Treatment Of Hypertension In Children Research Articles

Pharmacologic treatment of hypertension in children and adolescents

lthough hypertension is an infrequent problem among children and adolescents, hypertension has a greater likelihood of developing and requiring drug therapy in certain patients, including those with renal or cardiac disease, diabetes mellitus, parents with hypertension, or obesity. In making treatment decisions for such children, clinicians previously ad to adapt the results of adult trials in selecting anti-hypertensive agents. This approach, although possibly effective in owering blood pressure (BP), is fraught with problems, chief among them unknown differences in the metabolism and adverse ffect profiles of these drugs in children versus in adults and unknown long-term effects of anti-hypertensive medications on the rowth and development of children. Fortunately, this situation has changed significantly in the past decade, primarily because of the veritable explosion of ndustry-sponsored clinical trials of anti-hypertensive agents in children and adolescents stimulated by federal legislation. This eview will summarize the recent advances in our knowledge about the use of anti-hypertensive agents in children and provide pdated recommendations on the optimal use of anti-hypertensive agents in children and adolescents who require pharmacologic reatment.

Hypertension in Children: An Overview

Hypertension in children is an increasing concern for health care professionals. Updated guidelines for the treatment of hypertension in children and adolescents were published in 2004. This report reviews the epidemiology and management of pediatric hypertension and suggests an oral health protocol to apply to hypertensive children in the dental setting. A web search was performed using Medline, PubMed, ISI Citation Index, and Cochrane evidence-based databases for articles regarding hypertension in children published in English between 1998 and 2004. Relevant articles describing the epidemiology, classification, pathophysiology, and management of pediatric hypertension are discussed, and recommendations for dental treatment of pediatric patients are suggested. The incidence of pediatric hypertension can reach 5 percent. Data on the prevalence of pediatric hypertension in the dental setting is scarce. However, using the prevalence in the general population, at least fifty young patients will be hypertensive in a busy general or pediatric practice. Dental students and residents should have the opportunity to screen for hypertension during their training and familiarize themselves with the appropriate techniques in children. Oral health professionals should become aware of the implications of hypertension in children.

Efficacy and safety of a long-acting beta blocker, extended release metoprolol succinate, in hypertensive children

Clinical trial data on efficacy, safety, and tolerability of antihypertensive medications in the pediatric ages is emerging but remains limited. Even less data are available on the effects of the beta blocker class of antihypertensive drugs in children. To evaluate the dose range, safety, and blood pressure lowering effect of extended release metoprolol succinate (TOPROL-XL®, TXL). This multicenter clinical trial was a double-blind, placebo-controlled, randomized, parallel group study of children, age 6 to 16 years, with essential hypertension. Following a 2 week screening phase, each subject was randomized to one of a 4-arm treatment phase that lasted 4 weeks. The treatment arms were placebo or TXL (0.2 mg/kg, 1.0 mg/kg, or 2.0 mg/kg approximated by tablet strengths ranging from 12.5 to 200 mg). Data were analyzed using an intent-to-treat approach. Of 204 patients screened, 144 were randomized and 133 (92%) completed the treatment phase. 42% were <12 years, and 50% were < Tanner Stage 3. For the entire sample, mean age was 12.5 ± 2.8 yrs and mean baseline blood pressure (BP) was 132/78 ± 9/9 mmHg. Age, weight, and baseline BP were well balanced across the 4 treatment arms. Compared to placebo, there was a significantly greater reduction in SBP for the TXL 1.0 mg/kg dose and for all active doses combined, and in DBP at the TXL 2.0 mg/kg dose. There were no serious adverse events (AEs) or AEs requiring study drug discontinuation among patients receiving active therapy. Both SBP and DBP were lowered significantly, compared to placebo, following 4 weeks of TXL at doses within the range used in the study. In aggregate, these data indicate that TXL is an effective and well-tolerated treatment of hypertension in children, especially when a beta blocker is considered.

Extended-release metoprolol is effective in the treatment of primary hypertension in children,

Extended-release metoprolol is effective in the treatment of primary hypertension in children,

Measurement and treatment of elevated blood pressure in the pediatric patient with chronic kidney disease

Hypertension, as in adults, is a frequent complication found in children with chronic kidney disease (CKD). Indeed, hypertension has now become one of the most prevalent chronic diseases of childhood. The most recent data available (2003) indicate that at least 38% of children with CKD in the United States are receiving antihypertensive therapy. Only recently has it been shown in children that hypertension, traditionally considered a marker for disease severity in children, is additionally a significant and independent risk factor for accelerated deterioration of kidney function and progression of CKD and a significant risk factor for cardiovascular disease. The following review outlines the differences and similarities of childhood versus adult hypertension with respect to measurement, diagnosis, treatment, and consequence in CKD. The definition of hypertension changes continually as a child grows with or without CKD. Despite numerous guidelines, the diagnosis of childhood hypertension continues to be based on epidemiologic data rather than evidence. For children, the current definition includes 2 categories: high normal, which is blood pressure (BP) between the 90th and 95th percentile, and hypertensive, which is BP above the 95th percentile. The evaluation of all hypertensive children should include a complete assessment of end-organ damage, including eyes, cardiovascular system (including blood vessels), kidneys, and nervous system. For children with CKD and end-stage renal disease (ESRD), a high percentage have left ventricular hypertrophy (LVH). The finding of end-organ damage or comorbidity (CKD, diabetes) in any child is an absolute indication for immediate pharmacologic therapy, whereas the presence of hypertension above the 95th percentile in children without CKD warrants initial intervention such as life style modification. The guidelines for measurement of BP in children with CKD are similar to those in children without CKD and include casual BP measurement, self-measured BP, and ambulatory BP monitoring. The recommendation for BP measurement in children is, when permitted, by auscultative method with a well-calibrated mercury manometer. Most casual BP measurements are performed with an automated oscillometric device whose validation has not been confirmed in children with CKD. The ambulatory BP monitor (ABPM) has 2 advantages: it significantly correlates with the presence of end-organ damage, and it identifies abnormal BP patterns that are frequently present in CKD patients, such as hypertension during the sleep period. An abnormal ABPM pattern can also be predictive of the development of end-organ damage. Treatment of hypertension in children, with and without CKD, is based on 3 factors: degree of BP elevation, the presence of cardiovascular risk factors, and the presence of end-organ damage. Additionally, the initial antihypertensive agent may be selected on available and age-appropriate formulations (eg, suspension and dosage selection). A physician treating a hypertensive child with CKD faces multiple challenges. They include selecting the convenience of available automated devices and the ABPM versus traditional auscultatory techniques upon which all normative standards have been based. Current research initiatives propose to develop pharmacokinetic and pharmacodynamics properties of antihypertensive medications and to study the effect of early intervention on end-organ damage.

Somatotype, blood pressure and physical activity among 10- to 15- year old South African boys: the THUSA BANA study

Awareness of blood pressure issues in the pediatric population has increased, leading to conceptual changes in the diagnosis and treatment of childhood hypertension. Physical activity may be utilized in the prevention and treatment of an unhealthy body composition due to the increase in resting metabolic rate, and the energy use it facilitates. The purpose of this study was to determine the influence of physical activity on the prevalence of specific somatotypes and blood pressure levels among 10 to 15 year old boys. Anthropometric data were collected according to the methods of Norton & Olds (1996) and blood pressure was measured with the Finapres (“Finger Arterial Pressure”). The Previous Day Physical Activity Recall Questionnaire (PDPAR) was used to access the different activity levels among the subjects. A total of 603 boys from four different ethnic backgrounds were measured. One-way analysis of variance (ANOVA) and two-way multiple analysis of variance (MANOVA) procedures were used for all comparisons. Although there were no statistically significant differences (p < 0.05) between physical activity level, somatotype and elevated blood pressure, a trend was observed which indicated that the blood pressure of the endomorphic boys was the highest and rose with an increase in physical activity levels. An increase in physical activity did not lower the resting blood values of endomorphic boys. Key words: Physical activity, adolescent boys, anthropometry, body composition, somatotype, blood pressure, hypertension. (Af. J. Physical, Health Education, Recreation and Dance: 2003 Special Edition: 184-195)

ACE inhibition in the treatment of children after renal transplantation.

Currently, there are no data available on long-term effects of angiotensin-converting enzyme inhibitors (ACE-I) on graft function in children after renal transplantation. We therefore analyzed all children who were transplanted at our institution between 1989 and 1998 and followed for at least 2 years. Those treated with ACE-I, mainly because of failure of other antihypertensive medications, were compared to those without ACE-I. The ACE-I-treated children ( n=19) showed significantly better blood pressure control during the 1st year of follow-up ( p<0.05). In children with chronic allograft dysfunction ( n=8), treatment with ACE-I stabilized graft function, with improvement in creatinine clearance in 50% ( p<0.01). Serum potassium and hemoglobin levels remained stable. One patient discontinued ACE-I because of renal artery stenosis. Taken together, ACE-I were effective and safe in the treatment of hypertension in children following renal transplantation. Children with chronic allograft dysfunction experienced a stabilizing effect on graft function.

Diagnosis and treatment of hypertension in children and adolescents.

To provide nurse practitioners (NPs) with updated information regarding the etiology, diagnosis, and treatment of childhood hypertension. Extensive review of the scientific literature regarding hypertension, including the latest NIH recommendations. Hypertension affects more than 350,000 American children. While the majority of hypertension in early childhood occurs from secondary causes, the incidence of essential hypertension in later childhood and adolescence is rising, raising concerns as elevated pressures in childhood "track" into adulthood. Early detection and treatment of elevated childhood pressures represent important steps in reducing long-term cardiovascular risk. NPs must be able to accurately differentiate between primary and secondary hypertension in childhood. Secondary hypertension requires prompt diagnosis and treatment, and controlling primary childhood hypertension has lifelong implications. Given the familial predisposition to hypertension, it is important for adult NPs to be aware of the risks faced by children of hypertensive patients.

Pediatric hypertension 2001.

During the past decade, there has been a surge of interest in childhood and adolescent hypertension. The current review summarizes work published during the past year in the following areas: prenatal and early postnatal causes of hypertension; new information on the genetics of childhood hypertension; the relation of obesity, insulin resistance, and diabetes to hypertension; the use of ambulatory blood pressure monitoring to evaluate childhood hypertension; and advances in drug therapy for children with hypertension. The information obtained during the past year has improved our understanding of the pathogenesis, diagnosis, and treatment of childhood hypertension.

Pediatric hypertension: recent literature.

This article reviews selected recent literature specifically concerning pediatric hypertension, much of which has focused on measurement and monitoring of blood pressure, as well as on evaluating antihypertensive medications. Normative data for blood pressure in children have been widely available for some time, based upon seated in-office measurements. In recent years, ambulatory blood pressure monitoring (ABPM), facilitated by user-friendly instrumentation, has become more commonplace, though norms are not based on large populations. However, ABPM has important uses in assessing blood pressure as well as in monitoring antihypertensive. This review discusses issues involved in determining blood pressure, as well as the utility of ABPM in several situations. Recent developments concerning pediatric antihypertensive therapy are considered, as well as new information relevant to the diagnosis, course and treatment of hypertension in children and adolescents.

Approach to the treatment of hypertension in children.

Childhood hypertension necessitates a careful approach to diagnosis and a tailored approach to management. Hypertension in children should not be considered a rare condition. The diagnosis of hypertension must be assessed carefully, with attention to age, sex, and height standards. Also, careful attention should be given to the methods used to measure blood pressure. Once the diagnosis is made and the underlying etiologies have been evaluated and managed as necessary, both nonpharmacologic and pharmacologic approaches to treatment have been used. Nonpharmacologic approaches, especially weight reduction and increased physical activity, are beneficial. If pharmacologic approaches are needed, the goal of therapy should be to reduce blood pressure below the 95th percentile in the easiest, most effective manner that causes the fewest side effects. Angiotensin-converting enzyme inhibitors, calcium-channel blockers, alpha and beta blockers, and diuretics have all been used in children. Newer antihypertensives, such as angiotensin receptor blockers, are now being tested.

What's new in pediatric hypertension?

Research activities in the field of pediatric hypertension have been increasing in recent years, leading to important new findings in the epidemiology, diagnosis, and treatment of hypertension in children. This review summarizes recent work in these areas, focusing on the epidemic of obesity-related hypertension in children, advances in the drug therapy of childhood hypertension, and the increasing use of ambulatory blood pressure monitoring in evaluation of hypertensive children. Each of these three areas will no doubt develop further over the years ahead, resulting in further advances in the field of childhood hypertension.

An approach to the use of antihypertensive drugs in children and adolescents

Objective: The aim of this review article was to present one approach to the treatment of hypertension in children, although alternative approaches are certainly possible. Current issues that relate to antihypertensive therapy in children are considered, and basic principles of treatment are presented. Background: Less than 1% of all children require antihypertensive drug therapy. The first 2 reports from the National High Blood Pressure Education Program Task Force on Blood Pressure Control in Children recommended a stepped-care approach to treatment. As new classes of drugs become available, and as new evidence from studies completed in children and adults suggested that tailoring drug therapy to the underlying disease was advantageous in many circumstances, the individualized therapeutic approach has gained favor. However, despite a clear trend toward individualization, common therapeutic principles can be applied to bring a rational basis to the drug selection process. In the absence of data, opinion and experience often guide therapy for children with hypertension. Conclusions: Many factors affect the choice of an antihypertensive agent in children. Among the more important factors are diagnosis, severity of hypertension, patient demographics, patient compliance issues, concurrent diseases, concomitant drug therapy, drug formulation, and athletic participation. Special consideration should be given to children who have hypertensive emergencies, renal or renovascular disease, or diabetes mellitus. Neonates, competitive athletes, and adolescent females also represent unique subpopulations that have distinct needs. Apparent resistance to therapy is a significant problem in children. Many factors contribute to a less-than-expected response to drug therapy. These factors can be broadly classified into 3 groups: patient-related factors, disease-specific factors, and drug-related issues.

Hypertension in children and adolescents: definition, pathophysiology, risk factors, and long-term sequelae

Background: Awareness of hypertension as an adult public health issue has increased dramatically during the past 3 decades, leading to substantial decreases in morbidity and mortality related to stroke and coronary artery disease. Awareness of blood pressure issues in the pediatric population also has increased, leading to conceptual changes in the diagnosis and treatment of childhood hypertension. The current focus has shifted to early identification of mild to moderate hypertension in asymptomatic, otherwise healthy children and adolescents. Objective: The purpose of this article was to define hypertension in the pediatric population and describe the secondary causes of childhood hypertension, risk factors and potential pathophysiology of essential hypertension in childhood, and the long-term sequelae for individuals with hypertension identified during childhood. Methods: Information regarding pediatric hypertension was identified through a MEDLINE ® search of the literature from 1985 to 2000. Results: Definitions of pediatric hypertension have been carefully refined over the past 30 years, and normative data are available for children and adolescents, based on age, sex, and height. Childhood hypertension may be identified during evaluation of an acutely ill child, but is increasingly identified during routine blood pressure screening, particularly in adolescents. Although, historically, most pediatric hypertension was believed to be secondary in origin (related to an identifiable underlying disorder), recent data suggest that almost 90% of hypertensive adolescents have essential hypertension. The proposed factors that may be involved in the pathophysiology of essential hypertension include familial and genetic influences, race, and salt sensitivity. Although an essential hypertension gene has not yet been identified, several monogenic forms of hypertension have been described, which may account for a minority of individuals with presumed essential hypertension. In addition, a number of candidate genes that may be involved in the complex genetic susceptibility to hypertension have been described. There is growing evidence concerning adverse long-term consequences of hypertension identified in childhood and adolescence, including increased incidence of cardiovascular and coronary heart disease. Conclusions: Based on the generally accepted concept that essential hypertension begins in childhood, early optimization of blood pressure control in childhood may reduce an individual's lifetime risk of cardiovascular morbidity and mortality. In addition, aggressive treatment of cardiovascular risk factors during childhood and adolescence may have a major impact on the prevalence of adult cardiovascular disease.

Tratamiento farmacológico de la hipertensión arterial en pediatría

There are a great number of drugs available in the market for the treatment of arterial hypertension. New drugs whose effectiveness and toxicity are studied only in adults, are introduced, and so their efficacy, safety and effect on growth and development in children are not known. Hypertension in paedriatrics is usually due to renal causes. Choice of treatment will depend on the etiology, degree of hypertension and organ involvement as well as the physician´s experience. This article outlines step by step the usual treatment of hypertension in children and some special cases, such as hypertensive emergencies requiring admission to an ITU as well as newborn hypertension, which is being diagnosed with increasing frequency, and hypertension in chronic renal failure that require careful dose adjustments depending on renal function and in which careful management can prevent or retard further renal deterioration.

Initial Experience With Isradipine for the Treatment of Hypertension in Children

Isradipine is a calcium channel blocker of the dihydropyridine class. It has limited effects on myocardial contractility; is available in a powder-filled capsule and has a half-life of 6 to 8 hours. Pharmacy records were reviewed to identify pediatric patients who had received isradipine. The following demographic data were obtained: age, weight, sex, underlying medical problems, and initial blood pressure values. Information concerning isradipine included the initial dose and its interval, subsequent dose escalations, blood pressure response to the medication, and duration of therapy. The study population comprised 12 patients, ranging in age from 10 days to 11 years. The etiology of the hypertension was renal in 9 cases and nonrenal in 3. Initial dosing with isradipine was 0.1 mg/kg/dose. Six patients had emergent hypertension, and their blood pressure had been controlled with intravenous nicardipine before oral isradipine. Six patients received initial therapy with oral isradipine. Isradipine was monotherapy in 7 patients and in combination with other agents in 5 patients. The dose of isradipine required for blood pressure control was 0.6 +/- 0.3 mg/kg/day (range, 0.3 to 1.2 mg/kg/day). Isradipine failed to provide effective blood pressure control in 2 patients. In 1 of these patients, isradipine was effective after peritoneal dialysis. Isradipine is an effective, orally administered agent for control of hypertension in children.

Initial Experience With Isradipine for the Treatment of Hypertension in Children

Isradipine is a calcium channel blocker of the dihydropyridine class. It has limited effects on myocardial contractility; is available in a powder-filled capsule and has a half-life of 6 to 8 hours.Pharmacy records were reviewed to identify pediatric patients who had received isradipine. The following demographic data were obtained: age, weight, sex, underlying medical problems, and initial blood pressure values. Information concerning isradipine included the initial dose and its interval, subsequent dose escalations, blood pressure response to the medication, and duration of therapy.The study population comprised 12 patients, ranging in age from 10 days to 11 years. The etiology of the hypertension was renal in 9 cases and nonrenal in 3. Initial dosing with isradipine was 0.1 mg/kg/dose. Six patients had emergent hypertension, and their blood pressure had been controlled with intravenous nicardipine before oral isradipine. Six patients received initial therapy with oral isradipine. Isradipine was monotherapy in 7 patients and in combination with other agents in 5 patients. The dose of isradipine required for blood pressure control was 0.6 +/- 0.3 mg/kg/day (range, 0.3 to 1.2 mg/kg/day). Isradipine failed to provide effective blood pressure control in 2 patients. In 1 of these patients, isradipine was effective after peritoneal dialysis.Isradipine is an effective, orally administered agent for control of hypertension in children.

Ambulatory blood pressure monitoring of chronically dialyzed pediatric patients

Background Ambulatory blood pressure monitoring (ABPM) has been shown to be more representative of blood pressure levels in adult patients than are casual measurements of blood pressure. To evaluate, by means of ABPM, the behavior of blood pressure in children with chronic renal failure submitted to continuous ambulatory peritoneal dialysis and compare the results with casual blood pressure monitoring measurements. Evaluation of blood pressures in chronically dialyzed pediatric patients by ABPM. Ten pediatric patients, treated by continuous ambulatory peritoneal dialysis were evaluated by ABPM using the oscillometric SpaceLabs 90207 monitor, every 10 min during the day and every 15 min during the night, for 24h. Six of 10 patients were found normotensive by office measurement of blood pressure; four of 10 patients were found hypertensive by casual measurements of blood pressure. With ABPM we obtained a mean success rate of 92.5%, confirmed hypertension in all the patients classified hypertensive in terms of office readings and reclassified six of six patients from normotensive to hypertensive. The mean systolic and diastolic physiologic falls in blood pressure at night were respectively by 10 and 15%. At the time of the ABPM study end-organ damage was present in two patients judged to be normotensive in terms of office blood pressures. Casual recordings of blood pressure are not representative of average blood pressure in dialyzed pediatric patients. ABPM seems to be a useful diagnostic aid for assessing treatment of hypertension in children with end-stage renal disease.

The pharmacokinetics of extended release felodipine in children

Felodipine ER (extended release), a dihydropyridine calcium channel blocker, effectively lowers elevated blood pressure in adults [I] and children [2]. Once a day dosing, reduced fluctuation in plasma concentration, and improved compliance with felodipine ER would be beneficial in the treatment of hypertension in childhood. However, no kinetic data are available in the pediatric age group to guide the dosing regimen. To that end we studied felodipine ER steady state pharmacokinetics in children.

Ambulatory blood pressure monitoring in paediatric patients treated by regular haemodialysis and peritoneal dialysis

Ambulatory blood pressure monitoring (ABPM) has been shown to be more representative of blood pressure (BP) levels than casual BP measurements in adult patients treated by haemodialysis (HD). In this study we compared ABPM using the oscillometric SpaceLabs 90207 monitor with casual BP measurements in 35 paediatric patients [17 treated by peritoneal dialysis (PD) and 18 by HD]. Heart rate and plasma concentrations of atrial natriuretic peptide were also measured. No correlations were found between ABPM and causal BP measurements, except for systolic day-time BP in PD patients (r = 0.63). Seventy percent of PD and 33% of HD patients were regarded as hypertensive when evaluated by ABPM, while casual BP measurements demonstrated hypertension in 47% (P < 0.05) of PD patients and in 44% (NS) of HD patients. One-third of patients were reclassified by ABPM either from normotensive to hypertensive (7/19) or from hypertensive to normotensive (5/16). BP assessed by ABPM was higher in PD than in HD patients. The physiological decline of BP at night was significant and more pronounced in PD than in HD patients. In HD patients day-time BP did not differ between the 1st and the 2nd interdialytic day, but increased in the night hours before the following dialysis session. A positive correlation was found between day-time BP and pre-dialysis plasma atrial natriuretic peptide in both treatment groups. In conclusion this study demonstrates that casual BP recordings are not representative of average BP in dialysed paediatric patients. ABPM is useful in the diagnosis and treatment of hypertension in children with end-stage renal disease.