 weeks and a mean birth weight of 1022±299 g were genotyped and analysed. Infants with low genetic blood pressure estimates had significantly lower blood pressure if compared with infants with high genetic blood pressure estimates (27.3±6.2vs 27.9±6.4, p=0.009, t-test). Other risk factors for low blood pressure included low gestational age (-1.26 mm Hg/week) and mechanical ventilation (-2.24 mm Hg, p<0.001 for both variables, linear regression analysis). Mortality was significantly reduced in infants with high genetic blood pressure estimates (28-day mortality: 21/1395, 1.5% vs 44/1395, 3.2%, p=0.005, Fisher's exact test). This survival advantage was independent of treatment with catecholamines. CONCLUSIONS Our study provides first evidence that a genetic background of high blood pressure may be beneficial with regard to survival of preterm infants.
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Affiliation(s)
| | - Mirja Müller
- Paediatrics, University of Lübeck, Lübeck, Germany
| | - Heike Rabe
- Neonatology, Brighton Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Tanja K Rausch
- Institute for Medical Biometry and Statistics Lübeck, Lübeck, Germany
| | | | - Angela Kribs
- Neonatology and Pediatric Intensive Care, University Hospital of Cologne, Cologne, Germany
| | - Jörg Dötsch
- Department of Paediatrics, University of Cologne, Cologne, Germany
| | - David Ellinghaus
- Institute of Clinical Molecular Biology, Christian-Albrechts-Universitat zu Kiel, Kiel, Germany
| | | | - Claudia Roll
- Neonatology, Universitat Witten/Herdecke, Witten, Germany
| | - Miklos Szabo
- Neonatology, Semmelweis University, Budapest, Hungary
| | - Peter Nürnberg
- Cologne Center for Genomics, University Hospital of Cologne, Cologne, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-Universitat zu Kiel, Kiel, Germany
| | - Inke R König
- Institute for Medical Biometry and Statistics Lübeck, Lübeck, Germany
| | - Mark A Turner
- Division of Perinatal Reproductive Medicine, University of Liverpool, Liverpool, UK
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77
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Ryan A, Gilhooley M, Patel N, Reynolds BC. Prevalence of Acute Kidney Injury in Neonates with Congenital Diaphragmatic Hernia. Neonatology 2020; 117:88-94. [PMID: 31639793 DOI: 10.1159/000503293] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/10/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) often presents with severe cardio-respiratory impairment in the neonatal period. Affected infants may be exposed to multiple nephrotoxic insults, predisposing them to acute kidney injury (AKI). The prevalence of AKI in a CDH cohort has not previously been described. OBJECTIVES The primary aim of this study was to quantify the prevalence of AKI in patients with CDH treated in a single national centre. Secondarily, we investigated the association between AKI, select neonatal outcomes, and recognised AKI risk factors. METHODS This was a retrospective analysis of all patients with CDH treated at our regional neonatal surgical centre between September 2011 and December 2017. Data was collected on demographics, CDH Study Group stage (size), laboratory and physiological parameters, medications, mortality, and duration of hospitalisation. AKI severity was stratified using the modified paediatric RIFLE criteria, determined by comparing the percentage increase in serum creatinine from baseline. Statistical analysis was performed using Fisher's exact and Pearson's χ2 tests for parametric analysis and Mann-Whitney U testing for non-parametric analysis. RESULTS Fifty-four CDH patients met the inclusion criteria, 37% of whom developed AKI. The development of AKI was significantly associated with larger CDH defect (type C/D; p = 0.014), extracorporeal membranous oxygenation support (p = 0.003), patch repair (p = 0.004), and exposure to vancomycin, corticosteroids and diuretics (p = 0.004, p = 0.007, and p ≤ 0.001, respectively). There was no statistical association between AKI and gentamicin administration, umbilical arterial catheter insertion, or significant infection. Prolonged hospitalisation and patient mortality were significantly associated with AKI (p = 0.01 and p = 0.001, respectively). CONCLUSIONS AKI is common in CDH cases treated in our centre and is associated with adverse outcomes. Potentially modifiable risk factors include nephrotoxic medication exposure. Prevention and early recognition of contributory factors for AKI may improve outcomes in CDH.
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Affiliation(s)
- Aoife Ryan
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom,
| | | | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Ben C Reynolds
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, United Kingdom
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78
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Altschul DM, Wraw C, Der G, Gale CR, Deary IJ. Hypertension Development by Midlife and the Roles of Premorbid Cognitive Function, Sex, and Their Interaction. Hypertension 2019; 73:812-819. [PMID: 30776973 PMCID: PMC6426348 DOI: 10.1161/hypertensionaha.118.12164] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Higher early-life cognitive function is associated with better later-life health outcomes, including hypertension. Associations between higher prior cognitive function and less hypertension persist even when accounting for socioeconomic status, but socioeconomic status-hypertension gradients are more pronounced in women. We predicted that differences in hypertension development between sexes might be associated with cognitive function and its interaction with sex, such that higher early-life cognitive function would be associated with lower hypertension risk more in women than in men. We used accelerated failure time modeling with the National Longitudinal Study of Youth 1979. Cognitive function was assessed in youth, when participants were aged between 14 and 21 years. Of 2572 men and 2679 women who completed all assessments, 977 men and 940 women reported hypertension diagnoses by 2015. Socioeconomic status in youth and adulthood were investigated as covariates, as were components of adult socioeconomic status: education, occupational status, and family income. An SD of higher cognitive function in youth was associated with reduced hypertension risk (acceleration factor: ĉ=0.97; 95% CI, 0.96-0.99; P=0.001). The overall effect was stronger in women (sex×cognitive function: ĉ=0.97; 95% CI, 0.94-0.99; P=0.010); especially, higher functioning women were less at risk than their male counterparts. This interaction was itself attenuated by a sex by family income interaction. People with better cognitive function in youth, especially women, are less likely to develop hypertension later in life. Income differences accounted for these associations. Possible causal explanations are discussed.
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Affiliation(s)
- Drew M Altschul
- From the Department of Psychology (D.M.A., C.W., I.J.D.), University of Edinburgh, United Kingdom.,Centre for Cognitive Ageing and Cognitive Epidemiology (D.M.A., C.W., C.R.G., I.J.D.), University of Edinburgh, United Kingdom
| | - Christina Wraw
- From the Department of Psychology (D.M.A., C.W., I.J.D.), University of Edinburgh, United Kingdom.,Centre for Cognitive Ageing and Cognitive Epidemiology (D.M.A., C.W., C.R.G., I.J.D.), University of Edinburgh, United Kingdom
| | - Geoff Der
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, United Kingdom (G.D.)
| | - Catharine R Gale
- Centre for Cognitive Ageing and Cognitive Epidemiology (D.M.A., C.W., C.R.G., I.J.D.), University of Edinburgh, United Kingdom.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, United Kingdom (C.R.G.)
| | - Ian J Deary
- From the Department of Psychology (D.M.A., C.W., I.J.D.), University of Edinburgh, United Kingdom.,Centre for Cognitive Ageing and Cognitive Epidemiology (D.M.A., C.W., C.R.G., I.J.D.), University of Edinburgh, United Kingdom
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79
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Poisson K, Lin JJ, Chen A, McCrory MC. Case 2: Respiratory Failure and Multiple Organ System Dysfunction in a 7-day-old Infant. Pediatr Rev 2019; 40:593-595. [PMID: 31676533 DOI: 10.1542/pir.2017-0102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Kelsey Poisson
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Michael C McCrory
- Department of Pediatrics and.,Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, NC
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80
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Very-High-Dose Prednisolone Before ACTH for Treatment of Infantile Spasms: Evaluation of a Standardized Protocol. Pediatr Neurol 2019; 99:16-22. [PMID: 31331669 DOI: 10.1016/j.pediatrneurol.2019.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is ongoing debate regarding the comparative effectiveness of adrenocorticotropic hormone and prednisolone in the treatment of infantile spasms. With a large cohort and extended follow-up, we set out to evaluate a protocol in which adrenocorticotropic hormone is reserved for prednisolone nonresponders. METHODS The following standardized hormonal therapy protocol was adopted. Patients initially receive prednisolone (8 mg/kg/day [maximum 60 mg/day], divided in three daily doses for 14 days). Prednisolone responders taper it over 14 days, whereas prednisolone nonresponders immediately transition to natural adrenocorticotropic hormone (150 U/m2/day, divided in two daily doses for 14 days). We evaluated short-term response, defined as video-electroenecphaloagraphy-confirmed resolution of both epileptic spasms and hypsarrhythmia on day 14, without relapse for 28 additional days. We then evaluated long-term relapse and calculated the rates of sustained response at six, 12, and 18 months. RESULTS We identified 102 children with infantile spasms who were treated with prednisolone. Prior exposure to hormonal therapy and vigabatrin was observed among 12% and 35% of patients, respectively. Sixty (59%) patients responded to prednisolone, and 13 (33%) prednisolone nonresponders then responded to adrenocorticotropic hormone. Cumulative response to prednisolone and adrenocorticotropic hormone (if needed) was higher among treatment-naive patients (84%) than among patients with prior exposure to first-line treatment (51%), with P < 0.001. Relapse was relatively common among all subgroups. CONCLUSION Short-term response to prednisolone was favorable and higher among treatment-naive patients. These data suggest that prednisolone is a reasonable approach to initial therapy and that adrenocorticotropic hormone exhibits substantial efficacy after prednisolone failure.
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81
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Shimizu A, Tanaka K, Takazawa S, Nishi A, Shimoyama S, Kobayashi T, Imagawa T, Hirato J, Yamada Y. A large superior mesenteric artery aneurysm and ileal obstruction: a rare presentation of polyarteritis nodosa in an infant. Oxf Med Case Reports 2019; 2019:omz092. [PMID: 31772757 PMCID: PMC6765372 DOI: 10.1093/omcr/omz092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 07/27/2019] [Accepted: 08/04/2019] [Indexed: 11/24/2022] Open
Abstract
Polyarteritis nodosa (PAN) is a rare form of vasculitis that occurs in childhood and affects small- and medium-sized arteries. Large aneurysms due to PAN can induce fatal complications like rupturing or occlusion of the affected arteries. Here, we report a case of a 4-month-old girl with PAN complicated by a large superior mesenteric artery aneurysm and ileal obstruction. We controlled her blood pressure to prevent the artery from rupturing. A combination of prednisolone, intravenous cyclophosphamide, and plasma exchange reduced the inflammation. She developed mechanical ileus due to ileum stricture and underwent bowel resection. Histopathological examinations revealed reparative arteritis around the healed ulcer. Her postoperative course was uneventful without further dilatation of the aneurysm. This case highlights the importance of intensive immunosuppressive therapy and appropriate blood pressure control in pediatric patients with PAN complicated by large aneurysms. Mechanical ileus can develop and may require surgical management even after remission of vasculitis.
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Affiliation(s)
- Akihiko Shimizu
- Department of Allergy, Infectious Diseases and Immunology, Gunma Children's Medical Center, Shibukawa 377-8577, Japan
| | - Kensuke Tanaka
- Department of Cardiology, Gunma Children's Medical Center, Shibukawa 377-8577, Japan
| | - Shinya Takazawa
- Department of Surgery, Gunma Children's Medical Center, Shibukawa 377-8577, Japan
| | - Akira Nishi
- Department of Surgery, Gunma Children's Medical Center, Shibukawa 377-8577, Japan
| | - Shinya Shimoyama
- Department of Cardiology, Gunma Children's Medical Center, Shibukawa 377-8577, Japan
| | - Tomio Kobayashi
- Department of Cardiology, Gunma Children's Medical Center, Shibukawa 377-8577, Japan
| | - Tomoyuki Imagawa
- Department of Infectious Diseases and Immunology, Kanagawa Children's Medical Center, Yokohama 232-8555, Japan
| | - Junko Hirato
- Department of Laboratory, Gunma Children's Medical Center, Shibukawa 377-8577, Japan.,Department of Pathology, Public Tomioka General Hospital, Tomioka 370-2393, Japan
| | - Yoshiyuki Yamada
- Department of Allergy, Infectious Diseases and Immunology, Gunma Children's Medical Center, Shibukawa 377-8577, Japan
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82
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Gievers LL, Jenkins RD, Laird A, Macedo MC, Schilling D, McEvoy CT. Pulmonary Function and Systolic Blood Pressure in Very Low Birth Weight Infants at 34 - 36 Weeks of Corrected Age. RESEARCH AND REPORTS IN NEONATOLOGY 2019; 9:21-30. [PMID: 34084063 DOI: 10.2147/rrn.s208194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Preterm infants are at increased risk of systemic hypertension compared to term infants. Bronchopulmonary dysplasia (BPD) has been shown to be associated with hypertension in preterm infants albeit with no causation reported. BPD is characterized by abnormal pulmonary function tests (PFTs), specifically elevated passive respiratory resistance (Rrs), decreased passive respiratory compliance (Crs) and decreased functional residual capacity (FRC). There have been no studies comparing PFTs in very low birth weight (VLBW) infants with and without hypertension. We hypothesized that stable VLBW infants with hypertension will have altered PFTs. Patients and Methods Retrospective cohort study of infants < 1500 grams at birth (VLBW) who had PFTs performed near 34-36 weeks of corrected gestational age (CGA). We excluded infants with congenital anomalies, known hypertensive disorders or those at risk of medication-induced hypertension. Data obtained included PFT parameters (Rrs, Crs, FRC) and mean systolic blood pressure (SBP). Results 59 VLBW infants were identified for analysis, 14 with and 45 without hypertension. Hypertensive and normotensive patients were similar in terms of mean gestational age (26.6 vs 27.4 weeks), mean CGA at PFTs (36.1 vs 34.6 weeks) and proportion of BPD (36% vs 36%). The Rrs was significantly higher in hypertensive versus normotensive patients [median Rrs of 0.080 (0.069, 0.090) versus 0.066 (0.054, 0.083) cmH2O/mL/sec; p = 0.04]. There was no difference in systolic blood pressure in the infants with and without BPD. Conclusion In this cohort of contemporary VLBW infants, those with hypertension had increased Rrs. This finding warrants a prospective study with a larger sample size and long-term follow-up.
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Affiliation(s)
- Ladawna L Gievers
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Randall D Jenkins
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Amy Laird
- School of Public Health, Oregon Health and Science University, Portland, OR, USA
| | - Marissa C Macedo
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Diane Schilling
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Cindy T McEvoy
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
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83
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Jenkins R, Tackitt S, Gievers L, Iragorri S, Sage K, Cornwall T, O'Riordan D, Merchant J, Rozansky D. Phthalate-associated hypertension in premature infants: a prospective mechanistic cohort study. Pediatr Nephrol 2019; 34:1413-1424. [PMID: 31028470 PMCID: PMC6579777 DOI: 10.1007/s00467-019-04244-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/05/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Phthalates are associated with increased blood pressure in children. Large exposures to di-(2-ethylhexyl) phthalate (DEHP) among premature infants have been a cause for concern. METHODS We conducted a prospective observational cohort study to determine if DEHP exposures are related to systolic blood pressure (SBP) in premature infants, and if this exposure is associated with activation of the mineralocorticoid receptor (MR). Infants were monitored longitudinally for 8 months from birth. Those who developed idiopathic hypertension were compared with normotensive infants for DEHP exposures. Appearance of urinary metabolites after exposure was documented. Linear regression evaluated the relationship between DEHP exposures and SBP index and whether urinary cortisol/cortisone ratio (a surrogate marker for 11β-HSD2 activity) mediated those relationships. Urinary exosomes were quantified for sodium transporter/channel expression and interrogated against SBP index. RESULTS Eighteen patients met the study criteria, nine developed transient idiopathic hypertension at a postmenstrual age of 40.6 ± 3.4 weeks. The presence of urinary DEHP metabolites was associated with prior IV and respiratory tubing DEHP exposures (p < 0.05). Both IV and respiratory DEHP exposures were greater in hypertensive infants (p < 0.05). SBP index was related to DEHP exposure from IV fluid (p = 0.018), but not respiratory DEHP. Urinary cortisol/cortisone ratio was related to IV DEHP and SBP index (p < 0.05). Sodium transporter/channel expression was also related to SBP index (p < 0.05). CONCLUSIONS Increased blood pressure and hypertension in premature infants are associated with postnatal DEHP exposure. The mechanism of action appears to be activation of the MR through inhibition of 11β-HSD2.
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MESH Headings
- 11-beta-Hydroxysteroid Dehydrogenases/metabolism
- Administration, Intravenous/adverse effects
- Administration, Intravenous/instrumentation
- Airway Management/adverse effects
- Airway Management/instrumentation
- Blood Pressure/drug effects
- Diethylhexyl Phthalate/toxicity
- Female
- Humans
- Hypertension/chemically induced
- Hypertension/diagnosis
- Hypertension/epidemiology
- Hypertension/metabolism
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/chemically induced
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/epidemiology
- Male
- Plasticizers/toxicity
- Prospective Studies
- Receptors, Mineralocorticoid/metabolism
- Signal Transduction/drug effects
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Affiliation(s)
- Randall Jenkins
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA.
| | | | - Ladawna Gievers
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
| | - Sandra Iragorri
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
| | - Kylie Sage
- Biostatistics and Design Program, School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Tonya Cornwall
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
| | | | | | - David Rozansky
- Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Road, Mail Code CDRC-P, Portland, OR, 97239, USA
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84
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Harer MW, Kent AL. Neonatal hypertension: an educational review. Pediatr Nephrol 2019; 34:1009-1018. [PMID: 29974208 DOI: 10.1007/s00467-018-3996-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/29/2018] [Accepted: 06/01/2018] [Indexed: 01/19/2023]
Abstract
Hypertension is encountered in up to 3% of neonates and occurs more frequently in neonates requiring hospitalization in the neonatal intensive care unit (NICU) than in neonates in newborn nurseries or outpatient clinics. Former NICU neonates are at higher risk of hypertension secondary to invasive procedures and disease-related comorbidities. Accurate measurement of blood pressure (BP) remains challenging, but new standardized methods result in less measurement error. Multiple factors contribute to the rapidly changing BP of a neonate: gestational age, postmenstrual age (PMA), birth weight, and maternal factors are the most significant contributors. Given the natural evolution of BP as neonates mature, a percentile cutoff of 95% for PMA has been the most common definition used; however, this is not based on outcome data. Common causes of neonatal hypertension are congenital and acquired renal disease, history of umbilical arterial catheter placement, and bronchopulmonary dysplasia. The treatment of neonatal hypertension has mostly been off-label, but as evidence accumulates, the safety of medical management has increased. The prognosis of neonatal hypertension remains largely unknown and thankfully most often resolves unless secondary to renovascular disease, but further research is needed. This review discusses important factors related to neonatal hypertension including BP measurement, determinants of BP, and management of neonatal hypertension.
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Affiliation(s)
- Matthew W Harer
- Department of Pediatrics, Division of Neonatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alison L Kent
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, P.O. Box 11, Woden, ACT, 2606, Australia. .,Australian National University Medical School, Canberra, Australia.
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85
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Alvarez-Pitti J, Ros-Forés MA, Bayo-Pérez A, Palou M, Lurbe E, Palou A, Picó C. Blood cell transcript levels in 5-year-old children as potential markers of breastfeeding effects in those small for gestational age at birth. J Transl Med 2019; 17:145. [PMID: 31064394 PMCID: PMC6505189 DOI: 10.1186/s12967-019-1896-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/25/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Nutrition of the newborn during the early postnatal period seems to be of capital importance and there is clinical evidence showing the protective effect of breastfeeding compared with formula feeding on childhood obesity and its comorbidities. Infants born small for gestation age may be more sensitive to the type of feeding during lactation. Here, we aimed to analyze the impact of birth weight and the type of infant feeding on the expression levels in peripheral blood cells of selected candidate genes involved in energy homeostasis in 5-year-old children, to find out potential early biomarkers of metabolic programming effects during this period of metabolic plasticity. METHODS Forty subjects were recruited at birth and divided in four groups according to birth weight (adequate or small for gestational age) and type of infant feeding (breastfeeding or formula feeding). They were followed from birth to the age of 5 years. RESULTS At 5 years, no significant differences regarding anthropometric parameters were found between groups, and all children had normal biochemical values. Expression levels of UCP2 and MC4R in peripheral blood cells were lower and higher, respectively, in formula feeding children compared with breastfeeding ones (P = 0.002 and P = 0.064, two-way ANOVA). Differences were more marked and significant by Student's t test in small for gestation age children (P < 0.001 and P = 0.017, respectively). Transcript levels of FASN and FTO in peripheral blood cells were also different according to the type of infant feeding, but only in small for gestation age children. CONCLUSIONS Altogether, these results suggest that small for gestation age infants are more sensitive to the type of feeding during lactation, and transcript levels of particular genes in peripheral blood cells, especially the MC4R/UCP2 mRNA ratio, may precisely reflect these effects in the absence of clear differences in phenotypic traits.
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Affiliation(s)
- Julio Alvarez-Pitti
- Pediatric Department, Consorcio Hospital General, University of Valencia, Valencia, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- INCLIVA Biomedical Research Institute, Hospital Clínico. University of Valencia, Valencia, Spain
| | - Maria Amparo Ros-Forés
- Pediatric Department, Consorcio Hospital General, University of Valencia, Valencia, Spain
| | - Ana Bayo-Pérez
- Pediatric Department, Consorcio Hospital General, University of Valencia, Valencia, Spain
| | - Mariona Palou
- CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Laboratory of Molecular Biology, Nutrition and Biotechnology (Nutrigenomics), University of the Balearic Islands (UIB), Palma de Mallorca, Spain
- Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Empar Lurbe
- Pediatric Department, Consorcio Hospital General, University of Valencia, Valencia, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- INCLIVA Biomedical Research Institute, Hospital Clínico. University of Valencia, Valencia, Spain
| | - Andreu Palou
- CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Laboratory of Molecular Biology, Nutrition and Biotechnology (Nutrigenomics), University of the Balearic Islands (UIB), Palma de Mallorca, Spain
- Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Catalina Picó
- CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Laboratory of Molecular Biology, Nutrition and Biotechnology (Nutrigenomics), University of the Balearic Islands (UIB), Palma de Mallorca, Spain
- Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
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86
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Deitrick J, Stevenson K, Nguyen D, Sessions W, Linga V, Vasylyeva T. Hypertension secondary to renal hypoplasia presenting as acute heart failure in a newborn. Clin Hypertens 2019; 25:10. [PMID: 31061719 PMCID: PMC6492330 DOI: 10.1186/s40885-019-0115-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 03/14/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Neonatal hypertension is defined as persistent systolic and/or diastolic blood pressures above the 95th percentile compared to other infants of similar gestational age and size. Neonatal hypertension is a rare condition, occurring in only 0.2-3.0% of neonates. The most common etiology of neonatal hypertension is renal vascular or parenchymal disease, and it is usually detected on routine examination in an asymptomatic child. However, it may present in a variety of manners, including acute heart failure, renal dysfunction, feeding difficulties, failure to thrive, tachypnea, apnea, lethargy, irritability, or seizures. CASE PRESENTATION A term female was born via repeat caesarean section with vacuum extraction. On day of life (DOL) 3, the baby presented to the emergency department with poor feeding and lethargy. Initial laboratory tests indicated severe metabolic acidosis and the patient was transferred to our neonatal intensive care unit (NICU). During the hospital stay, the patient had intermittently high blood pressures. An echocardiogram was ordered, which demonstrated a severely decreased ejection fraction of 33%, but no signs of coarctation of the aorta. The low ejection fraction and constellation of symptoms were consistent with the diagnosis of acute heart failure, so treatment with milrinone was initiated. Further labs demonstrated elevated renin and aldosterone, and a computed tomography scan showed right kidney hypoplasia with reduced perfusion. This suggested a renovascular etiology of hypertension causing the initial presentation of acute heart failure. The patient was started on enalapril and clonidine for blood pressure control and was discharged with a home blood pressure monitoring system. At 5 months of life, this patient was still on enalapril and amlodipine as well as home blood pressure monitoring. CONCLUSIONS Acute heart failure is a rare presentation of neonatal hypertension, and prompt recognition and treatment for the underlying systemic hypertension is necessary to provide the best possible outcomes for patients. Due to the lack of sufficient evidence, treatment of hypertension in newborns is often anecdotal in nature. Further awareness of neonatal hypertension and research determining ideal methods of diagnosis and treatment would benefit physicians and their affected patients.
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Affiliation(s)
- Jena Deitrick
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX USA
| | - Kayle Stevenson
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX USA
| | - Daniel Nguyen
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX USA
| | - William Sessions
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX USA
| | - Vijay Linga
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX USA
| | - Tetyana Vasylyeva
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX USA
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87
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Muntner P, Shimbo D, Carey RM, Charleston JB, Gaillard T, Misra S, Myers MG, Ogedegbe G, Schwartz JE, Townsend RR, Urbina EM, Viera AJ, White WB, Wright JT. Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension 2019; 73:e35-e66. [PMID: 30827125 PMCID: PMC11409525 DOI: 10.1161/hyp.0000000000000087] [Citation(s) in RCA: 671] [Impact Index Per Article: 134.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The accurate measurement of blood pressure (BP) is essential for the diagnosis and management of hypertension. This article provides an updated American Heart Association scientific statement on BP measurement in humans. In the office setting, many oscillometric devices have been validated that allow accurate BP measurement while reducing human errors associated with the auscultatory approach. Fully automated oscillometric devices capable of taking multiple readings even without an observer being present may provide a more accurate measurement of BP than auscultation. Studies have shown substantial differences in BP when measured outside versus in the office setting. Ambulatory BP monitoring is considered the reference standard for out-of-office BP assessment, with home BP monitoring being an alternative when ambulatory BP monitoring is not available or tolerated. Compared with their counterparts with sustained normotension (ie, nonhypertensive BP levels in and outside the office setting), it is unclear whether adults with white-coat hypertension (ie, hypertensive BP levels in the office but not outside the office) have increased cardiovascular disease risk, whereas those with masked hypertension (ie, hypertensive BP levels outside the office but not in the office) are at substantially increased risk. In addition, high nighttime BP on ambulatory BP monitoring is associated with increased cardiovascular disease risk. Both oscillometric and auscultatory methods are considered acceptable for measuring BP in children and adolescents. Regardless of the method used to measure BP, initial and ongoing training of technicians and healthcare providers and the use of validated and calibrated devices are critical for obtaining accurate BP measurements.
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88
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Starr MC, Flynn JT. Neonatal hypertension: cases, causes, and clinical approach. Pediatr Nephrol 2019; 34:787-799. [PMID: 29808264 PMCID: PMC6261698 DOI: 10.1007/s00467-018-3977-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/12/2018] [Accepted: 05/01/2018] [Indexed: 12/24/2022]
Abstract
Neonatal hypertension is increasingly recognized as dramatic improvements in neonatal intensive care, advancements in our understanding of neonatal physiology, and implementation of new therapies have led to improved survival of premature infants. A variety of factors appear to be important in determining blood pressure in neonates, including gestational age, birth weight, and postmenstrual age. Normative data on neonatal blood pressure values remain limited. The cause of hypertension in an affected neonate is often identified with careful diagnostic evaluation, with the most common causes being umbilical catheter-associated thrombosis, renal parenchymal disease, and chronic lung disease. Clinical expertise may need to be relied upon to decide the best approach to treatment in such patients, as data on the use of antihypertensive medications in this age group are extremely limited. Available data suggest that long-term outcomes are usually good, with resolution of hypertension in most infants. In this review, we will take a case-based approach to illustrate these concepts and to point out important evidence gaps that need to be addressed so that management of neonatal hypertension may be improved.
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Affiliation(s)
- Michelle C. Starr
- Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Joseph T. Flynn
- Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA, USA
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89
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American Academy of Pediatrics Clinical Practice Guidelines for Screening and Management of High Blood Pressure in Children and Adolescents: What is New? Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1523-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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90
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Teufel U, Burgard P, Meyburg J, Lindner M, Poeschl J, Ruef P, Hoffmann GF, Kölker S. High blood pressure, a red flag for the neonatal manifestation of urea cycle disorders. Orphanet J Rare Dis 2019; 14:80. [PMID: 30961665 PMCID: PMC6454767 DOI: 10.1186/s13023-019-1055-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 04/01/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Neonatal manifestation of life-threatening hyperammonemic encephalopathy in urea cycle disorders (UCD) is often misdiagnosed as neonatal sepsis, resulting in significantly delayed start of specific treatment and poor outcome. The major aim of this study was to identify specific initial symptoms or signs to clinically distinguish hyperammonemic encephalopathy in neonates from neonatal sepsis in order to identify affected individuals with UCD and to start metabolic therapy without delay. Furthermore, we evaluated the impact of diagnostic delay, peak plasma ammonium (NH4+) concentration, mode of emergency treatment and transfer to a tertiary referral center on the outcome. METHODS Detailed information of 17 patients (born between 1994 and 2012) with confirmed diagnosis of UCD and neonatal hyperammonemic encephalopathy were collected from the original medical records. RESULTS The initially suspected diagnosis was neonatal sepsis in all patients, but was not confirmed in any of them. Unlike neonatal sepsis and not previously reported blood pressure increased above the 95th percentile in 13 (81%) of UCD patients before emergency treatment was started. Respiratory alkalosis was found in 11 (65%) of UCD patients, and in 14 (81%) plasma NH4+concentrations further increased despite initiation of metabolic therapy. CONCLUSION Detection of high blood pressure could be a valuable parameter for distinguishing neonatal sepsis from neonatal manifestation of UCD. Since high blood pressure is not typical for neonatal sepsis, other reasons such as encephalopathy and especially hyperammonemic encephalopathy (caused by e.g. UCD) should be searched for immediately. However, our result that the majority of newborns with UCD initially present with high blood pressure has to be evaluated in larger patient cohorts.
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Affiliation(s)
- Ulrike Teufel
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany. .,Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Peter Burgard
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jochen Meyburg
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Lindner
- University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Johannes Poeschl
- Department of Pediatrics, Clinic of Neonatology, University of Heidelberg, Heidelberg, Germany
| | - Peter Ruef
- Department of Pediatrics, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Georg F Hoffmann
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
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91
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Chinali M, Lucchetti L, Ricotta A, Esposito C, D'Anna C, Rinelli G, Emma F, Massella L. Cardiac Abnormalities in Children with Autosomal Recessive Polycystic Kidney Disease. Cardiorenal Med 2019; 9:180-189. [PMID: 30844805 DOI: 10.1159/000496473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND No previous study has defined the prevalence of cardiac geometric and mechanical function abnormalities through the analysis of advanced echocardiographic parameters in children with autosomal recessive polycystic kidney disease (ARPKD). AIM The purpose of this study was to evaluate cardiac geometry and function through advanced echocardiography in a well-characterized sample of pediatric patients with ARPKD. METHODS Standard echocardiograms were obtained in 27 children with ARPKD (0-18 years) and in 88 healthy children of similar age, gender distribution, and body build. Left ventricular (LV) hypertrophy was defined as LV mass > 45g/(m2.16 + 0.09) and cardiac remodeling was defined by age-adjusted relative wall thickness (RWT). Systolic function was assessed by ejection fraction, midwall fractional shortening (mFS), and global longitudinal (GLS) and circumferential strain (GCS). RESULTS Patients with ARPKD exhibited a higher LV mass index as compared to controls, and a more concentric LV geometry (both p < 0.001). Accordingly, the prevalence of abnormal LV geometry was significantly higher in ARPKD (33 vs. 0%; p < 0.005). No differences could be observed in the two groups for ejection fraction or GLS (both p = n.s.), while a significantly lower mFS (p < 0.05) as well as GCS (p < 0.001) could be observed. In the analysis of covariance, both LV mass index and RWT remained significantly higher in the ARPKD group, while mFS and GCS remained significantly lower (all p < 0.05). The prevalence of subclinical systolic dysfunction was significantly higher in patients with ARPKD as compared with control subjects (33 vs. 0%; p < 0.001). CONCLUSIONS Children with ARPKD show significantly impaired cardiac phenotype, characterized by high rates of LV abnormal geometry paired with systolic mechanical dysfunction.
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Affiliation(s)
- Marcello Chinali
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy,
| | - Laura Lucchetti
- Nephrology and Dialysis Unit, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Agnese Ricotta
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Claudia Esposito
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Carolina D'Anna
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Gabriele Rinelli
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Francesco Emma
- Nephrology and Dialysis Unit, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Laura Massella
- Nephrology and Dialysis Unit, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
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92
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Granlund PA, Ødegaard JS, Skjerven HO, Lødrup Carlsen KC, Hanséus K, Rögnvaldsson I, Sunnegårdh J, Turanlahti MI, Holmstrøm H. Survey of 23 Nordic university hospitals showed that 77% lacked written procedures for measuring and interpreting blood pressure in infants. Acta Paediatr 2019; 108:266-270. [PMID: 29978501 DOI: 10.1111/apa.14492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/18/2018] [Accepted: 07/04/2018] [Indexed: 11/28/2022]
Abstract
AIM This study determined the use of standardised procedures for infant noninvasive blood pressure (NIBP) measurements in the Nordic countries and aimed to identify factors included in the standardisation and interpretation of NIBP measurements in infants. METHODS A cross-sectional electronic questionnaire survey was sent to 84 physicians in all 23 university hospitals in Sweden, Norway, Denmark, Finland and Iceland and was completed from February to March 2017. The survey contained respondent characteristics, the presence and description of standardised procedures for NIBP measurements, daily practice of NIBP measurements and methodological considerations and interpretation of NIBP measurements in a healthy six-month-old child. RESULTS We received responses from 55 of 84 physicians working in all 23 Nordic university hospitals, in paediatric cardiology (n = 22), general paediatrics (n = 16), paediatric nephrology (n = 14) and other fields (n = 3). Less than a quarter (23%) said their hospital issued specific NIBP procedures relating to infants and they referred to 19 different sources of information. The factors that were most commonly assessed for interpretation were age (100%), arousal state (78%) and cuff size (76%). CONCLUSION Most of the university hospital units treating children lacked age-specific written procedures for measuring and interpreting infant NIBP, and there is a strong need for common Nordic guidelines.
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Affiliation(s)
| | | | - Håvard Ove Skjerven
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Karin C. Lødrup Carlsen
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Katarina Hanséus
- Department of Paediatric Cardiology; Skåne University Hospital; Lund Sweden
| | - Ingolfur Rögnvaldsson
- Division of Paediatric Cardiology; University Hospital of Iceland; Reykjavik Iceland
| | - Jan Sunnegårdh
- Institute of Clinical Sciences; Gothenburg University; Gothenburg Sweden
| | - Maila I. Turanlahti
- Division of Tertiary Pediatrics; Helsinki University Hospital; Helsinki Finland
| | - Henrik Holmstrøm
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
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93
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Abstract
The etiology of hypertension in children and adolescents is varied; however, the prevalence of pediatric primary hypertension is increasing. Early identification and appropriate management of hypertension in children and adolescents is important to prevent the development of hypertensive end organ disease. The 2017 American Academy of Pediatrics Clinical Practice Guidelines for the Screening and Management of High Blood Pressure in Children and Adolescents provide a comprehensive reference for evaluation and management of hypertension in this age group and should be used when assessing patients with elevated blood pressure and hypertension.
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Affiliation(s)
- Monica Guzman-Limon
- Division of Pediatric Nephrology and Hypertension, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin Street, MSB 3-121, Houston, TX 77030, USA
| | - Joshua Samuels
- Division of Pediatric Nephrology and Hypertension, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin Street, MSB 3-121, Houston, TX 77030, USA.
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94
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Dersch-Mills DA, Banasch HL, Yusuf K, Howlett A. Dexmedetomidine Use in a Tertiary Care NICU: A Descriptive Study. Ann Pharmacother 2018; 53:464-470. [PMID: 30501499 DOI: 10.1177/1060028018812089] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Continuous infusions of dexmedetomidine are increasingly used for sedation in critically ill pediatric patients. Emerging data suggest potential benefits when used for sedation in neonates, including reduced sedative requirements and earlier enteral feeds. OBJECTIVE To describe the use, adverse effects, and signs of withdrawal in a cohort of neonates receiving dexmedetomidine, the majority of whom were receiving concomitant opioids. METHODS This was a retrospective, descriptive review of 38 neonates receiving dexmedetomidine in a medical surgical neonatal intensive care unit, including data on duration of use, dose, adverse effects, weaning, and signs of withdrawal. RESULTS Dexmedetomidine was used for a median of 183 hours, at a median maximum dose of 0.5 µg/kg/h. Premature infants were started on dexmedetomidine at a later chronological age than term infants (41 vs 9 days, P = 0.004). Of 18 patients receiving an opioid infusion at the time of dexmedetomidine initiation, 67% had a dose reduction in opioids by 24 hours. The majority (89%) of neonates had at least 1 potentially related adverse effect during the dexmedetomidine infusion, though no discontinuations were needed as a result. In all, 80% of patients had their dexmedetomidine gradually weaned off, and 71% had at least 1 sign of withdrawal. CONCLUSIONS AND RELEVANCE In this cohort, dexmedetomidine was often used in a postsurgical setting, with concomitant opioids, over prolonged periods. These factors appear to affect and likely confound the rates of adverse effects and withdrawal signs from dexmedetomidine. Clinicians considering the use of dexmedetomidine in a similar population can draw guidance from our data.
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Affiliation(s)
| | | | - Kamran Yusuf
- 2 Department of Peditrics, University of Calgary, Calgary, AB, Canada
| | - Alixe Howlett
- 2 Department of Peditrics, University of Calgary, Calgary, AB, Canada
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95
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Baker-Smith CM, Flinn SK, Flynn JT, Kaelber DC, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Diagnosis, Evaluation, and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2018; 142:peds.2018-2096. [PMID: 30126937 DOI: 10.1542/peds.2018-2096] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED Systemic hypertension is a major cause of morbidity and mortality in adulthood. High blood pressure (HBP) and repeated measures of HBP, hypertension (HTN), begin in youth. Knowledge of how best to diagnose, manage, and treat systemic HTN in children and adolescents is important for primary and subspecialty care providers. OBJECTIVES To provide a technical summary of the methodology used to generate the 2017 "Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents," an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, and Excerpta Medica Database references published between January 2003 and July 2015 followed by an additional search between August 2015 and July 2016. STUDY SELECTION English-language observational studies and randomized trials. METHODS Key action statements (KASs) and additional recommendations regarding the diagnosis, management, and treatment of HBP in youth were the product of a detailed systematic review of the literature. A content outline establishing the breadth and depth was followed by the generation of 4 patient, intervention, comparison, outcome, time questions. Key questions addressed: (1) diagnosis of systemic HTN, (2) recommended work-up of systemic HTN, (3) optimal blood pressure (BP) goals, and (4) impact of high BP on indirect markers of cardiovascular disease in youth. Once selected, references were subjected to a 2-person review of the abstract and title followed by a separate 2-person full-text review. Full citation information, population data, findings, benefits and harms of the findings, as well as other key reference information were archived. Selected primary references were then used for KAS generation. Level of evidence (LOE) scoring was assigned for each reference and then in aggregate. Appropriate language was used to generate each KAS based on the LOE and the balance of benefit versus harm of the findings. Topics that could not be researched via the stated approach were (1) definition of HTN in youth, and (2) definition of left ventricular hypertrophy. KASs related to these stated topics were generated via expert opinion. RESULTS Nearly 15 000 references were identified during an initial literature search. After a deduplication process, 14 382 references were available for title and abstract review, and 1379 underwent full text review. One hundred twenty-four experimental and observational studies published between 2003 and 2016 were selected as primary references for KAS generation, followed by an additional 269 primary references selected between August 2015 and July 2016. The LOE for the majority of references was C. In total, 30 KASs and 27 additional recommendations were generated; 12 were related to the diagnosis of HTN, 13 were related to management and additional diagnostic testing, 3 to treatment goals, and 2 to treatment options. Finally, special additions to the clinical practice guideline included creation of new BP tables based on BP values obtained solely from children with normal weight, creation of a simplified table to enhance screening and recognition of abnormal BP, and a revision of the criteria for diagnosing left ventricular hypertrophy. CONCLUSIONS An extensive and detailed systematic approach was used to generate evidence-based guidelines for the diagnosis, management, and treatment of youth with systemic HTN.
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Affiliation(s)
- Carissa M Baker-Smith
- Division of Cardiology, Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland;
| | | | - Joseph T Flynn
- Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - David C Kaelber
- Division of General Internal Medicine, Departments of Pediatrics and Population and Quantitative Health Sciences, Case Western Reserve University and Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio
| | - Douglas Blowey
- University of Missouri-Kansas City, Children's Mercy Kansas City, Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | | | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samuel S Gidding
- Cardiology Division, Nemours Cardiac Center, A. I. duPont Hospital for Children and Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, Morehouse School of Medicine, Atlanta, Georgia
| | | | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern School of Medicine, University of Texas, Houston, Texas
| | - Madeline Simasek
- Department of Pediatrics, UPMC Shadyside Family Medicine Residency, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Molecular Genetics, Department of Pediatrics, Columbia University Irving Medical Center, Columbia University, New York, New York.,Broad Institute, Cambridge, Massachusetts; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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96
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Sehgal A, Krishnamurthy MB, Clark M, Menahem S. ACE inhibition for severe bronchopulmonary dysplasia - an approach based on physiology. Physiol Rep 2018; 6:e13821. [PMID: 30187692 PMCID: PMC6125606 DOI: 10.14814/phy2.13821] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 07/16/2018] [Indexed: 12/02/2022] Open
Abstract
Premature infants have a high incidence of bronchopulmonary dysplasia (BPD). Systemic hypertension, arterial thickness and stiffness, and increased systemic afterload may all contribute to BPD pathophysiology by altering left ventricular (LV) function and increasing pulmonary venous congestion by lowering end-diastolic compliance. This case series studied the usefulness of angiotensin-converting enzyme (ACE) inhibition by measuring clinical and echocardiographic improvements in six consecutive infants with "severe" BPD unresponsive to conventional therapy. The range of gestation and birthweight were 23-29 weeks and 505-814 g, respectively. All required mechanical ventilation (including high-frequency oscillation) and all but one were administered postnatal corticosteroids. Other treatments including sildenafil and diuretics made no clinical improvements. Captopril was started for systemic hypertension after cardiac and vascular ultrasounds which were repeated 5 weeks later. A significant reduction in oxygen (55 ± 25 to 29 ± 3%, two-tailed P = 0.03) and ventilator requirements, and improved cardiovascular parameters were noted. This included a trend toward reduction in aorta intima media thickness [840 ± 94 to 740 ± 83 μm, P = 0.07] and an increased pulsatile diameter [36 ± 14 to 63 ± 25 μm, P = 0.04]). Improvements were observed for both systolic (increased LV output, 188 ± 13 to 208 ± 13 mL/kg/min, P = 0.046 and mean velocity of circumferential fiber shortening, 1.6 ± 0.2 to 2.5 ± 0.3 [circ/sec], P = 0.0004) and diastolic (decreased isovolumic relaxation time, 69.6 ± 8.2 to 59.4 ± 5 msec, P = 0.044) function which was accompanied by increased pulmonary vein flow. Right ventricular output increased accompanied by a significant lowering of pulmonary vascular resistance. These findings suggest that improving respiratory and cardiac indices (especially diastolic function) warrants further exploration of ACE inhibition in BPD infants unresponsive to conventional therapy.
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Affiliation(s)
- Arvind Sehgal
- Monash NewbornMonash Children's HospitalMelbourneVictoriaAustralia
- Department of PediatricsMonash UniversityMelbourneVictoriaAustralia
| | | | - Megan Clark
- PharmacyMonash HealthClaytonMelbourneVictoriaAustralia
| | - Samuel Menahem
- Emeritus HeadPaediatric and Foetal Cardiac UnitsMonash Medical CentreMonash HealthMelbourneVictoriaAustralia
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Incidence of neonatal hypertension from a large multicenter study [Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates-AWAKEN]. Pediatr Res 2018; 84:279-289. [PMID: 29795211 DOI: 10.1038/s41390-018-0018-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/09/2018] [Accepted: 02/07/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hypertension occurs in up to 3% of neonates admitted to the Neonatal Intensive Care Unit (NICU), and is a potentially under-recognized condition. The aim of this study was to examine the incidence of documented and undiagnosed hypertension from the 24-center Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) database, and to assess risk factors for hypertension according to gestational age. METHODS Diagnosed hypertension was documented if an infant had a discharge diagnosis of hypertension and/or discharged on antihypertensive medications. Undiagnosed hypertension was defined when infants did not have a diagnosis of hypertension, but >50% of the lowest mean, diastolic and systolic blood pressure recordings were >95th percentile for gestational age. RESULTS Of the 2162 neonates enrolled in the study, hypertension was documented in 1.8%. An additional 3.7% were defined as having undiagnosed hypertension. There was a significant correlation with neonatal hypertension and acute kidney injury (AKI). Additional risk factors for neonatal hypertension were hyperbilirubinaemia, Caucasian race, outborn, vaginal delivery, and congenital heart disease. Protective factors were small for gestational age, multiple gestations, and steroids for fetal maturation. CONCLUSIONS Neonatal hypertension may be an under-recognized condition. AKI and other risk factors predispose infants to hypertension.
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Krmar RT, Ferraris JR. Clinical value of ambulatory blood pressure in pediatric patients after renal transplantation. Pediatr Nephrol 2018; 33:1327-1336. [PMID: 28842790 PMCID: PMC6019432 DOI: 10.1007/s00467-017-3781-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 12/19/2022]
Abstract
Hypertension is a highly prevalent co-morbidity in pediatric kidney transplant recipients. Undertreated hypertension is associated with cardiovascular complications and negatively impacts renal graft survival. Thus, the accurate measurement of blood pressure is of the utmost importance for the correct diagnosis and subsequent management of post-renal transplant hypertension. Data derived from the general population, and to a lesser extent from the pediatric population, indicates that ambulatory blood pressure monitoring (ABPM) is superior to blood pressure measurements taken in the clinical setting for the evaluation of true mean blood pressure, identification of patients requiring antihypertensive treatment, and in the prediction of cardiovascular outcome. This Educational Review will discuss the clinical value of ABPM in the identification of individual blood pressure phenotypes, i.e., normotension, new-onset hypertension, white-coat hypertension, masked hypertension, controlled blood pressure, and undertreated/uncontrolled hypertension in pediatric kidney transplant recipients. Finally, we examine the utility of performing repeated ABPM for treatment monitoring of post-renal transplant hypertension and on surrogate markers related to relevant clinical cardiovascular outcomes. Taken together, our review highlights the clinical value of the routine use of ABPM as a tool for identifying and monitoring hypertension in pediatric kidney transplant recipients.
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Affiliation(s)
- Rafael T. Krmar
- Department of Physiology and Pharmacology (FYFA), Karolinska Institute, C3, Nanna Svartz Väg 2, 171 77 Stockholm, Sweden
| | - Jorge R. Ferraris
- Departamento de Pediatría, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABB C.A.B.A, Código Argentina
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Habli M, Clifford CC, Brady TM, Rodriguez Z, Eschenbacher M, Wu M, DeFranco E, Gresh J, Kamath-Rayne BD. Antenatal exposure to nonsteroidal anti-inflammatory drugs and risk of neonatal hypertension. J Clin Hypertens (Greenwich) 2018; 20:1334-1341. [PMID: 30051971 DOI: 10.1111/jch.13354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/19/2018] [Accepted: 06/07/2018] [Indexed: 11/28/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used as tocolytics, which are medications that suppress uterine contractions for preterm birth prevention. Their effect on cerebral/systemic vascular beds poses the question of whether antenatal NSAID exposure is associated with neonatal hypertension. We performed a retrospective case-control study in a tertiary neonatal intensive care unit, including 40 hypertension cases (hospitalized neonates ≥ 35 weeks with systolic BP > 100 mm Hg on three consecutive days) compared to 134 controls matched by gestational age at delivery, plurality, and delivery date. Cases and controls were compared by antenatal NSAID exposure, other common tocolytics, and maternal/neonatal characteristics and complications. Multivariable logistic regression was used to estimate the odds of hypertension among those with prenatal exposure to NSAIDs versus those without exposure. Newborns with hypertension had a lower gestational age at delivery and increased incidence of neonatal complications, including respiratory distress syndrome, bronchopulmonary dysplasia, surfactant administration, longer duration of ventilation, and history of umbilical artery catheterization. Days of indomethacin exposure were positively associated with greater odds of neonatal hypertension (OR 1.17 [1.00 to 1.38], P = 0.055), even after adjustment for other factors associated with neonatal hypertension. Newborns with hypertension were less likely to have been exposed to calcium channel blockers as a tocolytic. The results of our study suggest an association between prenatal exposure to nonsteroidal anti-inflammatory drugs and neonatal hypertension. Furthermore, our data suggest that prenatal calcium channel blocker exposure may protect against the development of neonatal hypertension. Future multicenter studies are needed to understand the risks of tocolytics and subsequent consequences in preterm infants.
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Affiliation(s)
- Mounira Habli
- Maternal-Fetal Medicine, Good Samaritan Hospital, Cincinnati, Ohio.,Cincinnati Fetal Center, Cincinnati, Ohio
| | - Corey C Clifford
- Obstetrics/Gynecology, TriHealth Hospitals, Cincinnati, Ohio.,Obstetrics/Gynecology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Tammy M Brady
- Pediatric Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Zahidee Rodriguez
- Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Malcolm Wu
- University of Cincinnati, Cincinnati, Ohio
| | - Emily DeFranco
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Maternal-Fetal Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | | | - Beena D Kamath-Rayne
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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100
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Miyashita Y, Hanevold C. Evaluation and Management of Stage 2 Hypertension in Pediatric Patients. Curr Hypertens Rep 2018; 20:73. [PMID: 29980866 DOI: 10.1007/s11906-018-0873-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW To update the definition and clinical practice of stage 2 hypertension (HTN) in pediatrics. RECENT FINDINGS The 2017 American Academy of Pediatrics Clinical Practice Guideline (AAP CPG) for Screening and Management of High Blood Pressure in Children and Adolescent includes new normative blood pressure tables for children and adolescents ages 1 to 17 years and new definitions for stage 2 HTN. This review will highlight these aspects as well as new recommendations in the guideline specific to stage 2 HTN. It will outline how the new guideline differs from the previous 2004 guideline, the implications of these differences, and suggested changes in evaluation and management of stage 2 HTN. Lastly, the review will address topics relevant to daily clinical practice including competitive athletic participation, investigation for secondary HTN and HTN comorbidities, and blood pressure-lowering therapy. With the publication of the new AAP CPG introducing revised normative tables, the prevalence of stage 2 HTN in pediatrics is expected to rise. Based on the new guidelines, there is less emphasis on investigation for secondary HTN and more attention to lifestyle modifications for primary HTN. Future research should address whether there is BP level within the stage 2 HTN range above which the approach to evaluation and management should be altered in this heterogeneous patient population.
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Affiliation(s)
- Yosuke Miyashita
- Department of Pediatrics, Division of Pediatric Nephrology, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - Coral Hanevold
- Department of Pediatrics, Division of Pediatric Nephrology, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
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