Ambulatory blood pressure monitoring in children and adolescents

Technical solution for data collection, data safety and data privacy legislation: experiences from the SWEET study

BACKGROUND

One of the most important tasks of the SWEET study is benchmarking the data collected. Information on the occurrence of the disease of diabetes, the treatment, and their outcomes in children from the different member states of European Union (EU) is crucial. How the collection of data is realized is essential, concerning both the technical issues and the results. The creation of SWEET Centers of Reference (CoR), all over Europe will be facilitated by the access to safe data collection, where legal aspects and privacy are ascertained.

OBJECTIVE

To describe the rationale for- and the technical procedure in the data collection implementation, in the SWEET study.

SUBJECTS

Selected data on all patients treated at SWEET CoR are collected.

METHODS

The SWEET project data collection and management system, consists of modular components for data collection, online data interchange, and a database for statistical analysis.

CONCLUSION

The SWEET study and the organization of CoR aims for the goal of offering an updated, secure, and continuous evaluation of diabetes treatment regimens for all children with diabetes in Europe. To support this goal, an appropriate and secure data management system as described in this paper has been created.

The role of obesity, salt and exercise on blood pressure in children and adolescents

The increasing trends of blood pressure (BP) in children and adolescents pose great concern for the burden of hypertension-related cardiovascular disease. Although primary hypertension in childhood is commonly associated with obesity, it seems that other factors, such as dietary sodium and exercise, also influence BP levels in children and adolescents. Several studies support that sympathetic nervous system imbalance, impairment of the physiological mechanism of pressure natriuresis, hyperinsulinemia and early vascular changes are involved in the mechanisms causing elevated BP in obese children and adolescents. Under the current evidence on the association of salt intake and BP, dietary sodium restriction appears to be a rational step in the prevention of hypertension in genetically predisposed children and adolescents. Finally, interventional studies show that regular aerobic exercise can significantly reduce BP and restore vascular changes in obese with hypertensive pediatric patients. This article aims to summarize previous studies on the role of obesity, salt intake and exercise on BP in children and adolescents.

Questionnaire survey on pediatric hypertension in Japan and Korea

BACKGROUND

Hypertension (HTN) is no longer viewed as an adult disease. The purpose of the present study was to understand how hypertensive children are evaluated and managed, by surveying pediatricians in Japan and South Korea.

METHODS

A questionnaire was mailed to 109 Japanese (JA) and 159 Korean (KO) pediatric cardiologists, pediatric nephrologists, and other pediatricians.

RESULTS

A total of 127 replies were received (response rate 47%). Most of respondents did not check blood pressure (BP) routinely in outpatient clinics (JA 77%, KO 88%). A mercury sphygmomanometer was the most commonly used method for BP measurements (JA 72%, KO 62%). BP treatment goals were usually set at the 95th percentile for age, gender, and height (JA 47%, KO 54%). More KO used a lower goal in children with primary HTN than JA. KO respondents preferred angiotensin-converting enzyme inhibitors (ACEI) as initial agents regardless of underlying diseases whereas JA respondents chose various medications, that is, calcium channel blockers, diuretics, and ACEI. For BP monitoring, self-monitoring was found to be most frequent in both countries (JA 80%, KO 57%). Ambulatory BP monitoring was not frequently utilized in both countries (JA 33% KO 34%).

CONCLUSION

The current assessment, management and differing trends in pediatric HTN in Japan and Korea have been identified in the present study. Pediatricians should be aware of the growing implications of HTN in children.

Poor glycemic control is associated with abnormal changes in 24-hour ambulatory blood pressure in children and adolescents with type 1 diabetes mellitus

INTRODUCTION

Twenty-four hour ambulatory blood pressure (ABPM) is emerging as a valuable tool to assess blood pressure (BP) changes in children with type 1 diabetes mellitus (DM1). Hypertension (HTN) is an important risk factor for, and may be an important indicator of diabetic nephropathy. Early accurate identification of HTN in DM1 may improve outcomes.

AIM

To evaluate BP in adolescents with DM1 using 24-hour ABPM, and to identify risk factors associated with abnormal blood pressure.

METHOD

The ABPM of 105 children with DM1 was reviewed. Mean systolic BP (sBP) percentile was determined from the National High Blood Pressure Education Program (NHBPEP) tables. The patients with abnormal sBP were compared to those with normal sBP with respect to age, race, sex, body mass index (BMI) percentile, duration of DM1, average hemoglobin A1c (HbA1c) over the preceding year, and family history of hypertension.

RESULTS

Mean sBP was normal in 71%, whereas 23% had pre-hypertension, and 6% had stage 1 hypertension. Those who had abnormal sBP (pre-hypertension and stage 1 hypertension) had higher HbA1c (p = 0.023) and were more likely to be male (p = 0.03) than those with normal sBP.

CONCLUSION

Stage 1 hypertension is present in 6%, and pre-hypertension in 23% of adolescents with DM1. Poor diabetes control and male gender appear to be risk factors for abnormal sBP as measured by 24-hour ambulatory blood pressure monitoring.

Blood pressure load, proteinuria and renal function in pre-hypertensive children

It is as yet unclear whether blood pressure load (BPL) can affect renal function in pre-hypertensive children. We have studied 250 children, with a mean age of 9.12 +/- 3.28 years, with the aim of assessing if pre-hypertension in children can indeed affect renal function. The study cohort consisted of 146 children with pre-hypertension (group P) and a control group of 104 children with normal blood pressure (group C). All children were tested for orthostatic proteinuria, an exclusion criterion, glomerular filtration rate (GFR), and proteinuria, and ambulatory blood pressure monitoring was performed. Based on the BPL, group P was further subdivided into group P1 (BPL <or= 40%, low BPL) and group P2 (BPL > 40%, high BPL). We found that GFR was reduced in pre-hypertensive children (90.74 +/- 48.69 vs. 110.32 +/- 20.30 ml/min per 1.73 m(2), p < 0.0001) and that proteinuria was increased (145.36 +/- 110.91 vs. 66.84 +/- 42.94 mg/m(2) per 24 h; p < 0.0001). However, mean values were still within normal limits. A comparison of the group with high BPL and that with low BPL revealed that the former had relatively reduced GFR (79.15 +/- 42.04 vs. 96.78 +/- 51.20 ml/min per 1.73 m(2); p < 0.006) and increased proteinuria (198.29 +/- 142.17 vs. 118.31 +/- 80.07 mg/m(2) per 24 h; p < 0.036). In comparison to the reference values of the normal population, the GFR was reduced and proteinuria was increased in the group with high BPL. Based on our results, pre-hypertension in children with high BPL seems to be associated with reduced GFR and increased proteinuria. A reasonable doubt remains that the patients with higher proteinuria and larger reduction of GFR may harbor an as yet unknown subclinical renal condition responsible for the onset of pre-hypertension. Therefore, children with even mildly elevated BP are at risk of developing renal damage and should change their lifestyle to prevent further increases in BP.

Early changes in 24-hour ambulatory blood pressure are associated with high normal albumin excretion rate in children with type 1 diabetes mellitus

OBJECTIVE

The relationship between urinary albumin excretion rate (AER) and elevated blood pressure (BP) is unclear as a cause-effect phenomenon in the development of diabetic nephropathy. The aim of this study was to examine the association between AER, HbA1c and BP in children with normoalbuminuria.

METHODS

24-hour ambulatory BP assessment was performed in 78 children with type 1 diabetes mellitus (DM1), age mean +/- SD 13.4 +/- 2.7 yr, range 7.3-18.3 yr, DM1 duration mean +/- SD 6.6 +/- 2.9 yr, range 2.1-11.9 yr. Using generalised linear mixed models with systolic (SBP) and diastolic (DBP) blood pressure as dependent variables, the effects of AER and HbA1c were examined, adjusting for age, gender, DM1 duration and insulin dose.

RESULTS

Patients with high normal AER (7-20 microg/min) had higher SBP during daytime and night-time compared to the low normal AER (< or = 7 microg/min) (mean +/- SD 118.20 +/- 7.98 and 110.33 +/- 7.08 mm Hg, p = 0.02; mean +/- SD 108.76 +/- 9.21 and 100.20 +/- 7.75 mm Hg, p = 0.03, respectively). DBP was also higher both during day- and night-time when compared to the < or = 7 microg/min group (mean +/- SD 73.40 +/- 6.50 and 64.86 +/- 5.67 mm Hg, p = 0.002; mean +/- SD 62.50 +/- 6.75 and 56.30 +/- 5.56 mm Hg, p = 0.03 day- and night-time, respectively).

CONCLUSION

A rise in SBP and DBP is associated with increased levels of AER even within the normal range.

Twenty-four-hour ambulatory blood pressure monitoring in infants and toddlers

During the past several years, 24-hour (24-h) ambulatory blood pressure monitoring (ABPM) has become a useful tool for the diagnosis and management of children and adolescents with elevated blood pressure (BP). Some reports have also provided blood pressure nomograms for particular devices. However, there are very few reports of the use of this method in very young children. In our study we investigated the applicability of ABPM in 97 healthy infants and toddlers, aged from 2 to 30 months. A satisfactory ABPM profile was obtained in 86.6% of the children, with an average of 75.0% satisfactory BP recordings. The mean +/- SD systolic and diastolic BP of healthy infants and toddlers was 99+/-12/62+/-12 mmHg during the daytime and 95+/-11/57+/-10 mmHg during the night, with no gender difference being observed. The 24-h mean +/- SD systolic and diastolic BP, which may be a more appropriate measure of BP in this particular age group, was found to be 97+/-12/59+/-11 mmHg. We also confirmed the increase in systolic and diastolic BP with increased height (length). There was only a slight nocturnal decrease in BP. We conclude that this method is applicable for the assessment of blood pressure in very young children.

A diagnostic approach for the child with hypertension

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