Rossana Baracco

Prediction of Primary vs Secondary Hypertension in Children

J Clin Hypertens (Greenwich). 2012; 14:316–321. ©2012 Wiley Periodicals, Inc.

Evaluation of Hypertension in Children

Hypertension is an important public health problem, and increasingly children are being diagnosed with primary hypertension. As the list of secondary causes of hypertension is extensive, pediatric practitioners increasingly need to decide on investigations needed for evaluating children presenting with high blood pressure. The differentiation between primary and secondary hypertension is paramount to understanding this important health issue, since many forms of secondary hypertension require specific treatment. The review evaluates the current available guidelines and practice patterns for evaluating children with elevated blood pressure. The review also aims to provide a framework for cost-effective evaluation strategies for children with elevated blood pressure based on current recommendations and evidence.

Diagnosis and Management of Urinary Tract Infection and Vesicoureteral Reflux in the Neonate

Urinary tract infection (UTI) is the most common bacterial infection in febrile newborns, particularly those born prematurely and with a low birth weight. Vesicoureteral reflux (VUR) predisposes to UTI and renal scarring. Half of neonates with UTI may have only low-grade fever or no fever. Jaundice in the absence of any other symptoms or signs may be the only clinical manifestation of UTI in neonates. The urinalysis may be negative in a significant number of neonates with UTI. Newborns with UTI have a high incidence of congenital anomalies of kidney and urinary tract anomalies, and hence should undergo renal imaging.

Pediatric Hypertensive Emergencies

Hypertensive emergency is a life-threatening condition that requires immediate evaluation and treatment. In children, severe hypertension can be caused by a variety of different underlying conditions. It usually presents with neurological involvement; however, signs and symptoms of injury to the kidneys, myocardium and eyes can also be present. Hospitalization for intravenous treatment with antihypertensive(s) and close monitoring in an intensive care setting are required for these patients. Few studies in children with hypertensive emergency have been done in the last several years. The findings and observations of these studies are discussed in this review.

Pharmacologic Treatment of Pediatric Hypertension

Prevalence of hypertension is increasing in children and adolescents. Uncontrolled hypertension in children not only causes end organ damage but also increases the risk of adult hypertension and cardiovascular disease. Clinical trials have proven efficacy of antihypertensive medications in children. These medications are well tolerated by children with acceptable safety profile. The choice of agent is usually driven by underlying etiology of hypertension, profile of its side effects, and clinician’s preference. This article will review currently available pediatric data on mechanism of action, common adverse effects, pediatric indication, recent clinical trial, and newer drugs in the common classes of antihypertensive medications.

Treatment of Hypertension in Children With Catecholamine-Secreting Tumors: A Systematic Approach

Management of blood pressure in children with pheochromocytoma and other catecholamine‐secreting tumors (CSTs) is unique and challenging. The authors report a single‐center experience using sequential α‐adrenergic blockade (phenoxybenzamine), increased fluid intake, and β‐blockade for presurgical management of 10 CSTs in children. In this retrospective review, mean duration for blood pressure control in preparation for surgery was 4.5±2.6 weeks. Intraoperative hypertension was noted transiently (<2 hours) in eight patients (80%) and was treated with continuous infusion of short‐acting antihypertensive agents. Two (20%) patients required vasopressor medication infusion to manage intraoperative hypotension. Only two (20%) patients developed postoperative hypotension and required vasopressor medication infusion for <24 hours. All antihypertensive medications were discontinued in the immediate (≤4 days) postoperative period in 80% of patients. In conclusion, a systematic and multidisciplinary approach utilizing adrenergic blockade is effective in treating children with CSTs.

Clinical utility of valsartan in the treatment of hypertension in children and adolescents

Valsartan is a potent antagonist of the type 1 angiotensin receptor (AT1). By blocking the actions of angiotensin II on the AT1, it inhibits vasoconstriction and synthesis of aldosterone thus lowering systemic blood pressure. Valsartan has been approved by the FDA for the treatment of hypertension in children aged 6 years and older. Valsartan can be dosed once a day with a sustained 24-hour effect on blood pressure reduction. The starting dose recommended in children is 1.3 mg/kg once daily (maximum 40 mg) which needs adjustment according to blood pressure response (dose range 1.3–2.7 mg/kg daily; up to 160 mg). A suspension form (4 mg/mL) is available for children who cannot swallow tablets. In patients aged 6 to 16 years, valsartan treatment (from a low dose of 10–20 mg to a high dose of 80–160 mg) resulted in dose-dependent reductions of 7.9–11.5 mmHg in systolic blood pressure and 4.6–7.4 mmHg in diastolic blood pressure. In 1- to 5-year-olds, valsartan (from a low dose of 5–10 mg to a high dose of 40–80 mg) reduced the systolic blood pressure by 8.4–8.6 mmHg and the diastolic blood pressure by 5.5 mmHg. Similar to adults and other antihypertensive medications, the most frequent side effect in children subsequent to valsartan use is headache. Current studies have not shown adverse effects on linear growth, weight gain, head growth, or development in children aged 1 to 5 years subsequent to valsartan use. Based on limited pediatric data, valsartan appears to be well tolerated and efficacious in reducing elevated blood pressure.

An adolescent on peritoneal dialysis with acute encephalopathy: Answers

Total parenteral nutrition (TPN) was started on hospital day 7 as the patient was still intubated and stuporous. Prior to initiation of TPN, serum thiamine and cobalamin levels were obtained given the patient’s history of malnutrition and chronic peritoneal dialysis (PD). On hospital day 11, the patient began to improve. She was extubated, able to respond to basic questions but remained withdrawn and taciturn and not back to baseline. A repeat echocardiogram showed resolution of abnormal left ventricular function. TPN was discontinued as the patient began to tolerate small amounts of food. The patient was then transferred back to the Nephrology service for further care. On the Nephrology service, she continued to act withdrawn and minimally responsive. On hospital day 15, results for serum thiamine levels came back as 28 nMol/l (reference range 70 – 180 nMol/l). Cobalamin levels were within normal limits. She was given a 25 mg bolus of intravenous (IV) thiamine. Within several hours after this bolus, the patient showed a dramatic improvement in her neurological status. She became more responsive and was able to sit up on a chair at the bedside, order a meal on her own from the hospital menu and text her mother. She was later seen to be ambulating with assistance and interacting with her family members. Thiamine was continued at a dose of 50 mg IV for 1 week, and then continued orally at the same dose. Repeat measurements of the thiamine level obtained after 4 days of thiamine replacement therapy was shown to be >2,000 mMol/l. The patient required physical and occupational therapy services for deconditioning. On hospital day 29, she was discharged home in a much improved condition. Since then the patient has been doing well with no permanent neurological deficit.