Safety of short-acting nifedipine in children with severe hypertension

Critical Insights Into Neonatal Hypertension: A Comprehensive Review of Current Understanding and Management Strategies

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.

Management and outcomes of acute post-streptococcal glomerulonephritis in children

Acute post-streptococcal glomerulonephritis (APSGN) is the major cause of acute glomerulonephritis among children, especially in low- and middle-income countries. APSGN commonly occurs following pharyngitis due to the activation of antibodies and complements proteins against streptococcal antigens through the immune-complex-mediated mechanism. APSGN can be presented as acute nephritic syndrome, nephrotic syndrome, and rapidly progressive glomerulonephritis, or it may be subclinical. The management of APSGN is mainly supportive in nature with fluid restriction, anti-hypertensives, diuretics, and renal replacement therapy with dialysis, when necessary, as the disease is self-limiting. Congestive heart failure, pulmonary edema, and severe hypertension-induced encephalopathy might occur during the acute phase of APSGN due to hypervolemia. APSGN generally has a favorable prognosis with only a small percentage of patients with persistent urinary abnormalities, persistent hypertension, and chronic kidney disease after the acute episode of APSGN. Decreased complement levels, increased C-reactive protein, and hypoalbuminemia are associated with disease severity. Crescent formations on renal biopsy and renal insufficiency on presentation may be the predictors of disease severity and poor outcomes in APSGN in children.

Evaluation of the safety and efficacy of metoprolol infusion for children and adolescents with hypertensive crises: a retrospective case series

BACKGROUND

Acute severe hypertension occurs infrequently in pediatric patients and, consequently, data on the efficacy and safety of most antihypertensive agents, as well as the adverse events associated with these agents, are very limited in this population. In this case series, we evaluated the use of metoprolol infusion in children with hypertensive emergencies.

METHODS

The study population comprised children younger than 18 years who had been admitted to the pediatric intensive care unit at King Abdullah University Hospital with blood pressure above the 99th percentile for age, height, and sex and who were symptomatic at the time of presentation. Metoprolol was given as an infusion at a dose of 1-5 mcg/kg/min. The rate of decrease in blood pressure, side effects from the medication, and outcome were assessed.

RESULTS

Thirteen patients ranging in age from 2 months to 16 years were included in this study. The initial mean blood pressure was 23-75 mmHg above the 99th percentile for age, height, and sex. Metoprolol was initiated at a dose of 0.5 mcg/kg/min and titrated according to the target blood pressure to a maximum of 5 mcg/kg/min. Mean blood pressure fell by an average of 12.3, 20.4, and 27.1% at 1, 8, and 24 h, respectively, which is consistent with findings on the use of other intravenous medications reported in published studies. The heart rate did not decrease below the normal range for age. There were no significant side effects of the metoprolol infusion. All patients were discharged home with no neurological sequelae secondary to their hypertension.

CONCLUSION

An infusion of metoprolol for a hypertensive emergency is a safe and effective treatment for pediatric patients.

Evaluation and treatment of hypertensive crises in children

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.

Neonatal hypertension

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.

Hypertension in infancy: diagnosis, management and outcome

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.

The management of hypertensive emergencies in children after stem cell transplantation

AIM OF THE REVIEW

This work presents a short overview on the available data about drugs that are currently used to treat hypertensive emergencies in children with a focus on incidents after stem cell transplantation. It shows that the pediatric use of all hypotensive agents appears to be mainly based on personal experience of the attending physicians rather than on convincing clinical trials.

METHOD

A literature search was performed in MEDLINE, through PubMed, using the medical subject headings (MeSH) hypertensive emergencies, nifedipine, nicardipine, and children. Further articles were identified by checking cross-references of articles and books.

RESULTS

Hypertensive emergencies in children after stem cell transplantation usually have a renal etiology, because of the treatment with the calcineurin inhibitors cyclosporine and tacrolimus. In these severe cases an immediate action is necessary to avoid possible appearance or exacerbation of endorgan damage. Because of their mechanism of action and a potential nephroprotective effect calcium channel blockers may be particularly suitable in cases of hypertensive emergencies. An intravenous application of nifedipine may compensate the difficulties of accurate dosing, but keeping in mind possible severe side effects and the lack of published experience its use in children is at least questionable. Nicardipine appears to be the hypotensive agent of first choice. In adults, the treatment of hypertensive emergencies with intravenous nicardipine is well-documented, but for an evaluation of safety in pediatric use, the published studies and case reports appear to be barely adequate.

CONCLUSION

The actual treatment approaches vary widely, demonstrating the lack of hard science on which current treatment of hypertensive emergencies in children is based. The hypotensive agent for the individual situation should be chosen considering the properties, side effects, the limited experiences with its use and the patient's anamnesis.

Management of acute kidney injury in children: a guide for pediatricians

Acute kidney injury (AKI; previously called acute renal failure) is characterized by a usually reversible increase in the blood concentration of creatinine and nitrogenous waste products and by the inability of the kidney to appropriately regulate fluid and electrolyte homeostasis. The incidence of AKI in children appears to be increasing and the etiology of AKI over the past decades has shifted from primary renal disease to multifactorial causes, particularly in hospitalized children. Renal failure can be divided into prerenal failure, intrinsic renal disease including vascular insults, and obstructive uropathies. The history, physical examination, and laboratory studies including a urinalysis and radiographic studies can establish the likely cause(s) of AKI. Once intrinsic renal failure has become established, management of the metabolic complications of AKI requires meticulous attention to fluid balance, electrolyte status, acid-base balance, and nutrition. Many children with AKI will need renal replacement therapy to remove endogenous and exogenous toxins and to maintain fluid, electrolyte, and acid-base balance until renal function improves. Renal replacement therapy may be provided by peritoneal dialysis (PD), intermittent hemodialysis (HD), or hemofiltration with or without a dialysis circuit. Many factors--including the age and size of the child, the cause of renal failure, the degree of metabolic derangements, blood pressure, and nutritional needs--are considered in deciding when to initiate renal replacement therapy and which modality of therapy to use. The prognosis of AKI is highly dependent on the underlying etiology of the AKI. Children who have AKI as a component of multisystem failure have a much higher mortality rate than children with intrinsic renal disease. Recovery from intrinsic renal disease is also highly dependent on the underlying etiology of the AKI. Children who have experienced AKI from any cause are at risk for late development of renal failure long after the initial insult. Such children need life-long monitoring of their renal function, blood pressure, and urinalysis.