Hypertensive crisis in children

Dysmagnesemia Incidence in Hospitalized Dogs and Cats: A Retrospective Study

Magnesium plays a vital role in the body. This retrospective study aimed to evaluate dysmagnesemia incidence in hospitalized patients. Medical records of 430 dogs and 310 cats were reviewed, including patients with at least one venous blood gas analysis upon admission. Normal ionized magnesium values were considered 0.5-1 mmol/L for both species, according to the machine range. Data collected included patient demographics, hospitalization details, and outcome. In dogs, hypomagnesemia occurred in 35.5%, hypermagnesemia in 1.1%, and normomagnesemia in 62.2%. No survival differences were observed, but males showed a higher hypomagnesemia incidence. Neurological (51%), neoplastic (50%), and endocrine (42%) diseases were most associated with hypomagnesemia. In cats, hypomagnesemia was found in 6.8%, hypermagnesemia in 8%, and normomagnesemia in 85.2%. Hypermagnesemic cats had 2.3 times higher mortality. Endocrine (28.6%), systemic (13.6%), and urinary (12.9%) disorders had a higher incidence of hypermagnesemia. Dysmagnesemia was not linked to hospitalization length or blood pressure changes. In conclusion, dogs showed a high incidence of hypomagnesemia that was not associated with increased mortality. In contrast, although hypermagnesemia had a low incidence in cats, it was associated with increased mortality.

Clinical guidelines for the diagnosis, evaluation, and management of hypertension for Korean children and adolescents: the Korean Working Group of Pediatric Hypertension

Pediatric hypertension (HTN) is a significant, growing health concern worldwide and also in Korea. Diagnosis, evaluation, and treatment of HTN in Korean children and adolescents are uncertain due to limitations in using the current international guidelines, since the recommendations by the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) guidelines differ. Furthermore, these are guidelines for Western youth, who are racially and ethnically different from Koreans. In addition, reference blood pressure values for all pediatric age groups, which are essential for the diagnosis of HTN according to these two guidelines, are absent in Korea. Therefore, HTN guidelines for Korean children and adolescents should be established. The Korean Working Group of Pediatric Hypertension established clinical guidelines for the diagnosis, evaluation, and management of HTN in Korean children and adolescents. These guidelines were based on reported clinical evidence, expert recommendations, and AAP and ESH guidelines. The characteristics of Korean youth and the Korean medical and insurance system were considered during the establishment of the guidelines. By providing recommendations suitable for Korean youth, these guidelines will help in the prevention and management of childhood HTN, thus relieving the burden of cardiovascular disease in adulthood in Korea.

International consensus statement on the diagnosis and management of phaeochromocytoma and paraganglioma in children and adolescents

Phaeochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumours that arise not only in adulthood but also in childhood and adolescence. Up to 70-80% of childhood PPGL are hereditary, accounting for a higher incidence of metastatic and/or multifocal PPGL in paediatric patients than in adult patients. Key differences in the tumour biology and management, together with rare disease incidence and therapeutic challenges in paediatric compared with adult patients, mandate close expert cross-disciplinary teamwork. Teams should ideally include adult and paediatric endocrinologists, oncologists, cardiologists, surgeons, geneticists, pathologists, radiologists, clinical psychologists and nuclear medicine physicians. Provision of an international Consensus Statement should improve care and outcomes for children and adolescents with these tumours.

Managing severe hypertension in children

Severe childhood hypertension is uncommon and frequently not recognised and is best defined as a systolic blood pressure (SBP) above the stage 2 threshold of the 95th centile + 12 mmHg. If no signs of end-organ damage are present, this is urgent hypertension which can be managed by the slow introduction of oral or sublingual medication, but if signs are present, the child has emergency hypertension (or hypertensive encephalopathy if they include irritability, visual impairment, fits, coma, or facial palsy), and treatment must be started promptly to prevent progression to permanent neurological damage or death. However, detailed evidence from case series shows that the SBP must be lowered in a controlled manner over about 2 days by infusing short-acting intravenous hypotensive agents, with saline boluses ready in case of overshoot, unless the child had documented normotension within the last day. This is because sustained hypertension may increase pressure thresholds of cerebrovascular autoregulation which take time to reverse. A recent PICU study that suggested otherwise was significantly flawed. The target is to reduce the admission SBP by its excess, to just above the 95th centile, in three equal steps lasting about ≥ 6 h, 12 h, and finally ≥ 24 h, before introducing oral therapy. Few of the current clinical guidelines are comprehensive, and some advise reducing the SBP by a fixed percentage, which may be dangerous and has no evidence base. This review suggests criteria for future guidelines and argues that these should be evaluated by establishing prospective national or international databases.

Primary and secondary paediatric hypertension

High blood pressure (BP) or hypertension is a well known risk factor for developing heart attack, stroke, atrial fibrillation and renal failure. Although in the past hypertension was supposed to develop at middle age, it is now widely recognized that it begins early during childhood. As such, approximately 5-10% of children and adolescents are hypertensive. Unlike that previously reported, it is now widely accepted that primary hypertension is the most diffuse form of high BP encountered even in paediatric age, while secondary hypertension accounts just for a minority of the cases. There are significant differences between that outlined by the European Society of Hypertension (ESH), the European Society of Cardiology (ESC), and the last statement by the American Academy of Pediatrics (AAP) concerning the BP cut-offs to identify young hypertensive individuals. Not only that, but the AAP have also excluded obese children in the new normative data. This is undoubtedly a matter of concern. Conversely, both the AAP and ESH/ESC agree that medical therapy should be reserved just for nonresponders to measures like weight loss/salt intake reduction/increase in aerobic exercise. Secondary hypertension often occurs in aortic coarctation or chronic renal disease patients. The former can develop hypertension despite early effective repair. This is associated with significant morbidity and is arguably the most important adverse outcome in about 30% of these subjects. Also, syndromic patients, for example those with Williams syndrome, may suffer from a generalized aortopathy, which triggers increased arterial stiffness and hypertension. This review summarizes the state-of-the-art situation regarding primary and secondary paediatric hypertension.

Hypertension crisis as the first symptom of renovascular hypertension in children

BACKGROUND

Renovascular hypertension (RVH) is one of the main causes of hypertensive crisis (HTN-C). It is characterized by acute onset and severe disease, and early diagnosis and treatment are difficult. The objective was to describe the characteristics of RVH and factors associated with RVH leading to HTN-C in children. At present, there are few clinical studies on RVH in children with large cases in China.

METHODS

This study retrospectively analyzed the clinical data of inpatient children with RVH. Patients were divided into non-hypertensive crisis (non-HTN-C) group, and HTN-C group according to the first symptoms and blood pressure. Further, HTN-C were classified as hypertensive urgency (HTN-U) or hypertensive emergency (HTN-E).

RESULTS

Fifty-four pediatric cases (41 boys and 13 girls) were included. 83.3% of the RVH cases were ≥ 6 years old. Three cases were classified into the non-HTN-C group. Of the 51 HTN-C cases, 18 cases were grouped as HTN-U and 33 as HTN-E. The HTN-U group were mainly asymptomatic (50.0%, 9/18) while the HTN-E group mainly presented with neurological symptoms (72.7%, 24/33). The number of unknown etiology children was 32 (59.2%). The top three known etiologies were Takayasu's arteritis (50.0%, 11/22), congenital renal dysplasia (27.3%, 6/22) and fibromuscular dysplasia (13.6%, 3/22). As for the target organ damage of RVH, patients had a higher prevalence of left ventricular hypertrophy (71.4%, 35/49) and retinopathy (77.8%, 21/27).

CONCLUSIONS

Most RVH patients with HTN-C as the first symptoms, especially for males over 6 years old, should be assessed for RVH even if they were asymptomatic. Most asymptomatic patients with RVH already had target organ damage, and symptomatic patients even developed life-threatening complications. As preventive measures, routine monitoring of BP during children's physical examinations is advised.

Sudden-Onset Blindness in a Child With Hypertensive Emergency: Unmasking of Chronic Kidney Disease

A 10-year-old male presented with sudden-onset diminution of vision in both eyes. On systemic examination, he had severe hypertension, no pulse deficit, short stature, and no other focal neurological deficit. Dilated fundoscopy showed bilateral grade 4 hypertensive retinopathy with macular star formation. Detailed laboratory investigations revealed a stage 5 chronic kidney disease (CKD). We present this case to highlight this rare ocular manifestation of CKD in pediatric age group.

Evaluation of blood pressure trajectories and outcome in critically ill children with initial hypertension on admission to Paediatric Intensive Care

OBJECTIVE

Hypertension on paediatric intensive care (PICU) is associated with adverse outcomes. Management is complex; hypertension often represents a physiological adaptive response and exposure to hypertension could lead to altered pressure-flow autoregulation. International treatment consensus is to avoid rapid blood pressure (BP) reduction. Our aim was to examine if the rate and magnitude of BP reduction in hypertensive patients was correlated with harm.

PATIENTS AND METHODS

We performed a single centre, retrospective, observational study in a quaternary PICU analysing the first 24 h post admission high resolution BP profiles of children with admission BP above the 95^th centile. Individual BP profiles were analysed regarding both time spent and magnitude below a threshold; 75% of the admission BP in the first 24 h. Outcomes were organ support-free days at day 28, change in serum creatinine and PICU mortality.

MAIN FINDINGS

Of 3069 admissions in a 36-month period (2016-2018), 21.7% had initial hypertension on admission to PICU. A total of 3,259,111 BP measurements (99.4% invasive) were available. Pre-existing hypertension was documented in 4.9% of patients. Both time spent and magnitude below threshold BP was poorly correlated with duration of required organ support and risk of death after adjusting for PIM score, pre-existing hypertension and raised intracranial pressure. We did find an association with a rise in serum creatinine on both uni- and multivariable analysis.

CONCLUSIONS

The risk of harm due to early and significant reduction of raised blood pressure in critically ill children appears to be limited.

Efficacy and Safety of Intravenous Labetalol in Acute Hypertensive Crisis in Children

OBJECTIVE

To determine the efficacy and safety of intravenous (IV) labetalol in the management of hypertensive crisis in children.

METHODS

A retrospective chart review of 56 consecutive children (age > 1 mo to ≤ 12 y) with hypertensive crisis admitted to a pediatric intensive care unit (PICU) from July 2009 to 2019.

RESULTS

The proportion of children attaining the primary endpoint (target 95th percentile in > 12 to ≤ 48 h) was significantly more in the group receiving labetalol as first-line or add-on (n = 23) as compared to those not receiving labetalol (n = 33) (62% vs. 30.3%, p = 0.03). Higher proportion of neurological recovery was seen in the labetalol group (56.2% vs. 18.7%, p = 0.02). The proportion of children with hypotension before 12 h was similar in both treatment groups (13% vs. 15%, p = 0.82). The practice variations between two periods of 5 y each (2009-2013 and 2014-2019) showed significantly more use of labetalol in the latter cohort (53% for 2014-2019 vs. 25% for 2009-2013, p = 0.03).

CONCLUSION

Labetalol, when used alone or as an add-on drug, was more efficacious than IV nitroprusside/nitroglycerine in attaining the primary endpoint in children up to ≤ 12 y of age with hypertensive crisis. Labetalol was safe and associated with higher neurological recovery.

Management of Hypertensive Crises in Children: A Review of the Recent Literature

Hypertensive emergency is a life-threatening condition associated with severe hypertension and organ damage, such as neurological, renal or cardiac dysfunction. The most recent guidelines on pediatric hypertension, the 2016 European guidelines and the 2017 American guidelines, provide recommendations on the management of hypertensive emergencies, however in pediatric age robust literature is lacking and the available evidence often derives from studies conducted in adults. We reviewed PubMed and Cochrane Library from January 2017 to July 2021, using the following search terms: "hypertension" AND "treatment" AND ("emergency" OR "urgency") to identify the studies. Five studies were analyzed, according to our including criteria. According to the articles reviewed in this work, beta-blockers seem to be safe and effective in hypertensive crises, more than sodium nitroprusside, although limited data are available. Indeed, calcium-channel blockers seem to be effective and safe, in particular the use of clevidipine during the neonatal age, although limited studies are available. However, further studies should be warranted to define a univocal approach to pediatric hypertensive emergencies.

Therapeutics for paediatric oncological emergencies

Background

With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies.

Methods

An extensive PubMed^® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years.

Results

The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life.

Conclusions

Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.

Paediatric hypertension for the primary care provider: What you need to know

The prevalence of hypertension has increased in the paediatric and adolescent populations, and is estimated between 1% and 2% in Canada. Paediatric and adolescent hypertension differs from adult hypertension in many ways, and primary care providers may not be up to date with current guidelines and recommendations. Recently, the American Academy of Pediatrics updated and published guidelines on the diagnosis, evaluation, and management of hypertension in children and adolescents. This paper summarizes these new guidelines in addition to the existing Canadian guidelines in a simple four-step approach, catered to a primary care setting, detailing the diagnosis, evaluation, workup, and management of hypertension in children and adolescents.

Vitamin D status and blood pressure in children and adolescents: a systematic review of observational studies

BACKGROUND

Childhood hypertension is a growing public health problem. Simultaneously, hypovitaminosis D is widespread in this population and could be associated with hypertension. This study systematically reviewed the literature on the relationship between vitamin D status and blood pressure (BP) in children and adolescents.

METHODS

Following the PRISMA guidelines, PUBMED, MEDLINE, CINAHL, EMBASE, Cochrane Library, and ClinicalTrials.gov and the gray literature without language or time restrictions were searched. We included observational studies, assessed their risk of bias, and extracted data on population characteristics, vitamin D status and BP measurements, and the association between the two variables. A narrative analysis of the studies was performed.

RESULTS

In total, 85 studies were included. Prospective cohort studies showed no association between vitamin D and BP, and generally, they were flawed. Also, the majority of non-prospective cohort studies (cross-sectional, retrospective, case-control) did not report an association between vitamin D and BP. They were mostly flawed regarding BP measurement and adjusting to potential confounders.

CONCLUSION

The results on the relationship between vitamin D status and BP in children and adolescents varied between the studies, and mainly pointed towards lack of association.

Acute severe hypertension associated with acute gastroenteritis in children

Acute severe hypertension in otherwise healthy children with acute illness requiring hospitalization for BP management is uncommon and warrants immediate evaluation. We describe 10 cases of children presenting with acute gastroenteritis and found to have acute severe hypertension. They required admission to the hospital for antihypertensive treatment, including 2 to the intensive care unit, but all had normalization of BP and were able to stop treatment with resolution of the acute illness. All patients had thorough testing for secondary causes of hypertension and for signs of end-target organ damage, which were unremarkable. To our knowledge, acute severe hypertension in the setting of acute gastroenteritis without underlying kidney pathology and with complete resolution after illness has not been previously described. The mechanism of this association is not clear, although activation of the sympathetic nervous system is suspected. These cases illustrate the importance of thoroughly assessing BP in the acute setting.

Frequency and individual severity of arterial blood pressure changes in children and adolescents with attention-deficit/hyperactivity disorder treated with methylphenidate hydrochloride: a prospective non-interventional study

Background

Attention-deficit/hyperactivity disorder (ADHD) is a common behavioural disorder in childhood. The psychostimulant methylphenidate hydrochloride (MPH) is one of the major pharmacological options for ADHD. MPH is known to result, on average, in a small increase in arterial blood pressure (BP). However, there are few clinical data regarding the individual influences of MPH on BP among children and adolescents with ADHD. According to the European Union-wide standardised patient information sheet for MPH, BP changes >10 mm Hg compared with baseline values are ‘common’ (ie, ≥1% to <10%) in children and adolescents with ADHD during MPH therapy.

Aim

To investigate the frequency and individual severity of BP changes in children and adolescents with ADHD during the first 6 months of new MPH therapy.

Methods

In this study, 44 (77% male) children and adolescents (mean age (SD) 9.13 (1.86) years) with a diagnosis of ADHD according to the International Classification of Diseases, tenth revision, underwent ambulatory BP monitoring before and during the first 6 months of routine MPH therapy. Exclusion criteria were pre-existing MPH therapy and other medications that potentially influence BP or interfere with MPH. The non-interventional study was conducted prospectively at 10 paediatric cardiology centres in Germany and Austria.

Results

After beginning MPH therapy, 34% of participants (99% CI 15.52% to 52.66%) had BP increases/decreases >10 mm Hg. The mean changes in systolic BP and diastolic BP were 0.87 mm Hg (95% CI -1.75 mm Hg to 3.48 mm Hg) and 1.96 mm Hg (95% CI 0.21 mm Hg to 3.7 mm Hg), respectively. The proportion of participants with initial prehypertension/hypertension was 54.55%.

Conclusions

In our sample with a high baseline rate of prehypertension/hypertension, BP changes >10 mm Hg during MPH therapy were more frequent than those indicated by the patient information sheet. Moreover, individual BP changes, including increases and decreases >10 mm Hg, resulted in a small average BP increase in the sample, thus reflecting neither the severity nor the direction of individual BP changes. Therefore, the frequency and, due to the common use of the arithmetic mean, the individual severity of BP changes during MPH therapy may be underestimated. Further studies without averaging and with larger samples including patients in primary care settings are warranted.

Hypertensive Crisis in Pediatric Patients: An Overview

Hypertensive crisis can be a source of morbidity and mortality in the pediatric population. While the epidemiology has been difficult to pinpoint, it is well-known that secondary causes of pediatric hypertension contribute to a greater incidence of hypertensive crisis in pediatrics. Hypertensive crisis may manifest with non-specific symptoms as well as distinct and acute symptoms in the presence of end-organ damage. Hypertensive emergency, the form of hypertensive crisis with end-organ damage, may present with more severe symptoms and lead to permanent organ damage. Thus, it is crucial to evaluate any pediatric patient suspected of hypertensive emergency with a thorough workup while acutely treating the elevated blood pressure in a gradual manner. Management of hypertensive crisis is chosen based on the presence of end-organ damage and can range from fast-acting intravenous medication to oral medication for less severe cases. Treatment of such demands a careful balance between decreasing blood pressure in a gradual manner while preventing damage end-organ damage. In special situations, protocols have been established for treatment of hypertensive crisis, such as in the presence of endocrinologic neoplasms, monogenic causes of hypertension, renal diseases, and cardiac disease. With the advent of telehealth, clinicians are further able to extend their reach of care to emergency settings and aid emergency medical service (EMS) providers in real time. In addition, further updates on the evolving topic of hypertension in the pediatric population and novel drug development continues to improve outcomes and efficiency in diagnosis and management of hypertension and consequent hypertensive crisis.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.

Hypertensive crisis in children and adolescents

Hypertensive crisis is a relatively rare condition in children. However, if not treated, it might be life-threatening and lead to irreversible damage of vital organs. Clinical presentation of patients with hypertensive crisis can vary from very mild (hypertensive urgency) to severe symptoms (hypertensive emergency) despite similarly high blood pressure (BP). Individualized assessment of patients presenting with high BP with emphasis on the evaluation of end-organ damage rather than on the specific BP number is a key in guiding physician's initial management of a hypertensive crisis. The main aim of the treatment of hypertensive crisis is the prevention or treatment of life-threatening complications of hypertension-induced organ dysfunction, including neurologic, ophthalmologic, renal, and cardiac complications. While the treatment strategy must be directed toward the immediate reduction of BP to reduce the hypertensive damage to these organs, it should not be at a too fast rate to cause hypoperfusion of vital organs by an excessively rapid reduction of BP. Thus, intravenous continuous infusions rather than intravenous boluses of antihypertensive medications should be the preferable mode of initial treatment of children with hypertensive emergency.

Epidurals for Coarctation Repair in Children Are Associated with Decreased Postoperative Anti-Hypertensive Infusion Requirement as Measured by a Novel Parameter, the Anti-Hypertensive Dosing Index (ADI)

Background: Sympathetically-associated hypertension after coarctation repair is a common problem often requiring anti-hypertensive infusions in an intensive care unit. Epidurals suppress sympathetic output and can reduce blood pressure but have not been studied following coarctation repair in children. We sought to determine whether epidurals for coarctation repair in children were associated with decreased requirement for postoperative anti-hypertensive infusions, if they were associated with changes in hospital course, or with complications. Methods: In this observational retrospective cohort study, we evaluated all patients age 1–18 years undergoing coarctation repair at our institution during a 10-year period and compared the requirement for postoperative anti-hypertensive infusions in patients with and without epidurals using an anti-hypertensive dosing index (ADI) incorporating total dose-hours of all anti-hypertensive infusions (primary outcome). We also assessed intensive care unit (ICU) and hospital length of stay, discharge on oral anti-hypertensive medication, and complications potentially related to epidurals (secondary outcomes). Results: Children undergoing coarctation repair with epidurals had decreased requirements for postoperative anti-hypertensive infusions compared to children without epidurals (cumulative ADI 65.0 [28.5–130.3] v. 157.0 [68.6–214.7], p = 0.021; mean ADI 49.0 [33.3–131.2] v. 163.0 [66.6–209.8], p = 0.01). After multivariable cumulative logit mixed-effects regression analysis, mean ADI was decreased in patients with epidurals throughout the postoperative period (p < 0.001). Patients with epidurals were 1.6 years older and weighed 10.6 kg more than patients without epidurals but were otherwise comparable. Epidural complications included pruritus (three patients), agitation (one patient), somnolence (one patient), and transient orthostatic hypotension (one patient). Duration of intensive care unit admission, duration of hospital stays, and requirement for anti-hypertensive medication at discharge were similar in patients with and without epidurals. Conclusions: This is the first study of children receiving an epidural for surgical repair of aortic coarctation via open thoracotomy. In this small, single-institution, observational retrospective cohort study, epidurals for coarctation repair in children were associated with decreased postoperative anti-hypertensive infusion requirements. Epidurals were not associated with length of ICU or hospital stay, or with discharge on anti-hypertensive medication. No significant epidural complications were noted. Prospective study of larger populations will be necessary to confirm these associations, address causality, verify safety, and assess other effects.

Evaluation and Management of Stage 2 Hypertension in Pediatric Patients

PURPOSE OF REVIEW

To update the definition and clinical practice of stage 2 hypertension (HTN) in pediatrics.

RECENT FINDINGS

The 2017 American Academy of Pediatrics Clinical Practice Guideline (AAP CPG) for Screening and Management of High Blood Pressure in Children and Adolescent includes new normative blood pressure tables for children and adolescents ages 1 to 17 years and new definitions for stage 2 HTN. This review will highlight these aspects as well as new recommendations in the guideline specific to stage 2 HTN. It will outline how the new guideline differs from the previous 2004 guideline, the implications of these differences, and suggested changes in evaluation and management of stage 2 HTN. Lastly, the review will address topics relevant to daily clinical practice including competitive athletic participation, investigation for secondary HTN and HTN comorbidities, and blood pressure-lowering therapy. With the publication of the new AAP CPG introducing revised normative tables, the prevalence of stage 2 HTN in pediatrics is expected to rise. Based on the new guidelines, there is less emphasis on investigation for secondary HTN and more attention to lifestyle modifications for primary HTN. Future research should address whether there is BP level within the stage 2 HTN range above which the approach to evaluation and management should be altered in this heterogeneous patient population.

Experts' opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta

Background

The 2013 International Classification of Headache Disorders-3 was published in a beta version to allow clinicians to confirm the validity of the criteria or suggest improvements based on field studies. The aim of this work was to review the Secondary Headache Disorders and Cranial Neuralgias and Other Headache Disorders sections of ICHD-3 beta data on children and adolescents (age 0–18 years) and to suggest changes, additions, and amendments.

Methods

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the available literature on pediatric headache, they made observations and proposed suggestions for the mentioned headache disorders on children and adolescents.

Results

Some headache disorders in children have specific features, which are different from adults that should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psychosocial basis in children and adolescents making primary headache disorders in children distinct from those in adults.

Conclusions

Several recommendations are presented in order to make ICHD-3 more appropriate for use in children.

Treatment Strategies for Paradoxical Hypertension Following Surgical Correction of Coarctation of the Aorta in Children

BACKGROUND

Paradoxical hypertension after repair of coarctation of the aorta is a well-known phenomenon. The pathogenesis involves the activation of the sympathetic nervous system (first phase) and renin-angiotensin system (second phase). Only a limited number of different treatment strategies have been published in the literature, without any comparative studies.

METHODS

Our aim was to describe the current international practice variation surrounding pharmacological treatment currently being employed to treat paradoxical hypertension following the repair of coarctation of the aorta in children. We performed an online survey among 197 members of the Pediatric Cardiac Intensive Care Society. We also conducted a systematic review of the literature regarding the treatment of paradoxical hypertension.

RESULTS

Eighty-eight people (45%), from 62 different centers, responded and answered the questions regarding blood pressure control. Nitroprusside is the first drug of choice for initial blood pressure control in 66% of respondents, esmolol in 11%, labetalol in 11%, and angiotensin-converting enzyme inhibitors (ACEIs) are used by 3% of respondents. For oral blood pressure control after discharge from the pediatric intensive care unit, 75% of respondents use ACEIs, 18% use labetalol, and 12% use other beta-blockers (propranolol, carvedilol, atenolol, metoprolol). The systematic review identified 14 articles reporting pharmacological treatment of direct postoperative hypertension following coarctation repair.

CONCLUSION

There is wide practice variability, due to the lack of sufficient compelling evidence. The majority (66%) of caregivers use nitroprusside to control blood pressure in the acute postoperative phase. The ACEIs are the drug of choice for chronic blood pressure control.

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

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Hypertension in the Pediatric Intensive Care Unit

Hypertension in the pediatric intensive care unit (PICU) is common and it contributes to the overall morbidity and mortality. Patients may present with hypertensive emergencies or hypertension can manifest itself later in PICU course. Although hypertension can be seen in most patients during hospitalization, patients with some specific diseases and conditions are more prone to hypertension. Hypertension should be recognized promptly and treated accordingly. Different pathophysiologic mechanisms can be responsible for the hypertension and management differs based on the underlying etiology. Any patient with a hypertensive emergency must be admitted to PICU, and treatment and diagnostic workup should be initiated immediately.

Hypertensive crisis in children: an experience in a single tertiary care center in Korea

BACKGROUND

Hypertensive crisis is a medical emergency that can cause acute damage to multiple end-organs. However, relatively little is known on the etiology, treatment, and outcomes of hypertensive crisis in Korean children. The aim of this study was to determine the etiologies and efficacy of drugs for hypertensive crisis in children during the past 5 years at a single center in Korea.

METHODS

We analyzed data from 51 children with hypertensive crisis during the period between January 1, 2010 and April 1, 2014. The patients were divided into two groups: those diagnosed with a hypertensive emergency (hypertension with organ injury, n = 31) and those diagnosed with a hypertensive urgency (hypertension without organ injury, n = 20). Baseline etiologies and risk factors were compared between the two groups. In addition, systolic and diastolic blood pressures were evaluated at 1, 2, 4, and 5 hours after the administration of intravenous antihypertensive drugs.

RESULTS

Kidney injury and cancer were the common causes in patients with hypertensive crisis. Cardiovascular complications (cardiac hypertrophy) (p = 0.002), central nervous system complications (p = 0.004), and retinopathy (p = 0.034) were more frequently observed in children with hypertensive emergency than those with hypertensive urgency. However, the proportion of renal complications was similar in both groups. Hydralazine was most commonly used in both groups to control acute increasing blood pressure at first. However, it was often ineffective for controlling abrupt elevated blood pressure. Therefore, intravenous antihypertensive drugs were changed from hydralazine to nicardipine, labetalol, or nitroprusside to control the high blood pressure in 45.1 % of the patients. Particularly, in patients with hypertensive crisis, there was no significant difference in reduction of systolic and diastolic blood pressure and in improvement of clinical outcomes between nicardipine and labetalol administration.

CONCLUSION

Close blood pressure monitoring and careful examinations should be mandatory in children with underlying disease, especially renal diseases and cancer. Furthermore, both nicardipine and labetalol may be effective antihypertensive drug in lowering high blood pressure in children with hypertensive crisis.

Evaluation and treatment of hypertensive crises in children

Hypertensive crises in children are medical emergencies that must be identified, evaluated, and treated promptly and appropriately to prevent end-organ injury and even death. Treatment in the acute setting typically includes continuous intravenous antihypertensive medications with monitoring in the intensive care unit setting. Medications commonly used to treat severe hypertension have been poorly studied in children. Dosing guidelines are available, although few pediatric-specific trials have been conducted to facilitate evidence-based therapy. Regardless of what medication is used, blood pressure should be lowered gradually to allow for accommodation of autoregulatory mechanisms and to prevent cerebral ischemia. Determining the underlying cause of the blood pressure elevation may be helpful in guiding therapy.

Hypertension in children with end-stage renal disease

This review summarizes current data on the epidemiology, pathophysiology, and treatment of hypertension (HTN) in children with end-stage renal disease (ESRD). Worldwide prevalence of ESRD ranges from 5.0 to 84.4 per million age-related population. HTN is present in 27-79% of children with ESRD, depending on the modality of renal replacement therapy and the exact definition of hypertension. Ambulatory BP monitoring has been recommended for the detection of HTN and evaluation of treatment effectiveness. HTN in dialyzed patients is mostly related to hypervolemia, sodium overload, activation of the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system, impaired nitric oxide synthesis, reduced vitamin D levels, and effects of microRNA. In children undergoing chronic dialysis therapy, important factors include optimization of renal replacement therapy and preservation of residual renal function, allowing reduction of volume- and sodium-overload, along with appropriate drug treatment, particularly with calcium channel blockers, RAAS inhibitors, and loop diuretics.

Therapy of acute hypertension in hospitalized children and adolescents

Acute hypertension (HTN) in hospitalized children and adolescents occurs relatively frequently, and in some cases, if not recognized and treated promptly, it can lead to hypertensive crisis with potentially significant morbidity and mortality. In contrast to adults, where acute HTN is most likely due to uncontrolled primary HTN, children and adolescents with acute HTN are more likely to have secondary HTN. This review will briefly cover evaluation of acute HTN and various age-specific etiologies of secondary HTN and provide more in-depth discussion on treatment targets, potential risks of acute HTN therapy, and available pediatric data on intravenous and oral antihypertensive agents, and it proposes treatment schema including unique therapy of specific secondary HTN scenarios.

Anesthetic management of hypertensive crisis in a three-year-old patient with undiagnosed severe renal artery stenosis: a case report

Pediatric hypertensive crisis is a potentially life threatening medical emergency, usually secondary to an underlying disease. Hypertension commonly occurs during general anesthesia, and is usually promptly and appropriately treated by anesthesiologists. However in children with severe, unexplained, or refractory hypertension, it has the potential to cause morbidity and even mortality in susceptible patients. We report an anesthetic management of an unexpected hypertensive crisis that developed during general anesthesia in a three-year-old girl with undiagnosed severe left renal artery stenosis.

Reninoma: an uncommon cause of Renin-mediated hypertension

Reninoma (juxtaglomerular cell tumor) is a rare cause of renin-mediated hypertension. Reninomas are usually diagnosed in adolescents and young adults with occasional reports in younger children. Patients typically present with a long history of headaches leading to a diagnosis of severe hypertension that responds well to antihypertensive treatment targeting the renin-angiotensin-aldosterone system. The clue to clinical diagnosis is the presence of hypokalemia and metabolic alkalosis on the first blood sample drawn before any treatment is instituted. Elevated blood levels of renin and aldosterone confirm the clinical suspicion of renin-mediated hypertension. Diagnostic imaging is employed to identify the source of excessive renin production. While renal ultrasound can miss reninoma, contrast CT or magnetic resonance imaging of the kidneys are diagnostic modalities of choice leading to the correct diagnosis. Renal vein renin sampling with lateralization might help to identify the site of excessive renin production. Nephron-sparing surgery is curative with maintenance of normal blood pressure after discontinuation of antihypertensive medications in the majority of patients. In this paper, we present the case of reninoma in an adolescent girl emphasizing clinical presentation, diagnostic evaluation, and medical and surgical treatment of this rare tumor. We also discuss important points in the management of children presenting with renin-mediated hypertension.

Aggressive blood pressure control for chronic kidney disease unmasks moyamoya!

Hypertensive crises in children or adolescents are rare, but chronic kidney disease (CKD) is a major risk factor for occurrence. Vesicoureteral reflux nephropathy is a common cause of pediatric renal failure and is associated with hypertension. Aggressive blood pressure (BP) control has been shown to delay progression of CKD and treatment is targeted for the 50th percentile for height when compared with a target below the 90th percentile for the general pediatric hypertensive patient. We present a case of an adolescent presenting with seizures and renal failure due to a hypertensive crisis. Hypertension was thought to be secondary to CKD as she had scarred echogenic kidneys due to known reflux nephropathy. However, aggressive BP treatment improved kidney function which is inconsistent with CKD from reflux nephropathy. Secondly, aggressive BP control caused transient neurological symptoms. Further imaging identified moyamoya disease. We present this case to highlight the consideration of moyamoya as a diagnosis in the setting of renal failure and hypertensive crisis.

First-attack pediatric hypertensive crisis presenting to the pediatric emergency department

BACKGROUND

Hypertensive crisis in children is a relatively rare condition presenting with elevated blood pressure (BP) and related symptoms, and it is potentially life-threatening. The aim of this study was to survey children with first attacks of hypertensive crisis arriving at the emergency department (ED), and to determine the related parameters that predicted the severity of hypertensive crisis in children by age group.

METHODS

This was a retrospective study conducted from 2000 to 2007 in pediatric patients aged 18 years and younger with a diagnosis of hypertensive crisis at the ED. All patients were divided into four age groups (infants, preschool age, elementary school age, and adolescents), and two severity groups (hypertensive urgency and hypertensive emergency). BP levels, etiology, severity, and clinical manifestations were analyzed by age group and compared between the hypertensive emergency and hypertensive urgency groups.

RESULTS

The mean systolic/diastolic BP in the hypertensive crisis patients was 161/102 mmHg. The major causes of hypertensive crisis were essential hypertension, renal disorders and endocrine/metabolic disorders. Half of all patients had a single underlying cause, and 8 had a combination of underlying causes. Headache was the most common symptom (54.5%), followed by dizziness (45.5%), nausea/vomiting (36.4%) and chest pain (29.1%). A family history of hypertension was a significant predictive factor for the older patients with hypertensive crisis. Clinical manifestations and severity showed a positive correlation with age. In contrast to diastolic BP, systolic BP showed a significant trend in the older children.

CONCLUSIONS

Primary clinicians should pay attention to the pediatric patients who present with elevated blood pressure and related clinical hypertensive symptoms, especially headache, nausea/vomiting, and altered consciousness which may indicate that appropriate and immediate antihypertensive medications are necessary to prevent further damage.

Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies

Hypertension (HTN) in the pediatric population is estimated to have a world-wide prevalence of 2%–5%. As with adults, pediatric patients with HTN can present with hypertensive crises include hypertensive urgency and hypertensive emergencies. However, pediatric blood pressure problems have a greater chance of being from secondary causes of HTN, as opposed to primary HTN, than in adults. Thorough evaluation of a child with a hypertensive emergency includes accurate blood pressure readings, complete and focused symptom history, and appropriate past medical, surgical, and family history. Physical exam should include height, weight, four-limb blood pressures, a general overall examination and especially detailed cardiovascular and neurological examinations, including fundoscopic examination. Initial work-up should typically include electrocardiography, chest X-ray, serum chemistries, complete blood count, and urinalysis. Initial management of hypertensive emergencies generally includes the use of intravenous or oral antihypertensive medications, as well as appropriate, typically outpatient, follow-up. Emergency department goals for hypertensive crises are to (1) safely lower blood pressure, and (2) treat/minimize acute end organ damage, while (3) identifying underlying etiology. Intravenous antihypertensive medications are the treatment modality of choice for hypertensive emergencies with the goal of reducing systolic blood pressure by 25% of the original value over an 8-hour period.