What's new in pediatric hypertension?

The relationship between BMI and blood pressure in children aged 7-12 years in Ankara, Turkey

OBJECTIVE

Recent studies have reported an increasing prevalence of childhood hypertension. Obesity is probably the most important risk factor. The relationship between hypertension and BMI in children has not been studied in Ankara, which is the second largest city in Turkey.

DESIGN

Cross-sectional study analysing direct data on height, weight and blood pressure of students.

SETTING

Population-based study in Ankara, the capital city of Turkey.

SUBJECTS

In three schools, 2826 students aged 7-12 years.

RESULTS

The overall prevalence of hypertension was 7·9 %. Among the 222 hypertensive children, 124 (56 %) were boys and ninety-eight (44 %) were girls (P=0·40). In the whole group, 3·6 % had only systolic hypertension, 0·7 % had only diastolic hypertension and 3·5 % had both systolic and diastolic hypertension. The prevalences of overweight and obesity were both 13·9 %. BMI was significantly correlated with blood pressure (P<0·001). Overweight and obesity were more common in boys (P<0·001).

CONCLUSIONS

Hypertension was more common than has been reported in other studies. Blood pressure measurement should be routine and frequent in children, especially obese children.

Pediatric ambulatory blood pressure monitoring: indications and interpretations

The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient's BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.

Prediction of primary vs secondary hypertension in children

Despite current guidelines, variability exists in the workup of hypertensive children due to physician preferences. The study evaluates primary vs secondary hypertension diagnosis from investigations routinely performed in hypertensive children. This retrospective study included children 5 to 19 years with primary and secondary hypertension. The proportions of abnormal laboratory and imaging tests were compared between primary and secondary hypertension groups. Risk factors for primary vs secondary hypertension were evaluated by logistic regression and likelihood function analysis. Patients with secondary hypertension were younger (5-12 years) and had a higher proportion of abnormal creatinine, renal ultrasound, and echocardiogram findings. There was no significant difference in abnormal results of thyroid function, urine catecholamines, plasma renin, and aldosterone. Abnormal renal ultrasound findings and age were predictors of secondary hypertension by regression and likelihood function analysis. Children aged 5 to 12 years with abnormal renal ultrasound findings and high diastolic blood pressures are at higher risk for secondary hypertension that requires detailed evaluation.

The risk of developing type 2 diabetes mellitus associated with psychotropic drug use in children and adolescents: a retrospective cohort analysis

OBJECTIVE

Type 2 diabetes mellitus in children and adolescents has become an important public health concern, in parallel with the "epidemic" of overweight/obesity in this age group and a sharp increase in children being prescribed antidepressant or antipsychotic medications. In children and adolescents, the prevalence of being prescribed antidepressant or antipsychotic medications was examined as well as the association of these medications with developing type 2 diabetes mellitus.

METHOD

A retrospective cohort design evaluating South Carolina Medicaid medical and pharmacy claims between January 1, 1996, and December 31, 2006, was employed to identify 4,070 children and adolescents diagnosed initially with type 2 diabetes mellitus, 39% of whom were later reclassified as type 1 (using ICD-9 criteria). The added risk of developing type 2 diabetes mellitus posed by the use of antidepressants or antipsychotics was investigated in this cohort, controlling for individual risk factors and comorbid cardiometabolic conditions.

RESULTS

Use of antidepressants or antipsychotics alone, or the 2 in combination, conferred an increased risk (1.3 to 2 times greater) of having diagnosed type 2 diabetes mellitus and several comorbid cardiometabolic conditions (obesity, dyslipidemia, and hypertension). However, psychiatric illnesses generally developed and were treated after the initial development of diabetes.

CONCLUSIONS

Depression was diagnosed and treated in 10% to 20% of this cohort. While antidepressants and antipsychotics, alone or in combination, are associated with a diagnosis of type 2 diabetes mellitus and its cardiometabolic comorbidities by adolescence, they do not appear to be an explanatory factor in the early onset of type 2 diabetes mellitus in this age group and do not appear to cloud the initial, overlapping clinical picture between type 1 and type 2 diabetes mellitus.

Health-care costs of pediatric clients developing adverse events during treatment with antipsychotics

OBJECTIVE

To examine the differences over time in health-care costs associated with incident adverse events in children and adolescents treated with antipsychotic agents compared to an untreated control sample.

METHOD

A retrospective cohort design evaluating South Carolina's Medicaid medical and pharmacy claims between January 1996 and December 2005 was employed for 4140 children and adolescents prescribed antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications. The main outcome measures were total health-care costs and emergency, inpatient, and outpatient services use.

RESULTS

Patients with the focal adverse medical conditions incurred significantly higher total care costs (34% higher, on average, over 8–9 years) compared with those without these conditions (F = 710.08; P < 0.0001) or to children not treated with psychotropic medications (F = 2855.54; P < 0.0001). Patients with incident adverse events associated with antipsychotic treatment had significantly higher rates/time under Medicaid coverage of outpatient, emergency, and inpatient services utilization than the control sample patients, controlling for preexisting conditions, receipt of multiple psychotropic medications, and individual risk factor differences for males, adolescents, and non-African Americans.

CONCLUSIONS

The development of adverse medical conditions related to antipsychotic medication use in children and adolescents is significantly associated with higher total costs of health care and to utilization of outpatient, emergency, and inpatient services over time

Primary health care access, continuity, and cost among pediatric patients with obesity hypertension

The purpose of this study was to determine how comorbid medical conditions, and the need for early pharmacological intervention, race, gender, and age are associated with service utilization and primary health care costs. From a statewide Medicaid database, medical and pharmacy claims for 10 calendar years (January 1995 to December 2004) were extracted to identify a cohort of children, ages 0 to 17, with (n = 552) and without (n = 2943) a diagnosis of both obesity and primary hypertension. Pediatric African American patients had more diagnosed medical conditions, significantly fewer visits during their first year of primary health care (chi2, 161.16; p < or = .0001) and significantly lower total service utilization over time (chi2, 10.35; p < or = .0001); and received significantly fewer face-to-face visits from office-based practitioners (chi2, 19.38; p < or = .0001) and other medical diagnostic and laboratory services. They also received significantly less acute care through emergency departments (chi2, 25.88; p < or = .0001) and inpatient facilities (chi2, 23.92; p < or = .0001), but were in the treatment system for longer periods of time despite their higher prevalence of multiple comorbid conditions. The total cost of care for pediatric African American patients was significantly lower (F, 90.84; p < or = .0001) than for non-African Americans. In this primary care system, there were early and persistent disparities in the receipt of outpatient, emergency, and inpatient services over time delivered to African American children and adolescents with multiple medical needs.

Cardiovascular and neurological adverse events associated with antidepressant treatment in children and adolescents

A retrospective cohort design of Medicaid medical and pharmacy claims for 1996 through 2005 was employed for 14,171 children and adolescents prescribed an antidepressant medication and a random sample of 4500 children not treated with any class of psychotropic medication to compare the prevalence rates of cardiovascular and neurological adverse events. The treated cohort evinced a higher prevalence of cardiovascular events, orthostatic hypotension, seizures, insomnia, and headaches. In the treated cohort, patients were at a significantly higher risk for incident cardiovascular events when exposed to selective serotonin reuptake inhibitors and weight-inducing antidepressants, mood stabilizers, and antipsychotics. Incident orthostatic hypotension was associated with weight-inducing antidepressants and mood stabilizers. Incident seizures and extrapyramidal symptoms were unrelated to antidepressant or co-prescribed psychotropic medications, but both were significantly associated with comorbid central nervous system, organic brain/mental retardation, or preexisting cardiovascular or cerebrovascular conditions. Headaches and dizziness were significantly related to taking mood stabilizers.

Epidemiology of hypertension among a population of school children in Sousse, Tunisia

BACKGROUND

Pediatric hypertension is a field of increasing interest and importance. Early identification of children at risk for hypertension is important to prevent the serious, long-term complications associated with the condition. In Tunisia, there are no data available on the cardiovascular disease risk profile, such as hypertension, in the population of children.

OBJECTIVE

To establish the prevalence of hypertension, the percentile distribution of blood pressure and the inter-relationships between hypertension and other cardiovascular disease risk factors among school children.

METHODS

An epidemiological survey was conducted based on a representative sample of 1569 urban school children in Sousse, Tunisia.

RESULTS

The prevalence of arterial hypertension was 9.6%, with no significant difference between boys (9.2%) and girls (9.9%). The prevalence of systolic and diastolic hypertension was 6.4% and 4.5%, respectively. In both boys and girls, systolic pressure had a highly significant positive correlation with height (boys: r=0.33, P<0.001; girls: r=0.08, P=0.02), weight (boys: r=0.47, P < or = 0.001; girls: r=0.35, P<0.001) and triglyceride concentrations (boys: r=0.13, P<0.001; girls: r=0.10, P=0.006). Among boys, a positive correlation was found between systolic blood pressure and age (r=0.12, P=0.001) and, among girls, a negative correlation was found (r=-0.12, P=0.001).

CONCLUSION

This information will be used to help launch a regional program of heart health promotion in schools.

Utility of renal imaging in the diagnostic evaluation of obese childhood primary hypertension

Although childhood primary hypertension (CP-HTN) associated with obesity is considered an earlier manifestation of typical adult-onset primary hypertension (adult-HTN), the recommendations for diagnostic evaluation are not identical in the two conditions. In particular, renal imaging is not recommended in adult-HTN, but is still currently recommended in CP-HTN. In this study, the clinical value of renal imaging in the initial diagnostic evaluation of CP-HTN was determined. A retrospective chart review was conducted of older and overweight children (> 7 years of age) evaluated in the pediatric nephrology clinic at the University of Florida from 1999 to 2004 for hypertension. The final highly selected study group was composed of obese or overweight children (body mass index > 85th percentile for age and gender) with otherwise unremarkable history, physical examination, and urinalysis. Renal imaging was performed (ultrasound in 49, computed tomography in one) in 50 patients (M:F = 28:22; age range, 7-20 years) with clinical features compatible with CP-HTN, and was normal in all patients. In this study, renal imaging did not add any clinical value to the initial evaluation of CP-HTN associated with obesity. Larger studies may confirm that the evaluation of CP-HTN in older obese children could be similar to guidelines for evaluation of adult-HTN.

The assessment and management of hypertensive emergencies and urgencies in children

Although the prevalence of hypertension in the pediatric population is estimated at only 1% to 2%, hypertensive urgencies and emergencies may be encountered in the emergency department. Efficient management of these children is of utmost importance to avoid some of the life-threatening complications associated with hypertension and its treatment. This article serves to review some of the important aspects of pediatric hypertensive emergencies, including diagnosis, emergency department investigations, and pharmacologic management.

How are hypertensive children evaluated and managed? A survey of North American pediatric nephrologists

To assess how children with hypertension are currently evaluated and managed, we surveyed 438 North American pediatric nephrologists on how they measure blood pressure (BP), BP goals used in pharmacologically treated patients, and antihypertensive drug choices. 190 replies were received (43% response rate), and 185 were analyzable. Oscillometric and aneroid sphygmomanometers were the most commonly used devices for office BP measurement (74.8% of respondents). Ambulatory blood pressure monitoring was used by 63% of respondents. Goal BP in pharmacologically treated patients was set at the 95th percentile by 39% of respondents, and at the 90th percentile by 59%. Only 37% used a different goal BP in children with hypertension and renal disease; of these, 85% used a lower goal and 15% a higher goal. For hypertensive children with diabetes, 47% used a different goal; 99% lower and 1% higher. Whereas angiotensin-converting enzyme inhibitors (ACEI) and calcium-channel blockers (CCB) were chosen by similar proportions of respondents as initial agents for treatment of primary hypertension, most (84%) chose ACEI as their initial agent for hypertension in children with renal disease. Although most pediatric nephrologists treat hypertensive children to a BP goal below the 90th percentile, most do not use lower goals for patients with renal disease or diabetes, in contrast with current recommendations for treatment of adults with these conditions. These findings highlight the need for further studies to determine whether recommendations for treatment of hypertension in adults should be followed in children.

A diagnostic approach for the child with hypertension

Hypertension during childhood is not rare, with an estimated prevalence of between 1% and 2%, although it is often an underrecognized clinical entity. Elevated blood pressure may be a sign of underlying disease or it may represent early onset of essential hypertension. In recent years the measurement of blood pressure has been emphasized as an important component of the routine pediatric physical examination that enables early detection of children with hypertension. In the evaluation of the child with documented blood pressure elevation, confirmation of truly and persistently elevated blood pressure is of the utmost importance. In addition, a thorough history and a full clinical examination are essential. These are followed by appropriate investigations, which are tailored to the age of the child and to the severity of the blood pressure elevation. Investigations should not only focus on a search for the underlying cause, but also on establishing effects on target organs, complications or additional diseases and on assessment of the total cardiovascular risk to the individual patient. An algorithm, which is a valuable diagnostic tool for the diagnosis and management of the child with hypertension, is presented. All children with confirmed hypertension need long-term follow-up, counseling and treatment. In those cases where an underlying cause of the hypertension is detected, the established diagnosis then determines the specific therapy and management.

Elevated blood pressure and decreased cognitive function among school-age children and adolescents in the United States

OBJECTIVE

To evaluate the relationship between elevated blood pressure (BP) and cognitive test performance in a nationally representative sample of children. Study design The National Health and Nutrition Examination Survey III provides cross-sectional data for children 6 to 16 years, including BP and cognitive test scores. Elevated BP was defined as systolic or diastolic BP >or=90th percentile. Cognitive tests were compared for children with elevated and normal BP. Linear regression was used to evaluate the relation between elevated BP and decreased test scores.

RESULTS

Among the 5077 children, 3.4% had systolic BP >or=90th percentile and 1.6% diastolic BP >or=90th percentile. Children with elevated systolic BP had lower average scores compared with normotensive children for digit span (7.9 vs 8.7, P=.01), block design (8.6 vs 9.5, P=.03), and mathematics (89.6 vs 93.8, P=.01). Elevated diastolic BP was associated with lower average scores on block design (9.5 vs 11, P=.01). Linear regression showed that elevated systolic BP was independently associated with lower digit span scores (P=.032).

CONCLUSION

Children with elevation of systolic BP are at risk for central nervous system end-organ damage, as manifested by decreased digit span test scores.

Better renoprotective effect of angiotensin II antagonist compared to dihydropyridine calcium channel blocker in childhood

BACKGROUND

The dihydropyridine calcium channel blocker amlodipine and the angiotensin II antagonist irbesartan effectively reduce blood pressure in hypertensive children.

METHODS

Eligible for the open-label, randomized study were nephropathic children between 6.0 and 18 years of age with plasma creatinine <177 micromol/L, overt proteinuria, untreated arterial hypertension (systolic, 5 to 30 mm Hg; and diastolic, 1 to 15 mm Hg;>95th centile) and stable immunosuppressive treatment. The initial dose of amlodipine was 5 mg (body weight, 20 to 40 kg) and 10 mg (body weight,>40 kg), respectively, that of irbesartan, which was 75 mg (body weight, 20 to 40 kg) and 150 mg (body weight,>40 kg), respectively. The dosage was doubled if necessary.

RESULTS

A total of 26 children aged 6.1 to 17 years were allocated to receive either amlodipine (N = 13) or irbesartan (N = 13) for 16 weeks. Severe edema and headache occurred in two patients on amlodipine who withdrew from the study. No adverse experiences were noted in patients given irbesartan. Amlodipine [by 12 (10 to 14)/7 (5 to 10) mm Hg; median and interquartile range, respectively] and irbesartan [by 13 (9 to 16)/9 (7 to 11) mm Hg, respectively] reduced blood pressure (P < 0.01) in a similar fashion. Heart rate, plasma sodium, and creatinine did not change. Irbesartan slightly increased plasma potassium [by 0.1 (0.0 to 0.2) mmol/L; P < 0.05]. Plasma albumin and the urinary albumin/creatinine ratio were similar before and with amlodipine. On the contrary, irbesartan increased plasma albumin [by 4 (3 to 5) g/L; P < 0.03] and decreased the urinary albumin/creatinine ratio [by 242 (68 to 312) mg/mmol; P < 0.03].

CONCLUSION

The study demonstrates that in children the effect of angiotensin II antagonists on proteinuria is better than that of dihydropyridine calcium channel blockers.