2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Twenty-four-hour ambulatory central blood pressure in adolescents and young adults: association with peripheral blood pressure and preclinical organ damage

OBJECTIVES

To investigate the relationship of 24-h ambulatory central blood pressure (ABP) with preclinical organ damage in youth.

METHODS

Individuals aged 10-25 years referred for suspected hypertension and healthy volunteers had simultaneous 24-h peripheral and central ABP monitoring (Mobil-O-Graph 24 h PWA). Central BP was calculated using two different calibration methods (c1 using oscillometric systolic/diastolic ABP; c2 using mean arterial/diastolic ABP). Their association with preclinical organ damage [left ventricular mass index (LVMI), carotid intima-media thickness (IMT), 24-h pulse wave velocity (PWV)] was investigated.

RESULTS

A total of 136 participants were analyzed (age 17.9 ± 4.7 years, 54% adolescents, 77% males, 34% with elevated ABP). Twenty-four-hour peripheral systolic ABP (pSBP) was higher than c1 systolic ABP (c1SBP) by 14.1 ± 3.7 mmHg, but lower than c2SBP by 6.5 ± 7.6 mmHg (all P < 0.01). c2SBP quartiles provided better stratification of preclinical organ damage than pSBP. Both c1SBP/c2SBP were significantly associated with LVMI (r = 0.35/0.33) and IMT (r = 0.23/0.42; all P < 0.01; primary endpoint). These associations were stronger for c2SBP compared with those of pSBP in adolescents but not in adults. PWV was more closely associated with pSBP than c2SBP (r = 0.94/0.83, P < 0.01). LVMI variation was best determined by c2SBP in adolescents and pSBP in adults; IMT by c2SBP and PWV by pSBP in both subgroups.

CONCLUSION

These findings suggest that in young individuals, the calibration method for 24-h central ABP plays a major role in determining its association with preclinical organ damage. In adolescents, 24-h central ABP appears to be more strongly associated with early cardiac and carotid damage than peripheral BP.

Kidney involvement and associated risk factors in children with Duchenne muscular dystrophy

BACKGROUND

Kidney dysfunction is a common complication in adults with Duchenne muscular dystrophy (DMD); however, little attention has been paid to kidney function in pediatric patients.

METHODS

Medical records of patients with DMD who were followed up for ≥ 12 months were retrospectively reviewed. Inclusion criteria were (i) aged 5-18 years, (ii) proven mutations in the dystrophin gene, and (iii) absence of structural anomalies of the kidney and urinary tract. Serum creatine kinase (CK) was used as an indirect marker of muscle destruction.

RESULTS

Forty-four patients (mean age, 10.9 ± 3.3 years) were included. Blood pressure was evaluated by 24-h ambulatory blood pressure monitoring in 28 patients. Hypertension was found in 9 (32.1%), eight of whom were using steroids. Mild proteinuria, hypercalciuria, hypocalciuria, and hyperphosphaturia in 24-h urine collection (n = 36) were detected in 3 (8.3%), 5 (13.9%), 7 (19.7%), and 6 (16.7%) patients, respectively. Twenty-one (58.3%) demonstrated hyperuricosuria, associated with hyperuricemia in 4. Logarithmic cystatin C (CysC) had a positive correlation to creatinine (Cr) (p = 0.001, r = 0.54), CK (p = 0.048, r = 0.30), and parathormone (PTH) (p = 0.001, r = 0.49). Moreover, the patients were divided into two groups according to median CysC value: group 1 (n = 20, CysC ≤ 0.76 mg/l) and group 2 (n = 24, CysC > 0.76 mg/l). Mean CK, PTH, and Cr levels were significantly elevated in group 2 compared with group 1 (p = 0.010, 0.033, and 0.023, respectively).

CONCLUSIONS

Long-term exposure to the excessive burden of intracellular components released from damaged muscles may be associated with an increased risk over time of chronic kidney impairment in pediatric DMD patients. Graphical abstract.

Impact of complex congenital heart disease on the prevalence of arterial hypertension after aortic coarctation repair

OBJECTIVES

This study was designed to evaluate the difference in the prevalence of long-term arterial hypertension among patients with corrected aortic coarctation according to the existence of associated cardiac congenital lesions.

METHODS

We identified 235 patients who had undergone surgery for aortic coarctation and classified them into 2 groups: patients with isolated coarctation of the aorta (CoA) and patients with aortic coarctation associated with complex congenital heart disease. Data were retrospectively analysed.

RESULTS

There were 148 subjects with isolated CoA and 87 with complex CoA (CoA-c). Patients were defined as hypertensive if they required antihypertensive treatment and/or when blood pressure was above 95th percentile. Patients with isolated aortic coarctation were significantly younger than patients with CoA-c (P < 0.001) and a markedly higher prevalence of arterial hypertension (44% vs 24%) was documented in the isolated coarctation group. The difference in the prevalence of hypertension in the 2 groups was still significant after correcting for differences in age (P < 0.001), confirming that the prevalence of arterial hypertension in patients with CoA-c was half of that of patients with isolated CoA.

CONCLUSIONS

We conclude that complex congenital heart disease in patients who have undergone surgical correction for aortic coarctation results in a significantly lower prevalence of late-onset hypertension. Reduced systemic flow and pressure before surgery in patients with CoA-c might be associated with a lower rate of arterial hypertension.

Maternal prenatal urinary bisphenol A level and child cardio-metabolic risk factors: A prospective cohort study

Exposure to endocrine disrupting chemicals during the first 1000 days of life may have long-lasting adverse effects on cardio-metabolic risk in later life. This study aimed to examine the associations between maternal prenatal Bisphenol A (BPA) exposure and child cardio-metabolic risk factors at age 2 years in a prospective cohort. During 2012-2013, 218 pregnant women were enrolled at late pregnancy from Shanghai, China. Urinary BPA concentration was measured in prenatal and child 2-year spot urine samples, and classified into high, medium and low tertiles. Child adiposity anthropometric measurements, random morning plasma glucose, serum insulin, and lipids (high-density lipoprotein, low-density lipoprotein, cholesterol, triglyceride), systolic (SBP) and diastolic blood pressure (DBP) were measured. Linear regression was used to evaluate the associations between prenatal BPA and each of the cardio-metabolic risk factors in boys and girls, respectively, adjusting for pertinent prenatal, perinatal and postnatal factors. BPA was detectable (>0.1 μg/L) in 98.2% of mothers prenatally and 99.4% of children at age 2 years. Compared to those with low prenatal BPA, mean SBP was 7.0 (95%CI: 2.9-11.2) mmHg higher, and DBP was 4.4 (95%CI: 1.2-7.5) mmHg higher in girls with high prenatal BPA levels, but these associations were not found in boys. In boys, medium maternal prenatal BPA level was associated with 0.36 (95% CI: 0.04-0.68) mmol/L higher plasma glucose. No associations were found between prenatal BPA and child BMI, skinfold thicknesses, serum lipids, or insulin in either girls or boys. There were no associations between concurrent child urinary BPA and cardio-metabolic risk factors. These results support that BPA exposure during prenatal period, susceptible time for fetal development, may be associated with increase in child BP and plasma glucose in a sex-specific manner. Further independent cohort studies are needed to confirm the findings.

[Sleep apnoea-hypopnoea syndrome in the obese and non-obese: clinical, polysomnographical and clinical characteristics]

INTRODUCTION

Sleep apnoea-hypopnoea syndrome (SAHS) and childhood obesity are la high prevalence conditions that represent a public health challenge.

OBJECTIVE

To analyse the association between both and comparing child groups that had or did not have both conditions.

PATIENTS AND METHODS

A prospective study in children (3-14 years), referred to the "Multidisciplinary Sleep Unit" due to suspected SAHS, between 1 November 2015 and 1 August 2017. The following parameters were evaluated: anthropometry, symptoms, blood pressure, ear, nose, and throat examination, polysomnography (nocturnal PSG) and laboratory tests.

RESULTS

A total of 67 children were evaluated (64% non-obese and 36% obese. It was observed that the obese were older (P<.001), slept less hours (P=.028), did less physical exercise (P=.029), ate less in the school dining room (P=.009), had la lower sleep efficiency, and had abnormal values in carbohydrate and lipid metabolism. The children with SAHS were younger (P=.010), a high percentage of daytime sleepiness (P=.001), and breathing through the mouth (P=.006), greater percentile of diastolic blood pressure (P=.019) and a lower IGF-1 (P=.003) than those that did not have SAHS. The comparison of the SAHS non-obese and SAHS obese groups, showed that the first group were younger (P=.010), snored more (P=.012), had a more severe SAHS (IAH 13.1 vs. 5.4, P=.041), and a higher GOT (P<.001). In the second group, they slept less hours P=.038) and showed lower values of glucose (P=.039), insulin (P<.001), and HOMA (P<.001).

CONCLUSION

The behaviour of SAHS is different in obese children and non-obese children, with differences in age, clinical characteristics, severity of SAHS, and metabolic changes. The children diagnosed with SAHS were in the higher percentile of diastolic blood pressure. Obesity was associated with worse sleep quality, and changes in carbohydrate and lipid metabolism.

Elevated blood pressure, cardiometabolic risk and target organ damage in youth with overweight and obesity

BACKGROUND AND AIM

To compare cardiometabolic risk profile and preclinical signs of target organ damage in youth with normal and elevated blood pressure (BP), according to the American Academy of Pediatrics (AAP) guidelines.

METHODS AND RESULTS

This cross-sectional multicenter study included 2739 youth (5-17 year-old; 170 normal-weight, 610 overweight and 1959 with obesity) defined non hypertensive by the AAP guidelines. Anthropometric, biochemical and liver ultrasound data were available in the whole population; carotid artery ultrasound and echocardiographic assessments were available respectively in 427 and 264 youth. Elevated BP was defined as BP ≥ 90th to <95th percentile for age, gender and height in children or BP ≥ 120/80 to <130/80 in adolescents. The overall prevalence of elevated BP was 18.3%, and significantly increased from normal-weight to obese youth. Young people with elevated BP showed higher levels of body mass index (BMI), insulin resistance and a higher prevalence of liver steatosis (45% vs 36%, p < 0.0001) than normotensive youth, whilst they did not differ for the other cardiometabolic risk factors, neither for carotid intima media thickness or left ventricular mass. Compared with normotensive youth, individuals with elevated BP had an odds ratio (95%Cl) of 3.60 (2.00-6.46) for overweight/obesity, 1.46 (1.19-1.78) for insulin-resistance and 1.45 (1.19-1.77) for liver steatosis, controlling for centers, age and prepubertal stage. The odds for insulin resistance and liver steatosis persisted elevated after correction for BMI-SDS.

CONCLUSION

Compared to normotensive youth, elevated BP is associated with increased BMI, insulin resistance and liver steatosis, without significant target organ damage.

Obesity treatment effect in Danish children and adolescents carrying Melanocortin-4 Receptor mutations

Objectives

To determine the prevalence of Melanocortin-4 Receptor (MC4R) mutations in a cohort of children and adolescents with overweight or obesity and to determine whether treatment responses differed between carriers and noncarriers.

Methods

Using target region capture sequencing, an MC4R mutation screen was performed in 1261 Danish children and adolescents enrolled at a tertiary multidisciplinary childhood obesity treatment center. Measurements of anthropometrics, blood pressure, fasting blood biochemistry including lipid and hormone levels, and dual-energy X-ray absorptiometry were performed at baseline and throughout treatment.

Results

Of 1209 children and adolescents that met all criteria to be included in the described analyses, 30 (2.5%) carried damaging or unresolved MC4R mutations. At baseline, mutation carriers exhibited higher concentrations of plasma thyroid-stimulating hormone (p = 0.003), and lower concentrations of plasma thyroxine (p = 0.010) compared to noncarriers. After a median of 1 year of treatment (range 0.5–4.0 years), body mass index (BMI) standard deviation score (SDS) was reduced in noncarriers but not in carriers, and this difference in treatment response was statistically significant (p = 0.005). Furthermore, HDL cholesterol was reduced in carriers, a response significantly different from that of noncarriers (p = 0.017).

Conclusion

Among Danish children and adolescents with overweight or obesity entering a tertiary lifestyle intervention, 2.5% carried damaging or unresolved MC4R mutations. In contrast to noncarriers, carriers of damaging or unresolved MC4R mutations failed to reduce their BMI SDS during obesity treatment, indicating a need for personalized treatment based on the MC4R genotype.

Blood Pressure and Body Weight Have Different Effects on Pulse Wave Velocity and Cardiac Mass in Children

Background: High blood pressure (BP) and excess weight can lead to early cardiovascular organ damage already in children. Carotid-femoral pulse wave velocity (cf-PWV) is the non-invasive gold standard method for assessing aortic stiffness, while carotid-radial PWV (cr-PWV) provides information on the distensibility of the upper limb arteries. The aim of this study was to evaluate the relationship of BP and BMI z-scores with arterial stiffness and left ventricular mass index (LVMI) in a pediatric population. Methods: In 343 children (57.7% males; age ± SD 11.7 ± 2.9 years), systolic (SBP) and diastolic (DBP) BP, BMI, cf-PWV, cr-PWV and LVMI were measured. A multiple linear regression model was used to assess the impact of BMI and SBP (or DBP) z-scores on cf-PWV, cr-PWV and LVMI. Results: About 21% of children were normal weight, 34% were overweight and 45% obese. Adjusted for possible confounders, SBP and DBP z-scores were significantly associated with cf-PWV (p < 0.001), while only DBP z-scores were related to cr-PWV (p < 0.01). BMI was neither associated with cf-PWV nor with cr-PWV values but was a strong predictor of LVMI (<0.001), whereas cardiac mass and BP z-scores were not related. Conclusions: Our study suggests that, in children, elevated BP values and excess weight may have different effects on the heart and the vessels in causing early cardiovascular alterations.

Association Between Physical Activity Intensity Levels and Arterial Stiffness in Healthy Children

BACKGROUND

Physical activity (PA) has a substantial impact on arterial stiffness in adults; however, evidence regarding children is scarce. The aim of this study was to examine the association between objectively measured PA with different intensities and surrogate measures of arterial stiffness in healthy children.

METHODS

Altogether, 80 children (41 girls and 39 boys, ranging from 8-11 y) participated in this prospective, cross-sectional study. Sedentary time and PA of light, moderate, and vigorous intensity levels were measured over a period of 7 days by accelerometry. Arterial stiffness parameters, including pulse wave velocity and central systolic blood pressure (cSBP), were noninvasively assessed by the oscillometric Mobil-O-Graph. Associations were tested using multiple linear regressions with adjustments for potential confounders (α ≤ .05).

RESULTS

PA of moderate intensity was negatively associated with cSBP (β = -0.266, P = .017). PA of vigorous intensity was inversely related to pulse wave velocity (β = -0.225, P = .045) and cSBP (β = -0.286, P = .010), respectively.

CONCLUSION

Higher time spent in PA of moderate and vigorous intensity is associated with reduced pulse wave velocity and lower cSBP values in children. It suggests that PA is a favorable determinant of arterial health.

Insight into the 24-hour ambulatory central blood pressure in adolescents and young adults

This study attempted to investigate the behavior of 24-hour central ambulatory blood pressure (ABP) in adolescents and young adults. Adolescents and young adults (age 10-25 years) referred for elevated blood pressure (BP) and healthy volunteers had simultaneous 24-hour peripheral (brachial) and central (aortic) ABP monitoring using the same automated upper-arm cuff device (Mobil-O-Graph 24h PWA). Central BP was calculated by the device using two different calibration methods (C1SBP using peripheral systolic (pSBP)/diastolic BP and C2SBP using mean arterial/diastolic BP). A total of 136 participants (age 17.9 ± 4.7 years, 54% adolescents, 77% males, 25% volunteers, 34% with elevated peripheral ABP) were analyzed. Twenty-four-hour pSBP was higher than C1SBP, with this difference being more pronounced during daytime than nighttime (16.3 ± 4.5 and 10.5 ± 3.2 mm Hg, respectively, P < .001). Younger age, higher body height, and male gender were associated with greater systolic ABP amplification (pSBP-C1SBP difference). C1SBP followed the variation pattern of pSBP, yet with smaller nighttime dip (8.4 ± 6.0% vs 11.9 ± 4.6%, P < .001), whereas C2SBP increased (2.4 ± 7.2%) during nighttime sleep (P < .001 for comparison with pSBP change). Older age remained independent determinant of larger nighttime BP fall for pSBP and C1SBP, whereas male gender predicted a larger nighttime C2SBP rise. These data suggest that the calibration method of the BP monitor considerably influences the diurnal variation in central BP, showing a lesser nocturnal dip than pSBP or even nocturnal BP rise, which are determined by the individual's age and gender.

Ambulatory blood pressure profile in office normotensive obese children: prevalence of masked hypertension and impact of parental hypertension

Objectives The objectives of this study were to analyze ambulatory blood pressure (ABP) data in office normotensive obese children, to determine the prevalence and characteristics of masked hypertension (MH) and to investigate the impact of parental hypertension (PH) on ABP. Methods Seventy-nine obese and 35 normal weight children were enrolled. Each weight group was further divided in accordance with the presence of PH. ABP was recorded in an outpatient setting. Results Obese children had higher systolic ABP (p<0.05) and heart rate (p<0.001) compared with normal weight children. In obese children with PH, only nighttime systolic ABP (p=0.01) was higher compared with obese without PH, whereas normal weight children with PH had higher 24 h and daytime systolic and diastolic BP (all p<0.05) and nighttime DBP (p<0.001) compared with those without PH. PH but not obesity was associated with nondipping phenomenon. Prevalence of MH in the whole group was 23.6% being significantly higher in obese than in nonobese subjects (31.6 vs. 5.7%; p=0.0026) as well as in obese subjects with PH compared with obese subjects without PH (48.7 vs. 15%; χ2=10.37; p=0.001). MH was diagnosed more frequently in obese with high-normal office BP compared with obese with normal office BP, although it did not reach statistical significance (50 vs. 26.2%; χ2=3.631; p=0.056). In the normal weight group, neither PH nor office BP category had an impact on the prevalence of MH. Conclusions Office normotensive obese children had higher ABP values. MH was associated with obesity, PH and high-normal BP.

Cardiovascular Risk Factors are Inversely Associated With Omega-3 Polyunsaturated Fatty Acid Plasma Levels in Pediatric Kidney Transplant Recipients

OBJECTIVES

High plasma levels of the omega-3 fatty acids eicosapentaenoic acid (EPA), docosahexaenoic acid, and docosapentaenoic acid associates with positive outcomes in adult renal transplant recipients. However, data from pediatric populations are scarce. The aim of the study was to assess the fatty acid profile in a pediatric renal transplantation cohort and to examine the associations between plasma omega-3 fatty acids and cardiovascular disease (CVD) risk factors.

METHODS

In this cross-sectional study comprising 53 children (median age, 12.2 years; 32 boys) with a renal transplant, we assessed the prevalence of CVD risk factors as well as markers of end organ damage: carotid intima-media thickness (cIMT) and left ventricular mass index. The associations between plasma omega-3 fatty acids and CVD risk factors were assessed.

RESULTS

Twenty-five (47%) patients were preemptively transplanted. Seventy-six percent had dyslipidemia and 51% had hypertension. The mean left ventricular mass index was 40.4 ± 14.3 g/m^2.7, and 14% had left ventricular hypertrophy. The mean cIMT was 0.41 ± 0.04 mm. In a multivariate linear regression, EPA levels were inversely associated to blood pressure (β coeff. = -0.37, P = .007), triglycerides (β coeff. = -0.44, P = .01), and high-density lipoprotein cholesterol (β coeff. = -0.41, P = .01).

CONCLUSION

EPA levels are inversely associated with components of the metabolic syndrome, which may provide support for specific dietary advice or supplementation in this patient population. cIMT is less pronounced in our cohort than in comparable cohorts with lower rate of preemptive transplantations. Our results need replication in prospective cohorts.

Tracking hydration status changes by bioimpedance spectroscopy in children on peritoneal dialysis

BACKGROUND

This 6-month prospective longitudinal study investigates the association between hydration status changes using bioimpedance spectroscopy (BIS) and systolic blood pressure (SBP), pulse pressure (PP), and serum albumin (sAlb) changes in children on peritoneal dialysis (PD).

METHODS

Thirteen patients (median age: 12.58 years) were enrolled. Normal hydration, moderate hydration, severe overhydration, and dehydration were defined as -7% ≤ relative overhydration (Re-OH) < +7%, +7% ≤ Re-OH < +15%, Re-OH ≥ +15%, and Re-OH < -7%, respectively. Automated office blood pressure z-score, sAlb, and weight z-score were recorded.

RESULTS

Fifty-two Re-OH measurements were recorded: three in five, four in five, five in two, and seven in one patient, respectively. SBP was higher and sAlb lower in cases with severe overhydration (9 readings) (p < 0.001, p < 0.001), but distribution of these parameters did not differ between normal hydration/dehydration (28 readings) and moderate overhydration (15 readings) cases. In patients with hydration status change, SBP and PP were higher while sAlb lower in cases with higher hydration status level (p = 0.026, p = 0.05, and p = 0.109, respectively). In all patients, visit-to-visit SBP, PP, and sAlb changes were correlated to Re-OH changes (rs = 0.693, p < 0.001; rs = 0.643, p < 0.001; rs = -0.444, p = 0.008, respectively) but not to weight changes (rs = 0.052, p = 0.754; rs = 0.034, p = 0.838; rs = -0.156, p = 0.378, respectively). Visit-to-visit Re-OH changes, which were >+4% or <-4%, were linearly correlated to SBP (r = 0.858, p < 0.001), PP (r = 0.757, p < 0.001), and sAlb (r = -0.699, p = 0.002) changes.

CONCLUSION

In children on PD, longitudinal Re-OH changes are superior to weight changes in assessing volume-dependent variations of SBP, PP, and sAlb. Routine BIS application, rather than single BIS measurements, seems useful in the intra-patient monitoring of hydration status.

Vitamin D Receptor Gene Polymorphisms and the Risk of Metabolic Syndrome (MetS): A Meta-Analysis

BACKGROUND

Several studies have assessed the association between the vitamin D receptor (VDR) polymorphism and the risk of metabolic syndrome (MetS). However, the results were inconsistent and inconclusive. Therefore, we conducted a meta-analysis to clarify the exact association between the vitamin D receptor (VDR) polymorphisms and the risk of MetS.

METHODS

All accessible studies reporting the association between the FokI (rs2228570) or/and TaqI (rs731236) or/and BsmI (rs1544410) or/and ApaI (rs7975232 polymorphisms of the Vitamin D Receptor and susceptibility to MetS published prior to February 2019 were systematically searched in Web of Science, Scopus, and PubMed. After that, Odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were estimated to evaluate the strength of the association in five genetic models.

RESULTS

A total of 9 articles based on four gene variations, and comprising 3348 participants with 1779 metabolic syndrome patients were included. The overall results suggested a significant association between BsmI (rs1544410) polymorphism and MetS susceptibility in recessive model (OR, 0.72, 95% CI, 0.55-0.95, fixed effect model), allelic model (OR, 0.83, 95% CI, 0.72-0.95, fixed effect model), and bb vs BB (OR, 0.65, 95% CI, 0.46-0.93, fixed effect). However, no significant association was identified between TaqI (rs731236) polymorphism, ApaI (rs7975232) polymorphism, and FokI (rs2228570) polymorphism and MetS.

CONCLUSION

This meta-analysis suggested an association between the BsmI (rs1544410) polymorphism and MetS. Indeed, BsmI (rs1544410) acts as a protective factor in the MetS. As a result, the VDR gene could be regarded as a promising pharmacological and physiological target in the prevention or treatment of the MetS.

Unmasking hypertension in children and adolescents with sickle/beta-thalassemia

Sickle cell disease (SCD) is associated with increased risk of cardiovascular disease, although blood pressure (BP) levels have been reported to be lower in SCD patients compared to general population. Aims of the present study were to investigate the prevalence of BP phenotypes and levels of arterial stiffness in pediatric patients with SCD and to assess the differences with children at risk for hypertension. We included in the study 16 pediatric SCD (HbS/β-thalassemia, S/β-thal) patients and 16 consecutive children at risk for hypertension referred to our hypertension clinic that served as high-risk controls. All patients underwent ambulatory BP monitoring and measurement of carotid-femoral pulse wave velocity (PWV). S/β-thal patients had lower office systolic BP than the high-risk control group (115.43 ± 10.03 vs 123.37 ± 11.92, P = .05) but presented similar levels of day and night ambulatory BP. Office hypertension was found in 12.5% of the S/β-thal patients and in 43.8% of the high-risk controls (P = .06), while 18.8% of the S/β-thal patients and 25% of the high-risk controls presented hypertension by ambulatory BP levels (P = .21). All of the S/β-thal patients with ambulatory hypertension had night hypertension (one combined night and day hypertension) with office normotension (masked hypertension). S/β-thal patients and high-risk controls presented equal prevalence of masked hypertension (18.8%). Children and adolescents with S/β-thal present similar prevalence of BP phenotypes and levels of PWV with children at risk for hypertension. A significant number of children and adolescents with S/β-thal may have masked nighttime hypertension despite normal office BP levels.

Cardiometabolic risk in adolescents students of high school: influence of work

OBJECTIVES

to evaluate and compare the prevalence of cardiometabolic risk factors among high school adolescents with or without jobs, and to establish an association between risk factors and changes in lifestyle after starting to work.

METHODS

quantitative cross-sectional study. An instrument was applied to assess socio-demographic characteristics and habits. Dietary pattern was assessed by the Brazilian Healthy Eating Index. Nutritional status was assessed by the Z-score. Data were submitted to statistical analysis and comparison between groups and periods, as well as association and correlation was done.

RESULTS

the prevalence of high blood pressure was 7.7%. High BP affected 4.5% of non-workers and 10.9% of workers. Dietary patterns were inappropriate and 51.2% did not engage in physical activity. The prevalence of obesity was 28.3%. The results showed an association between work and alcohol consumption, lack of physical activity and reduced sleep quality.

CONCLUSIONS

work increased exposure to certain cardiometabolic risk factors.

EVIDENCE OF THE ASSOCIATION BETWEEN SLEEP DURATION AND BLOOD PRESSURE IN ADOLESCENTS: A SYSTEMATIC REVIEW

OBJECTIVE

To review the epidemiological evidence of the association between sleep duration and blood pressure in adolescents.

DATA SOURCES

We performed a systematic review of observational studies in Medline, Scopus, Lilacs, Web of Science, Science Direct databases and Virtual Libraries in English, Spanish and Portuguese published until September 2018. Studies were selected first by title and abstract, then by complete reading, according to the eligibility criteria. The reference list of selected articles was evaluated in order to retrieve relevant studies.

DATA SYNTHESIS

Initially, 1,455 articles were retrieved. After exclusion due to duplicity or not meeting the eligibility criteria, 13 articles were included in the review. Studies varied greatly in sample size (143 to 6,940 patients), methods of measuring blood pressure and sleep duration, cutoff points, categorization and adjustment of variables. The main evidence from the studies is that short sleep duration is associated with high blood pressure in adolescence, although the presence of association between high blood pressure and long sleep duration is possible, but not clear in the literature.

CONCLUSIONS

Sleep duration, especially short duration, is associated with high blood pressure in adolescents. Such evidence draws attention to implications on cardiovascular health in this age group.

French preparticipation physical evaluation for children in 2020: What has changed?

At the end of 2019, there was discussion in France about whether to abolish the obligatory medical certificate of no contraindication for a minor to obtain a sports license. It was finally decided not to abolish the certificate, but it raises the question of which steps should be taken to assess the physical capacities of children. General practitioners or pediatricians are responsible for the preparticipation physical evaluation of children wishing to obtain a sports license, in particular involving over 20 mandatory consultations between the ages of 0 and 18. The purpose of the article is to propose a course of action to be taken considering the French legislation and general pediatric resources concerning the medical examination and warning signs that should lead to vigilance.

Single blood pressure chart for children up to 13 years to improve the recognition of hypertension based on existing normative data

OBJECTIVE

To produce a single 'growth-chart-style' blood pressure (BP) chart with clear diagnostic thresholds to assist paediatricians to make prompt and accurate diagnoses of hypertension.

DESIGN

The well-established but complex published data on normal BP ranges in prepubertal children were identified and analysed to determine if it was possible to produce a single, user-friendly, colour-coded chart, showing diagnostic hypertension thresholds for systolic and diastolic BP without losing clinically important information.

RESULTS

There were sufficient published normative childhood BP data available to define systolic and diastolic BP centiles from term onwards but only sufficient to determine systolic BP centiles from 28 weeks of gestation to term. Up to 13 years of age, it was possible to combine boys' and girls' data without loss of precision and to define the threshold between stage 1 and stage 2 (severe) hypertension as the 95th centile +12 mm Hg. This allowed the production of single colour-coded charts for systolic and diastolic BP and to advise on making simple adjustments for the impact of stature on individual children's results.

CONCLUSIONS

A simplified, integrated BP chart with colour-coded diagnostic thresholds was produced to assist the prompt diagnosis of hypertension in prepubertal children. This information could be included into a Paediatric Early Warning System score.

Metformin use in obese mothers is associated with improved cardiovascular profile in the offspring

BACKGROUND

Maternal obesity increases the risk for pregnancy complications and adverse neonatal outcome and has been associated with long-lasting adverse effects in the offspring, including increased body fat mass, insulin resistance, and increased risk for premature cardiovascular disease. Lifestyle interventions in pregnancy have produced no or modest effects in the reduction of adverse pregnancy outcomes in obese mothers. The Metformin in Obese Pregnant Women trial was associated with reduced adverse pregnancy outcomes and had no effect on birthweight. However, the long-term implications of metformin on the health of offspring remain unknown.

OBJECTIVE

The purpose of this study was to assess whether prenatal exposure to metformin can improve the cardiovascular profile and body composition in the offspring of obese mothers.

STUDY DESIGN

In 151 children from the Metformin in Obese Pregnant Women trial, body composition, peripheral blood pressure, and arterial pulse wave velocity were measured. Central hemodynamics (central blood pressure and augmentation index) were estimated with the use of an oscillometric device. Left ventricular cardiac function and structure were assessed by echocardiography.

RESULTS

Children were 3.9±1.0 years old, and 77 of them had been exposed to metformin prenatally. There was no significant difference in peripheral blood pressure, arterial stiffness, and body composition apart from gluteal and tricep circumferences, which were lower in the metformin group (P<.05). The metformin group, compared with the placebo group, had lower central hemodynamics (mean adjusted decrease, -0.707 mm Hg for aortic systolic blood pressure, -1.65 mm Hg for aortic pulse pressure, and -2.68% for augmentation index; P<.05 for all) and lower left ventricular diastolic function (adjusted difference in left atrial area, -0.525 cm², in isovolumic relaxation time, -0.324 msec, and in pulmonary venous systolic wave, 2.97 cm/s; P<.05 for all). There were no significant differences in metabolic profile between the groups.

CONCLUSION

Children of obese mothers who were exposed prenatally to metformin, compared with those who were exposed to placebo, had lower central hemodynamic and cardiac diastolic indices. These results suggest that the administration of metformin in obese pregnant women potentially may have a beneficial cardiovascular effect for their offspring.

IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome

Idiopathic nephrotic syndrome newly affects 1-3 per 100,000 children per year. Approximately 85% of cases show complete remission of proteinuria following glucocorticoid treatment. Patients who do not achieve complete remission within 4-6 weeks of glucocorticoid treatment have steroid-resistant nephrotic syndrome (SRNS). In 10-30% of steroid-resistant patients, mutations in podocyte-associated genes can be detected, whereas an undefined circulating factor of immune origin is assumed in the remaining ones. Diagnosis and management of SRNS is a great challenge due to its heterogeneous etiology, frequent lack of remission by further immunosuppressive treatment, and severe complications including the development of end-stage kidney disease and recurrence after renal transplantation. A team of experts including pediatric nephrologists and renal geneticists from the International Pediatric Nephrology Association (IPNA), a renal pathologist, and an adult nephrologist have now developed comprehensive clinical practice recommendations on the diagnosis and management of SRNS in children. The team performed a systematic literature review on 9 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, formulated recommendations and formally graded them at a consensus meeting, with input from patient representatives and a dietician acting as external advisors and a voting panel of pediatric nephrologists. Research recommendations are also given.

Lower prevalence of aortic dilatation among preemptive pediatric renal transplant recipients - A cross-sectional cohort study

BACKGROUND

Aortic dilatation is a cardiovascular complication in pediatric renal transplant recipients and may have an increased risk of aortic dissection, aortic rupture, and death. Studies failed to show an association between blood pressure and aortic dilatation; however, 24-hours ambulatory blood pressure monitoring (ABPM) was not performed. There was also no comparison between preemptive transplantation and dialysis.

METHODS

After ethics approval, a retrospective cross-sectional study was performed on all prevalent pediatric renal transplant recipients from a single tertiary care center. The presence of aortic dilatation was determined using standard echocardiographic measurements, and those with other risk factors for aortic dilatation were excluded. Associations between 24-hours ABPM, renal function, dialysis history, and aortic dimensions were determined.

RESULTS

We enrolled 37 participants with the following characteristics: 46% female, mean age 14.5 ± 3.7 years, 16% preemptive transplantation, and median end-stage renal disease (ESRD) combined vintage (time from ESRD onset to echocardiogram) 597 days (range 289-1290 days). We found 16/37 patients (43%) with aortic dilatation at any level, mostly mild. There was no association between 24-hours ABPM measurements and aortic dilatation. None of the preemptively transplanted children had aortic dilatation.

CONCLUSION

This study confirms a high prevalence of aortic dilatation among pediatric renal transplant recipients, which appears to be independent of hypertension on 24-hour ABPM. Patients with preemptive renal transplantation did not have aortic dilatation, suggesting that the effects of dialysis may contribute to the high prevalence of this complication. Pediatric cardiologists need to carefully assess aortic dimensions in these at-risk patients.

Age-, sex-, and height-based blood pressure reference charts, Yazd children 6-18 years, Iran

BACKGROUND

Pediatric hypertension is the main cause of morbidity and mortality in pediatric populations.

PURPOSE

To examine pediatric hypertension in a clinical setting, we used the percentile rank approach and defined hypertension as that above the 95th percentile.

METHODS

The present study was linked to the a national analytical cross-sectional community-based Iranian Children and Adolescents' Psychiatric Disorders (IRCAP) survey. The survey was nationwide and funded by the National Institute of Medical Research Development. The IRCAP survey included 31,000 children and adolescents aged 6-18 years in all 31 Iran provinces. The current study included 1,035 children and adolescents and linked the data of the risk factors of cardiovascular disease only in Yazd province via random cluster sampling.

RESULTS

Of the total participants, 456 (44.1%) were male and 579 (55.9%) were female. The mean age was 11.2±3.8 years (11.7±3.7 years for males, 11.0±3.6 years for females), while mean height was 146±20.0 cm overall, 147.2±22.0 cm for males, and 144.6±17.0 cm for females (P=0.009). The blood pressure distributions and percentiles were evaluated.

CONCLUSION

Here we determined age- and height-specific 50th, 90th, 95th, and 99th percentiles of systolic and diastolic blood pressures in Yazd boys and girls using 10-cm height intervals.

The associations between noise annoyance and psychological distress with blood pressure in children and adolescents: The CASPIAN-V Study

Although blood pressure (BP) tracks from childhood to adulthood, and the prevalence of pediatric primary hypertension is increasing, related determinants are not well understood. The role of noise pollution and psychological distress in increasing BP is well documented in adults, but it remains elusive in children. This study aims to investigate the association of noise annoyance and psychological distress with BP in a pediatric population. This national cross-sectional study was conducted in 2015 on a sample of 14400 Iranian students, aged 7-18 years. Information regarding noise annoyance and psychological distress were assessed using questionnaires, and BP values were measured. Levels of noise annoyance and psychological distress were classified based on tertiles to no/low, moderate, and high. Data of 14274 students were completed. The mean age of participants was 12.28 (0.05), with 51% boys and 71.4% urban inhabitant. Diastolic BP and mean arterial BP (MAP) had positive correlations with noise annoyance (regression coefficient: 0.028, 95 % CI: 0.005 - 0.05 and 0.025, 95 % CI: 0.002 - 0.04, respectively). Participants with higher psychological distress were 15 % more likely to experience abnormally high BP compared to those with normal psychological status or mild distresses (OR: 1.15, 95 % CI: 1.003 - 1.34). Here, we found significant positive relationships between the level of noise annoyance and values of diastolic BP and MAP. Moreover, high psychological distress showed to increase the chance of abnormally high BP. The clinical impact of these findings should be assessed in further longitudinal studies.

Clinical assessment of primary and secondary hypertension in children and adolescents

The aim of this study was to compare the clinical features of patients with elevated blood pressure and to detect variables associated with the diagnosis of primary hypertension. We identified 383 (69%) hypertensive children (197 [51.5%] with primary hypertension, and 186 [48.5%] with secondary hypertension) out of 553 children referred to our clinic with a history of elevated blood pressure. The primary hypertension group was significantly older and had higher BMI, positive family history of hypertension, and lower prevalence of preterm birth compared with those with secondary hypertension. No difference was found between the two groups in terms of the frequency of target organ damage. Multiple regression analysis showed that a family history of hypertension, obesity, age over 10 years, elevated uric acid, and presence of higher systolic blood pressure values at admission were independent predictors of primary hypertension; therefore, these parameters can be considered important clues for diagnosing primary hypertension.

Updated and revised normal values of aortic pulse wave velocity in children and adolescents aged 3-18 years

Measurement of aortic pulse wave velocity (PWV_ao) is recommended for stratifying individual cardiovascular (CV) risk in adults. Diseases in children and adolescents might influence aortic stiffness. It is necessary to exclude overweight (OW), obese (O) subjects, and individuals with increased systolic (SBP) and/or diastolic blood pressure (DBP) from the population, when creating normal values of PWV_ao in children and adolescents. Body mass index (BMI), SBP/DBP cut-off values have remarkably changed in this population during the last decade. Aims of our study were to expand our previously published PWV_ao database and to revise it by using the recently determined normal values. PWV_ao was measured by an occlusive-oscillometric device (Arteriograph, TensioMed Ltd, Budapest, Hungary) in a healthy population aged 3-18 years. 7940 (4374 boys) participants were recruited, 1912 OW/O subjects and 1368 individuals with high SBP/DBP were excluded. Finally, n = 4690 (2599 boys) participants were enrolled. Mean PWV_ao values increased from 5.4 ± 0.6 to 6.4 ± 0.5 m/s (p < 0.05) in boys and from 5.5 ± 0.6 to 6.4 ± 0.5 m/s (p < 0.05) in girls. Mean PWV_ao values were significantly lower in our new study, in boys in age groups of 9-16, in girls in age groups of 11-17. This is the largest and widest age-ranged database of PWV_ao published to date. Due to the change of BMI and SBP/DBP reference values during the last decade, the "old" database of PWV_ao needed to be revised. As a result of this, normal values of PWV_ao decreased significantly in both sexes.

Epinephrine stress testing during cardiac catheterization in patients with aortic coarctation

BACKGROUND

The severity of aortic coarctation (CoA) may be underestimated during cardiac catheterization. We aimed to investigate whether epinephrine stress testing improves clinical decision making and outcome in CoA.

METHODS

We retrospectively evaluated CoA patients >50 kg with a peak systolic gradient (PSG) ≤20 mm Hg during cardiac catheterization who underwent epinephrine stress testing. Subsequent interventional management (stenting or balloon dilatation), complications, and medium-term clinical outcome were assessed.

RESULTS

Fifty CoA patients underwent cardiac catheterization with epinephrine stress testing. Patients with a high epinephrine PSG (>20 mm Hg; n = 24) were younger and more likely to have a hypertensive response to exercise compared to patients with a low epinephrine PSG (≤20 mm Hg; n = 26). In total, 21 patients (88%) with a high epinephrine PSG underwent intervention, and 20 patients (77%) with a low epinephrine PSG were treated conservatively. After a mean follow-up of 25 ± 18 months, there was a lower prevalence of hypertension in patients with a high epinephrine PSG who underwent intervention compared to patients with a low epinephrine PSG treated conservatively (19% vs. 76%; P = .001). In a multivariate model, intervention was independently associated with a 14.3-mm Hg reduction in systolic blood pressure (P = .001) and a decrease in the use of antihypertensive agents.

CONCLUSIONS

In CoA patients with a low baseline PSG but high epinephrine PSG, percutaneous intervention is associated with a substantial reduction in systemic blood pressure and the use of antihypertensive medication. Accordingly, epinephrine stress testing may be a useful addition in the evaluation of CoA.

National data with high validity and completeness showed that only 0.04% of Danish children had been registered with diagnosed hypertension

AIM

Hypertension has been reported in up to 4.0% of American children, but no national data exist in Europe. We studied the frequency of registered hypertension in Danish children and evaluated the data.

METHODS

This 2014-2015 study focused on patients under the age of 16 registered with hypertension in the Danish National Patient Register and 10 paediatric departments in central and eastern Denmark. The diagnoses were coded according to the International Classification of Diseases, 10th revision. All the subjects' medical records were reviewed, including any confirmed diagnoses.

RESULTS

There were 55 784 children under 16 in the study regions at 30 April 2014. By May 2015, 222 of those had been registered with hypertension: 200 in the Danish National Patient Register and 191 in the 10 paediatric departments. Their medical records confirmed hypertension in 187 and 185 cases, respectively. The prevalence of registered and confirmed hypertension was 222/553 784 (0.04%). The positive predictive values of hypertension were 187/200 (94%) and 185/191 (97%), and the completeness of diagnosed hypertension was 187/222 (84%) and 185/222 (83%).

CONCLUSION

The registers had high-quality positive predictive values and completeness, but only 0.04% of the Danish children were registered with a verified diagnosis of hypertension.

Results of targeted next-generation sequencing in children with cystic kidney diseases often change the clinical diagnosis

Cystic kidney diseases are a very heterogeneous group of chronic kidney diseases. The diagnosis is usually based on clinical and ultrasound characteristics and the final diagnosis is often difficult to be made. Next-generation sequencing (NGS) may help the clinicians to find the correct final diagnosis. The aim of our study was to test the diagnostic yield of NGS and its ability to improve the diagnosis precision in a heterogeneous group of children with cystic kidney diseases. Next-generation sequencing of genes responsible for the formation of cystic kidneys was performed in 31 unrelated patients with various clinically diagnosed cystic kidney diseases gathered at the Department of Pediatrics of Motol University Hospital in Prague between 2013 and 2018. The underlying pathogenic variants were detected in 71% of patients (n = 22), no or only one (in case of autosomal recessive inheritance) pathogenic variant was found in 29% of patients (n = 9). The result of NGS correlated with the clinical diagnosis made before the NGS in 55% of patients (n = 17), in the remaining 14 children (45%) the result of NGS revealed another type of cystic kidney disease that was suspected clinically before or did not find causal mutation in suspected genes. The most common unexpected findings were variants in nephronophthisis (NPHP) genes in children with clinically suspected autosomal recessive polycystic kidney disease (ARPKD, n = 4). Overall, 24 pathogenic or probably pathogenic variants were detected in the PKHD1 gene, 8 variants in the TMEM67 gene, 4 variants in the PKD1 gene, 2 variants in the HNF1B gene and 2 variants in BBS1 and NPHP1 genes, respectively. NGS is a valuable tool in the diagnostics of various forms of cystic kidney diseases. Its results changed the clinically based diagnoses in 16% (n = 5) of the children.

Nomograms to identify elevated blood pressure values and left ventricular hypertrophy in a paediatric population: American Academy of Pediatrics Clinical Practice vs. Fourth Report/European Society of Hypertension Guidelines

OBJECTIVE AND METHODS

The study aimed at evaluating, in a large sample of Italian children, the reclassification of blood pressure categories with the new U.S. nomograms, obtained in a population of normal-weight children (American Academy of Pediatrics Clinical Practice Guidelines, AAP-CPG), compared with the Fourth Report/European Society of Hypertension (ESH) nomograms. The performance of the two classifications in identifying the presence of left ventricular hypertrophy was also assessed.

RESULTS

In 951 individuals referred to a Pediatric Center for Cardiovascular Risk Prevention, a 12% increase in the prevalence of children with blood pressure at least 90th percentile was observed by using the new nomograms. In the subsample of children aged at least 13 years, the application of the blood pressure fixed cutoff values of 120/<80 mmHg (for 'elevated' blood pressure) and of 130/80 mmHg (for hypertension) led to a change in the blood pressure category (worse or better) in about 30% of cases as compared with the AAP-CPG classification based on percentiles. Regarding the identification of individuals with left ventricular hypertrophy, the AAP-CPG classification led to an increase in the true positive fraction (sensitivity) of 5.5%, and to an increment of the false-positive fraction (1 - specificity) of 5.8%. The logistic regression model, adjusted for possible confounding factors, and the ROC curves obtained from the linear predictor of the model showed an identical performance of the Fourth Report/ESH and the AAP-CPG classifications.

CONCLUSION

In our paediatric population, the AAP-CPG classification slightly increased the prevalence of elevated blood pressure values compared with the Fourth Report/ESH classification. Moreover, the application of more 'physiological' nomograms, based on a population of normal-weight children, did not yield any advantage in identifying individuals with early cardiac organ damage.

Impact of ESH and AAP hypertension guidelines for children and adolescents on office and ambulatory blood pressure-based classifications

BACKGROUND

The objective was to assess the differences between the 2016 European Society of Hypertension (ESH) and the 2017 American Academy of Pediatrics (AAP) hypertension (HTN) guidelines in the distribution of office blood pressure (BP) categories as well as in the office and ambulatory BP mismatches.

MATERIAL AND METHODS

The study included 4940 clinical evaluations performed in 2957 youth (5-18 years) of both sexes. BP and anthropometric parameters were measured following standard conditions. The classification of the BP measurements was normotension, high-normal, stages 1 and 2 HTN, following the criteria of both guidelines. In a subgroup of 2467 participants, 3941 office BP assessment was completed with 24-h ambulatory BP monitoring using an oscillometric monitor under standard conditions. The classification on white-coat (WCH) and masked HTN was recorded.

RESULTS

The AAP classified more participants, 70 per 1000 BP evaluations in the categories of high-normal and stage 1 HTN, than the ESH did. The differences were greater in obese, but also present in normal weight participants. Likewise, significant discrepancies were observed in the prevalence of WCH and masked HTN. The AAP identified more participants with WCH, with greater differences in older participants, mainly in boys, independent of weight category. In contrast, the ESH identified more participants with masked HTN. The excess of WCH by AAP was three times higher than the excess of masked HTN by ESH.

CONCLUSION

The application of the two guidelines may result in marked differences in the classification of high-normal BP and HTN and in the mismatched conditions when ambulatory BP monitoring is applied.

Diagnostic Precision of Anthropometric Variables for the Detection of Hypertension in Children and Adolescents

Introduction: High blood pressure (HBP) is a health problem the prevalence of which has increased in young populations. Overweight and obesity in early ages have been directly related to its development. Due to the impact of HBP, it is necessary to provide tools that facilitate its early diagnosis, with useful anthropometric variables being those that assess obesity. The objective of this paper was to determine the diagnostic accuracy of anthropometric variables to detect HBP. Methods: A cross-sectional study was conducted on 265 students aged 6-16. The diagnosis of HBP was made following the criteria proposed by the Spanish Association of Pediatrics. Through different statistical methods, the association between anthropometric variables of general obesity with HBP was analyzed. Results: Waist circumference (WC) showed the best diagnostic capacity (area under the receiver operating characteristic curve = 0.729), with a sensitivity and specificity of 72.2% and 76%, respectively, for a cut-off point of 73.5 cm. In the adjusted multivariate analysis, an association was found between HBP and anthropometric variables: WC (odds ratio (OR) = 10.7), body mass index (OR = 7.5), waist-to-height ratio (OR = 5.5) and body fat percentage (OR = 5.3) (p < 0.05). Conclusions: The anthropometric variables studied showed a moderate predictive capacity for HBP, highlighting WC, which showed the strongest association with HBP in the infant and child population.

The relationship of plasma renin, angiotensin, and aldosterone levels to blood pressure variability and target organ damage in children with essential hypertension

BACKGROUND

To investigate the relationships of plasma renin, angiotensin, and aldosterone levels to blood pressure variability and target organ damage in children with essential hypertension.

METHODS

A case-control study was conducted on 132 children diagnosed with essential hypertension (103 males and 29 females with the mean age of 11.8 ± 2.4 years). The plasma RAAS levels were measured using the enhanced chemiluminescence method, the ambulatory blood pressure was monitored for 24 h, and then the average real variability (ARV) was calculated. Data on indicators were used for assessing cardiac and renal damages. The correlations of plasma renin, angiotensin, and aldosterone (RAAS) levels to blood pressure variability (BPV) and target organ damage (TOD) were studied. A comparison between the groups was conducted using SPSS 20.

RESULTS

Among the 132 children, 55 cases had target organ damage. The 24-h ARV and the daytime ARV of the systolic blood pressure of the high angiotensin II (AT II) group was significantly higher than that of the normal AT II group (t = 2.175, P = 0.031; t = 2.672, P = 0.009). Plasma AT II and aldosterone levels were significantly associated with the left ventricular mass index (r = 0.329, P = 0.0001; r = 0.175, P = 0.045). Linear regression analysis showed that AT II [β ± s.e. = 0.025 ± 0.006, 95% CI (0.013-0.038), P = 0.0001] and aldosterone [β ± s.e. = 0.021 ± 0.007, 95% CI (0.008-0.034), P = 0.002] were risk factors for LVH.

CONCLUSIONS

The AT II level in children with essential hypertension affected the variability of the 24-h and the daytime SBP. Plasma AT II and aldosterone levels were associated with cardiac damage. Results from this study indicated that AT II and aldosterone are risk factors for LVH in childhood hypertension and are of great significance for improving the clinical prognosis of pediatric patients with hypertension.

Evidence Gaps in the Identification and Treatment of Hypertension in Children

The ultimate goal of recognizing and treating hypertension in childhood is to prevent target-organ damage during childhood and to reduce the risk of adulthood cardiovascular disease. The quality of evidence to guide blood pressure management in children is lower than in adult medicine, yet some common findings support clinical practice recommendations. Oscillometric devices are increasingly replacing manual blood pressure measurements, but evidence shows that readings are not equivalent between the 2 methods. In addition, multiple blood pressure readings are needed before diagnosing a child with hypertension, but the optimal number and timing are still being determined. The recent American Academy of Pediatrics blood pressure guideline has revised the normative data tables and included threshold blood pressure limits which seem to identify children with higher cardiovascular risks. Threshold limits vary between guidelines, and the most accurate threshold has yet to be determined. Lifestyle modifications are a cornerstone of hypertension management, but the optimal diet and physical activity changes for beneficial effect are not known. When pharmacotherapy is needed, physicians have used drugs from all antihypertensive classes in children, yet only a few classes have been systematically studied. The long-term cardiovascular consequences of elevated blood pressure during childhood are under investigation and it seems that the lower the childhood blood pressure the better and that the rate of change during childhood is predictive of adulthood disease. With much still to learn, this article summarizes the evidence and the evidence gaps for the diagnosis, investigation, management, and outcomes of pediatric hypertension.

Subclinical retinal microvascular alterations assessed by optical coherence tomography angiography in children with systemic hypertension

PURPOSE

To compare the foveal avascular zone (FAZ) macular and peripapillary vessel density between children with high blood pressure and healthy subjects.

METHODS

A total of 40 eyes of 20 children with hypertension and 40 eyes of 20 age- and sex-matched healthy controls were included. Capillary vessel density (CVD) in superficial (SCP) and deep (DCP) retinal capillary plexus, peripapillary region, and FAZ were analyzed by optical coherence tomography angiography.

RESULTS

The mean ages were 15.2 ± 1.5 years (range, 10-18) in patients with hypertension and 14.4 ± 2.8 years (range, 10-18) in healthy controls (P = 0.742). The mean FAZ area measured 0.25 ± 0.10 mm² in children with hypertension and 0.25 ± 0.09 mm² in healthy controls (P = 0.765). There was no significant difference between study groups in any measure of the macular SCP (P > 0.05 for all); however, the mean whole image, inferior hemisphere, and para- and perifoveal measurements of the macular DCP were significantly lower in children with hypertension than in controls (P < 0.05 for all).

CONCLUSIONS

Although there was no evidence of hypertensive retinopathy, subthreshold microvascular alterations were found in the DCP of the retinal circulation in pediatric hypertensives. These alterations should be considered as prognostic cues when defining whole systemic response to high blood pressure in childhood.

Fatty Acid Profile and Desaturase Activities in 7-10-Year-Old Children Attending Primary School in Verona South District: Association between Palmitoleic Acid, SCD-16, Indices of Adiposity, and Blood Pressure

In previous studies, dietary and circulating fatty acids (FA) and desaturases activity (delta-5 desaturase [D5D], delta-6 desaturase [D6D], and stearoyl-CoA desaturase [SCD-16]) involved in their metabolism were associated with metabolic and cardiovascular disorders. The aim of the study was to assess the association between different FAs and desaturases activity (estimated as product:precursor ratios) with individual cardiovascular risk factors (in particular, anthropometric measurements and blood pressure [BP]) in children. The FA profile was determined on a whole-blood drop in 243 children (age: 8.6 ± 0.72 years) participating in a school-based cross-sectional study. Docosahexaenoic acid (DHA) inversely correlated with indices of adiposity, glucose, and triglycerides. Palmitoleic acid and SCD-16 were directly associated with markers of adiposity and BP, even after adjustment for main confounders. D6D correlated directly with the waist/height ratio. Children with excess weight (>85th percentile; that is overweight plus obese ones) showed higher palmitic acid, palmitoleic acid, and higher SCD-16 activity as compared to normal-weight children. Most of the associations were confirmed in the excess-weight group. Omega-3 FAs, particularly DHA, but not omega-6 FA, showed a potentially beneficial association with metabolic parameters, whereas palmitoleic acid and SCD-16 showed a potentially harmful association with indices of adiposity and BP, especially in obese children.

Arterial Hypertension in Children

Pharmacological treatment of arterial hypertension in children is mainly based on individual experience, but there is evidence that blocking the angiotensin system reduces systolic and diastolic blood when compared to placebo, and these drugs are safe to use for a short duration, also in children under 6 years of age. Blocking the angiotensin system either by angiotensin-converting enzyme inhibitors or by antagonizing the angiotensin 1 receptor is effective, but did not display a consistent dose-response relationship with escalating doses, but the effective doses are known. Calcium channel antagonists are effective antihypertensives in children, but the evidence is limited. Based on small-sized studies, beta-blockers modestly reduce systolic blood pressure, but have no significant effect on diastolic blood pressure compared to placebo. They act in combination to antagonize reflex tachycardia induced by vasodilators. The most commonly used antihypertensive agents are safe to use in short-term studies.

Sex Differences in Association of Elevated Blood Pressure with Variables Characterizing Cardiometabolic Risk in Young Subjects with or Without Metabolic Abnormalities

Males present higher blood pressure (BP) values, higher prevalence of elevated BP, and a different prevalence of cardiometabolic risk factors when compared with females. We assumed that the trends of risk markers across BP categories (normotension, high normal BP, and hypertension) differ in young males and females, and between subjects without metabolic abnormalities (without obesity, insulin resistance, atherogenic dyslipidemia, hyperuricemia, or microinflammation) and those presenting them. Data from 2543 subjects (48% males) aged from 16 to 23 years were analyzed. The findings showed that 15% of males and 4% of females presented high normal BP while 9% and 1%, respectively, had hypertension. In males, variables characterizing obesity status, insulin sensitivity, atherogenic dyslipidemia, uric acid, adiponectin, a soluble receptor for advanced glycation end-products, and leukocyte counts showed worsening trends across BP categories. Females presented significant trends only for obesity measures, LDL-cholesterol, and non-HDL-cholesterol. Across BP categories, trends of variables characterizing cardiometabolic risk differed among abnormalities-free and presenting males. The multivariate model selected measures of central obesity, atherogenic dyslipidemia, insulin resistance, and uric acid as significant predictors of BP in both genders, and C-reactive protein in females. Sex differences in measures of cardiovascular health in juveniles may remain undiscovered unless two sexes are analyzed separately. These differences may have implications for sex-specific disease risk in adulthood.

[Diagnostic accuracy of the tri-ponderal mass index in identifying the unhealthy metabolic obese phenotype in obese patients]

INTRODUCTION

The metabolically healthy obese (MHO) phenotype defines obese patients who have preserved insulin sensitivity and absence of metabolic complications. This phenotype is associated with a lower risk of cardiovascular disease and type2 diabetes in adulthood.

OBJECTIVES

To determine the prevalence of MHO and the metabolically unhealthy obesity (MUO) phenotype in a cohort of obese children and adolescents and to establish the predictive capacity of the tri-ponderal mass index (TMI) and other anthropometric parameters in order to identify these patients.

PATIENTS AND METHODS

A cross-sectional study was conducted on 239 obese patients (125males) from 8 to 18years of age. Grade3 obesity was present in 45.9% of the patients. ROC curves were used to find the best cut-off point for: TMI, body mass index (BMI), BMI z-score (BMIzs), and waist/height index (WHI). MHO components: plasma blood glucose, plasma triglycerides, HDL-cholesterol, and blood pressure.

RESULTS

The prevalence of MUO in the study cohort was 62.4%. No differences between genders were observed, and it was increasing with the age and obesity degree. The TMI has a sensitivity of 75.8 and a specificity of 42.2 to identify the MUO patients. The best cut-off point for TMI is 18.7kg/m³, for BMI it was 30.4kg/m², for BMIzs +3.5SD, and 0.62 for WHI.

CONCLUSIONS

The diagnostic accuracy of TMI in identifying obese adolescents with metabolic risk was similar to BMI and WHI. However, the TMI is much simpler to use and simplifies the categorization of the obesity in both genders.

Use of amlodipine oral solution for the treatment of hypertension in children

Background Amlodipine is a widely used antihypertensive agent for the treatment of paediatric hypertension, but the commercially available tablets are not suitable to treat young patients, who need lower, flexible dosages and a liquid formulation. Objective To determine the pharmacokinetic properties of amlodipine and the acceptability of a standardised, extemporaneous oral solution. Method A newly developed liquid formulation of amlodipine was administered to hypertensive children between the age of 6 months and 11 years. Using a limited sampling strategy, population PK analysis was performed using nonlinear mixed effects modelling. Results Nine children, with a median age of 2.9 years (IQR 1.8-8.4), receiving stable amlodipine therapy in a median dose of 0.15 mg kg^-1 day^-1 (IQR 0.11-0.18), were switched to study medication. The population pharmacokinetic model was able to accurately predict the clearance of amlodipine in the study population. Based on the final model, clearance was reduced by 31.2% (RSE: 10%) in females. Patient reported outcomes on taste from a five-point hedonic scale were available for five patients, who scored the taste from positive to slightly negative. Conclusion The results from the PK study and the acceptability assessment show that the amlodipine oral solution presented in this study offers an appropriate treatment option for young children.