Management Of Hypertension In Children Research Articles

Ambulatory blood pressure monitoring: what a pediatrician should know

Ambulatory blood pressure monitoring is a useful tool for the evaluation and management of hypertension in children and adolescents. This review provides a basic overview of ambulatory blood pressure monitoring and summarizes the most recent available knowledge regarding its use in the pediatric population. Evaluation and validation of ambulatory blood pressure monitoring equipment in children remains limited, although advances in the interpretation of results for this age group have been reported specifically in the area of circadian (24 h) and ultradian (<24 h) variability. Blood pressure is a dynamic phenomenon that varies not only with time but also with changing patient and environmental circumstances. Growing evidence regarding conditions identified when this variability is considered, specifically white coat and masked hypertension, suggests that office blood pressure measurement may not be a sufficient screening test for hypertension-related target-organ damage. Information regarding ambulatory blood pressure monitoring use in children is increasing, although due to its limitations and expense, it remains a tool primarily utilized by the pediatric sub-specialist.

Preeclampsia: Exposing Future Cardiovascular Risk in Mothers and Their Children

There is an increased risk for future cardiovascular disease in women who have had preeclampsia. In infants born to mothers with preeclampsia, there is growing evidence of increased risk for both cardiovascular disease and preeclampsia. Epidemiologic and experimental data provide a strong link between intrauterine exposure to preeclampsia and subsequent risk for the development of cardiovascular disease in women.

Utility of ambulatory blood pressure monitoring in children and adolescents

Diagnosis of hypertension is critically dependent on accurate blood pressure measurement. "Accurate" refers to carefully following the guidelines for blood pressure measurement laid out for children and adults to minimize observer and subject errors that commonly occur in clinical blood pressure measurement. Accurate blood pressure measurement is more important in children and adolescents as the misdiagnosis of hypertension may have a life-long adverse impact on insurability and employment. Automated blood pressure measurement offers multiple advantages in achieving high-quality blood pressure determinations by reducing observer errors. The most commonly used form of automated blood pressure measurement is 24-h ambulatory blood pressure measurement (ABPM). Information on ABPM in children has grown exponentially over the last decade. Normative data exists for diagnosis of hypertension in children using ABPM including a novel method for determining normal values with the LMS method. There is further information about the utility of different determinants of 24-h blood pressure such as dipping status, morning surge and blood pressure load. ABPM has been able to detect significant differences in blood pressure in many disease states in children including chronic renal failure, polycystic kidney disease, solitary functioning kidney, and after renal transplantation. Increasingly nonambulatory automated blood pressure determinations have been used in management of hypertension in children. Although nonambulatory automated readings lack information about nocturnal blood pressure or blood pressure during daily activity, studies have suggested that home automated blood pressure measurements are a helpful adjunct to the usual office blood pressure reading.

Management of Hypertension in Children and Adolescents With the Metabolic Syndrome

Because elevated blood pressure is one of the defining criteria of the metabolic syndrome, treatment of hypertension will be required in many, if not most, children and adolescents diagnosed with the metabolic syndrome. This review highlights several aspects of the approach to treatment of hypertension in young patients with the metabolic syndrome, including the definition of hypertension, use of nonpharmacologic measures, indications for instituting antihypertensive medications, and the potential adjunctive role that insulin-sensitizing agents may play in blood pressure reduction. The choice of antihypertensive agent is also discussed, along with consideration of the diabetogenic effects of various classes of antihypertensive agents. Consideration of all of these issues is important in achieving blood pressure control in children and adolescents with the metabolic syndrome, as appropriate treatment may help to forestall the development not only of type 2 diabetes but also of the cardiovascular disease that is frequently already present at the time of diagnosis of type 2 diabetes in adults.

Blood Pressure Measurement in Diabetes Clinic

The American Diabetes Association statement (1), “Care of Children and Adolescents With Type 1 Diabetes,” outlines recommendations for management of hypertension in children with type 1 diabetes. Hypertension in children can be missed if appropriate norms are not used, and, as the authors state, “clinicians who care for children with diabetes often pay little or no attention to blood pressure.” Here, we report results of a retrospective chart review of serial clinic blood pressure measurements among 217 youth with type 1 diabetes for ≥5 years. Hypertension was defined …

Ambulatory blood pressure values in healthy children

Ambulatory blood pressure monitoring (ABPM) is an important tool in the diagnosis and management of childhood hypertension. Normal ambulatory blood pressure (ABP) values in children with body heights between 100 and 120 cm have not been reported. The aim of the study was to establish the normal range of values for ABPM in these children. 24-hour ABPM was performed in 40 normotensive (auscultatory casual blood pressure was obtained before ABPM) subjects, aged from 4 to 6 years (26 males, 14 females) with body heights between 95 and 125 cm. ABPM was carried out on non-dominant arm using the oscillometric device (SpaceLab 90207) with appropriate cuff size. The monitor was programmed to measure BP every 15 min. during the day (6 a.m. to 10 p.m.) and every 30 min. during the night (10 p.m. to 6 a.m.). The mean daytime SBP/DBP in boys and girls was 108+/-6/67+/-5 and 105+/-5/66+/-1, respectively. The mean nighttime SBP/DBP in boys and girls was 98+/6/56+/-5 and 97+/-7/56+/-4, respectively. There was a significant difference between day and night readings of SBP, DBP and heart rate (nocturnal fall was observed). The distribution of ABP noted in this study could serve as preliminary reference. A multicenter study should be performed to provide normal ranges of ABP.

Evaluation and Management of Hypertension in Children and Adolescents (Part Two): Evaluation and Management

Section Editors Polly F. Cromwell, MSN, RN, CPNP School-Based Health Centers Division Bridgeport Health Department Bridgeport, Connecticut Robert J. Yetman, MD University of Texas Medical School at Houston Houston, Texas Polly F. Cromwell, MSN, RN, CPNP School-Based Health Centers Division Bridgeport Health Department Bridgeport, Connecticut Robert J. Yetman, MD University of Texas Medical School at Houston Houston, Texas Polly F. Cromwell, MSN, RN, CPNP School-Based Health Centers Division Bridgeport Health Department Bridgeport, Connecticut Robert J. Yetman, MD University of Texas Medical School at Houston Houston, Texas Nancy Munn is the Senior Nurse Practitioner in the School-Based Health Centers Division, Bridgeport Health Department, Bridgeport, Connecticut. Joanna Zolkowski-Wynne is an Assistant Clinical Professor at the Yale University School of Medicine, New Haven, Connecticut, and Chief of Adolescent Medicine and Co-Director of Ambulatory Pediatrics, Bridgeport Hospital, Bridgeport, Connecticut.

Evaluation and management of hypertension in children and adolescents (part one): Diagnosis

Although hypertension (HTN) affects only 1% to 3% of the pediatric population, immediate and long-term health consequences are possible. Even young children and adolescents with borderline or untreated hypertension have evidence of left ventricular hypertrophy and beginning changes of atherosclerosis. Hypertension in children and adolescents persists into adulthood and is a significant risk factor for cardiovascular disease (ie, atherosclerosis, coronary artery disease, cerebrovascular disease).

Guest editorial: hypertension and kidney disease

Guest editorial: hypertension and kidney disease

Ambulatory blood pressure monitoring in pediatric renal transplantation.

Over last two decades ABPM has evolved from a research device to an established and valuable clinical tool for BP evaluation. More than 10 yrs ago ABPM was introduced to pediatrics and since that time, its importance has been increasing in the management of hypertension in children and adolescents. This review summarizes the information gathered from the studies of ABPM in adult and pediatric patients with renal transplants. We will review the importance of hypertension in this patient subset, discuss the advantage of ABPM over CBP and focus on specific abnormalities and clinical significance of ABPM in renal transplant recipients.

Systemic Hypertension: Management in Children and Adolescents.

Recognition of systemic hypertension in children and adolescents requires careful blood pressure measurement using proper technique to compare with appropriate normative data. Selected use of ambulatory blood pressure monitoring can identify children with "white coat" hypertension, thus avoiding unnecessary diagnostic testing and treatment in these children. Nonpharmacologic therapies including dietary sodium restriction, weight loss, and exercise may benefit children and adolescents with borderline hypertension and mild essential hypertension. These therapies may be important adjunctive agents in children requiring antihypertensive therapy as well. Historically, pharmacologic management of hypertension in children has been limited by a lack of controlled studies and age-appropriate formulations. Recent clinical trials have provided new information regarding a number of antihypertensive agents in this age group.

Utility of computed tomographic renal angiogram in the management of childhood hypertension.

The purpose of this study was to evaluate the utility of computed tomography (CT) renal angiogram (CTRA) in the management of childhood hypertension. This is a retrospective study of 24 children with clinical suspicion of renovascular disease who underwent CTRA examinations. CTRA demonstrated surgically correctable etiology of hypertension in 38% of the patients [5 with renal artery stenosis (RAS) and 4 with renal pathology]. In 5 patients, CTRA findings of RAS were confirmed by catheter angiogram. CTRA missed RAS in 1 patient in whom catheter angiogram showed beaded narrowing of the renal artery. All 6 patients with RAS had resolution of hypertension immediately after angioplasty or surgery. One patient with diffuse renal artery stenosis had an ipsilateral multicystic dysplastic kidney. In this patient hypertension resolved spontaneously as the dysplastic kidney shrunk in size. Seven patients had a renal etiology for hypertension. In 3 of these patients hypertension resolved after nephrectomy. Malignant hypertension in the 4th patient with reflux nephropathy was controlled medically after she underwent bilateral ureteral reimplantation. The remaining 3 patients with renal etiology were managed medically. We found that the etiology was central for hypertension in 4 patients with brain abnormalities, obesity in 1 overweight patient, essential hypertension in 4 patients, and thoracic aorta coarctation in 1 patient. Our study showed that in all except 1 instance CTRA could diagnose a surgically correctable cause for hypertension. CTRA provided useful information for the management of pediatric hypertension in all our patients.

Evaluation and management of hypertension in childhood

Hypertension, a relatively uncommon problem in childhood except in certain groups of children, is an important cardiovascular risk factor that can have significant health implications, especially the tendency for an elevated blood pressure in childhood to predict the development of adult hypertension. Common causes of childhood hypertension include renal and cardiac disease, as well as essential hypertension in adolescents. Given these factors, it is usually possible to evaluate the hypertensive child in a focused manner that should reveal not only the underlying cause of hypertension, but also its severity. Treatment should incorporate non-pharmacologic approaches as well as antihypertensive medications, and should take into account other cardiovascular risk factors such as hyperlipidemia. This review highlights these and other important issues in the evaluation and management of hypertensive children, and provides practical guidance to the practitioner involved in caring for such patients.

Impact of ambulatory blood pressure monitoring on the management of hypertension in children.

Ambulatory blood pressure monitoring (ABPM) is widely utilized for the evaluation and management of hypertension in adults but has not been routinely used in the care of hypertensive children. To examine the potential impact that the routine use of ABPM might have on the evaluation and management of hypertension in children, we reviewed our early experience with this technique, comparing management decisions based on ABPM with those based on casual blood pressure readings. Twenty children (4-17 years old) underwent ABPM for either the initial evaluation of suspected hypertension or the ongoing management of known hypertension. ABPM studies were considered abnormal if over 40% of both systolic and/or diastolic blood pressure readings were above the 95th percentile for the child's age and gender. Of 13 children studied for suspected hypertension, nine had abnormal ABPM studies and were treated, but four had normal results and were therefore not treated. Of seven children with known hypertension studied by ABPM to assess their blood pressure control further, three had normal results and no management changes were made, but four had abnormal studies, prompting a change in therapy or further diagnostic testing. Overall, eight out of 20 ABPM studies led to the initiation of further diagnostic evaluation or a change in planned or ongoing therapy. We conclude that ABPM has the potential to become an important tool in the evaluation and management of childhood hypertension, and suggest that more widespread use of this technique in children is appropriate.

ACE inhibition scintigraphy in the management of hypertension in children.

Angiotensin converting enzyme (ACE) inhibition scintirenography was performed to help establish the diagnosis and plan treatment of renovascular hypertension (RVH) in 57 hypertensive pediatric patients, 33 infants and 24 children older than 1 year. In 16 of 33 hypertensive infants, ACE inhibition scintirenography established the diagnosis of RVH from renal ischemia (due to aortic or renal arterial thrombi). Two scintigraphic criteria were used for the diagnosis of RVH: criterion I, ischemic and damaged kidney (a non-functioning kidney on or off ACE inhibition) and criterion II, ischemic but not damaged kidney (ACE inhibition induced deterioration of function of the kidney). When criterion I was present and the contralateral kidney was normal, ACE inhibitors could be used for treatment of hypertension without deterioration of renal function; kidneys satisfying criterion I eventually involuted or manifested growth arrest and frequently caused persistent RVH, even after resolution of the thrombus, requiring nephrectomy. When criterion II was present bilaterally, or it was associated with criterion I contralaterally, the use of antihypertensive drugs other than ACE inhibitors was necessary in order to prevent renal insufficiency or failure from ACE inhibitors. However, kidneys with criterion II showed normal growth and, following retraction or dissolution of the aortic thrombus, hypertension resolved. In 2 of 24 hypertensive children older than 1 year, the test was diagnostic of branch renal artery stenosis; RVH was cured by selective angioplasty. ACE inhibition scintirenography is useful in the evaluation and planning of treatment in children with hypertension and may predict the outcome of therapy and ultimate renal function.

Diagnosis and Management of Hypertension in Childhood

Blood pressure measurements should be taken at intervals on all children. At the very least, blood pressure measurements should be recorded on school and hospital admission. Once obtained, the pressure should be compared to established normals. If the pressure is repeatedly high, hypertension may be diagnosed and a cause sought. Unfortunately, most hypertension is usually mild in childhood, treatment programs should be initiated using nonpharmacologic measures. If needed a number of effective antihypertensive medications are available. The step-care approach presented in this article may be helpful in guiding the pediatric practitioner in this therapy.

The management of raised intracranial pressure in children

Raised intracranial pressure in children can arise from many conditions and may lead to serious morbidity or death despite modern intensive-care management. The presenting signs may be subtle in very young children, leading to delays in recognition and treatment. This review discusses the pathophysiology, differential diagnosis, and clinical management of intracranial hypertension in children, with particular emphasis on the practical aspects of intensive-care management.

Hypertension in pediatric patients

The importance of hypertension in the pediatric population has not been as well-appreciated as in adults. This may be due in part to the much lower prevalence of hypertension in children. Nevertheless, hypertension is an important clinical problem in pediatrics, and the approach to its management differs from that in adults in several major respects. Compared with adults, a much greater percentage of hypertension in childhood is caused by secondary, potentially correctable, disease states. Elevated blood pressure in children may also represent the early expression of primary or essential hypertension. In addition, the technique of blood pressure measurement, the definitions of high blood pressure, and the classifications of blood pressure values in children are different than in adults. These factors dictate a pediatric approach to the detection, evaluation, and management of hypertension in children and adolescents.

Efficacy of 24-hour ambulatory blood pressure monitoring in children

To determine whether the use of an ambulatory blood pressure monitor (ABPM) is feasible and gives accurate readings in children, and to provide data on normal daily blood pressures (BPs) and BP patterns in children. Cohort. Ninety-nine healthy fifth-grade students. Students wore an ABPM for 24 hours while recording their activities in diaries. Before and after the study period, each subject had three BPs simultaneously measured with the ABPM and a mercury manometer to assess the accuracy of the ABPM. An activity scale was retrospectively applied to diary entries to help explain the variety of BP patterns noted during data analysis. Systolic BPs obtained with the ABPM at the beginning and end of the study were slightly higher than those obtained with a mercury manometer; diastolic BPs were virtually identical. A circadian pattern of BPs was noted: mean systolic and diastolic BPs were higher during the day than at night. The BP patterns ranged from "hypoactive" (little baseline variation) to "hyperactive" (wide fluctuations with spikes to elevated BP ranges) during various activities. In general, higher BPs were noted at times of increased activity or emotional levels. Ambulatory BP monitoring was well tolerated, and measurements were reproducible and accurate. The variety of BP measurements noted at different activity levels indicate that a child's activity should be considered during data analysis. As further experience is gained, the ABPM should prove helpful in diagnosis and management of hypertension in children.

Management of extrahepatic portal hypertension in children

Management of extrahepatic portal hypertension in children