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Taksande A, Khandelwal R, Javvaji CK. Critical Insights Into Neonatal Hypertension: A Comprehensive Review of Current Understanding and Management Strategies. Cureus 2024; 16:e62421. [PMID: 39011229 PMCID: PMC11248457 DOI: 10.7759/cureus.62421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/15/2024] [Indexed: 07/17/2024] Open
Abstract
Hemodynamic adaptation to the extrauterine environment results in rapid blood pressure (BP) fluctuations during the neonatal period, particularly in premature infants. BP levels in neonates are influenced by several factors, including gestational age, birth weight, and maternal health. Diagnosing neonatal hypertension (HTN) typically requires a thorough diagnostic evaluation. Common etiologies include renal parenchymal disease, umbilical catheter-related thrombosis, and chronic lung disease. Despite the prevalence of HTN-associated factors and risk factors in neonates, management can be challenging. Fortunately, most cases of neonatal HTN resolve over time. This review explores these concepts and highlights the evidentiary gaps that need to be addressed.
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Affiliation(s)
- Amar Taksande
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Rahul Khandelwal
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Chaitanya Kumar Javvaji
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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2
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Seo J, Gaddis NC, Patchen BK, Xu J, Barr RG, O'Connor G, Manichaikul AW, Gharib SA, Dupuis J, North KE, Cassano PA, Hancock DB. Exploiting meta-analysis of genome-wide interaction with serum 25-hydroxyvitamin D to identify novel genetic loci associated with pulmonary function. Am J Clin Nutr 2024; 119:1227-1237. [PMID: 38484975 PMCID: PMC11130669 DOI: 10.1016/j.ajcnut.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 02/12/2024] [Accepted: 03/07/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Higher 25-hydroxyvitamin D (25(OH)D) concentrations in serum has a positive association with pulmonary function. Investigating genome-wide interactions with 25(OH)D may reveal new biological insights into pulmonary function. OBJECTIVES We aimed to identify novel genetic variants associated with pulmonary function by accounting for 25(OH)D interactions. METHODS We included 211,264 participants from the observational United Kingdom Biobank study with pulmonary function tests (PFTs), genome-wide genotypes, and 25(OH)D concentrations from 4 ancestral backgrounds-European, African, East Asian, and South Asian. Among PFTs, we focused on forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) because both were previously associated with 25(OH)D. We performed genome-wide association study (GWAS) analyses that accounted for variant×25(OH)D interaction using the joint 2 degree-of-freedom (2df) method, stratified by participants' smoking history and ancestry, and meta-analyzed results. We evaluated interaction effects to determine how variant-PFT associations were modified by 25(OH)D concentrations and conducted pathway enrichment analysis to examine the biological relevance of our findings. RESULTS Our GWAS meta-analyses, accounting for interaction with 25(OH)D, revealed 30 genetic variants significantly associated with FEV1 or FVC (P2df <5.00×10-8) that were not previously reported for PFT-related traits. These novel variant signals were enriched in lung function-relevant pathways, including the p38 MAPK pathway. Among variants with genome-wide-significant 2df results, smoking-stratified meta-analyses identified 5 variants with 25(OH)D interactions that influenced FEV1 in both smoking groups (never smokers P1df interaction<2.65×10-4; ever smokers P1df interaction<1.71×10-5); rs3130553, rs2894186, rs79277477, and rs3130929 associations were only evident in never smokers, and the rs4678408 association was only found in ever smokers. CONCLUSION Genetic variant associations with lung function can be modified by 25(OH)D, and smoking history can further modify variant×25(OH)D interactions. These results expand the known genetic architecture of pulmonary function and add evidence that gene-environment interactions, including with 25(OH)D and smoking, influence lung function.
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Affiliation(s)
- Jungkyun Seo
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - Nathan C Gaddis
- RTI International, Research Triangle Park, NC, United States
| | - Bonnie K Patchen
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, United States
| | - Jiayi Xu
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - R Graham Barr
- Divisions of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY, United States
| | - George O'Connor
- Pulmonary Center and Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Ani W Manichaikul
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, United States
| | - Sina A Gharib
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, United States; Division of Pulmonary, Critical Care and Sleep Medicine, Computational Medicine Core, Center for Lung Biology, University of Washington, Seattle, WA, United States
| | - Josée Dupuis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Kari E North
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - Patricia A Cassano
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, United States; Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, NY, United States
| | - Dana B Hancock
- RTI International, Research Triangle Park, NC, United States.
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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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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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Bertazza Partigiani N, Spagnol R, Di Michele L, Santini M, Grotto B, Sartori A, Zamperetti E, Nosadini M, Meneghesso D. Management of Hypertensive Crises in Children: A Review of the Recent Literature. Front Pediatr 2022; 10:880678. [PMID: 35498798 PMCID: PMC9051430 DOI: 10.3389/fped.2022.880678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Hypertensive emergency is a life-threatening condition associated with severe hypertension and organ damage, such as neurological, renal or cardiac dysfunction. The most recent guidelines on pediatric hypertension, the 2016 European guidelines and the 2017 American guidelines, provide recommendations on the management of hypertensive emergencies, however in pediatric age robust literature is lacking and the available evidence often derives from studies conducted in adults. We reviewed PubMed and Cochrane Library from January 2017 to July 2021, using the following search terms: "hypertension" AND "treatment" AND ("emergency" OR "urgency") to identify the studies. Five studies were analyzed, according to our including criteria. According to the articles reviewed in this work, beta-blockers seem to be safe and effective in hypertensive crises, more than sodium nitroprusside, although limited data are available. Indeed, calcium-channel blockers seem to be effective and safe, in particular the use of clevidipine during the neonatal age, although limited studies are available. However, further studies should be warranted to define a univocal approach to pediatric hypertensive emergencies.
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Affiliation(s)
- Nicola Bertazza Partigiani
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Rachele Spagnol
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Laura Di Michele
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Micaela Santini
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Benedetta Grotto
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Alex Sartori
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Elita Zamperetti
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Davide Meneghesso
- Paediatric Nephrology Unit, Department of Womens's and Children's Health, University Hospital of Padua, Padua, Italy
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6
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Severe hypertension in children needs a rapid response and thorough investigation. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-020-00782-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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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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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Siddiqi N, Shatat IF. Antihypertensive agents: a long way to safe drug prescribing in children. Pediatr Nephrol 2020; 35:2049-2065. [PMID: 31676933 PMCID: PMC7515858 DOI: 10.1007/s00467-019-04314-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 01/07/2023]
Abstract
Recently updated clinical guidelines have highlighted the gaps in our understanding and management of pediatric hypertension. With increased recognition and diagnosis of pediatric hypertension, the use of antihypertensive agents is also likely to increase. Drug selection to treat hypertension in the pediatric patient population remains challenging. This is primarily due to a lack of large, well-designed pediatric safety and efficacy trials, limited understanding of pharmacokinetics in children, and unknown risk of prolonged exposure to antihypertensive therapies. With newer legislation providing financial incentives for conducting clinical trials in children, along with publication of pediatric-focused guidelines, literature available for antihypertensive agents in pediatrics has increased over the last 20 years. The objective of this article is to review the literature for safety and efficacy of commonly prescribed antihypertensive agents in pediatrics. Thus far, the most data to support use in children was found for angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), and calcium channel blockers (CCB). Several gaps were noted in the literature, particularly for beta blockers, vasodilators, and the long-term safety profile of antihypertensive agents in children. Further clinical trials are needed to guide safe and effective prescribing in the pediatric population.
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Affiliation(s)
- Nida Siddiqi
- Department of Pharmacy, Sidra Medicine, Doha, Qatar
| | - Ibrahim F. Shatat
- Pediatric Nephrology and Hypertension, Sidra Medicine, HB. 7A. 106A, PO Box 26999, Doha, Qatar ,Weill Cornell College of Medicine-Qatar, Ar-Rayyan, Qatar ,grid.259828.c0000 0001 2189 3475Medical University of South Carolina, Charleston, SC USA
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10
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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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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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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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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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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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15
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Auda SH, Al-Omrani AH, Alanazi FK, Badran MM, Shakeel F. Design, characterization and evaluation of oral fast dissolving polymeric films of isradipine inclusion complex. Polym Bull (Berl) 2018. [DOI: 10.1007/s00289-018-2503-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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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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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: 1885] [Impact Index Per Article: 269.3] [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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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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Abstract
The incidence of neonatal hypertension (HTN) remains low, at less than 2%, and its etiology is varied. Strict definitions of HTN in neonates are unavailable, and the decision to treat is based on opinion rather than evidence. More studies are needed to define normal blood pressure in neonates and to refine current reference values, thus permitting a better definition of HTN. Most causes of neonatal HTN, the most common of which seems to be renovascular disease, are determined by history and basic clinical investigations. Treatment is guided by clinical judgment and expert opinion, given the limited number of clinical trials.
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Affiliation(s)
- Donald L Batisky
- Pediatric Hypertension Program, Children's Healthcare of Atlanta, Emory - Children's Center, 2015 Uppergate Drive North East, Atlanta, GA 30322, USA.
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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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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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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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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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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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26
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Abstract
Traditionally, antihypertensive medications were used in few children or adolescents, usually just those with underlying renal or other organ system disease. However, with recent data suggesting that the incidence of primary hypertension may be increasing in the young, it is possible that more children and adolescents will be prescribed antihypertensive agents. This article will review currently available pediatric data on the use of calcium channel blockers, agents affecting the renin-angiotensin-aldosterone system and other classes of antihypertensive medications in children, highlighting appropriate indications and safety considerations. Guidelines for use of antihypertensive medications, including choice of initial agent and how to prescribe appropriately, will be presented.
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27
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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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