1
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Coulthard MG. Managing severe hypertension in children. Pediatr Nephrol 2023; 38:3229-3239. [PMID: 36862252 PMCID: PMC10465398 DOI: 10.1007/s00467-023-05896-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 03/03/2023]
Abstract
Severe childhood hypertension is uncommon and frequently not recognised and is best defined as a systolic blood pressure (SBP) above the stage 2 threshold of the 95th centile + 12 mmHg. If no signs of end-organ damage are present, this is urgent hypertension which can be managed by the slow introduction of oral or sublingual medication, but if signs are present, the child has emergency hypertension (or hypertensive encephalopathy if they include irritability, visual impairment, fits, coma, or facial palsy), and treatment must be started promptly to prevent progression to permanent neurological damage or death. However, detailed evidence from case series shows that the SBP must be lowered in a controlled manner over about 2 days by infusing short-acting intravenous hypotensive agents, with saline boluses ready in case of overshoot, unless the child had documented normotension within the last day. This is because sustained hypertension may increase pressure thresholds of cerebrovascular autoregulation which take time to reverse. A recent PICU study that suggested otherwise was significantly flawed. The target is to reduce the admission SBP by its excess, to just above the 95th centile, in three equal steps lasting about ≥ 6 h, 12 h, and finally ≥ 24 h, before introducing oral therapy. Few of the current clinical guidelines are comprehensive, and some advise reducing the SBP by a fixed percentage, which may be dangerous and has no evidence base. This review suggests criteria for future guidelines and argues that these should be evaluated by establishing prospective national or international databases.
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Affiliation(s)
- Malcolm G Coulthard
- Great North Children's Hospital, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP, UK.
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2
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Giammattei VC, Weaver DJ, South AM. Management of acute severe hypertension in youth: from the philosophical to the practical. Curr Opin Pediatr 2023; 35:251-258. [PMID: 36437756 PMCID: PMC9992153 DOI: 10.1097/mop.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Acute severe hypertension remains an uncommon but important source of morbidity and mortality in youth. However, there has been very little progress made in our understanding of how to best manage youth with acute severe hypertension to improve patient outcomes. RECENT FINDINGS Our understanding of what is acute severe hypertension is undergoing a philosophical change. Management of patients with acute severe hypertension is evolving towards more of a risk and outcomes-based approach. SUMMARY We should be intentional when we consider whether a patient has acute severe hypertension and if they are truly at an increased risk for life-threatening target organ injury. We should consider their specific risk factors to best interpret the risks and benefits of how best to treat a patient with acute severe hypertension, rather than relying on traditional approaches and conventional wisdom. We should always ask 'why' when we are pursuing a given management course. Future studies should clearly define the research questions they are investigating to best advance the field to ultimately improve patient outcomes.
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Affiliation(s)
| | - Donald J. Weaver
- Division of Nephrology and Hypertension, Department of Pediatrics, Atrium Health Levine Children's, Charlotte, NC, USA
| | - Andrew M. South
- Section of Nephrology, Department of Pediatrics, Brenner Children’s, Wake Forest University School of Medicine, Winston Salem, NC, USA
- Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, NC, USA
- Cardiovascular Sciences Center, Wake Forest University School of Medicine, Winston Salem, NC, USA
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3
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Abstract
Neonatal hypertension is uncommon but is becoming increasingly recognized. Normative blood pressure data are limited, as is research regarding the risks, treatment, and long-term outcomes. Therefore, there are no clinical practice guidelines and management is based on clinical judgment and expert opinion. Recognition of neonatal hypertension requires proper blood pressure measurement technique. When hypertension is present there should be a thorough clinical, laboratory, and imaging evaluation to promptly diagnose causes needing medical or surgical management. This review provides a practical overview for the practicing clinician regarding the identification, evaluation, and management of neonatal hypertension.
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Affiliation(s)
- Rebecca Hjorten
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, OC.9.820 - Nephrology, Seattle, WA 98105, USA
| | - Joseph T Flynn
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, OC.9.820 - Nephrology, Seattle, WA 98105, USA.
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4
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Efficacy and Safety of Intravenous Labetalol in Acute Hypertensive Crisis in Children. Indian J Pediatr 2022; 89:7-12. [PMID: 33893609 DOI: 10.1007/s12098-021-03707-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of intravenous (IV) labetalol in the management of hypertensive crisis in children. METHODS A retrospective chart review of 56 consecutive children (age > 1 mo to ≤ 12 y) with hypertensive crisis admitted to a pediatric intensive care unit (PICU) from July 2009 to 2019. RESULTS The proportion of children attaining the primary endpoint (target 95th percentile in > 12 to ≤ 48 h) was significantly more in the group receiving labetalol as first-line or add-on (n = 23) as compared to those not receiving labetalol (n = 33) (62% vs. 30.3%, p = 0.03). Higher proportion of neurological recovery was seen in the labetalol group (56.2% vs. 18.7%, p = 0.02). The proportion of children with hypotension before 12 h was similar in both treatment groups (13% vs. 15%, p = 0.82). The practice variations between two periods of 5 y each (2009-2013 and 2014-2019) showed significantly more use of labetalol in the latter cohort (53% for 2014-2019 vs. 25% for 2009-2013, p = 0.03). CONCLUSION Labetalol, when used alone or as an add-on drug, was more efficacious than IV nitroprusside/nitroglycerine in attaining the primary endpoint in children up to ≤ 12 y of age with hypertensive crisis. Labetalol was safe and associated with higher neurological recovery.
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5
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Tobias JD, Naguib A, Simsic J, Krawczeski CD. Pharmacologic Control of Blood Pressure in Infants and Children. Pediatr Cardiol 2020; 41:1301-1318. [PMID: 32915293 DOI: 10.1007/s00246-020-02448-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/30/2020] [Indexed: 01/04/2023]
Abstract
Alterations in blood pressure are common during the perioperative period in infants and children. Perioperative hypertension may be the result of renal failure, volume overload, or activation of the sympathetic nervous system. Concerns regarding end-organ effects or postoperative bleeding may mandate regulation of blood pressure. During the perioperative period, various pharmacologic agents have been used for blood pressure control including sodium nitroprusside, nitroglycerin, β-adrenergic antagonists, fenoldopam, and calcium channel antagonists. The following manuscript outlines the commonly used pharmacologic agents for perioperative BP including dosing regimens and adverse effect profiles. Previously published clinical trials are discussed and efficacy in the perioperative period reviewed.
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Affiliation(s)
- Joseph D Tobias
- Departments of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Aymen Naguib
- Departments of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Janet Simsic
- Department of Pediatrics and Division of Pediatric Cardiology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Catherine D Krawczeski
- Department of Pediatrics and Division of Pediatric Cardiology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
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6
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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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7
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Charlton GA, Ladd DR, Friesen RM, Friesen RH. Labetalol Infusion Attenuates Paradoxical Hypertension and Decreases Plasma Renin Activity After Repair of Coarctation of the Aorta in Children. J Cardiothorac Vasc Anesth 2020; 34:3348-3351. [PMID: 32593586 DOI: 10.1053/j.jvca.2020.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Paradoxical hypertension after repair of coarctation of the aorta in children is associated with the release of catecholamines and activation of the renin-angiotensin system. The objective of the present study was to describe the effects of labetalol infusion on blood pressure, plasma catecholamine levels, and plasma renin activity in a series of children undergoing repair of coarctation of the aorta. DESIGN Prospective, observational cohort study. SETTING Tertiary children's hospital with university affiliation. PARTICIPANTS The study was comprised of 15 consecutive children older than 1 year undergoing repair of coarctation of the aorta. INTERVENTIONS Intravenous infusion of labetalol, up to 20 µg/kg/min, was administered when patients became hypertensive after release of the aortic cross-clamp. Supplementation with nitroprusside was allowed as needed. MEASUREMENTS AND MAIN RESULTS Blood pressure was maintained below baseline values throughout the labetalol infusion. Plasma norepinephrine increased from 160 ± 81 pg/mL (preoperative) to 657 ± 268 pg/mL (6 h after release of aortic cross-clamp). Plasma renin activity decreased from 16.6 ± 9.7 ng/kg/h (at cross-clamp release) to 2.2 ± 2.2 ng/kg/h (6 h after cross-clamp release). Nitroprusside was added for 12 patients, at a highest mean dose of 2.4 ± 2.5 μg/kg/min. CONCLUSIONS Labetalol inhibited activation of the renin-angiotensin system and helped control paradoxical hypertension after coarctation repair in children.
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Affiliation(s)
- Gareth A Charlton
- Shackleton Department of Anaesthesia, University Hospitals Southampton NHS Trust, Southampton, UK
| | - David R Ladd
- Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO
| | - Richard M Friesen
- Division of Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Robert H Friesen
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
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Abstract
Severe hypertension in children may result in life-threatening complications. Although there has not been extensive research in this area in children, and recommendations are mostly derived from adult data, in the last few years, there have been more pediatric studies on the safety and effectiveness of antihypertensives. The clinical presentation of a child with severe hypertension varies and may be completely asymptomatic or include signs and symptoms of end-organ damage. Treatment of a child with severe hypertension is emergent and should be done concomitantly with the evaluation.
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Affiliation(s)
- Rossana Baracco
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien St, Detroit, MI, 48201, USA.
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9
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Raina R, Mahajan Z, Sharma A, Chakraborty R, Mahajan S, Sethi SK, Kapur G, Kaelber D. Hypertensive Crisis in Pediatric Patients: An Overview. Front Pediatr 2020; 8:588911. [PMID: 33194923 PMCID: PMC7606848 DOI: 10.3389/fped.2020.588911] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/08/2020] [Indexed: 01/17/2023] Open
Abstract
Hypertensive crisis can be a source of morbidity and mortality in the pediatric population. While the epidemiology has been difficult to pinpoint, it is well-known that secondary causes of pediatric hypertension contribute to a greater incidence of hypertensive crisis in pediatrics. Hypertensive crisis may manifest with non-specific symptoms as well as distinct and acute symptoms in the presence of end-organ damage. Hypertensive emergency, the form of hypertensive crisis with end-organ damage, may present with more severe symptoms and lead to permanent organ damage. Thus, it is crucial to evaluate any pediatric patient suspected of hypertensive emergency with a thorough workup while acutely treating the elevated blood pressure in a gradual manner. Management of hypertensive crisis is chosen based on the presence of end-organ damage and can range from fast-acting intravenous medication to oral medication for less severe cases. Treatment of such demands a careful balance between decreasing blood pressure in a gradual manner while preventing damage end-organ damage. In special situations, protocols have been established for treatment of hypertensive crisis, such as in the presence of endocrinologic neoplasms, monogenic causes of hypertension, renal diseases, and cardiac disease. With the advent of telehealth, clinicians are further able to extend their reach of care to emergency settings and aid emergency medical service (EMS) providers in real time. In addition, further updates on the evolving topic of hypertension in the pediatric population and novel drug development continues to improve outcomes and efficiency in diagnosis and management of hypertension and consequent hypertensive crisis.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, United States.,Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, United States
| | - Zubin Mahajan
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, United States
| | - Aditya Sharma
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, United States
| | - Sarisha Mahajan
- Cleveland Clinic Akron General Medical Center, Akron, OH, United States
| | - Sidharth K Sethi
- Pediatric Nephrology and Pediatric Kidney Transplantation, The Medicity Hospital, Kidney and Urology Institute, Medanta, Gurgaon, India
| | - Gaurav Kapur
- Division of Pediatric Nephrology and Hypertension, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, United States
| | - David Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and Metro Health System, Cleveland, OH, United States
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10
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Seeman T, Hamdani G, Mitsnefes M. Hypertensive crisis in children and adolescents. Pediatr Nephrol 2019; 34:2523-2537. [PMID: 30276533 DOI: 10.1007/s00467-018-4092-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 12/28/2022]
Abstract
Hypertensive crisis is a relatively rare condition in children. However, if not treated, it might be life-threatening and lead to irreversible damage of vital organs. Clinical presentation of patients with hypertensive crisis can vary from very mild (hypertensive urgency) to severe symptoms (hypertensive emergency) despite similarly high blood pressure (BP). Individualized assessment of patients presenting with high BP with emphasis on the evaluation of end-organ damage rather than on the specific BP number is a key in guiding physician's initial management of a hypertensive crisis. The main aim of the treatment of hypertensive crisis is the prevention or treatment of life-threatening complications of hypertension-induced organ dysfunction, including neurologic, ophthalmologic, renal, and cardiac complications. While the treatment strategy must be directed toward the immediate reduction of BP to reduce the hypertensive damage to these organs, it should not be at a too fast rate to cause hypoperfusion of vital organs by an excessively rapid reduction of BP. Thus, intravenous continuous infusions rather than intravenous boluses of antihypertensive medications should be the preferable mode of initial treatment of children with hypertensive emergency.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics and Biomedical Center, 2nd Faculty of Medicine and Faculty of Medicine in Pilsen, Charles University in Prague, V Uvalu 84, 15006, Prague 5, Czech Republic. .,Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic.
| | - Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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11
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Lim AM, Chong SL, Ng YH, Chan YH, Lee JH. Epidemiology and Management of Children with Hypertensive Crisis: A Single-Center Experience. J Pediatr Intensive Care 2019; 9:45-50. [PMID: 31984157 DOI: 10.1055/s-0039-1698759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023] Open
Abstract
Most children who present with hypertensive crisis have a secondary cause for hypertension. This study describes the epidemiology and management of children with hypertensive crisis. A retrospective cohort study was done in a tertiary pediatric hospital from 2009 to 2015. Thirty-seven patients were treated for hypertensive crisis. Twelve (32.4%) patients were treated for hypertensive emergency. The majority of our patients (33 [89.1%]) had a secondary cause of hypertension. The most common identifiable cause of hypertension was a renal pathology (18/37 [48.6%]). Oral nifedipine (23 [62.1%]) was the most frequently used antihypertensive, followed by intravenous labetalol (8 [21.6%]). There were no mortalities or morbidities. Hypertensive crisis in children is likely secondary in nature. Oral nifedipine and intravenous labetalol are both effective treatments.
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Affiliation(s)
- Alicia May Lim
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Siew Le Chong
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yong Hong Ng
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,Office of Clinical Sciences, Duke-NUS School of Medicine, Singapore, Singapore
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12
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Evaluation and management of elevated blood pressures in hospitalized children. Pediatr Nephrol 2019; 34:1671-1681. [PMID: 30171355 DOI: 10.1007/s00467-018-4070-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 08/14/2018] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
Abstract
Elevated blood pressures (BP) are common among hospitalized children and, if not recognized and treated promptly, can lead to potentially significant consequences. Even though we have normative BP data and well-developed guidelines for the diagnosis and management of hypertension (HTN) in the ambulatory setting, our understanding of elevated BPs and their relationship to HTN in hospitalized children is limited. Several issues have hampered our ability to diagnose and manage HTN in the inpatient setting including the common presence of physiologic conditions, which are associated with transient BP elevations (i.e., pain or anxiety), non-standard approaches to BP measurement, a lack of clarity regarding appropriate diagnostic and therapeutic thresholds, and marginal outcome data. The purpose of this review is to highlight the issues and challenges surrounding BP monitoring, assessment of elevated BPs, and the diagnosis of HTN in hospitalized children. Extrapolating from currently available clinical practice guidelines and utilizing the best data available, we aim to provide guidelines regarding evaluation and treatment of elevated BP in hospitalized children.
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13
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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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14
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Dionne JM, Flynn JT. Management of severe hypertension in the newborn. Arch Dis Child 2017; 102:1176-1179. [PMID: 28739634 DOI: 10.1136/archdischild-2015-309740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/29/2017] [Accepted: 06/12/2017] [Indexed: 11/04/2022]
Abstract
Blood pressure is considered a vital sign, as values too low or too high can be related with serious morbidity and mortality. In neonates, normal blood pressure values undergo rapid changes, especially in premature infants, making the recognition of abnormal blood pressures more challenging. Severe hypertension can occur in neonates and infants and is a medical emergency, often manifesting with congestive heart failure or other life-threatening complications. The cause or risk factors for the hypertension can usually be identified and may guide management. Most classes of antihypertensive medications have been used in the neonatal population. For severe hypertension, intravenous short-acting medications are preferred for a controlled reduction of blood pressure. In this article, we focus on identification, aetiology and management of severe hypertension in the newborn.
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Affiliation(s)
- Janis M Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, Canada
| | - Joseph T Flynn
- Department of Pediatrics, Division of Nephrology, University of Washington, Seattle Children's Hospital, Washington, USA
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15
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Saqan R, Thiabat H. Evaluation of the safety and efficacy of metoprolol infusion for children and adolescents with hypertensive crises: a retrospective case series. Pediatr Nephrol 2017; 32:2107-2113. [PMID: 28733751 DOI: 10.1007/s00467-017-3720-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 06/02/2017] [Accepted: 06/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute severe hypertension occurs infrequently in pediatric patients and, consequently, data on the efficacy and safety of most antihypertensive agents, as well as the adverse events associated with these agents, are very limited in this population. In this case series, we evaluated the use of metoprolol infusion in children with hypertensive emergencies. METHODS The study population comprised children younger than 18 years who had been admitted to the pediatric intensive care unit at King Abdullah University Hospital with blood pressure above the 99th percentile for age, height, and sex and who were symptomatic at the time of presentation. Metoprolol was given as an infusion at a dose of 1-5 mcg/kg/min. The rate of decrease in blood pressure, side effects from the medication, and outcome were assessed. RESULTS Thirteen patients ranging in age from 2 months to 16 years were included in this study. The initial mean blood pressure was 23-75 mmHg above the 99th percentile for age, height, and sex. Metoprolol was initiated at a dose of 0.5 mcg/kg/min and titrated according to the target blood pressure to a maximum of 5 mcg/kg/min. Mean blood pressure fell by an average of 12.3, 20.4, and 27.1% at 1, 8, and 24 h, respectively, which is consistent with findings on the use of other intravenous medications reported in published studies. The heart rate did not decrease below the normal range for age. There were no significant side effects of the metoprolol infusion. All patients were discharged home with no neurological sequelae secondary to their hypertension. CONCLUSION An infusion of metoprolol for a hypertensive emergency is a safe and effective treatment for pediatric patients.
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Affiliation(s)
- Rola Saqan
- Jordan University of Science and Technology, Irbid, Irbid, Jordan.
| | - Hanan Thiabat
- Jordan University of Science and Technology, Irbid, Irbid, Jordan
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16
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1912] [Impact Index Per Article: 273.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - 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 and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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17
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Lee GH, Lee IR, Park SJ, Kim JH, Oh JY, Shin JI. Hypertensive crisis in children: an experience in a single tertiary care center in Korea. Clin Hypertens 2016; 22:10. [PMID: 27092268 PMCID: PMC4834822 DOI: 10.1186/s40885-016-0040-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 01/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive crisis is a medical emergency that can cause acute damage to multiple end-organs. However, relatively little is known on the etiology, treatment, and outcomes of hypertensive crisis in Korean children. The aim of this study was to determine the etiologies and efficacy of drugs for hypertensive crisis in children during the past 5 years at a single center in Korea. METHODS We analyzed data from 51 children with hypertensive crisis during the period between January 1, 2010 and April 1, 2014. The patients were divided into two groups: those diagnosed with a hypertensive emergency (hypertension with organ injury, n = 31) and those diagnosed with a hypertensive urgency (hypertension without organ injury, n = 20). Baseline etiologies and risk factors were compared between the two groups. In addition, systolic and diastolic blood pressures were evaluated at 1, 2, 4, and 5 hours after the administration of intravenous antihypertensive drugs. RESULTS Kidney injury and cancer were the common causes in patients with hypertensive crisis. Cardiovascular complications (cardiac hypertrophy) (p = 0.002), central nervous system complications (p = 0.004), and retinopathy (p = 0.034) were more frequently observed in children with hypertensive emergency than those with hypertensive urgency. However, the proportion of renal complications was similar in both groups. Hydralazine was most commonly used in both groups to control acute increasing blood pressure at first. However, it was often ineffective for controlling abrupt elevated blood pressure. Therefore, intravenous antihypertensive drugs were changed from hydralazine to nicardipine, labetalol, or nitroprusside to control the high blood pressure in 45.1 % of the patients. Particularly, in patients with hypertensive crisis, there was no significant difference in reduction of systolic and diastolic blood pressure and in improvement of clinical outcomes between nicardipine and labetalol administration. CONCLUSION Close blood pressure monitoring and careful examinations should be mandatory in children with underlying disease, especially renal diseases and cancer. Furthermore, both nicardipine and labetalol may be effective antihypertensive drug in lowering high blood pressure in children with hypertensive crisis.
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Affiliation(s)
- Geum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - I Re Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Se Jin Park
- Department of Pediatrics, Daewoo General Hospital, Ajou University School of Medicine, Geoje, Korea
| | - Ji Hong Kim
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Young Oh
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatric Nephrology, Severance Children’s Hospital, Seoul, Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatric Nephrology, Severance Children’s Hospital, Seoul, Korea
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18
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Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crises in children. Integr Blood Press Control 2016; 9:49-58. [PMID: 27051314 PMCID: PMC4803257 DOI: 10.2147/ibpc.s50640] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hypertensive crises in children are medical emergencies that must be identified, evaluated, and treated promptly and appropriately to prevent end-organ injury and even death. Treatment in the acute setting typically includes continuous intravenous antihypertensive medications with monitoring in the intensive care unit setting. Medications commonly used to treat severe hypertension have been poorly studied in children. Dosing guidelines are available, although few pediatric-specific trials have been conducted to facilitate evidence-based therapy. Regardless of what medication is used, blood pressure should be lowered gradually to allow for accommodation of autoregulatory mechanisms and to prevent cerebral ischemia. Determining the underlying cause of the blood pressure elevation may be helpful in guiding therapy.
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Affiliation(s)
- Deborah R Stein
- Division of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael A Ferguson
- Division of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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19
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Antihypertensives. Pediatr Crit Care Med 2016; 17:S101-8. [PMID: 26945324 DOI: 10.1097/pcc.0000000000000621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hypertension remains a common condition in pediatric cardiac intensive care. The physiologic effects of hypertension in this population are complex and are impacted by patient age, comorbidities, and primary cardiac disease. The objective of this study is to review current pharmacotherapies for the management of systemic hypertension in the pediatric cardiac ICU. DATA SOURCES Relevant literature to the treatment of systemic hypertension in children was included. Specific focus was given to literature studying the use of therapies in critically ill children and those with heart disease. Reference textbooks and drug packaging inserts were used for drug-specific pediatric guidelines. STUDY SELECTION A search of MEDLINE, PubMed, and the Cochrane Database was performed to find literature about the management of hypertension in children. Metaanalyses and pediatric-specific studies were primarily considered and cross-referenced. Pertinent adult studies were included. DATA EXTRACTION Once the studies for inclusion were finalized, priority for data extraction was given to pediatric-specific studies that focused on children with heart disease and critical illness. CONCLUSIONS Systemic hypertension is common, and there is significant heterogeneity in the patient population with critical heart disease. There are limited large, prospective analyses of safety and efficacy for pediatric drug antihypertensive agents. Despite patient heterogeneity, most pharmacotherapies are safe and efficacious.
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20
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Ostrye J, Hailpern SM, Jones J, Egan B, Chessman K, Shatat IF. The efficacy and safety of intravenous hydralazine for the treatment of hypertension in the hospitalized child. Pediatr Nephrol 2014; 29:1403-9. [PMID: 24554119 DOI: 10.1007/s00467-014-2772-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 01/21/2014] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intravenous (IV) hydralazine is frequently used for the treatment of elevated blood pressure (BP) in hospitalized children. Its safety and efficacy have not been examined. METHODS This is a retrospective chart review of IV hydralazine use in hospitalized children (birth to 17 years) over a 3-year period. Demographic data and data on adverse effects (AE), BP, and heart rate (HR) prior to and after each first dose were collected. RESULTS The patient cohort comprised 110 children admitted to the hospital during the study period, of whom 77 received the recommended dose. Mean age of the children was 8.5 ± 5.4 years; 33 % were male, and 32.5 % were white. Pre-dose systolic and diastolic BP indexes were 1.3 and 1.2, respectively. The median reduction in systolic and diastolic BP was 8.5 and 11.5 %, respectively. Sixteen (21 %) children achieved a 25 % reduction in systolic or diastolic BP, and BP increased in 30 % of patients; 10 % of children had a BP of <95th percentile for age, sex, and height after one dose. Seven (9 %) children had a documented AE. HR increased by a median of 3.5 %. In the multivariable models examining percentage change in systolic and diastolic BP, male gender was significantly associated with a change in systolic BP. CONCLUSIONS In hospitalized children, IV hydralazine was well tolerated, BP response was variable, and 21 % of the patients achieved a ≥25 % reduction of systolic or diastolic BP. Further studies are needed to compare the safety and efficacy of IV hydralazine to other short-acting antihypertensive agents.
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Affiliation(s)
- Julie Ostrye
- Cincinnati Children's Hospital Medical Center, Department of Pharmacy, Cincinnati, OH, USA
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21
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22
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Abstract
Acute hypertension (HTN) in hospitalized children and adolescents occurs relatively frequently, and in some cases, if not recognized and treated promptly, it can lead to hypertensive crisis with potentially significant morbidity and mortality. In contrast to adults, where acute HTN is most likely due to uncontrolled primary HTN, children and adolescents with acute HTN are more likely to have secondary HTN. This review will briefly cover evaluation of acute HTN and various age-specific etiologies of secondary HTN and provide more in-depth discussion on treatment targets, potential risks of acute HTN therapy, and available pediatric data on intravenous and oral antihypertensive agents, and it proposes treatment schema including unique therapy of specific secondary HTN scenarios.
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Affiliation(s)
- Tennille N. Webb
- Pediatric Nephrology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15206, USA, Phone: 412-692-5182, Fax: 412-692-7443
| | - Ibrahim F. Shatat
- Division of Pediatric Nephrology and Hypertension, Medical University of South Carolina, Children's Hospital, 96 Jonathan Lucas Street, CSB-428, Charleston, SC 29425, USA, Phone: 843-792-8904, Fax: 843-792-2033
| | - Yosuke Miyashita
- Pediatric Nephrology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15206, USA, Phone: 412-692-5182, Fax: 412-692-7443
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23
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Filler G, Hart L, Chan A, Cairney E, Prasad AN. Cyproheptadine for central hypertension? QSCIENCE CONNECT 2014. [DOI: 10.5339/connect.2014.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Guido Filler
- 1Department of Paediatrics, Division of Paediatric Nephrology, Schulich School of Medicine & Dentistry, London, ON, Canada N6A 5W9
- 2Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada N5A 5A5
| | - Lara Hart
- 1Department of Paediatrics, Division of Paediatric Nephrology, Schulich School of Medicine & Dentistry, London, ON, Canada N6A 5W9
| | - April Chan
- 3School of Pharmacy, University of Western Ontario, London, ON, Canada 5A 5A5
| | - Elizabeth Cairney
- 4Department of Paediatrics, Division of Hematology/Oncology, Schulich School of Medicine & Dentistry, London, ON, Canada N6A 5W9
| | - Asuri N Prasad
- 5Department of Paediatrics, Division of Neurology, Schulich School of Medicine & Dentistry, London, ON, Canada N6A 5W9
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24
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Clevidipine for perioperative blood pressure control in infants and children. Pharmaceuticals (Basel) 2013; 6:70-84. [PMID: 24275788 PMCID: PMC3816677 DOI: 10.3390/ph6010070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 12/28/2012] [Accepted: 01/11/2013] [Indexed: 11/29/2022] Open
Abstract
Various pharmacologic agents have been used for perioperative BP control in pediatric patients, including sodium nitroprusside, nitroglycerin, β-adrenergic antagonists, fenoldopam, and calcium channel antagonists. Of the calcium antagonists, the majority of the clinical experience remains with the dihydropyridine nicardipine. Clevidipine is a short-acting, intravenous calcium channel antagonist of the dihydropyridine class. It undergoes rapid metabolism by non-specific blood and tissue esterases with a half-life of less than 1 minute. As a dihydropyridine, its cellular and end-organ effects parallel those of nicardipine. The clevidipine trials in the adult population have demonstrated efficacy in rapidly controlling BP in various clinical scenarios with a favorable adverse effect profile similar to nicardipine. Data from large clinical trials regarding the safety and efficacy of clevidipine in children is lacking. This manuscript aims to review the commonly used pharmacologic agents for perioperative BP control in children, discuss the role of calcium channel antagonists such as nicardipine, and outline the preliminary data regarding clevidipine in the pediatric population.
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25
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Abstract
PURPOSE OF REVIEW This review summarizes recent insights into the epidemiology of primary hypertension in children, with emphasis on the most important risk factors for the development of hypertension, and also updates current options for treating primary hypertension in children. RECENT FINDINGS There is growing evidence that the prevalence of hypertension has increased over the past decade and that the epidemic of obesity has played a key role in the increase of blood pressure (BP) in the USA and abroad. Recent studies have shown that in addition to obesity, environmental factors such as second-hand smoking and sedentary lifestyle are important in development of hypertension even in preschool age children. Studies also have confirmed the effect of vegetables and fruits on lowering BP. Recent clinical trials of valsartan and olmesartan have provided efficacy and safety information for use in children. SUMMARY The increased prevalence of hypertension in children in recent years emphasizes the need for a more aggressive approach to screen and diagnose elevated BP even in early childhood. Early initiation of treatment is important to decrease the risk of cardiovascular morbidity in adulthood.
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26
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Chandar J, Zilleruelo G. Hypertensive crisis in children. Pediatr Nephrol 2012; 27:741-51. [PMID: 21773822 DOI: 10.1007/s00467-011-1964-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 06/21/2011] [Accepted: 06/21/2011] [Indexed: 12/27/2022]
Abstract
Hypertensive crisis is rare in children and is usually secondary to an underlying disease. There is strong evidence that the renin-angiotensin system plays an important role in the genesis of hypertensive crisis. An important principle in the management of children with hypertensive crisis is to determine if severe hypertension is chronic, acute, or acute-on-chronic. When it is associated with signs of end-organ damage such as encephalopathy, congestive cardiac failure or renal failure, there is an emergent need to lower blood pressures to 25-30% of the original value and then accomplish a gradual reduction in blood pressure. Precipitous drops in blood pressure can result in impairment of perfusion of vital organs. Medications commonly used to treat hypertensive crisis in children are nicardipine, labetalol and sodium nitroprusside. In this review, we discuss the pathophysiology, differential diagnosis and recent developments in management of hypertensive crisis in children.
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Affiliation(s)
- Jayanthi Chandar
- Department of Pediatrics, Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL, USA
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27
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Stephens MM, Fox BA, Maxwell L. Therapeutic options for the treatment of hypertension in children and adolescents. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2012; 6:13-25. [PMID: 22408373 PMCID: PMC3296488 DOI: 10.4137/ccrpm.s7602] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Primary hypertension in children is increasing in prevalence with many cases likely going undiagnosed. The prevalence is currently estimated at between 3%-5% in the United States and may be higher in certain ethnic groups. Primary hypertension, once felt to be rare in children, is now considered to be about five times more common than secondary hypertension. This review provides information to guide physicians through an organized approach to: 1) screening children and adolescents for hypertension during routine visits; 2) using normative percentile data for diagnosis and classification; 3) performing a clinical evaluation to identify the presence of co-morbidities; 4) initiating a plan of care including subsequent follow-up blood pressure measurements, therapeutic lifestyle changes and pharmacologic therapies.
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Affiliation(s)
- Mary M Stephens
- Department of Family and Community Medicine Christiana Care Health System
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28
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Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol 2012; 27:17-32. [PMID: 21258818 DOI: 10.1007/s00467-010-1755-z] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 12/16/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
Advances in the ability to identify, evaluate, and care for infants with hypertension, coupled with advances in the practice of Neonatology, have led to an increased awareness of hypertension in modern neonatal intensive care units. This review will present updated data on blood pressure values in neonates, with a focus on the changes that occur over the first days and weeks of life in both term and preterm infants. Optimal blood pressure measurement techniques as well as the differential diagnosis of hypertension in the neonate and older infants will be discussed. Recommendations for the optimal immediate and long-term evaluation and treatment, including potential treatment parameters, will be presented. We will also review additional information on outcome that has become available over the past decade.
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Affiliation(s)
- Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
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29
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Abstract
Hypertensive crisis is a relatively rare event and is associated with significant morbidity and mortality in adults and pediatric patients alike. Rapid, safe, and effective treatment is imperative to alleviate immediate presenting clinical symptoms, prevent devastating morbidity, preserve long-term quality of life, and prevent mortality. Many medications in the hypertensive crisis arsenal have been used for nearly half a century. Nearly all treatment options have been utilized in children for decades, yet reliable data and sound clinical literature remain elusive. Every agent considered to be a first-line, second-line, or adjunctive option has yet to be evaluated in a randomized controlled trial in pediatric patients. With a paucity of clinical data to form evidence-based decisions, the clinician must rely entirely on the extrapolation from adult data and small retrospective studies, case series, and case reports of medication use in pediatric patients. Although more research in the treatment of pediatric hypertensive crisis is desperately needed, current practice demands a sharp knowledge of the pediatric clinical literature and pharmacology in this area as an essential tool to consistently improve patient outcomes with respect to morbidity and mortality.
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Affiliation(s)
- Christopher A Thomas
- Department of Pharmacy, Riley Hospital for Children - Indiana University Health, Indianapolis, IN 46202, USA.
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30
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Peacock WF, Hilleman DE, Levy PD, Rhoney DH, Varon J. A systematic review of nicardipine vs labetalol for the management of hypertensive crises. Am J Emerg Med 2011; 30:981-93. [PMID: 21908132 DOI: 10.1016/j.ajem.2011.06.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 05/27/2011] [Accepted: 06/30/2011] [Indexed: 11/16/2022] Open
Abstract
Hypertensive emergencies are acute elevations in blood pressure (BP) that occur in the presence of progressive end-organ damage. Hypertensive urgencies, defined as elevated BP without acute end-organ damage, can often be treated with oral agents, whereas hypertensive emergencies are best treated with intravenous titratable agents. However, a lack of head-to-head studies has made it difficult to establish which intravenous drug is most effective in treating hypertensive crises. This systematic review presents a synthesis of published studies that compare the antihypertensive agents nicardipine and labetalol in patients experiencing acute hypertensive crises. A MEDLINE search was conducted using the term "labetalol AND nicardipine AND hypertension." Conference abstracts were searched manually. Ultimately, 10 studies were included, encompassing patients with hypertensive crises across an array of indications and practice environments (stroke, the emergency department, critical care, surgery, pediatrics, and pregnancy). The results of this systematic review show comparable efficacy and safety for nicardipine and labetalol, although nicardipine appears to provide more predictable and consistent BP control than labetalol.
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Affiliation(s)
- W Frank Peacock
- Department of Emergency Medicine E19, The Cleveland Clinic, Cleveland, OH 44195, USA.
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31
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Horn DG, Trame MN, Hempel G. The management of hypertensive emergencies in children after stem cell transplantation. Int J Clin Pharm 2011; 33:165-76. [PMID: 21394568 DOI: 10.1007/s11096-011-9495-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
AIM OF THE REVIEW This work presents a short overview on the available data about drugs that are currently used to treat hypertensive emergencies in children with a focus on incidents after stem cell transplantation. It shows that the pediatric use of all hypotensive agents appears to be mainly based on personal experience of the attending physicians rather than on convincing clinical trials. METHOD A literature search was performed in MEDLINE, through PubMed, using the medical subject headings (MeSH) hypertensive emergencies, nifedipine, nicardipine, and children. Further articles were identified by checking cross-references of articles and books. RESULTS Hypertensive emergencies in children after stem cell transplantation usually have a renal etiology, because of the treatment with the calcineurin inhibitors cyclosporine and tacrolimus. In these severe cases an immediate action is necessary to avoid possible appearance or exacerbation of endorgan damage. Because of their mechanism of action and a potential nephroprotective effect calcium channel blockers may be particularly suitable in cases of hypertensive emergencies. An intravenous application of nifedipine may compensate the difficulties of accurate dosing, but keeping in mind possible severe side effects and the lack of published experience its use in children is at least questionable. Nicardipine appears to be the hypotensive agent of first choice. In adults, the treatment of hypertensive emergencies with intravenous nicardipine is well-documented, but for an evaluation of safety in pediatric use, the published studies and case reports appear to be barely adequate. CONCLUSION The actual treatment approaches vary widely, demonstrating the lack of hard science on which current treatment of hypertensive emergencies in children is based. The hypotensive agent for the individual situation should be chosen considering the properties, side effects, the limited experiences with its use and the patient's anamnesis.
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Affiliation(s)
- D G Horn
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Münster, Münster, Germany
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