Characteristics of systemic hypertension in preterm children

Assessment of Vascular Indices by Abdominal Aortic Ultrasonography in Preterm Neonates with Bronchopulmonary Dysplasia

Preterm infants with bronchopulmonary dysplasia (BPD) frequently encounter systemic hypertension, yet the underlying cause remains elusive. Given the absence of prior investigations concerning the correlation between systemic hypertension and aortic thickness, we undertook this study to assess and juxtapose diverse vascular indices amidst preterm neonates with BPD, preterm neonates lacking BPD, and healthy neonates, utilizing abdominal aorta ultrasonography. This cross-sectional study encompassed 20 preterm neonates, 20 preterm neonates with BPD, and 20 healthy neonates, meticulously matched for sex and postnatal age. Comprehensive demographic, anthropometric, and clinical evaluation data were documented. The neonates underwent abdominal aortic ultrasonography for comparative evaluation of aortic wall thickness and vasomotor function across the three groups. The study revealed that neonates with BPD exhibited a notably higher average systolic blood pressure than preterm and term neonates (P < 0.05). Conversely, echocardiographic parameters such as input impedance, and arterial wall stiffness index displayed no substantial variance among the three groups (P > 0.05). The mean (SD) aortic intima-media thickness (aIMT) for preterm neonates with BPD, preterm neonates, and term neonates were 814 (193.59) μm, 497.50 (172.19) μm, and 574.00 (113.20) μm, correspondingly (P < 0.05). Furthermore, the mean (SD) pulsatile diameter for preterm neonates with BPD, preterm neonates, and term neonates were 1.52 (0.81) mm, 0.91 (0.55) mm, and 1.34 (0.51) mm, respectively (P < 0.05). Following adjustment for birth weight, sex, and gestational age at birth, the study identified a noteworthy correlation between aIMT and BPD. The investigation concluded that the mean aortic intima-media thickness (aIMT) was significantly elevated in preterm neonates with BPD, signifying a potential early indicator of atherosclerosis and predisposition to future heightened blood pressure and cardiovascular ailments. Consequently, the study postulates that aIMT could be a consistent and well-tolerated marker for identifying BPD patients at risk of developing these health complications.

Oral sodium supplementation on growth and hypertension in preterm infants: an observational cohort study

OBJECTIVE

To evaluate the association between enteral sodium supplementation on growth and hypertension (HTN) in preterm infants.

STUDY DESIGN

A retrospective cohort study of infants born between 22-32 weeks and weighing 450-1500 grams (N = 821). Enteral sodium supplementation amounts, systolic blood pressures (SBP), weight gain, and other infant and maternal risk factors for HTN were electronically extracted.

RESULTS

Infants receiving sodium supplementation were smaller and less mature. Sodium supplementation improved serum sodium levels, weight gain, and head circumference growth without causing hypernatremia. There was no correlation between urine and serum sodium or urine sodium and weight gain. Although infants receiving sodium had higher average SBP and rates of HTN, analysis demonstrated sodium supplementation did not increase odds of hypertension (ORADJ 1.02;0.64-1.64). Postnatal steroids were associated with HTN.

CONCLUSIONS

In preterm infants with poor weight gain, enteral sodium supplementation improved growth without increasing hypertension or hypernatremia.

Exome sequencing implicates ancestry-related Mendelian variation at SYNE1 in childhood-onset essential hypertension

Childhood-onset essential hypertension (COEH) is an uncommon form of hypertension that manifests in childhood or adolescence and, in the United States, disproportionately affects children of African ancestry. The etiology of COEH is unknown, but its childhood onset, low prevalence, high heritability, and skewed ancestral demography suggest the potential to identify rare genetic variation segregating in a Mendelian manner among affected individuals and thereby implicate genes important to disease pathogenesis. However, no COEH genes have been reported to date. Here, we identify recessive segregation of rare and putatively damaging missense variation in the spectrin domain of spectrin repeat containing nuclear envelope protein 1 (SYNE1), a cardiovascular candidate gene, in 3 of 16 families with early-onset COEH without an antecedent family history. By leveraging exome sequence data from an additional 48 COEH families, 1,700 in-house trios, and publicly available data sets, we demonstrate that compound heterozygous SYNE1 variation in these COEH individuals occurred more often than expected by chance and that this class of biallelic rare variation was significantly enriched among individuals of African genetic ancestry. Using in vitro shRNA knockdown of SYNE1, we show that reduced SYNE1 expression resulted in a substantial decrease in the elasticity of smooth muscle vascular cells that could be rescued by pharmacological inhibition of the downstream RhoA/Rho-associated protein kinase pathway. These results provide insights into the molecular genetics and underlying pathophysiology of COEH and suggest a role for precision therapeutics in the future.

Echocardiography Assessment of Left Ventricular Function in Extremely Preterm Infants, Born at Less Than 28 Weeks' Gestation, With Bronchopulmonary Dysplasia and Systemic Hypertension

BACKGROUND

The survival of smaller and more immature premature infants has been associated with lifelong cardiorespiratory comorbidities. Infants with bronchopulmonary dysplasia (BPD) undergo routine screening echocardiography to evaluate for development of chronic pulmonary hypertension, a late manifestation of pulmonary vascular disease.

METHODS

Our aim was to evaluate left ventricular (LV) performance in infants with BPD and pulmonary vascular disease who developed systemic hypertension. We hypothesized that infants with hypertension were more likely to have impaired LV performance. We present a single-center cross-sectional study of premature infants born at less than 28 0/7 weeks' gestational age with a clinical diagnosis of BPD. Infants were categorized by the systolic arterial pressure (SAP) at time of echocardiography as hypertensive (SAP ≥90 mm Hg) or normotensive (SAP <90 mm Hg). Sixty-four patients were included.

RESULTS

Infants with hypertension showed altered LV diastolic function with prolonged tissue Doppler imaging-derived isovolumic relaxation time (54.2 ± 5.1 vs 42.9 ± 8.2, P < .001), lower E:A, and higher E:e'. Indices of left heart volume/pressure loading (left atrium:aorta and LV end-diastolic volume [6.1 ± 2 vs 4.2 ± 1.2, P < .001]) were also higher in the hypertensive group. Finally, infants in the hypertensive group had higher pulmonary vascular resistance index (4.42 ± 1.1 vs 3.69 ± 0.8, P = .004).

CONCLUSIONS

We conclude that extremely preterm infants with BPD who develop systemic hypertension are at risk of abnormal LV diastolic dysfunction. Increased pulmonary vascular resistance index in the hypertensive group may relate to pulmonary venous hypertension secondary to LV dysfunction. This is an important consideration in this cohort when selecting the physiologically most appropriate treatment.

Clinical characteristics of pediatric hypertension: a multicenter study in China

OBJECTIVES

Hypertension in children has attracted increasing attention. However, clinical-based studies investigating characteristics and secular trends of pediatric hypertension remain limited. This study aimed to investigate the clinical characteristics and secular trends of different types of hypertension among hospitalized children in China.

METHODS

This retrospective analysis was based on medical records from nine tertiary children's hospitals in China during 2010∼2020. A total of 5847 pediatric inpatients (aged <18 years) with the diagnosis of hypertension were enrolled. Information on the clinical characteristics of each patient was obtained from their first admission records.

RESULTS

During the past decade, secondary hypertension sustained to be the dominant type of hypertension in children, with the proportion increased from 51.2% during 2010∼2015 to 59.8% during 2016∼2020. The main causes of secondary hypertension were neurologic disorders in children aged 0∼2 years, which changed to renal diseases after 3 years of age. Compared with primary hypertension, secondary hypertension was common in girls (43.1 vs. 23.3%) and children under 5 years of age (32.2 vs. 2.1%). Moreover, over four-fifths of primary hypertensive individuals had obesity and obesity-related comorbidities, and the proportion of clusters of one or more comorbidities increased in the past decade (79.7 → 85.2%).

CONCLUSION

Secondary hypertension sustained to be the dominant type of hypertension among children, especially in girls. Renal diseases were the most common causes of secondary hypertension in children, followed by rheumatic immune diseases. For primary hypertension, over four-fifths of inpatients had obesity and obesity-related diseases, and the proportion kept rising.

Neonatal hypertension: concerns within and beyond the neonatal intensive care unit

Neonatal hypertension occurs in 1%-2% of neonates in the neonatal intensive care unit (NICU) although may be underdiagnosed. Blood pressure values in premature neonates change rapidly in the first days and weeks of life which may make it more difficult to recognize abnormal blood pressure values. In addition, the proper blood pressure measurement technique must be used to ensure the accuracy of the measured values as most blood pressure devices are not manufactured specifically for this population. In premature neonates, the cause of the hypertension is most commonly related to prematurity-associated complications or management while in term neonates is more likely to be due to an underlying condition. Both oral and intravenous antihypertensive medications can be used in neonates to treat high blood pressure although none are approved for use in this population by regulatory agencies. The natural history of most neonatal hypertension is that it resolves over the first year or two of life. Of concern are the various neonatal risk factors for later cardiovascular and kidney disease that are present in most NICU graduates. Prematurity increases the risk of adulthood hypertension while intrauterine growth restriction may even lead to hypertension during childhood. From neonates through to adulthood NICU graduates, this review will cover each of these topics in more detail and highlight the aspects of blood pressure management that are established while also highlighting where knowledge gaps exist.

Endotypes of Prematurity and Phenotypes of Bronchopulmonary Dysplasia: Toward Personalized Neonatology

Bronchopulmonary dysplasia (BPD), the chronic lung disease of prematurity, is increasingly recognized as the consequence of a pathological reparative response of the developing lung to both antenatal and postnatal injury. According to this view, the pathogenesis of BPD is multifactorial and heterogeneous with different patterns of antenatal stress (endotypes) that combine with varying postnatal insults and might distinctively damage the development of airways, lung parenchyma, interstitium, lymphatic system, and pulmonary vasculature. This results in different clinical phenotypes of BPD. There is no clear consensus on which are the endotypes of prematurity but the combination of clinical information with placental and bacteriological data enables the identification of two main pathways leading to birth before 32 weeks of gestation: (1) infection/inflammation and (2) dysfunctional placentation. Regarding BPD phenotypes, the following have been proposed: parenchymal, peripheral airway, central airway, interstitial, congestive, vascular, and mixed phenotype. In line with the approach of personalized medicine, endotyping prematurity and phenotyping BPD will facilitate the design of more targeted therapeutic and prognostic approaches.

Systemic Hypertension in Infants with Bronchopulmonary Dysplasia

PURPOSE OF REVIEW

Neonatal hypertension is increasingly recognized as improvements in neonatal intensive care have led to increased survival of premature infants. Among infants with bronchopulmonary dysplasia (BPD), the rates of hypertension are much higher than the general neonatal population. However, the etiology and pathophysiology of this increased risk of hypertension in neonates with lung disease remain unclear.

RECENT FINDINGS

Among infants with bronchopulmonary dysplasia, the rates of hypertension are much higher than the general neonatal population. New studies suggest outcomes in neonates with BPD with hypertension are usually good, with resolution of hypertension in most infants with lung disease. Several potential mechanisms of hypertension in this patient population have been recently proposed. This review focuses on the recent epidemiologic data on prevalence of hypertension in neonates with bronchopulmonary dysplasia, reviews the typical clinical course, and discusses available strategies for management of infants with bronchopulmonary dysplasia that develop hypertension.

Microcephalic Osteodysplastic Primordial Dwarfism Type II With Associated Glucose-6-Phosphate Dehydrogenase Deficiency in a Saudi Girl

Microcephalic primordial dwarfism is a group of disorders that result in growth restriction and multiple morbidities. The condition is subdivided into three categories, with microcephalic osteodysplastic primordial dwarfism type II (MOPDII) being the most prevalent. Globally, only a few cases have been reported, with only available information about these disorders described in the literature. In this case report, we present the clinical findings seen in an infant with MOPDII in Saudi Arabia with associated glucose-6-phosphate dehydrogenase deficiency hemolytic anemia.

The associations of low birth weight with primary hypertension in later life: A systematic review and meta-analysis

Background:

The purpose of this study was to evaluate of the study the role of LBW on EH in children and by studying the existing published literature.

Materials and Methods:

A comprehensive literature search for original studies was conducted in Clarivate Analytics Web of Science, PubMed, Scopus, and Embase until July 2019. The search used all of the main keywords and its synonyms include essential hypertension, primary hypertension, essential arterial hypertension, idiopathic hypertension, spontaneous hypertension; child, childhood, children, pediatric, pediatrics, infant, infancy, newborn, neonatal, adolescence, teenagers; and BW, newborn weight, neonatal weight, BW.

Results:

Twelve articles were eligible for the final evaluation. Due to the difference among studies in the report, studies were divided into two-part. The first part, articles were reported in the LBW and NBW groups (interested outcome were SBP and DBP), and the second part was composed as the EH and NR groups (interested outcome were LBW and NBW). In the first part, SMD for SBP was -1.09 with 95% CI (-1.91,-0.26), and was statistically significant (Z=2.58, P=0.010). As well, SMD for DBP was -0.68 with 95% CI (-1.32,-0.05) statistically significant (Z=2.10, P=0.036). In the second part, SMD for SBP was 0.77 with 95% CI (-0.85, 2.39), and was statistically significant (Z=0.93, P=0.352). Subgroup analysis was performed on the pre-term and full- term babies. SMD for SBP was -0.08 with 95% CI (-0.51, 0.35) in the pre-term, and the full-term was -2.07 with 95% CI (-3.47, -0.67). As well, SMD for DBP was -0.02 with 95% CI (-0.20, 0.17) in the preterm, and the term was -1.35 with 95% CI (-1.57, -1.13).

Conclusion:

Although findings of the correlation between BW and EHTN have conflicted. To our knowledge, this is the first report that attempts to a conclusion.

Association between High-Sensitivity C-Reactive Protein and Blood Pressure among Children with History of Low Birth Weight Appropriate for Gestational Age, Low Birth Weight Small for Gestational Age, and Normal Birth Weight in Manado, North Sulawesi

Over the past years, low birth weight (LBW) has been proven to be attributed to a wide variety of long-term morbidities, including hypertension. This study aimed to investigate the association between high-sensitivity C-reactive protein (hs-CRP) and blood pressure (BP) in children with a history of LBW appropriate for gestational age (LBW AGA), LBW small for gestational age (LBW SGA), and normal birth weight appropriate for gestational age (NBW AGA). The study cohort comprised children aged 9-12 years who were born in 2007-2010 at Prof. Dr. R. D. Kandou General Hospital Manado and resided in the city of Manado from March to August 2019. The children who met the inclusion criteria were evaluated for BP and hs-CRP level. A total of 120 children who met the inclusion criteria were enrolled in this study. Analysis for the association between LBW and NBW with systolic blood pressure (SBP) showed statistical significance (p=0.007). Linear regression analysis indicated a strongly significant influence of BW on serum hs-CRP level and SBP. Every 1 g increase in BW results in a decrease of serum hs-CRP level of 0.001 mg/L. Every 1 g increase in BW is attributed to 0.004 mmHg decrease in SBP. An increase in hs-CRP by 1 mg/L increases the SBP by 4.99 mmHg and DBP by 2.88 mmHg. LBW significantly correlates with hs-CRP level and higher SBP. A comprehensive education must be undertaken for the families who have children with LBW to reduce the risk of developing hypertension later in their life.

Neonatal hypertension: cases, causes, and clinical approach

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.

Antenatal exposure to nonsteroidal anti-inflammatory drugs and risk of neonatal hypertension

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used as tocolytics, which are medications that suppress uterine contractions for preterm birth prevention. Their effect on cerebral/systemic vascular beds poses the question of whether antenatal NSAID exposure is associated with neonatal hypertension. We performed a retrospective case-control study in a tertiary neonatal intensive care unit, including 40 hypertension cases (hospitalized neonates ≥ 35 weeks with systolic BP > 100 mm Hg on three consecutive days) compared to 134 controls matched by gestational age at delivery, plurality, and delivery date. Cases and controls were compared by antenatal NSAID exposure, other common tocolytics, and maternal/neonatal characteristics and complications. Multivariable logistic regression was used to estimate the odds of hypertension among those with prenatal exposure to NSAIDs versus those without exposure. Newborns with hypertension had a lower gestational age at delivery and increased incidence of neonatal complications, including respiratory distress syndrome, bronchopulmonary dysplasia, surfactant administration, longer duration of ventilation, and history of umbilical artery catheterization. Days of indomethacin exposure were positively associated with greater odds of neonatal hypertension (OR 1.17 [1.00 to 1.38], P = 0.055), even after adjustment for other factors associated with neonatal hypertension. Newborns with hypertension were less likely to have been exposed to calcium channel blockers as a tocolytic. The results of our study suggest an association between prenatal exposure to nonsteroidal anti-inflammatory drugs and neonatal hypertension. Furthermore, our data suggest that prenatal calcium channel blocker exposure may protect against the development of neonatal hypertension. Future multicenter studies are needed to understand the risks of tocolytics and subsequent consequences in preterm infants.

Antihypertensive drug exposure in premature infants from 1997 to 2013

BACKGROUND

Systemic hypertension is increasingly recognised in premature infants. There is limited evidence regarding treatment, and most published treatment recommendations are based solely on expert opinions.

METHODS

We identified all infants born ⩽32 weeks of gestation and ⩽1500 g birth weight discharged from one of 348 neonatal ICUs managed by the Pediatrix Medical Group between 1997 and 2013. We defined antihypertensive drugs as vasodilators, angiotensin-converting enzyme inhibitors, β receptor blockers, calcium channel blockers, and central α2 receptor agonists. We compared characteristics between infants who were treated with at least one antihypertensive drug during their initial hospitalisation and infants who were not prescribed antihypertensive drugs using Wilcoxon's ranked sum test or Pearson's χ2-test.

RESULTS

We identified 2504/119,360 (2.1%) infants who required at least one antihypertensive drug. The median postnatal age of first exposure was 48 days (25th, 75th percentile 15, 86), and the median length of therapy was 6 days (1, 16). Hydralazine was the most commonly prescribed antihypertensive with 1280/2504 (51.1%) treated infants exposed to the drug. More than two antihypertensive drugs were administered in 582/2504 (23.2%) infants, and 199/2097 (9.5%) of the treated infants were discharged home on antihypertensive therapy. Infants who received antihypertensive drugs were of lower gestational age (p<0.001) and birth weight (p<0.001) compared with infants not prescribed antihypertensive drugs.

CONCLUSIONS

Our study is the largest to describe current antihypertensive drug exposure in a cohort of exclusively premature infants born ⩽32 weeks of gestation. We found wide variations in practice for treating hypertension in premature infants.

Long-term metabolic risk among children born premature or small for gestational age

Accumulating evidence suggests that both the intrauterine environment and growth during early life can influence the development of chronic noncommunicable diseases, such as type 2 diabetes mellitus and cardiovascular disease, in adulthood. Here, we review the available human data supporting increased metabolic risk among children born premature or small for gestational age; the adrenal and pubertal modifications that contribute to this risk; metabolic changes that occur during adolescence and early adulthood; and approaches to potentially modify or decrease risk of metabolic disease. The risks associated with delivery at term or preterm are compared for each period of life. Knowledge of these associations is fundamental for the paediatric community to develop preventive strategies early during postnatal life.

Neonatal hypertension

Neonatal hypertension (HT) is a frequently under reported condition and is seen uncommonly in the intensive care unit. Neonatal HT has defined arbitrarily as blood pressure more than 2 standard deviations above the base as per the age or defined as systolic BP more than 95% for infants of similar size, gestational age and postnatal age. It has been diagnosed long back but still is the least studied field in neonatology. There is still lack of universally accepted normotensive data for neonates as per gestational age, weight and post-natal age. Neonatal HT is an important morbidity that needs timely detection and appropriate management, as it can lead to devastating short-term effect on various organs and also poor long-term adverse outcomes. There is no consensus yet about the treatment guidelines and majority of treatment protocols are based on the expert opinion. Neonate with HT should be evaluated in detail starting from antenatal, perinatal, post-natal history, and drug intake by neonate and mother. This review article covers multiple aspects of neonatal hypertension like definition, normotensive data, various etiologies and methods of BP measurement, clinical features, diagnosis and management.