Pediatric hypertension: an updated review

Dietary Strategies in the Prevention and Treatment of Hypertension in Children and Adolescents: A Narrative Review

This study aims to gather information on effective dietary strategies for the prevention and treatment of hypertension (HTN) in children and adolescents. It discusses specific nutritional models such as the Diet Approaches to Stop Hypertension (DASH diet), traditional Asian diets, plant-based diets, the Southern European traditional Atlantic diet, and the Mediterranean diet, highlighting the benefits of these approaches. The manuscript also addresses dehydration resulting from insufficient fluid intake among children, as well as the consumption of inappropriate beverages, like soft drinks and energy drinks, which contributes to the development of HTN. Additionally, it examines the role of oxidative stress in the pathomechanism of HTN in children, particularly in relation to the antioxidant potential of food components such as selenium, magnesium, and selected vitamins. The relationship between sodium and potassium intake from food and the development of HTN in children is also explored. Finally, this study discusses public health strategies for the prevention of HTN in children. A comprehensive search was performed across multiple databases, such as PubMed/MEDLINE, the Cochrane Library, Science Direct, and EBSCO. This search focused on locating English-language meta-analyses, systematic reviews, randomized clinical trials, and observational studies from around the globe.

Pediatric Hypertension: A Condition That Matters

Systemic hypertension has been considered mainly as an adult health issue for a long time, but it is now being increasingly acknowledged as a significant problem also among pediatric patients. The frequency of pediatric hypertension has grown mostly because of increases in childhood obesity and sedentary lifestyles, but secondary forms of hypertension play a role as well. Considering that unaddressed hypertension during childhood can result in enduring cardiovascular complications, timely identification and intervention are essential. Strategies for addressing this disease encompass not only lifestyle adjustments, but also the use of medications when needed. Lifestyle modifications entail encouraging a nutritious diet, consistent physical activity, and the maintenance of a healthy weight. Moreover, educating both children and their caregivers about monitoring blood pressure at home can aid in long-term management. Thus, the aim of this review is to discuss the etiologies, classification, and principles of the treatment of hypertension in pediatric patients.

Unraveling cradle-to-grave disease trajectories from multilayer comorbidity networks

We aim to comprehensively identify typical life-spanning trajectories and critical events that impact patients' hospital utilization and mortality. We use a unique dataset containing 44 million records of almost all inpatient stays from 2003 to 2014 in Austria to investigate disease trajectories. We develop a new, multilayer disease network approach to quantitatively analyze how cooccurrences of two or more diagnoses form and evolve over the life course of patients. Nodes represent diagnoses in age groups of ten years; each age group makes up a layer of the comorbidity multilayer network. Inter-layer links encode a significant correlation between diagnoses (p < 0.001, relative risk > 1.5), while intra-layers links encode correlations between diagnoses across different age groups. We use an unsupervised clustering algorithm for detecting typical disease trajectories as overlapping clusters in the multilayer comorbidity network. We identify critical events in a patient's career as points where initially overlapping trajectories start to diverge towards different states. We identified 1260 distinct disease trajectories (618 for females, 642 for males) that on average contain 9 (IQR 2-6) different diagnoses that cover over up to 70 years (mean 23 years). We found 70 pairs of diverging trajectories that share some diagnoses at younger ages but develop into markedly different groups of diagnoses at older ages. The disease trajectory framework can help us to identify critical events as specific combinations of risk factors that put patients at high risk for different diagnoses decades later. Our findings enable a data-driven integration of personalized life-course perspectives into clinical decision-making.

Elevated preoperative blood pressure and its relationship to intraoperative mean arterial pressure and blood loss in posterior spinal fusion for adolescent idiopathic scoliosis

PURPOSE

The relationship between preoperative blood pressure (BP) and intraoperative mean arterial pressure (MAP) and estimated blood loss (EBL) in pediatric spine surgery is currently unknown. The objectives of this study were to determine if elevated preoperative BP is associated with elevated intraoperative MAP, EBL, and percentage estimated blood volume (EBV) lost, and to determine if intraoperative MAP is associated with percentage of EBV lost during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

This is a retrospective cohort analysis of 209 patients undergoing PSF for AIS between 2016 and 2019 by a single surgeon. Data extracted included demographic characteristics, preoperative systolic and diastolic BP, continuous intraoperative MAP measured by arterial line, EBL, radiographic, and surgical characteristics. Time points of interest for MAP included incision and exposure. Elevated BP was defined as > 1 standard deviation above the mean BP of patients included in the study, and elevated MAP was defined as > 65 mmHg.

RESULTS

Elevated preoperative systolic BP was associated with elevated MAP at incision (p = 0.002). Patients with elevated preoperative diastolic BP had significantly higher MAP at exposure and throughout the procedure (p = 0.04). MAP > 65 at incision was associated with a 5% increase in EBV lost (p < 0.001).

CONCLUSIONS

Patients with elevated preoperative BP parameters have increased MAPs at incision, exposure, and throughout surgery. Elevated MAP at incision is associated with an increased percentage of EBV lost in a small number of patients undergoing PSF for AIS.

Prevalence of Elevated Blood Pressure and Its Relationship With Anthropometric Risk Factors in Students of a Pre-university Girls' College in Bangalore: A Cross-Sectional Study

Background There is a growing concern regarding elevated blood pressure in adolescence. Children and adolescents with high blood pressure are at risk for adult hypertension. Being overweight and obese are important risk factors for hypertension. This study aimed to determine the prevalence of elevated blood pressure and its association with anthropometric risk factors among students of a pre-university girls' college. Methodology A cross-sectional study was conducted among 337 students at a pre-university girls' college aged 15-19 years in urban Bangalore. A self-administered, semi-structured, pretested questionnaire collected the sociodemographic details, family history, and lifestyle. Height, weight, waist circumference (WC), and hip circumference were measured. Standard cut-off levels were used for body mass index (BMI), WC, waist-hip ratio (WHR), and waist-height ratio (WHtR). Resting blood pressure was determined using a digital blood pressure monitor. It was classified into normotensive, pre-hypertension (>90th to <95th percentile), and hypertension (>95th percentile). Data were analyzed using SPSS version 18 (SPSS Inc., Chicago, IL, USA). Pre-hypertension and hypertension were considered as having elevated blood pressure. Results The prevalence of pre-hypertension and hypertension was 21.4% (n = 72, 95% confidence interval (CI) = 17.0-25.7) and 9.8% (n = 33, 95% CI = 6.6-13.0), respectively. The prevalence of overweight was 20.2% (n = 68, 95% CI = 15.9-24.5) and obesity was 12.2% (n = 41, 95% CI = 8.7-15.7). WC, WHR, and WHtR were abnormal in 34.7% (n = 117, 95% CI = 29.6-39.8), 47.5% (n = 160, 95% CI = 42.1-52.8), and 45.7% (n = 154, 95% CI = 50.4-51.0), respectively. There was a statistically significant correlation between systolic blood pressure and BMI (p < 0.001), WC (p < 0.001), and WHtR (p < 0.001), as well as diastolic blood pressure and BMI (p < 0.001), WC (p = 0.008), and WHtR (p = 0.011). Statistically significant differences in mean BMI (p = 0.004), WC (p < 0.001), WHR (p = 0.007), and WHtR (p = 0.001) between normal, pre-hypertensive, and hypertensive students were also noted. Conclusions Pre-hypertension and hypertension are fundamental problems in pre-university girl students. With a similarly increased prevalence of obesity and other anthropometric risk factors, students must be aware of hypertension and its risk factors.

Captopril Polyvinyl Alcohol/Sodium Alginate/Gelatin-Based Oral Dispersible Films (ODFs) with Modified Release and Advanced Oral Bioavailability for the Treatment of Pediatric Hypertension

Hypertension can begin in childhood; elevated blood pressure in children is known as pediatric hypertension. Contrary to adult hypertension, there is a scarcity of commercial medications suitable for the treatment of pediatric hypertension. The aim of this study was to develop orally dispersible films (ODFs) loaded with captopril for the treatment of hypertension in children. Captopril-loaded ODFs were composed of different blends of synthetic polymers, such as polyvinyl alcohol (PVA) and polyvinyl pyrrolidone, and natural polymers, such as sodium alginate (SA) and gelatin. The ODFs were characterized based on their mechanical and thermal properties, drug content, surface morphology, in vitro disintegration, in vitro release, and bioavailability. A novel HPLC method with precolumn derivatization was developed to precisely and selectively determine captopril levels in plasma. A low concentration of PVA and a high concentration of SA generated ODFs with faster hydration and disintegration rates. SA-based films exhibited fast disintegration properties (1-2 min). The optimized modified-release film (F2) showed significant (p < 0.05) enhancement in bioavailability (AUC = 1000 ng min/mL), with a value 1.43 times that of Capoten® tablets (701 ng min/mL). While the plasma concentration peaking was in favor of the immediate-release tablet, Tmax was significantly prolonged by 5.4 times for the optimized ODF (3.59 h) compared with that of the tablets (0.66 h). These findings indicate uniform and sustained plasma concentrations, as opposed to the pulsatile and rapid plasma peaking of captopril from the immediate-release tablets. These findings suggest that the modified release of oral films could offer more favorable plasma profiles and better control of hypertension than the conventional release tablets.

Impact of puberty, sex determinants and chronic inflammation on cardiovascular risk in young people

Worrying trends of increased cardiovascular disease (CVD) risk in children, adolescents and young people in the Modern Era have channelled research and public health strategies to tackle this growing epidemic. However, there are still controversies related to the dynamic of the impact of sex, age and puberty on this risk and on cardiovascular health outcomes later in life. In this comprehensive review of current literature, we examine the relationship between puberty, sex determinants and various traditional CVD-risk factors, as well as subclinical atherosclerosis in young people in general population. In addition, we evaluate the role of chronic inflammation, sex hormone therapy and health-risk behaviours on augmenting traditional CVD-risk factors and health outcomes, ultimately aiming to determine whether tailored management strategies for this age group are justified.

Epicardial Adipose Tissue: A Piece of The Puzzle in Pediatric Hypertension

Background and purpose: Epicardial adipose tissue (EAT) is a metabolically active tissue located on the surface of the myocardium, which might have a potential impact on cardiac function and morphology. The aim of this study was to evaluate whether EAT is associated with essential arterial hypertension (AH) in children and adolescents. Methods: Prospective cardiovascular magnetic resonance (CMR) study and clinical evaluation were performed on 72 children, 36 of whom were diagnosed with essential AH, and the other 36 were healthy controls. The two groups were compared in volume and thickness of EAT, end-diastolic volume, end-systolic volume, stroke volume, left ventricular (LV) ejection fraction, average heart mass, average LV myocardial thickness, peak filling rate, peak filling time and clinical parameters. Results: Hypertensive patients have a higher volume (16.5 ± 1.9 cm3 and 10.9 ± 1.5 cm3 (t = −13.815, p < 0.001)) and thickness (0.8 ± 0.3 cm and 0.4 ± 0.1 cm, (U = 65.5, p < 0.001)) of EAT compared to their healthy peers. The volume of EAT might be a potential predictor of AH in children. Conclusions: Our study indicates that the volume of EAT is closely associated with hypertension in children and adolescents.

Formulation and Characterization of Buccal Films Containing Valsartan with Additional Support from Image Analysis

The present study was aimed to the development and characterization of valsartan-containing buccal films with an introduction to a novel technique of image analysis. Visual inspection of the film provided a wealth of information that was difficult to quantify objectively. The obtained images of the films observed under the microscope were embedded in a convolutional neural network (CNN). The results were clustered according to their visual quality and on the basis of data distances. Image analysis proved to be a promising method to characterize buccal films appearance and their visual properties. The differential behavior of film composition was investigated using a reduced combinatorial experimental design. Formulation properties such as dissolution rate, moisture content, valsartan particle size distribution, film thickness, and drug assay were evaluated. In addition, more advanced methods such as Raman microscopy and image analysis were used to characterize the developed product in more detail. The results of dissolution tests using four different dissolution apparatuses showed a significant difference between the formulations containing the active ingredient in different polymorphic states. The dynamic contact angle of a water droplet on the surface of the films was measured, which correlated well with the dissolution times at 80% of the released drug (t80).

A School-based survey among adolescents on Dietary pattern, Exercise, and Knowledge of Cardiovascular risk factors (ADEK) Study

Background. Cardiovascular disease is a global emerging problem and its risk starts in children and adolescents. Adolescents have modifiable cardiovascular risk factors that have been found globally, and nationally, and early intervention programs may be able to lower these risks for both individuals and populations. Accurate risk factor evaluation at the individual level is crucial in this situation for the prevention of cardiovascular disease. Objective. The study aimed to investigate cardiovascular disease knowledge and to determine physical activity, and dietary patterns among school-going adolescents in Arakkonam, Tamil Nadu, India. Methods. A school-based cross-sectional survey was conducted to assess cardiovascular disease knowledge among 500 adolescents aged 10-18 from public schools. The study period was from September 2021 to February 2022. The measurement taken on anthropometrics such as height, weight, body mass index, and bio-physiological measurement as blood pressure, structured questionnaire assessed for knowledge, dietary questionnaire assessed previous week food consumption which the investigator developed, and physical activity standard questionnaire assessed the past week’s exercise level. Data were analyzed using IBM Statistical Package for Social Sciences version 20. Results. The mean study population age was 13.7±1.7, 53% were boys, and 47% were girls. Factors like age 16-18 years (p=0.01), site of residence from urban (p=0.001), education of teenagers (p=0.01), and family history of cardiovascular disease (p=0.001) are significantly correlated with the level of knowledge score, with better-educated adolescents having fair knowledge score than others. Level of knowledge score and demographic traits are associated with physical activity, such as 16 to 18 years (p=0.03), living in an urban region (p=0.03), being in a joint household (p=0.001), adolescents who are at higher secondary (p=0.02), and having a family history contribute more to cardiovascular disease (p=0.001) than other variables. Mean days eating diets were egg (4.18±2.27), vegetables (3.92±0.93), milk products (3.85±1.87), fried foods (3.75±1.25), toffees, and chocolates (3.35±1.81) all had higher percentages of consumed foods than others. Conclusion: There is a risk of cardiovascular disease higher among adolescents. Still a need for school-based primordial preventive educational approaches needed to improve to curb this burden.

Temporal Associations between Tri-Ponderal Mass Index and Blood Pressure in Chinese Children: A Cross-Lag Analysis

Background: No longitudinal studies have explored the relationship between tri-ponderal mass index (TMI) and blood pressure (BP) in children. This study is aimed to investigate the temporal associations between TMI and BP among children in China. Methods: A longitudinal study was carried out with Chinese children from 2014 to 2019. Data of the anthropometric examination and blood pressure were collected annually. TMI was calculated by dividing weight by the cube of height. BP was measured using a standard mercury sphygmomanometer. We investigated temporal associations between TMI and BP with a cross-lagged panel model using repeated measure data from 2014 (Wave 1), 2016 (Wave 2), and 2018 (Wave 3). Results: Results of the cross-lagged panel model showed that TMI was associated with subsequent BP. Participants with higher levels of TMI presented higher levels of BP (Wave 1: β = 0.737 for systolic blood pressure (SBP) and β = 0.308 for diastolic blood pressure (DBP), Wave 2: β = 0.422 for SBP and β = 0.165 for DBP, p < 0.01). In addition, children with higher BP could also present higher TMI (Wave 1: β = 0.004 for SBP and β = 0.006 for DBP, Wave 2: β = 0.003 for SBP and β = 0.005 for DBP, p < 0.01), but the cross-lag path coefficient indicated that the influence of TMI on BP was stronger than the influence of BP on TMI. Conclusions: There was a temporal association between TMI and BP in Chinese children. Higher TMI predicted higher subsequent BP rather than the reverse relationship.

Blood pressure measurements and hypertension in infants, children, and adolescents: from the postmercury to mobile devices

A mercury sphygmomanometer (MS) has been the gold standard for pediatric blood pressure (BP) measurements, and diagnosing hypertension is critical. However, because of environmental issues, other alternatives are needed. Noninvasive BP measurement devices are largely divided into auscultatory and oscillometric types. The aneroid sphygmomanometer, the currently used auscultatory method, is inferior to MS in terms of limitations such as validation and regular calibration and difficult to apply to infants, in whom Korotkoff sounds are not audible. The oscillometric method uses an automatic device that eliminates errors caused by human observers and has the advantage of being easy to use; however, owing to its measurement accuracy issues, the development of an international validation protocol for children is important. The hybrid method, which combines the auscultatory and electronic methods, solves some of these problems by eliminating the observer bias of terminal digit preference while maintaining measurement accuracy; however, the auscultatory method remains limited. As the age-related characteristics of the pediatric group are heterogeneous, it is necessary to reconsider the appropriate BP measurement method suitable for this indication. In addition, the mobile application-based BP measurement market is growing rapidly with the development of smartphone applications. Although more research is still needed on their accuracy, many experts expect that mobile application-based BP measurement will effectively reduce medical costs due to increased ease of access and early BP management.

The Bioequivalence Between Valsartan Oral Solution and Suspension Formulations Developed for Pediatric Use

The bioequivalence of valsartan 160 mg oral solution compared to suspension was assessed in a single-dose, open-label, randomized, 2-period, 2-way crossover study in 82 healthy adults. The participants were randomly assigned (1:1) to receive a single dose of the solution or suspension formulation in each of the two treatment periods. Serial blood samples for pharmacokinetic evaluation were collected up to 48 hours post-dose. The pharmacokinetic parameters were estimated by noncompartmental methods and analyzed as per bioequivalence criteria of statistical analysis. The peak plasma concentration of valsartan was reached with median time of 1 and 3 hours with solution and suspension formulation, respectively. Compared to suspension formulation, the mean peak plasma concentration with solution formulation was higher by 32% (90%CI, 1.27-1.38) while the geometric mean ratios (1.09) and the associated 90%CIs (1.05-1.13) of both the areas under the concentration time-curves (from time zero to the last quantifiable concentration and from time zero to infinity) were contained in the required range of 0.80 to 1.25. No new safety signals were observed with either of the formulations.