Antihypertensive agents: a long way to safe drug prescribing in children

The Prevalence of Hypertension Among Children and Antihypertensive Use: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

Early-onset hypertension (HT) presents compounded risks for cardiovascular, renal, and other systemic complications. Childhood HT is associated with HT during adulthood and detrimental lifelong cardiovascular disease events. However, most of the cases are not detectable as HT measurement in children is complicated and unstable. The global prevalence of HT among children is rapidly increasing. A previous study (2019) reported that the pooled global HT prevalence is 4.0% and the number is believed to be elevated. However, prevalence estimates of childhood HT have rarely been synthesized globally.

OBJECTIVE

This study aims to systematically pool all evidence from published articles and synthesize the evidence on the global prevalence of childhood HT and antihypertensive (anti-HT) use among children and its effects.

METHODS

This systematic review of observational and experimental studies will investigate the overall prevalence of HT and anti-HT use among children. We will search articles from 4 web-based databases: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Scopus using the specific keywords across the databases. During the article search conducted until October 2024, we retrieved 14,575 articles. Articles published in the English language with full text and are peer-reviewed journals included children aged between 0 and 18 years, confirmed with HT or high blood pressure (BP) on at least 3 separate occasions, and stated the definition of HT will be included in this protocol. Study selection and reporting will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and the Meta-Analysis of Observational Studies in Epidemiology guidelines and Cochrane Risk of bias tool (ACROBAT) for experimental studies. Data will be extracted using a standardized data extraction form using Microsoft Excel software and the studies' quality will be assessed using the Joanna Briggs Institute's guideline according to the study design. We will use STATA software (version 17.0; StataCorp LLC) to calculate the global pooled prevalence and RevMan software (version 5.4; StataCorp LLC) to observe the effect of anti-HT use and BP among children. The risk of bias will be assessed using a funnel plot.

RESULTS

We retrieved 14,575 articles from 4 databases in October 2024. We will report the current global overall or pooled prevalence of HT as well as by region, risk factors, anti-HT use, and the anti-HT BP-lowering effect among the general children population. The findings will be presented in summary table findings and forest plot. This review is expected to be completed in the middle of 2025.

CONCLUSIONS

This review will provide a comprehensive synthesis of the overall prevalence of HT among children-a public health issue of growing concern with long-term impact. This review will also provide important information to inform practice in developing effective strategies for preventing and managing childhood HT.

TRIAL REGISTRATION

PROSPERO CRD42024500248; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024500248.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/65807.

Pediatric Chronic Kidney Disease: Mind the Gap Between Reality and Expectations

Pediatric chronic kidney disease (CKD) is a growing concern that often originates early in life, yet significant challenges remain in translating clinical guidelines into real-world practice. World Kidney Day 2025 highlights the importance of early detection, but the three levels of preventive strategies commonly recommended for adults may not be directly applicable to children. Unlike adult CKD, primary prevention in pediatrics should focus on prenatal, neonatal, and early-life factors such as congenital anomalies of the kidney and urinary tract (CAKUT), preterm birth, maternal health, and environmental exposures. Secondary prevention, involving early detection through screening, is crucial, yet the effectiveness of mass urinary screening in children remains a subject of global debate. Several key challenges persist, including the accurate estimation of glomerular filtration rate (eGFR), consistent definition and diagnosis of pediatric hypertension, identification of reliable biomarkers, and targeted screening in specific pediatric populations. Although clear guidelines exist to manage CKD progression and enhance quality of life, a critical gap remains between what is known and what is practiced. Closing this gap requires robust evidence to inform best practices, improve health-related quality of life, and advance pediatric kidney replacement therapies. To protect and improve kidney health for every child worldwide, these challenges must be acknowledged, and sustainable, evidence-based solutions must be developed and implemented without further delay.

Pediatric hypertension: Current definition and knowledge gaps

Elevated blood pressure (BP) and hypertension are common in children and adolescents, significantly increasing the risk of cardiovascular disease (CVD) in adulthood. Accurately assessing the prevalence and significance of pediatric hypertension requires a clear definition. The use of age-, sex-, and height-dependent percentiles to define pediatric hypertension began in 1977. Since then, several national and international clinical practice guidelines have refined its classification, diagnosis, and management, with notable contributions from The Fourth Report in 2004, the European Society of Hypertension (ESH) in 2016, and the American Academy of Pediatrics (AAP) in 2017. The 2017 AAP guideline redefined pediatric hypertension, increasing the number of children classified with elevated BP or hypertension. Despite these advancements, a universal diagnostic criterion for pediatric hypertension is still lacking. This review aims to summarize recent research on pediatric hypertension, focusing on evolving definitions, persistent knowledge gaps, and future directions. Addressing pediatric hypertension early with a lifespan approach is essential to reducing the global prevalence of hypertension and its associated CVD burden. The need for continued study and innovative strategies is underscored by research gaps in the prevention, detection, classification, and treatment of pediatric hypertension.

Real-world evidence of lisinopril in pediatric hypertension and nephroprotective management: a 10-year cohort study

BACKGROUND

Over the last 20 years, pediatric hypertension (pHTN) prevalence in Western society has risen from 3.5 to 9% due to childhood overweight, obesity, and secondary kidney and cardiological conditions. Few studies have assessed commonly used antihypertensive medication lisinopril's (ACE-inhibitor) long-term efficacy and the long-term value of renin-angiotensin-aldosterone system (RAAS) biomarkers.

METHODS

This is a retrospective cohort study at Ghent University Hospital, Belgium, with 106 young patients (1-18 years) treated with lisinopril due to hypertension (HTN) and chronic kidney disease (CKD) assessed for treatment outcomes against clinical benchmarks over 10 years.

RESULTS

Lisinopril was mainly initiated for secondary hypertension or nephroprotection (89%) due to kidney causes. A starting dose across groups was lower than 0.07 mg/kg for 48% (n = 50). HTN patients without CKD achieved systolic blood pressure below the 95th percentile within 2 years, but efficacy declined after 2.5 years. CKD patients maintained a steady response, reaching systolic targets by 40 months and showing improved diastolic control over 70 months. Proteinuria reduction had a median urine protein creatinine ratio (UPCR) to 0.57 g/g at 6 months, with a reappearance of UPCR 2 g/g creatinine after 40 months. Aldosterone breakthrough occurred from 6 months onward in all groups. Over 70 months, aldosterone and aldosterone-renin-ratio (ARR) progression significantly differ between children with and without normal kidney function.

CONCLUSIONS

Treatment efficacy for systolic blood pressure in hypertensive patients with abnormal kidney function diminishes after 2.5 years and for proteinuria in children after 3 years, highlighting the need for dosage recalibration according to guidelines and/or the need for alternative treatments.

Adverse Drug Reactions in Children with Congenital Heart Disease: A Scoping Review

BACKGROUND

Congenital heart disease (CHD) is one of the leading causes of death. Safe and timely medical interventions, especially in children, can prolong their survival. The drugs prescribed for children with CHD are mainly based on the outcomes of drug therapy in adults with cardiovascular diseases, and their adverse drug reactions (ADRs) might be different. Therefore, the aim of this study was to investigate ADRs in children with CHD.

METHODS

This was a scoping review conducted in 2023. PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, ProQuest, and Google Scholar databases were searched. All studies that reported ADRs for children with CHD and were published in English by 1 November 2023 were included in this study. Finally, the results were reported using a content analysis method.

RESULTS

A total of 87 articles were included in the study. The results showed that symptoms/signs/clinical findings, and cardiovascular disorders were the most common ADRs reported in children with CHD. The results also showed that most of the ADRs were reported for prostaglandin E1, amiodarone, prostaglandin E2, dexmedetomidine, and captopril, respectively.

CONCLUSION

The review underscores the wide array of ADRs in children with CHD, particularly in antiarrhythmics, diuretics, beta-blockers, anticoagulants, and vasodilators, which affected cardiovascular, respiratory, endocrine, metabolic, genitourinary, gastrointestinal, and musculoskeletal systems. Tailored treatment is imperative, considering individual patient characteristics, especially in the vulnerable groups. Further research is essential for optimizing dosing, pharmacogenetics, and alternative therapies to enhance patient outcomes in CHD management.

Characterization of Liquid Dosage Forms of Atenolol and Enalapril Maleate for Oral and Enteral Feeding Administration

The limited availability of pharmaceutical formulations tailored for cardiovascular diseases in both pediatric and geriatric populations generates the need for compounded dosage forms to guarantee precise dosing and medication adherence. This study aimed to analyze the physicochemical properties and stability of formulations of atenolol and enalapril maleate prepared with a proprietary oral vehicle, SuspendIt®. To this end, palatability, injectability, pH, rheological behavior, and physical, microbiological, and chemical stability over a 180-day storage period at 25 °C and 5 °C were evaluated. Injectability tests confirmed the suitable use of both formulations for administration through enteral feeding tubes. By using a potentiometric electronic tongue, it was confirmed that the SuspendIt® vehicle effectively served as a bitter-blocking strategy for atenolol and enalapril maleate. Adequate stability throughout the storage period was confirmed in terms of the mechanical properties, pH, and effectiveness of the preservative system. The atenolol concentration remained above 90% of the initial amount, while the concentration of enalapril maleate decreased to 88% after 90 days of storage at 25 °C. In summary, the atenolol formulation maintained suitable chemical, physical, and microbiological stability after 180 days at both storage temperatures, while the enalapril maleate formulation remained stable up to 60 days at 25 °C and for 180 days at 5 °C.

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.

Management of the congenital solitary kidney: consensus recommendations of the Italian Society of Pediatric Nephrology

In recent years, several studies have been published on the prognosis of children with congenital solitary kidney (CSK), with controversial results, and a worldwide consensus on management and follow-up is lacking. In this consensus statement, the Italian Society of Pediatric Nephrology summarizes the current knowledge on CSK and presents recommendations for its management, including diagnostic approach, nutritional and lifestyle habits, and follow-up. We recommend that any antenatal suspicion/diagnosis of CSK be confirmed by neonatal ultrasound (US), avoiding the routine use of further imaging if no other anomalies of kidney/urinary tract are detected. A CSK without additional abnormalities is expected to undergo compensatory enlargement, which should be assessed by US. We recommend that urinalysis, but not blood tests or genetic analysis, be routinely performed at diagnosis in infants and children showing compensatory enlargement of the CSK. Extrarenal malformations should be searched for, particularly genital tract malformations in females. An excessive protein and salt intake should be avoided, while sport participation should not be restricted. We recommend a lifelong follow-up, which should be tailored on risk stratification, as follows: low risk: CSK with compensatory enlargement, medium risk: CSK without compensatory enlargement and/or additional CAKUT, and high risk: decreased GFR and/or proteinuria, and/or hypertension. We recommend that in children at low-risk periodic US, urinalysis and BP measurement be performed; in those at medium risk, we recommend that serum creatinine also be measured; in high-risk children, the schedule has to be tailored according to kidney function and clinical data.

Congenital Heart Disease: The State-of-the-Art on Its Pharmacological Therapeutics

Congenital heart disease is one of the most common causes of death derived from malformations. Historically, its treatment has depended on timely diagnosis and early pharmacological and surgical interventions. Survival rates for patients with this disease have increased, primarily due to advancements in therapeutic choices, but mortality remains high. Since this disease is a time-sensitive pathology, pharmacological interventions are needed to improve clinical outcomes. Therefore, we analyzed the applications, dosage, and side effects of drugs currently used for treating congenital heart disease. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and potassium-sparing diuretics have shown a mortality benefit in most patients. Other therapies, such as endothelin receptor antagonists, phosphodiesterase-5 inhibitors, prostaglandins, and soluble guanylyl cyclase stimulators, have benefited patients with pulmonary artery hypertension. Likewise, the adjunctive symptomatic treatment of these patients has further improved the outcomes, since antiarrhythmics, digoxin, and non-steroidal anti-inflammatory drugs have shown their benefits in these cases. Conclusively, these drugs also carry the risk of troublesome adverse effects, such as electrolyte imbalances and hemodynamic compromise. However, their benefits for survival, symptom improvement, and stabilization outweigh the possible complications from their use. Thus, cases must be assessed individually to accurately identify interventions that would be most beneficial for patients.

The Bioequivalence Between Valsartan Oral Solution and Suspension Formulations Developed for Pediatric Use

The bioequivalence of valsartan 160 mg oral solution compared to suspension was assessed in a single-dose, open-label, randomized, 2-period, 2-way crossover study in 82 healthy adults. The participants were randomly assigned (1:1) to receive a single dose of the solution or suspension formulation in each of the two treatment periods. Serial blood samples for pharmacokinetic evaluation were collected up to 48 hours post-dose. The pharmacokinetic parameters were estimated by noncompartmental methods and analyzed as per bioequivalence criteria of statistical analysis. The peak plasma concentration of valsartan was reached with median time of 1 and 3 hours with solution and suspension formulation, respectively. Compared to suspension formulation, the mean peak plasma concentration with solution formulation was higher by 32% (90%CI, 1.27-1.38) while the geometric mean ratios (1.09) and the associated 90%CIs (1.05-1.13) of both the areas under the concentration time-curves (from time zero to the last quantifiable concentration and from time zero to infinity) were contained in the required range of 0.80 to 1.25. No new safety signals were observed with either of the formulations.

Renovascular hypertension in pediatric patients: update on diagnosis and management

Renovascular hypertension (RVH) is defined as an elevated blood pressure caused by kidney hypoperfusion, generally as a result of anatomic stenosis of the renal artery with consequent activation of the Renin Angiotensin-Aldosterone System. The main causes include genetic and inflammatory disorders, extrinsic compression, and idiopathic alterations. RVH is often asymptomatic and should be suspected in any child with refractory hypertension, especially if other suggestive findings are present, including those with severe hypertension, abdominal bruit, and abrupt fall of glomerular filtration rate after administration of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. There is a consensus that digital subtraction angiography is the gold standard method for the diagnosis of RVH. Nevertheless, the role of non-invasive imaging studies such as Doppler ultrasound, magnetic resonance angiography, or computed tomographic angiography remains controversial, especially due to limited pediatric evidence. The therapeutic approach should be individualized, and management options include non-surgical pharmacological therapy and revascularization with percutaneous transluminal renal angioplasty (PTRA) or surgery. The prognosis is related to the procedure performed, and PTRA has a higher restenosis rate compared to surgery, although a decreased risk of complications. This review summarizes the causes, physiopathology, diagnosis, treatment, and prognosis of RVH in pediatric patients. Further studies are required to define the best approach for RVH in children.

In vitro antioxidant and antihypertensive properties of sesame seed enzymatic protein hydrolysate and ultrafiltration peptide fractions

The objective of this study was to determine the in vitro antioxidant and antihypertensive potentials of sesame seed protein hydrolysate and its membrane ultrafiltration peptide fractions in comparison to the unhydrolyzed protein. Sesame seed protein isolate (SESPI) was prepared from the defatted sesame seed meal and then hydrolyzed using consecutive additions of pepsin and pancreatin to yield sesame protein hydrolysate (SESPH). The SESPH was subjected to membrane ultrafiltration consecutively to obtain fractions with peptide sizes of <1, 1-3, 3-5, and 5-10 kDa, respectively, which were then assayed for in vitro antioxidant and antihypertensive properties. The results showed that protein hydrolysis and fractionation led to significant (p < .05) increases in the content of hydrophobic amino acids. Radical scavenging and metal ion chelation were also significantly (p < .05) enhanced by these treatments. Inhibition of linoleic acid oxidation was stronger with the 1.0 mg/ml of sesame peptide samples in comparison to the mild inhibitory effect exhibited by the 0.5 mg/ml of samples. The <1 kDa peptide fraction was the most active inhibitor (81%) against angiotensin converting enzyme, whereas the bigger peptides (>3-5 and 5-10 kDa) were the most effective (75%-85% ) inhibitors against renin. These sesame products could be used as therapeutic agents in the development of health enhancing foods for the prevention and management of chronic diseases. PRACTICAL APPLICATIONS: Bioactive peptides have been produced from plant protein sources through in vitro enzymatic activities. Sesame seed peptides have demonstrated multifunctional potential to act as antioxidative and antihypertensive agents that could be utilized as ingredients for the development of novel functional foods and nutraceuticals.

Arterial Hypertension in Children

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