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

Pharmacological Treatment of Arterial Hypertension in Children and Adolescents in Lithuania

The global prevalence of arterial hypertension (AH) in the pediatric population is increasing, but therapeutic approaches and the choice of the most suitable antihypertensive medications remains challenging. The study aimed to estimate the prevalence, treatment rates, and pharmacological treatment patterns of children and adolescents with AH in Lithuania during 2019 using real-world data. The study population consisted of citizens of Lithuania aged 0 to 17 years, who were diagnosed with AH according to the International Classification of Diseases (ICD). The analysis of reimbursed antihypertensive medication prescriptions was performed according to AH etiology and age. The overall prevalence of AH by diagnostic ICD codes in 2019 was 0.29%:0.24% for primary and 0.05% for secondary. Treatment rates were 39.8% for primary AH and 66.3% for secondary AH. Angiotensin-converting enzyme inhibitors (ACEi) were the most popular medications irrespective of the etiology of AH or age. Beta-blockers were in the second place and used more often in older children. Calcium channel blockers were the third and angiotensin receptor blockers were the fourth most frequent choices. Enalapril was the most popular agent in the ACEi group and metoprolol in the beta-blocker group. Nearly forty percent of Lithuanian children with primary AH receive pharmacological therapy compared to two-thirds with secondary AH. Although ACEi are the predominant class of antihypertensive medications, discordances with available guidelines are evident, particularly in the overuse of beta-blockers and underuse of diuretics.

Nutrition, Body Composition, and Blood Pressure in Children and Adolescents from the Korea National Health and Nutrition Examination Survey

We aimed to investigate the association between nutrition and blood pressure and the role that body composition plays in this relationship. Korea National Health and Nutrition Examination Survey data from the years 2008-2020 were reviewed. A total of 11,234 subjects (5974 boys and 5260 girls) aged 10-18 years of age were selected. We analyzed the correlation between nutrition (intakes of energy, protein, fat, carbohydrate, sodium, saturated fatty acid (SFA), unsaturated fatty acid (USFA), and dietary fiber (DF)) and body composition (height, weight, waist circumference (WC), body mass index (BMI), and waist to height ratio (WHtR)), and performed multiple regression analysis to find the independent correlation between body composition and blood pressure (BP). We then compared the correlation between nutrition and BP, with or without adjustment for body composition. The intakes of energy, protein, fat, carbohydrate, sodium, and USFA had positive associations with height, weight, WC, and BMI. Systolic BP (SBP) and diastolic BP (DBP) were independently positively correlated with height and BMI. The intakes of energy, protein, fat, carbohydrate, sodium, and SFA had positive correlations with SBP and DBP, which disappeared when additionally adjusted for BMI and height. In conclusion, nutrition seems to affect BP via height and BMI in Korean children and adolescents.

Phenotypic characterization of a pediatric cohort with cystinuria and usefulness of newborn screening

BACKGROUND

Cystinuria is an inherited metabolic disease involving the defective transport of cystine and the dibasic amino acids in the renal proximal tubules that causes the formation of stones in the urinary system. In our regional child health program, cystinuria is included in newborn metabolic screening. Our objectives are the phenotypic characterization of our cystinuric pediatric cohort and to present our experience in neonatal cystinuria screening.

METHODS

The study of clinical cases of pediatric patients diagnosed with cystinuria over a period of 32 years. All patients were studied at demographic, clinical, laboratory, radiological, and therapeutic levels.

RESULTS

We diagnosed 86 pediatric patients with cystinuria; 36% of them had the homozygous biochemical phenotype. 95.3% of the patients were detected by neonatal metabolic screening. We performed urine biochemical analyses of parents with additional diagnoses of 63 adult patients. The mean follow-up time was 16.8 ± 8.5 years. 11.6% of patients developed one or more episodes of urinary tract infection during that period. Chronic kidney disease, proteinuria, and hypertension were uncommon (1.2%). 10.5% developed kidney stones at the mean age of presentation of 7.78 ± 7.6 years; 33% were recurrent. The risk of developing lithiasis was higher for homozygous biochemical-phenotype patients. Hypercalciuria was a significant risk factor in the development of lithiasis.

CONCLUSIONS

Our clinical data suggest that diagnosing cystinuria through neonatal screening could be a useful strategy for the detection of presymptomatic cases, in order to establish preventive measures, as well as for the detection of relatives at risk. A higher resolution version of the Graphical abstract is available as Supplementary information.

Prevalence trends of hypertension and influence factors among children and adolescents aged 7-17 years in China, 2011-2015: A serial cross-sectional study

Hypertension has rapidly increased in the last decades throughout the world. It is an emerging disease. However, limited information is available on secular trends and factors of childhood and adolescents' hypertension in China. In this study, 5-year successive data were derived from a cross-sectional study of the China Health and Nutrition Survey (CHNS) in 2011 and 2015. We used systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) at least 95th percentile on the basis of age, sex, and height percentiles to define hypertension (HBP). A total of 2,827 children and adolescents aged 7-17 years were included. The age-standardized prevalence of hypertension was increased significantly across 5 years: the standardized prevalence of hypertension was increased from 8.08% (2011) to 11.46% (2015) in China (P < 0.01). The mean SBP of boys increased from 101.21 to 102.79 mmHg, while the mean SBP of girls increased from 98.96 to 100.04 mmHg. The mean DBP of boys increased from 61.20 to 67.40 mmHg, while the mean DBP of girls increased from 64.34 to 65.76 mmHg. The prevalence of hypertension grew continuously in both sexes, but the pace of change for boys was more rapid than that for girls. This study confirmed that the association between rural (odds ratio [OR] = 1.394, 95%CI 1.032-1.883), overweight/obesity (OR = 2.621, 95%CI 1.506-4.562), and BP levels was highly correlated (P < 0.05). The possible protecting factors associated with hypertension were being a girl (OR = 0.788, 95%CI 0.595-1.043). There was no association between weekly physical activity, daily sleep duration, and hypertension (P > 0.05). Further in-depth analysis of influencing factors and comprehensive interventions should be urgently implemented to combat the hypertension epidemic among children and adolescents in China.

Are adherence to the Mediterranean diet and siesta individually or jointly associated with blood pressure in Spanish adolescents? Results from the EHDLA study

Background

Both dietary and sleep patterns can influence both blood pressure levels and heart rate, but these associations have been understudied in adolescents. Furthermore, it is not known whether diet and sleep could exert a synergistic effect with respect to the maintenance of optimal BP levels in this population.

Objective

To investigate the relationship of blood pressure levels with the combination of higher adherence to the Mediterranean diet and the habit of siesta (daytime napping) in Spanish adolescents.

Methods

A cross-sectional study was conducted with data obtained through personal interviews and physical examination from a representative sample of 1,378 adolescents (12-17 years of age) from the Valle de Ricote (Region of Murcia, Spain) selected using a simple random sampling technique. Adherence to the Mediterranean diet was assessed with the Mediterranean Diet Quality Index in Children and Adolescents, and the frequency and duration of siesta were self-reported. Objective measurements of systolic and diastolic blood pressure were obtained under standardized conditions. Statistical procedures were performed with SPSS software (v.25) and included logistic and generalized regression models adjusted for sex, age, socioeconomic status, body mass index, total energy intake, nighttime sleep duration, and moderate-to-vigorous physical activity.

Results

Of the 698 adolescents finally studied (mean age 13.9 ± 1.5 years; 56.2% female), 37.1% (n = 259) had high adherence to the Mediterranean diet and 19.6% (n = 137) reported frequent siesta. In the completely adjusted models, compared to adolescents with low Mediterranean diet adherence and no or infrequent siesta, those with high Mediterranean diet adherence and frequent siesta were less likely to have high-normal blood pressure or hypertension (odds ratio = 0.47; 95% confidence interval: 0.26, 0.88) and showed slightly lower systolic blood pressure (ß-coef. = -2.60; 95% CI: -5.18, -0.02).

Conclusion

Greater adherence to the Mediterranean diet and frequent siesta have a synergistic effect on maintaining lower blood pressure levels in adolescence. These findings reinforce that adherence to both Mediterranean lifestyle behaviors early in life may be an important strategy to prevent hypertension throughout adulthood.

Isolated systolic hypertension in the young: a heterogeneous condition

Isolated systolic hypertension in the youth, is still a challenging problem. The prevalence of this hypertensive subtype may vary according to the different population study and is peculiar of male subjects among the youngest age classes. Several are the mechanisms reported as possible underlying causes of isolated systolic blood pressure elevation and again these differ according to the different study cohort and may vary from overweight and obesity status, linked to sympathetic overactivity, to increased and earlier arterial stiffness, hyperkinetic state, or exaggerated pulse pressure amplification form central to peripheral sites, due to enhanced arterial elasticity. Evidence is lacking regarding whether this condition is benign or associated to unfavorable cardiovascular events. The few long-term studies that followed isolated systolic hypertensives in the long-term, again reported conflicting results. Waiting for future studies, some clinical and hemodynamic characteristics of young isolated systolic hypertensives may help clinicians to better characterized patient's risk profile and decide whether to perform a strict follow-up with non-pharmacological measurements or to start drug treatment.

Endogenous sex hormones homeostasis disruption combined with exogenous phthalates exposure increase the risks of childhood high blood pressure: A cohort study in China

BACKGROUND

The structural similarity between sex hormones and exogenous phthalates (PAEs) enabled them as disrupters in regulating childhood blood pressure (BP). We aim to explore the association of sex hormones homeostasis and PAEs metabolites with childhood high BP (HBP).

METHODS

A cohort study was conducted with 1416 children aged 7-13 years at baseline and with 824, 819, and 801 children completing three waves' follow up. Serum testosterone (TT) and estradiol (E2) in children during three consecutive waves of surveys were measured by radioimmunoassay, and then TT/E2 ratio calculated as TT divided by E2 were used to represent sex hormones homeostasis. Seven urinary PAEs metabolites were measured in children of first wave. The BP Z-Scores and HBP across waves were obtained by sex, age, and height specific percentiles. Log-binomial regression models with adjusted risk ratios (aRR) after adjusting for confounders were utilized.

RESULTS

The prevalence of HBP at the baseline survey was 25.5%, and increased from 26.3% in the first wave of survey to 35.0% in the third wave of survey. PAEs were negatively correlated with E2, while positively correlated with TT and TT/E2 ratio. A positive association of the serum TT levels, TT/E2 ratio, and total PAEs was found with HBP prevalence (in wave 1, 2 and 3 with TT (aRR): 1.63, 1.37 and 1.45; with TT/E2: 1.63, 1.42 and 1.20; with PAEs: 1.40, 1.32 and 1.32), persistent HBP (with TT (aRR): 2.19; TT/E2: 2.16; PAEs: 2.57), occasional HBP (with TT (aRR): 1.94; TT/E2: 1.72; PAEs: 1.38), and new HBP incidence (with TT (aRR): 1.44; TT/E2: 1.57; PAEs: 1.67), but E2 had a negative association with HBP phenotypes (HBP prevalence in wave 1, 2 and 3 (aRR): 0.77, 0.93, and 1.10; persistent HBP: 0.47; occasional HBP: 0.96; new HBP incidence: 0.81). The E2 and PAEs had antagonistic effects on HBP risks in children, particularly in girls and those with high BMI group, but the TT levels, TT/E2 ratio and PAEs had synergistic effects on HBP risks in children, particularly in boys and those with high BMI group.

CONCLUSION

Exogenous PAEs exposure and endogenous sex hormones homeostasis disruption independently increase the risks of HBP. Moreover, the exogenous PAEs exposure could disrupt the endogenous sex hormones homeostasis in children, thereby combinedly increased risks of childhood HBP.

Psoriasis and Cardiovascular Risk in Children: The Usefulness of Carotid Intima-Media Thickness

Psoriasis is a skin disorder which mostly affects adults, beginning in childhood in almost one-third of patients. In adults it is associated with increased risk for cardiovascular diseases (CVD), while this association is still debated at younger age. Our aim was to evaluate the association between psoriasis and metabolic markers and cardiovascular findings in this age group. Twenty consecutive patients previously diagnosed with psoriasis (group A) were enrolled and compared with healthy non- psoriatic age- and sex-matched subjects (group B). The severity of the disease, CV risk factors, including anthropometric data with adiposity and its distribution, blood pressure (BP), laboratory metabolic tests, echocardiography and vascular ultrasound (transcranial echo-Doppler and carotid artery echo-Doppler with carotid intima-media thickness, cIMT) were performed for each subject. Personal history for CV risk, BP, anthropometric data were similar between the two groups, while familiar history for psoriasis was more frequent in group A (p < 0.02). C-IMT was significantly higher in group A compared to B (right, p = 0.001; left, p = 0.002). In addition, c-IMT was positively correlated with disease duration, triglycerides and triglycerides/glucose. Cerebral flow velocities, cardiac measurements, systo-diastolic function, ventricle geometry and mass were normal and comparable between the two groups, and did not correlate with CV risk factors. In childhood psoriasis c-IMT could represent a marker of pre-clinical cardiovascular involvement and contribute to start a personalized management, while cardiac findings seem to be normal in the early stage of disease. Longitudinal studies can clarify the progression of CV involvement in paediatric-onset psoriasis.

Arterial Stiffness and Chronic Kidney Disease Progression in Children

BACKGROUND AND OBJECTIVES

CKD has been linked to increased arterial stiffness in adults, but data in children with CKD remain conflicting. We aimed to investigate the longitudinal dynamics and determinants of pulse wave velocity in children with CKD and its association with CKD progression.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed an analysis of the Cardiovascular Comorbidity in Children with Chronic Kidney Disease (4C) study, which prospectively followed children aged 6-17 years with CKD stages 3-5. Follow-up was censored at the time of KRT initiation. Two separate analyses were performed: with absolute pulse wave velocity (primary outcome) and with pulse wave velocity standardized to height (z score; restricted to participants ≤17 years) as a sensitivity analysis.

RESULTS

In total, 667 patients with a mean baseline eGFR of 27 ml/min per 1.73 m2 were included. Pulse wave velocity above the 95th percentile was observed in 124 (20%) patients at baseline. Absolute pulse wave velocity increased gradually over the median follow-up of 2.7 (interquartile range, 0.7-4.4) years, whereas pulse wave velocity z score remained relatively stable. Absolute pulse wave velocity over time associated with time; older age; higher mean arterial pressure, LDL cholesterol, and albuminuria; and lower ferritin. Pulse wave velocity z score (n=628) was associated with the same variables and additionally, with higher diastolic BP z score, lower height z score, younger age, and girls. Of 628 patients, 369 reached the composite end point of CKD progression (50% eGFR loss, eGFR <10 ml/min per 1.73 m2, or the start of KRT) during a median follow-up of 2.4 (interquartile range, 0.9-4.6) years. Pulse wave velocity z score did not associate with CKD progression by univariable or multivariable proportional hazard analysis correcting for the established predictors eGFR, proteinuria, and BP.

CONCLUSIONS

Pulse wave velocity is increased in children with CKD but does not associate with eGFR or CKD progression.

Blood pressure response to exercise in children and adolescents

Blood pressure changes during exercise are part of the physiological response to physical activity. Exercise stress testing can detect an exaggerated blood pressure response in children and adolescent. It is applied for certain clinical conditions, but is also commonly used as part of the assessment of athletes. The interpretation of blood pressure values in response to exercise during childhood and adolescence requires appropriate reference data. We discuss the available reference values and their limitations with regard to device, exercise protocol and normalization. While the link between an exaggerated blood pressure response and cardiovascular events and mortality has been demonstrated for adults, the situation is less clear for children and adolescents. We discuss the existing evidence and propose that under certain circumstances it might be reasonable to have children and adolescents undergo exercise stress testing as a rather non-invasive procedure to add additional information with regard to their cardiovascular risk profile. Based on the existing data future studies are needed to extend our current knowledge on possible links between the presence of certain clinical conditions, the detectability of an exaggerated blood pressure response during childhood and adolescence and the risk of developing cardiovascular morbidity and mortality in later life.

Childhood Obesity: Position Statement of Polish Society of Pediatrics, Polish Society for Pediatric Obesity, Polish Society of Pediatric Endocrinology and Diabetes, the College of Family Physicians in Poland and Polish Association for Study on Obesity

Childhood obesity is one of the most important problems of public health. Searching was conducted by using PubMed/MEDLINE, Cochrane Library, Science Direct, MEDLINE, and EBSCO databases, from January 2022 to June 2022, for English language meta-analyses, systematic reviews, randomized clinical trials, and observational studies from all over the world. Five main topics were defined in a consensus join statement of the Polish Society of Pediatrics, Polish Society for Pediatric Obesity, Polish Society of Pediatric Endocrinology and Diabetes and Polish Association for the Study on Obesity: (1) definition, causes, consequences of obesity; (2) treatment of obesity; (3) obesity prevention; (4) the role of primary care in the prevention of obesity; (5) Recommendations for general practitioners, parents, teachers, and regional authorities. The statement outlines the role of diet, physical activity in the prevention and treatment of overweight and obesity, and gives appropriate recommendations for interventions by schools, parents, and primary health care. A multisite approach to weight control in children is recommended, taking into account the age, the severity of obesity, and the presence of obesity-related diseases. Combined interventions consisting of dietary modification, physical activity, behavioral therapy, and education are effective in improving metabolic and anthropometric indices. More actions are needed to strengthen the role of primary care in the effective prevention and treatment of obesity because a comprehensive, multi-component intervention appears to yield the best results.

Hypertension in children and adolescents

Definition and management of arterial hypertension in children and adolescents are uncertain, due to different positions of current guidelines. The European Society of Cardiology task-force, constituted by Associations and Councils with interest in arterial hypertension, has reviewed current literature and evidence, to produce a Consensus Document focused on aspects of hypertension in the age range of 6-16 years, including definition, methods of measurement of blood pressure, clinical evaluation, assessment of hypertension-mediated target organ damage, evaluation of possible vascular, renal and hormonal causes, assessment and management of concomitant risk factors with specific attention for obesity, and anti-hypertensive strategies, especially focused on life-style modifications. The Consensus Panel also suggests aspects that should be studied with high priority, including generation of multi-ethnic sex, age and height specific European normative tables, implementation of randomized clinical trials on different diagnostic and therapeutic aspects, and long-term cohort studies to link with adult cardiovascular risk. Finally, suggestions for the successful implementation of the contents of the present Consensus document are also given.

Circadian Blood Pressure Profile in Pediatric Patients with Primary Hypertension

Our study aimed to evaluate factors affecting circadian BP profile and its association with hypertension-mediated organ damage (HMOD) in pediatric patients with primary hypertension (PH). The study included 112 children (14.7 ± 2.1 age, 79 boys, 33 girls) with untreated PH. Non-dipping was defined as a nocturnal drop in systolic or diastolic BP (SBP, DBP) < 10%, and a nocturnal drop >20% was defined as extreme dipping. The nocturnal SBP drop was 10.9 ± 5.9 (%), and the DBP drop was 16.2 ± 8.5 (%). Non-dipping was found in 50 (44.6%) children and extreme dipping in 29 (25.9%) patients. The nocturnal SBP decrease correlated with BMI Z-score (r = −0.242, p = 0.010) and left ventricular mass index (LVMI) (r = −0.395, p = 0.006); diastolic DBP decrease correlated with augmentation index (AIx75HR) (r = 0.367, p = 0.003). Patients with a disturbed blood pressure profile had the highest LVMI (p = 0.049), while extreme dippers had the highest augmentation index (AIx75HR) (p = 0.027). Elevated systolic and diastolic BP dipping were risk factors for positive AIx75HR (OR 1.122 95CI (1.009−1.249) and OR 1.095 95CI (1.017−1.177). We concluded that disturbed circadian BP profile was common in children with PH and should not be considered a marker of secondary hypertension. A disturbed circadian BP profile may be associated with higher body weight. In pediatric patients with PH, non-dipping is associated with increased left ventricular mass, and extreme dipping may be a risk factor for increased arterial stiffness.

Mediating role of body composition and insulin resistance on the association of arterial stiffness with blood pressure among adolescents: The ALSPAC study

Background

Emerging evidence among adolescents suggests that arterial stiffness temporally precedes elevated blood pressure/hypertension in the casual pathway. It remains unknown whether insulin resistance and body composition mediate this relationship. Therefore, we examined the mediating role of total fat mass, lean mass, and insulin resistance in the association between arterial stiffness and blood pressure among adolescents.

Materials and methods

We studied 3,764 participants, aged 17 years from the Avon Longitudinal Study of Parents and Children (ALSPAC) United Kingdom birth cohort. Arterial stiffness accessed with Vicorder device measured carotid-femoral pulse wave velocity (cfPWV), body composition was measured by dual-energy Xray Absorptiometry, blood pressure by Omron device, and homeostatic model assessment of insulin resistance (HOMA-IR) was computed. Data were analysed with structural equation models mediation path analyses and adjusted for cardiometabolic and lifestyle factors.

Results

Among 1,678 [44.6%] male and 2,086 [55.4%] female participants, higher cfPWV was directly and independently associated with higher systolic and diastolic blood pressure, irrespective of the mediator [Standardized regression coefficient (β) = 0.248–0.370, p for all = 0.002]. Lean mass [β = 0.010; p = 0.026; 3.3% mediation] and HOMA-IR [β = 0.004; p = 0.033; 1.1% mediation] but not total fat mass [β &lt; 0.0001; p = 0.615; 0% mediation] partly mediated the association of cfPWV with systolic blood pressure after full adjustments. Similarly, lean mass [β = –0.004; p = 0.021; 1.4% mediation] and HOMA-IR [β = 0.007; p = 0.039; 2.8% mediation] but not total fat mass [β = –0.002; p = 0.665; 0.7% mediation] partly mediated the association of cfPWV with diastolic blood pressure.

Conclusion

Attenuating insulin resistance may be a potentially valuable strategy in lowering higher blood pressure precipitated by higher arterial stiffness.

Reduced Blood Pressure Dipping Is A Risk Factor for the Progression of Chronic Kidney Disease in Children

Background: Elevated blood pressure and proteinuria are well-established risk factors for chronic kidney disease (CKD) progression in children. This study aimed to analyze risk factors for CKD progress, emphasizing detailed ambulatory blood pressure (ABPM) data. Methods: In 55 children with CKD II−V, observed for ≥1 year or until initiation of kidney replacement therapy, we analyzed ABPM, clinical, and biochemical parameters. Results: At the beginning, the glomerular filtration rate (eGFR) was 66 (interquartile range—IQR: 42.8−75.3) mL/min/1.73 m2, and the observation period was 27 (16−36) months. The mean eGFR decline was 2.9 ± 5.7 mL/min/1.73 m2/year. eGFR decline correlated (p < 0.05) with age (r = 0.30), initial proteinuria (r = 0.31), nighttime systolic and mean blood pressure (r = 0.27, r = 0.29), and systolic and diastolic blood pressure dipping (r = −0.37, r = −0.29). There was no relation between mean arterial pressure during 24 h (MAP 24 h Z-score) and eGFR decline and no difference in eGFR decline between those with MAP 24 h < and ≥50 th percentile. In multivariate analysis, systolic blood pressure dipping (beta = −0.43), presence of proteinuria (beta = −0.35), and age (beta = 0.25) were predictors of eGFR decline. Conclusions: Systolic blood pressure dipping may be a valuable indicator of CKD progression in children.

Arterial stiffness and nocturnal hypertension in preterm children and adolescents

BACKGROUND AND OBJECTIVES

Preterm birth has been associated with increased risk for developing hypertension and other chronic diseases during childhood and adulthood. The aim of the current prospective case-control study was to investigate the associations of preterm birth with ambulatory blood pressure (BP) levels and arterial stiffness during childhood and adolescence.

METHODS

The study population included 52 children and adolescents born preterm and 26 healthy children born full term with similar age. The participants underwent ambulatory BP monitoring (ABPM) and assessment of carotid-femoral pulse wave velocity (PWV).

RESULTS

Preterm children presented higher night SBP z score values compared to controls, but did not differ in other ABPM parameters, office peripheral and central SBPs. Nocturnal hypertension was found in 78% (7/9) of ex-preterm children with ambulatory BP hypertension. Preterm birth was an independent predictor of PWV z score adjusted for heart rate. Estimated marginal means for PWV z score adjusted for age, sex, presence of kidney disease at birth, office BPs, night BPs, central SBP, and BMI z scores were significantly higher in preterm individuals compared to controls (0.703, 95% confidence interval [CI] 0.431-0.975 versus -0.19, 95% CI -0.574-0.536, respectively, P  = 0.027). Preterm children who were overweight presented the highest values of night SBP and PWV z score.

CONCLUSION

Preterm birth is associated with higher nocturnal BP and increased arterial stiffness in childhood and adolescence. Increased awareness for detection of hypertension and prevention of obesity in childhood could prevent future adverse cardiovascular outcomes in preterm individuals.

Relationship between sexual maturation and anthropometric and blood pressure indicators in teenagers

This study aimed to investigate the relationship between sexual maturation and anthropometric and blood pressure indicators in teenagers. This was a population-based cross-sectional study, conducted with 345 teenagers, aged 10 to 19 years, between 2018 and 2020. In this study, data referent to sociodemographic and anthropometric variables, blood pressure, and sexual maturation were collected. The data analysis was performed by applying the Principle Component Analysis (PCA), which generated three components and then tested the correlation between sexual maturation and the generated components. Most of the teenagers were female (53%), normotensive (66.1%), and with a normal weight (73%). A positive correlation was found between breast development and component 1 and component 2, as well as a negative correlation between the breasts and component 3. In the boys, the development of genitals and pubic hair was positively correlated with component 2 and inversely correlated with component 3. It could therefore be concluded that there is a relationship between sexual maturation and the anthropometric and blood pressure indicators, which proved to be representative variables for cardiovascular risk in teenagers, even if not in their entirety.

Multi-centre cross-sectional study on vascular remodelling in children following successful coarctation correction

Coarctation of the aorta is an arteriopathy with life-long sequelae, with remarkably increased cardiovascular events in young adults even after successful repair and despite blood pressure status. There are data on arterial remodelling in adults after coarctation correction, however, these data are scarce in childhood. Thus, the aim of this cross-sectional study was to evaluate changes in arterial wall function and morphology in children following successful coarctation repair and to compare these changes among patients with different blood pressure status and coarctation correction modes. Blood pressure status, echocardiographic parameters, arterial wall structure and stiffness, endothelial function and central blood pressure measurements were evaluated in 110 children aged 6-18 years following successful coarctation repair with right arm blood pressure not exceeding leg blood pressure by ≥20 mmHg. The prevalence of arterial hypertension was 50%. The mean carotid intima-media thickness SDS was 3.1 ± 1.5 and above 1.65 SDS in 91 of 110 patients. Increased right carotid intima-media thickness was associated with left ventricular hypertrophy, office blood pressure difference between leg and right arm, recoarctation in the past and interventional coarctation correction. Increased local common carotid artery stiffness was associated with increased pulse pressure and central systolic blood pressure. Potentially decreased endothelial function was related to a slight increase of peak and mean systolic gradient in the descending aorta. After successful coarctation repair and with a low blood pressure gradient, children still have a high prevalence of arterial hypertension and significant arterial remodelling, indicating accelerated biological age and advanced arteriosclerosis.

Associations of maternal gestational diabetes mellitus with alterations in cardiovascular system in early childhood

AIMS

The association of maternal gestational diabetes mellitus (GDM) with childhood cardiovascular alterations is not well established. This study aims to test the hypothesis that prenatal exposure to GDM is associated with vascular and cardiac alterations in early childhood.

METHODS

In a population-based prospective cohort among 1094 mothers and their offspring, GDM was diagnosed according to the International Association of Diabetes and Pregnancy Study Groups criteria. Childhood blood pressure (BP) measurement, echocardiography and vascular ultrasound were performed using standardised methods at 4 years old. The associations between maternal GDM and childhood cardiovascular outcomes were modelled using linear regression and binary logistic regression. Mediation analysis was conducted to test the potential mediators.

RESULTS

Maternal GDM was associated with higher systolic BP (SBP; β, 1.20; [0.11, 2.28]), lower left ventricular end-diastolic diameter (LVEDD; β, -0.36; [-0.71, -0.01]), lower end-diastolic volume (EDV; β, -1.42; [-2.71, -0.13]) and increased risk of high blood pressure (HBP, OR = 1.522; 95% CI, 1.023 to 2.264) in offspring at the age of 4 years. After stratification by sex, the association remained strong only in male offspring (SBP: β, 1.94; [0.37, 3.51]; LVEDD: β, -0.60; [-1.09, -0.12]; EDV: β, -2.09; [-3.86, -0.31]; HBP: OR = 1.797; 95% CI, 1.063 to 3.037) and was independent of maternal and child characteristics. However, carotid intima-media thickness (cIMT) was not associated with maternal GDM. Mediation analysis showed that the effects on childhood cardiovascular alterations were attributable mostly to the direct effects of maternal GDM.

CONCLUSIONS

Our results provide evidence that maternal GDM is associated with offspring cardiovascular adaptations at preschool age. Further studies are needed to replicate our results and the long-term effect of these adaptations on later cardiovascular risks needs further investigation.

Relationship between sexual maturation and anthropometric and blood pressure indicators in teenagers

Abstract This study aimed to investigate the relationship between sexual maturation and anthropometric and blood pressure indicators in teenagers. This was a population-based cross-sectional study, conducted with 345 teenagers, aged 10 to 19 years, between 2018 and 2020. In this study, data referent to sociodemographic and anthropometric variables, blood pressure, and sexual maturation were collected. The data analysis was performed by applying the Principle Component Analysis (PCA), which generated three components and then tested the correlation between sexual maturation and the generated components. Most of the teenagers were female (53%), normotensive (66.1%), and with a normal weight (73%). A positive correlation was found between breast development and component 1 and component 2, as well as a negative correlation between the breasts and component 3. In the boys, the development of genitals and pubic hair was positively correlated with component 2 and inversely correlated with component 3. It could therefore be concluded that there is a relationship between sexual maturation and the anthropometric and blood pressure indicators, which proved to be representative variables for cardiovascular risk in teenagers, even if not in their entirety.

Evaluation of tissue perfusion status in moderate to late preterm

The aim of this study was to investigate the tissue perfusion status and circadian rhythm in moderately premature infants. As a prospective study, from July 2019 to October 2019, the haemodynamic stability of moderate to late preterm, including such indicators as perfusion index (PI), blood pressure (systolic/diastolic) (BP), heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2) and body temperature were monitored in the morning and at night within eight days after birth. There was no difference of statistical significance between PI values in the morning and at night (P>0.05). The HR from days six to eight after birth was higher than days one to three (P<0.05). The HR increased significantly on days seven and eight compared with days four and five (P<0.05). The BP from days three to eight was significantly higher than on day one (P<0.05), and the BP from days four to eight was higher than on day two. There was a weak positive correlation between the PI values and gestational age (GA) (r=0.097), HR (r=0.067) and time (r=0.284), and a negative correlation with SpO2 (r=-0.113). The PI and HR of moderate to late preterm increased within eight days after birth. BP was relatively lower after birth and gradually increased to a stable level on days three to four. The PI and BP circadian rhythms associated with tissue perfusion were not established on day eight after birth.

Vascular biomarkers in the prevention of childhood cardiovascular risk: From concept to clinical implementation

Vascular biomarkers allow for non-invasive assessment of vascular structure and function and have been shown to be surrogates for cardiovascular (CV) outcome in adults. They reflect the cumulative risk of a plethora of single CV risk factors, such as obesity and hypertension, on the arterial wall. The process of atherosclerosis oftentimes has its origin in childhood and tracks into adulthood. Obesity-related CV risk in childhood is a main determinant of manifest CV disease and adverse outcome in adulthood. To date, prevention strategies are directed toward the detection and reduction of CV disease in adulthood. This review updates and puts into perspective the potential use of vascular biomarkers in children. With reference to the concept of early vascular aging in adults, it elaborates on the role of vascular biomarkers for CV risk stratification in children. The concept of primordial vascular aging implies that young children be screened for vascular health, in an attempt to timely detect subclinical atherosclerosis and initiate treatment strategies to reverse vascular damage in a period of life with high probability for risk regression. The evidence for the validity of macro- and microvascular candidate biomarkers as screening tools of CV risk in children is reviewed, and limitations as well as remaining research gaps are highlighted. Furthermore, an overview on the effects of exercise treatment on vascular biomarkers is given. Vascular biomarkers susceptible to lifestyle or drug treatment have the potential to qualify as monitoring tools to guide clinicians. This review discusses evidence for vascular biomarkers to optimize screening of childhood CV risk from initial concepts to potential future clinical implementation in cardiovascular prevention.

Demographics of childhood hypertension in the UK: a report from the Southeast England

We aimed to describe hypertensive phenotype and demographic characteristics in children and adolescents referred to our paediatric hypertension service. We compared age, ethnicity and BMI in primary hypertension (PH) compared to those with secondary hypertension (SH) and white coat hypertension (WCH). Demographic and anthropometric data were collected for children and adolescents up to age 18 referred to our service for evaluation of suspected hypertension over a 6 year period. Office blood pressure (BP) and out of office BP were performed. Patients were categorised as normotensive (normal office and out of office BP), WCH (abnormal office BP, normal out of office BP), PH (both office and out of office BP abnormal, no underlying cause identified) and SH (both office and out of office BP abnormal, with a secondary cause identified). 548 children and adolescents with mean ± SD age of 10.1 ± 5.8 years and 58.2% girls. Fifty seven percent (n = 314) were hypertensive; of these, 47 (15%), 84 (27%) and 183 (58%) had WCH, PH and SH, respectively. SH presented throughout childhood, whereas PH and WCH peaked in adolescence. Non-White ethnicity was more prevalent within those diagnosed with PH than both the background population and those diagnosed with SH. Higher BMI z-scores were observed in those with PH compared to SH. Hypertensive children <6 years are most likely to have SH and have negligible rates of WCH and PH. PH accounted for 27% of hypertension diagnoses in children and adolescents, with the highest prevalence in adolescence, those of non-White Ethnicity and with excess weight.

Effects of Ramipril on Biomarkers of Endothelial Dysfunction and Inflammation in Hypertensive Children on Maintenance Hemodialysis: the SEARCH Randomized Placebo-Controlled Trial

BACKGROUND

Hypertension, endothelial dysfunction, and inflammation are associated with increased cardiovascular mortality in end-stage kidney disease. We evaluated the effects of ACE (angiotensin-converting enzyme) inhibition on biomarkers of endothelial dysfunction and inflammation in hypertensive children with end-stage kidney disease on maintenance hemodialysis.

METHODS

In a randomized, double-blind, placebo-controlled trial, 135 (72 males/63 females) children and adolescents (age 7-15 years) were randomly assigned to treatment with either 2.5 mg once daily ramipril (n=68) or placebo (n=67) for 16 weeks. Primary outcome were the serum concentrations of asymmetrical dimethylarginine, a marker of endothelial dysfunction and hs-CRP (high-sensitivity C-reactive protein), a marker of inflammation. Changes in IL-6 (interleukin-6), TNF-α (tumor necrosis factor-alpha), systolic (S), and diastolic (D) blood pressure were secondary outcomes. Change in potassium levels and incidence of hyperkalemia were among the safety parameters.

RESULTS

Ramipril, but not placebo, significantly reduced serum levels of asymmetrical dimethylarginine (-79.6%; P<0.001), hs-CRP (-46.5%; P<0.001), IL-6 (-27.1%; P<0.001), and TNF-α (-51.7%; P<0.001). Systolic blood pressure and diastolic blood pressure were significantly lowered in both groups with a greater reduction in children receiving ramipril (median between-group differences -12.0 [95% CI -18.0 to -9.5] and -9.0 [95% CI -12.0 to -4.5]; P<0.001, respectively). Changes in asymmetrical dimethylarginine, hs-CRP, IL-6, or TNF-α in the ramipril group did not significantly correlate with blood pressure reductions. No severe cases of hyperkalemia or other serious treatment-associated adverse events were observed.

CONCLUSIONS

Ramipril improves biomarkers of endothelial dysfunction and inflammation in hypertensive children on maintenance hemodialysis in addition to its efficacious and safe potential to lower blood pressure.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04582097.

The compatibility of new blood pressure reference values for Korean children and adolescents with the US reference: the Korean Working Group of Pediatric Hypertension

Background

Childhood hypertension is associated with hypertension and metabolic syndrome in adulthood. Since the definition of childhood hypertension is based on the distribution of normative blood pressure (BP), a reference range is essential to create hypertension guidelines for children. We aimed to investigate the compatibility of the new Korean BP reference with the United States (US) BP reference based on the 2017 Clinical Practice Guideline.

Methods

We compared the new Korean reference BP values for children and adolescents aged 10 to 17 years with those in the 2017 Clinical Practice Guidelines. We also analyzed the differences in the prevalence of hypertension in Korean children and adolescents when reference value was applied. Considering Korean and US BP references together, linear trend lines were sought.

Results

Systolic BP (SBP) and diastolic BP (DBP) values in 95th percentiles showed no significant differences between the two BP references. Applying the two reference values, there was no significant difference in the prevalence of elevated BP and a combination of elevated BP and hypertension. Combining the Korean and US BP values and plotting them against age, approximate lines for the 90th and 95th SBP and DBP percentiles were observed.

Conclusions

The BP values of the new Korean BP reference were similar to those of the US BP reference; they were reliable and interchangeable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-022-00200-x.

Association of Newborn Telomere Length With Blood Pressure in Childhood

IMPORTANCE

Adult telomere length (TL) is a biological marker of aging associated with vascular health. TL at birth is associated with later life TL and may contain early biological information of later life cardiovascular health and disease.

OBJECTIVE

To evaluate whether newborn TL is associated with early life blood pressure differences in childhood.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was part of the ENVIRONAGE (Environmental Influence on Aging in Early Life) study, a birth cohort of Belgian mother-child pairs with recruitment at birth and a median follow-up of 4.5 years conducted between October 2014 and July 2021. Participants included for analysis provided full data for evaluation at follow-up visit. Data analysis was conducted between August and September 2021.

MAIN OUTCOMES AND MEASURES

Cord blood and placental average relative TL were measured at birth using quantitative polymerase chain reaction (qPCR). Systolic, diastolic, and mean arterial pressure (MAP) were evaluated at follow-up. High childhood blood pressure (standardized for child age, sex, and height) was defined following the 2017 American Academy of Pediatrics guidelines. Multivariable adjusted linear and logistic regression models were used to associate newborn TL and blood pressure indicators in childhood.

RESULTS

This study included 485 newborn children (52.8% girls) with a mean (SD) age of 4.6 (0.4) years at the follow-up visit. Newborn TL was associated with lower blood pressure in childhood. A 1-IQR increase in cord blood TL was associated with a -1.54 mm Hg (95% CI, -2.36 to -0.72 mm Hg) lower diastolic blood pressure and -1.18 mm Hg (95% CI, -1.89 to -0.46 mm Hg) lower MAP. No association was observed with systolic blood pressure. Furthermore, a 1-IQR increase in cord blood TL was associated with lower odds of having high blood pressure at the age of 4 to 6 years (adjusted OR, 0.72; 95% CI, 0.53 to 0.98). In placenta, a 1-IQR increase in TL was associated with a -0.96 mm Hg (95% CI, -1.72 to -0.21 mm Hg) lower diastolic, -0.88 mm Hg (95% CI, -1.54 to -0.22 mm Hg) lower MAP, and a lower adjusted OR of 0.69 (95% CI, 0.52 to 0.92) for having a high blood pressure in childhood.

CONCLUSIONS AND RELEVANCE

In this prospective birth cohort study, variation in early life blood pressure at school-age was associated with TL at birth. Cardiovascular health may to some extent be programmed at birth, and these results suggest that TL entails a biological mechanism in this programming.

Differences in the proportion of Croatian adolescents with abnormal individual metabolic syndrome components adjusted to gender and different criterion for individual metabolic syndrome component

OBJECTIVES

There are different approaches to diagnosing of the metabolic syndrome (MetS) in adolescents. We aim to compare the proportions of adolescents with abnormal values of MetS components between the NCEP/ATP criteria and the proposed cut-off values from the local population percentile distribution adjusted to gender.

METHODS

Subjects were 358 high school students (246 girls, 112 boys) aged 14-17 years from three Croatian regions. The serum glucose levels were determined by hexokinase method, serum triglycerides by GPO-PAP method, and serum high-density lipoprotein-cholesterol by automated homogeneous assays on Beckman Coulter AU 680 analyser (Minneapolis, USA).

RESULTS

Differences were seen between genders by NCEP/ATPIII modified criteria in the proportion of the adolescents with the proposed cut-off values for HDL-C levels, SBP, and DBP with a higher prevalence in boys. The proportion of girls differs between data set percentile criteria, and NCEP/ATP III modified criteria for HDL-C value, serum fasting glucose value and DBP value. The proportion of boys with higher values than suggested differs between proposed NCEP/ATP III modified criteria and percentile criteria for serum fasting glucose values and DBP.

CONCLUSIONS

Our study has shown differences in the proportion of 14-17-year-old adolescents between gender according to modified NCEP/ATPIII criteria for HDL-C, SBP and DBP with a higher prevalence of SBP and DBP related to other individual MetS components for both genders. Gender adjusted cut-off value from own populations avoids possible under- or over-estimation in the distribution of individual MetS components with no difference in the proportion of adolescents between gender.

Uric acid and cardiometabolic risk by gender in youth with type 1 diabetes

The aim of this study was to investigate the association between uric acid (UA) and cardiometabolic risk factors (CMRFs) by sex in youth with type 1 diabetes (T1D). Retrospective data collected from 1323 children and adolescents (5–18 years; 716 boys) with T1D recruited in 9 Italian Pediatric Diabetes Centers were analyzed. CMRFs included UA, HbA_1c, blood pressure (BP), cholesterol (TC), HDL, triglycerides (TG), neutrophils (N) and lymphocytes (L) count, glomerular filtration rate (eGFR) (calculated using Schwartz-Lyon equation). In boys, we found a higher age, daily insulin dose, TG, TG/HDL ratio, TC/HDL ratio, systolic BP, N/L ratio and lower HDL, and eGFR across UA tertiles (p = 0.01–0.0001). Similar results were found in girls but not for TG and systolic BP. In boys, the odds ratio (OR) of high levels of TG/HDL ratio, TC/HDL ratio, BP and mildly reduced eGFR (MRGFR) increased for 0.5 mg/dL of UA. Instead, in girls an increased levels of 0.5 mg/dL of UA were associated with high OR of TC/HDL ratio, N/L ratio and MRGFR. Uric acid may represent a useful marker for identifying youth with T1D at high cardiometabolic risk, and this association appears to vary by sex.

Arterial stiffness precedes hypertension and metabolic risks in youth: a review

Arterial stiffness is a strong predictor of cardiovascular events and all-cause mortality in middle-aged and old adults. Arterial stiffness has been limited to being an intermediate marker of atherosclerotic cardiovascular events in adolescents and young adult studies. The paucity of normative longitudinal data and repeated gold-standard assessments of arterial stiffness among the young population has occasioned a huge knowledge gap in its clinical utility. This review summarizes recent longitudinal evidence in a large adolescent population, supporting the value of arterial stiffness as a novel risk factor for hypertension, overweight/obesity and insulin resistance. Preventing or decreasing arterial stiffness during adolescence may confer cardiometabolic health benefits in later life, but further pathological and mechanistic research is needed. The review also offers suggestions for incorporating arterial stiffness measures into routine paediatric and young adult clinical practice.

Relationship between serum 25-hydroxyvitamin D and target organ damage in children with essential hypertension

Researchers have shown that 25-hydroxyvitamin D (25[OH] D), a kind of active vitamin D in the human body, plays a role in cardiovascular disease (CVD). Low serum 25(OH) D levels have been found to be associated with elevated blood pressure (BP) in adults. However, measurement of 25(OH) D in hypertensive children has not been documented. The aim of this study was to investigate the relationship between 25(OH) D and target organ damage (TOD) in children with essential hypertension. We recruited a total of 346 children with essential hypertension and analyzed the correlation between serum 25(OH) D and TOD. Serum 25(OH) D concentration was significantly lower in the TOD than in the no-TOD group (t = 2.416, P = 0.016), as well as significantly lower in the two-organ damage than in the single-organ damage group (t = 3.140, P = 0.002). Pearson's correlation coefficient (PCC) indicated that serum 25(OH) D levels were negatively correlated with left ventricular mass index (LVMI; r = -0.110, P = 0.041) and albuminuria (r = -0.120, P = 0.026). Linear- regression analysis showed that 25(OH) D was a risk factor for left ventricular hypertrophy (LVH; β ± s.e. =-0.074 ± 0.036; 95% confidence interval [CI], - 0.145 to -0.003; P < 0.001) and renal damage (β ± s.e.= -0.018 ± 0.008; 95% CI, - 0.035 to -0.002; P = 0.004). In total, our data revealed that serum 25(OH) D was independently associated with hypertensive cardiac and renal damage, meaning that it was a risk factor for LVH and albuminuria in childhood hypertension.

Disparities between determinants of impaired vascular structure and function in young people with primary hypertension: a systematic review

OBJECTIVE

Early effects of primary hypertension on arterial structure and function in children and young people (CYP) and their determinants remain elusive. We aimed to review independent determinants of carotid intima-media thickness (cIMT), carotid wall cross-sectional area (WCSA) and carotid-femoral pulse wave velocity (cfPWV) in CYP with primary hypertension.

METHODS

We performed a systematic review of studies reporting multivariable analysis of cfPWV, cIMT and WCSA in CYP (up to 25 years of age) with primary hypertension. Literature search was performed in PubMed database and 13, 12 and two articles including 3860 (age range 4-25 years, 50% male individuals), 2038 children (5-25 years, 55% male individuals) and 136 children (5-17 years, 85% male individuals) were selected for final analysis of cfPWV, cIMT and WCSA, respectively.

RESULTS

Ninety and 86% of the studies reported higher cfPWV and cIMT in CYP with elevated blood pressure (BP) compared with normotensive controls. Different indices of BP were positively associated with cfPWV in 92% of studies, whereas BMI showed association in 31%. Carotid IMT associated with BP indices in 50% and with BMI in 25% of the studies. WCSA was studied longitudinally and its improvement associated with decrease in measures of central obesity.

CONCLUSION

We found a disparity between the determinants of structural and functional impairment of arterial tree in CYP with primary hypertension. In contrast to cIMT and WCSA, increase of cfPWV is almost exclusively determined by BP.

Monogenic forms of low-renin hypertension: clinical and molecular insights

Monogenic disorders of hypertension are a distinct group of diseases causing dysregulation of the renin-angiotensin-aldosterone system and are characterized by low plasma renin activity. These can chiefly be classified as causing (i) excessive aldosterone synthesis (familial hyperaldosteronism), (ii) dysregulated adrenal steroid metabolism and action (apparent mineralocorticoid excess, congenital adrenal hyperplasia, activating mineralocorticoid receptor mutation, primary glucocorticoid resistance), and (iii) hyperactivity of sodium and chloride transporters in the distal tubule (Liddle syndrome and pseudohypoaldosteronism type 2). The final common pathway is plasma volume expansion and catecholamine/sympathetic excess that causes urinary potassium wasting; hypokalemia and early-onset refractory hypertension are characteristic. However, several single gene defects may show phenotypic heterogeneity, presenting with mild hypertension with normal electrolytes. Evaluation is based on careful attention to family history, physical examination, and measurement of blood levels of potassium, renin, and aldosterone. Genetic sequencing is essential for precise diagnosis and individualized therapy. Early recognition and specific management improves prognosis and prevents long-term sequelae of severe hypertension.

Prevalence of hypertension and hypertension phenotypes after three visits in Chinese urban children

OBJECTIVE

This study aims to evaluate the prevalence of hypertension and hypertension subtypes among Chinese children aged 6-17 years in a multicenter school-based sample by three separate screenings.

METHODS

Students from six major cities in China (Changchun, Beijing, Jinan, Shanghai, Chongqing, and Chengdu) were recruited in this cross-sectional survey during 2012 and 2015. Each participant was seated and had three consecutive blood pressure measurements on the right arm in the morning by an automated oscillometric device and the hypertensive ones were followed to the next visit. Hypertension was diagnosed by BP references for Chinese children and adolescents in 2010.

RESULTS

Data from 44 396 children aged 6-17 years were included in analysis, 50.9% of whom were boys. The prevalence of confirmed hypertension after three separate screenings was 4% in the total population, 5% in boys, and 3% in girls, respectively. The prevalence of confirmed isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic and diastolic hypertension (SDH) in the total population was 2.7, 0.3 and 1%, respectively.

CONCLUSION

Around 4% urban Chinese children and adolescents aged 6 -17 years were hypertensive after three separate BP screenings in 2012 -2015. ISH was the most frequent form of hypertension in children.

Cardiovascular Burden Is High in Pediatric Lung Transplant Recipients

BACKGROUND

Cardiovascular morbidity is common in adults after lung transplantation (LTx) but has not been described for pediatric LTx recipients. Early subclinical cardiovascular damage is reflected by increases in pulse wave velocity (PWV; indicating arteriosclerosis), intima-media thickness (IMT; indicating atherosclerosis), and left ventricular mass index (LVMI; indicating left ventricular hypertrophy).

METHODS

We annually assessed 47 pediatric LTx recipients in a prospective longitudinal study (144 observations, mean 3.1 visits/patient, range of 1-4 visits, mean follow-up 2.2 y).

RESULTS

At inclusion, increased PWV and IMT were detected in 13% and 30%, respectively, and elevated LVMI was detected in 33%. Higher PWV was associated with male sex, longer time since LTx, higher diastolic blood pressure, and lower glomerular filtration rate. Male sex and lower hemoglobin levels were associated with higher IMT, and the presence of diabetes was associated with higher LVMI.

CONCLUSIONS

Pediatric LTx recipients suffer from a high and sustained burden of subclinical cardiovascular damage. In light of improving long-term outcomes, cardiovascular morbidity needs to be addressed. Our analysis identified classical and nonclassical risk factors to be associated with the measures for cardiovascular damage, which could serve as targets for intervention.

Definition, diagnosis and clinical management of non-obstructive kidney dysplasia: a consensus statement by the ERKNet Working Group on Kidney Malformations

Kidney dysplasia is one of the most frequent causes of chronic kidney failure in children. While dysplasia is a histological diagnosis, the term 'kidney dysplasia' is frequently used in daily clinical life without histopathological confirmation. Clinical parameters of kidney dysplasia have not been clearly defined, leading to imprecise communication amongst healthcare professionals and patients. This lack of consensus hampers precise disease understanding and the development of specific therapies. Based on a structured literature search, we here suggest a common basis for clinical, imaging, genetic, pathological and basic science aspects of non-obstructive kidney dysplasia associated with functional kidney impairment. We propose to accept hallmark sonographic findings as surrogate parameters defining a clinical diagnosis of dysplastic kidneys. We suggest differentiated clinical follow-up plans for children with kidney dysplasia and summarize established monogenic causes for non-obstructive kidney dysplasia. Finally, we point out and discuss research gaps in the field.

Development and Validation of a Nomogram-Based Prognostic Model to Predict High Blood Pressure in Children and Adolescents—Findings From 342,736 Individuals in China

Objectives

Predicting the potential risk factors of high blood pressure (HBP) among children and adolescents is still a knowledge gap. Our study aimed to establish and validate a nomogram-based model for identifying youths at risk of developing HBP.

Methods

HBP was defined as systolic blood pressure or diastolic blood pressure above the 95th percentile, using age, gender, and height-specific cut-off points. Penalized regression with Lasso was used to identify the strongest predictors of HBP. Internal validation was conducted by a 5-fold cross-validation and bootstrapping approach. The predictive variables and the advanced nomogram plot were identified by conducting univariate and multivariate logistic regression analyses. A nomogram was constructed by a training group comprised of 239,546 (69.9%) participants and subsequently validated by an external group with 103,190 (30.1%) participants.

Results

Of 342,736 children and adolescents, 55,480 (16.2%) youths were identified with HBP with mean age 11.51 ± 1.45 years and 183,487 were boys (53.5%). Nine significant relevant predictors were identified including: age, gender, weight status, birth weight, breastfeeding, gestational hypertension, family history of obesity and hypertension, and physical activity. Acceptable discrimination [area under the receiver operating characteristic curve (AUC): 0.742 (development group), 0.740 (validation group)] and good calibration (Hosmer and Lemeshow statistics, P > 0.05) were observed in our models. An available web-based nomogram was built online on https://hbpnomogram.shinyapps.io/Dyn_Nomo_HBP/.

Conclusions

This model composed of age, gender, early life factors, family history of the disease, and lifestyle factors may predict the risk of HBP among youths, which has developed a promising nomogram that may aid in more accurately identifying HBP among youths in primary care.

The Importance of Office Blood Pressure Measurement Frequency and Methodology in Evaluating the Prevalence of Hypertension in Children and Adolescents With Type 1 Diabetes: The SWEET International Database

OBJECTIVE

The prevalence of hypertension is higher in children and adolescents with type 1 diabetes (T1D) compared with those without. This retrospective analysis of a large cohort of children and adolescents with T1D from the SWEET (Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) international consortium of pediatric diabetes centers aimed to 1) estimate the prevalence of elevated office blood pressure (BP) and hypertension and 2) investigate the influence of BP measurement methodology on the prevalence of hypertension.

RESEARCH DESIGN AND METHODS

A total of 27,120 individuals with T1D, aged 5-18 years, were analyzed. Participants were grouped into those with BP measurements at three or more visits (n = 10,440) and fewer than 3 visits (n = 16,680) per year and stratified by age and sex. A subgroup analysis was performed on 15,742 individuals from centers providing a score indicating BP measurement accuracy.

RESULTS

Among participants with BP measurement at three or more visits, the prevalence of hypertension was lower compared with those with fewer than three visits (10.8% vs. 17.5% P < 0.001), whereas elevated BP and normotension were higher (17.5% and 71.7% vs. 15.3% and 67.1%, respectively; both P < 0.001). The prevalence of hypertension and elevated BP was higher in individuals aged ≥13 years than in younger ones (P < 0.001) and in male than female participants (P < 0.001). In linear regression models, systolic and diastolic BP was independently determined by the BP measurement methodology.

CONCLUSIONS

The estimated prevalence of elevated BP and hypertension in children and adolescents with T1D is ∼30% and depends on the BP measurement methodology. Less frequent BP evaluation may overestimate the prevalence of hypertension.

Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association

Use of ambulatory blood pressure monitoring in children and adolescents has markedly increased since publication of the last American Heart Association scientific statement on pediatric ambulatory blood pressure monitoring in 2014. In addition, there has also been significant expansion of the evidence base for use of ambulatory blood pressure monitoring in the pediatric population, including new data linking ambulatory blood pressure levels with the development of blood pressure-related target organ damage. Last, additional data have recently been published that enable simplification of the classification of pediatric ambulatory monitoring studies. This scientific statement presents a succinct review of this new evidence, guidance on optimal application of ambulatory blood pressure monitoring in the clinical setting, and an updated classification scheme for the interpretation of ambulatory blood pressure monitoring in children and adolescents. We also highlight areas of uncertainty where additional research is needed.

Hypertension in Patients with Insulin Resistance: Etiopathogenesis and Management in Children

Insulin resistance (IR) is a key component in the etiopathogenesis of hypertension (HS) in patients with diabetes mellitus (DM). Several pathways have been found to be involved in this mechanism in recent literature. For the above-mentioned reasons, treatment of HS should be specifically addressed in patients affected by DM. Two relevant recently published guidelines have stressed this concept, giving specific advice in the treatment of HS in children belonging to this group: the European Society of HS guidelines for the management of high blood pressure in children and adolescents and the American Academy of Pediatrics Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Our aim is to summarize the main pathophysiological mechanisms through which IR causes HS and to highlight the specific principles of treatment of HS for children with DM.

Hypertension in obese children is associated with vitamin D deficiency and serotonin dysregulation

Background

Obesity and hypertension represent serious health issues affecting the pediatric population with increasing prevalence. Hypovitaminosis D has been suggested to be associated with arterial hypertension. Serotonin by modulating nitric oxide synthase affect blood pressure regulation. The biological mechanism by which vitamin D specifically regulates serotonin synthesis was recently described. The aim of this paper is to determine the associations between vitamin D, serotonin, and blood pressure in obese children.

Methods

One hundred and seventy-one children were enrolled in the prospective cross-sectional study. Two groups of children divided according to body mass index status to obese (BMI ≥95th percentile; n = 120) and non-obese (n = 51) were set. All children underwent office and ambulatory blood pressure monitoring and biochemical analysis of vitamin D and serotonin. Data on fasting glucose, insulin, HOMA, uric acid, and complete lipid profile were obtained in obese children.

Results

Hypertension was found only in the group of obese children. Compared to the control group, obese children had lower vitamin D and serotonin, especially in winter. The vitamin D seasonality and BMI-SDS were shown as the most significant predictors of systolic blood pressure changes, while diastolic blood pressure was predicted mostly by insulin and serotonin. The presence of hypertension and high-normal blood pressure in obese children was most significantly affected by vitamin D deficiency and increased BMI-SDS.

Conclusions

Dysregulation of vitamin D and serotonin can pose a risk of the onset and development of hypertension in obese children; therefore, their optimization together with reducing body weight may improve the long-term cardiovascular health of these children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03337-8.

Ambulatory Blood Pressure Monitoring in Children and Adults Prenatally Exposed to Dexamethasone Treatment

CONTEXT

The clinical use of dexamethasone (DEX) prenatally to reduce virilization of external genitalia in female fetuses with congenital adrenal hyperplasia (CAH) is efficient but still controversial. It remains challenging to prevent the excessive exposure of DEX in unborn healthy babies during the first trimester of pregnancy.

OBJECTIVE

Since endogenous glucocorticoids contribute to the maintenance of blood pressure (BP) and since events during fetal life may program the fetus and affect future metabolic health, the aim of this study was to analyze ambulatory BP measurements in CAH-unaffected children and adults that were prenatally exposed to DEX treatment.

METHODS

Ambulatory BP measurements were analyzed in 33 (16 female) DEX-treated participants aged 5.1 to 26.3 years (19 participants aged ≤ 18 years) and in 54 (28 female) age- and sex-matched apparently healthy controls aged 5.5 to 25.3 years (27 participants aged ≤ 18 years) with ambulatory normotension.

RESULTS

Participants' age, height, weight, and body mass index were similar between the DEX-treated group and the control group. Heart rate, 24-hour BP, pulse pressure, and nighttime dipping did not statistically significantly differ between DEX-treated participants and controls.

CONCLUSION

Our study suggests that prenatal DEX treatment in CAH-unaffected children and adults does not appear to adversely affect ambulatory BP later in life. Our observations need to be confirmed in larger studies.

Vascular dysfunction and increased cardiovascular risk in hypospadias

AIMS

Hypogonadism is associated with cardiovascular disease. However, the cardiovascular impact of hypogonadism during development is unknown. Using hypospadias as a surrogate of hypogonadism, we investigated whether hypospadias is associated with vascular dysfunction and is a risk factor for cardiovascular disease.

METHODS AND RESULTS

Our human study spanned molecular mechanistic to epidemiological investigations. Clinical vascular phenotyping was performed in adolescents with hypospadias and controls. Small subcutaneous arteries from penile skin from boys undergoing hypospadias repair and controls were isolated and functional studies were assessed by myography. Vascular smooth muscle cells were used to assess: Rho kinase, reactive oxygen species (ROS), nitric oxide synthase/nitric oxide, and DNA damage. Systemic oxidative stress was assessed in plasma and urine. Hospital episode data compared men with a history of hypospadias vs. controls. In adolescents with hypospadias, systolic blood pressure (P = 0.005), pulse pressure (P = 0.03), and carotid intima-media thickness standard deviation scores (P = 0.01) were increased. Arteries from boys with hypospadias demonstrated increased U46619-induced vasoconstriction (P = 0.009) and reduced acetylcholine-induced endothelium-dependent (P < 0.0001) and sodium nitroprusside-induced endothelium-independent vasorelaxation (P < 0.0001). Men born with hypospadias were at increased risk of arrhythmia [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.4-5.6, P = 0.003]; hypertension (OR 4.2, 95% CI 1.5-11.9, P = 0.04); and heart failure (OR 1.9, 95% CI 1.7-114.3, P = 0.02).

CONCLUSION

Hypospadias is associated with vascular dysfunction and predisposes to hypertension and cardiovascular disease in adulthood. Underlying mechanisms involve perturbed Rho kinase- and Nox5/ROS-dependent signalling. Our novel findings delineate molecular mechanisms of vascular injury in hypogonadism, and identify hypospadias as a cardiovascular risk factor in males.

Evaluation of Active Renin Concentration in A Cohort of Adolescents with Primary Hypertension

Our study aimed to assess active renin concentration in children with primary hypertension. Thus, we evaluated active renin concentration, clinical parameters, office and ambulatory blood pressure, and biochemical parameters in 51 untreated adolescents with primary hypertension (median: 14.4 [interquartile range—IQR: 13.8–16.8] years) and 45 healthy adolescents. Active renin concentration did not differ between patients with hypertension and healthy children (median: 28.5 [IQR: 21.9–45.2] vs. 24.9 [IQR: 16.8–34.3] [pg/mL], p = 0.055). In the whole group of 96 children, active renin concentration correlated positively with serum potassium and office and ambulatory systolic and diastolic blood pressures. Among children with hypertension, patients with isolated systolic hypertension had lower renin concentration than patients with systolic-diastolic hypertension (26.2 [IQR: 18.6–34.2] vs. 37.8 [IQR: 27.0–49.6] [pg/mL], p = 0.014). The active renin concentration did not differ between patients with isolated systolic hypertension and healthy children. In multivariate analysis, diastolic blood pressure Z-score (beta = 0.238, 95 confidence interval [0.018–0.458], p = 0.035) was the only predictor of active renin concentration in the studied children. We concluded that active renin concentration is positively associated with blood pressure and potassium in children, and diastolic blood pressure was the strongest predictor of renin level. Patients with isolated systolic hypertension may differ from patients with systolic-diastolic hypertension in less severe activation of the renin-angiotensin-aldosterone system.

Evaluation of pulse wave velocity and central systolic blood pressure in children and adolescents with chronic kidney disease

OBJECTIVE

Investigate pulse wave velocity and central systolic blood pressure among pediatric population with chronic kidney disease.

METHODS

In this cross-sectional study, 57 patients (61.4% male) aged 6.2 to 17.5 years old, 44 with nondialysis chronic kidney disease and 13 on chronic dialysis, were included in the analysis. The pulse wave velocity and the central systolic blood pressure were measured with an oscillometric device with an inbuilt ARC SolverⓇ algorithm and were compared with previously established percentiles.

RESULTS

The prevalence of elevated pulse wave velocity was 21.1% (95%Cl: 11.4-33.9) and elevated central systolic blood pressure was 28.1% (95%CI: 17.0-41.5). According to the generalized linear model, there was a higher risk of elevated pulse wave velocity in patients undergoing chronic dialysis treatment than nondialysis chronic kidney disease patients (adjPR=4.24, 95%CI: 1.97-9.13, p=<0.001). Hypertensive patients (stage 2) had a higher risk of elevated pulse wave velocity than normotensive ones (adjPR=2.70, 95%CI: 1.05-6.95, p=0.040), as did patients younger than 12 years than the older patients (adjPR=2.95, 95%CI: 1.05-8.40, p=0.041). Hypertensive patients had a higher risk of elevated central systolic blood pressure than normotensives (adjPR=3.29, 95%Cl: 1.36-7.94), as did patients undergoing chronic dialysis treatment when comparing to nondialysis chronic kidney disease patients (adjPR=2.08, 95%Cl: 1.07-4.02).

CONCLUSION

Younger age, dialysis, and hypertension in children are independently associated with higher pulse wave velocity. Hypertension and dialysis are independently associated with higher central systolic blood pressure.

Early pregnancy vitamin D status is associated with blood pressure in children: an Odense Child Cohort study

BACKGROUND

Blood pressure in childhood tracks into later life. Vitamin D status in adults is associated with blood pressure, but the impact of vitamin D status in pregnancy and childhood on blood pressure still needs investigation.

OBJECTIVE

We investigated whether fetal rather than current vitamin D status is associated with blood pressure in children.

METHODS

In a prospective observational study within the population-based Odense Child Cohort (OCC), we examined serum 25-hydroxyvitamin D2+3 [s-25(OH)D] in early and late pregnancy, cord blood, and at 5 y age, and the associations with systolic and diastolic blood pressure (SBP/DBP) in the 5-y-old children (n = 1,677). Multiple regression models were adjusted for maternal country of origin, parity, smoking during pregnancy, 5-y height, and weight. Two-stage mixed effect modeling was performed, integrating all s-25(OH)D data from pregnancy and cord blood.

RESULTS

The median (IQR) s-25(OH)D in early pregnancy, late pregnancy, the umbilical cord, and at 5 y was 65.5 (50.7-78.5), 78.5 (60.3- 95.8), 45.4 (31.1- 60.7), and 71.9 (54.6- 86.5) nmol/L, respectively. The mean ±SD 5-y SBP/DBP was 101.0/63.8 (7.1/5.9) mmHg. In adjusted analyses, a 10 nmol/L increase of s-25(OH)D in early pregnancy associated with a 0.3/0.2 mmHg lower SBP/DBP at 5 y (P < 0.05). Optimal s-25(OH)D (>75 nmol/L) in early pregnancy was associated with lower 5-y SBP and DBP, β (95% CI) -1.45 (-2.6, -0.3), and -0.97 (-1.9, -0.1), compared with reference s-25(OH)D (50-74.9 nmol/L). Two-stage analysis combining early pregnancy, late pregnancy, and cord s-25(OH)D data showed an inverse association with 5-y SBP and DBP for boys (P < 0.025) with significant sex-difference for DBP (Pinteraction = 0.004). No associations were found between s-25(OH)D and 5-y BP above the 90th percentile.

CONCLUSION

Early pregnancy s-25(OH)D concentrations, especially >75 nmol/L, were inversely associated with 5-y blood pressure in the offspring. A novel identified protective effect of optimal vitamin D levels in early pregnancy on offspring BP is suggested.

Associations between toxic elements and blood pressure parameters in adolescents

BACKGROUND

Both exposure to toxic elements and hypertension (HT) are a global health problem. We planned to examine the associations between some toxic elements in urine, and blood pressure (BP) and its diurnal changes in adolescents.

METHODS

In this cross-sectional study, 48 adolescents who were newly diagnosed with HT and 38 adolescents with age-appropriate BP and normal physical examination were included. Anthropometric measurements, urinary toxic elements, carotid intima media thickness (cIMT), and office and 24-hour ambulatory BP measurements (ABPM) of participants were taken. Urinary elements levels were studied with ICP-MS. Elements were grouped in tertiles according to urinary levels. Logistic regression analyses were performed to show the interactions.

RESULTS

Urinary cadmium, mercury, lead, and arsenic were found to be at detectable level in 90.7%, 69.8%, 91.9% and 100% of the participants, respectively. Univariate analyses showed that elevated daytime systolic and/or diastolic BP was associated with urinary cadmium and mercury. No association between urinary toxic elements and nighttime BP was found. When height and body mass index z-scores adjusted for, age, gender, and all four urinary creatinine-corrected toxic elements analyzed, multiple logistic regression revealed that there was an association between mercury (high vs. low; AOR:3.85) and office HT, and mercury (high vs. low; AOR:6.18) and cadmium (middle vs. low; AOR: 13.38) were associated with "elevated 24-hour systolic BP and/or diastolic BP", and "elevated 24-hour mean arterial BP" in ABPM.

CONCLUSION

There are complex relationships between toxic elements and BP parameters in adolescents, and more studies are needed to define the evolution of these relations.