Hypertension in children and adolescents

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.

Obesity and hypertension in Latin America: Current perspectives

In the countries of Central America, South America and the Caribbean, there has been a dramatic rise in obesity, the metabolic syndrome, hypertension and other cardiovascular risk factors in the last few decades. Epidemiological evidence highlights a consistent correlation between obesity and hypertension, and the presence of obesity predisposes an individual to a greater risk of hypertension although the mechanisms remain unclear. Obesity and hypertension are two key drivers of the cardio-renal disease continuum, and patients with uncontrolled cardiovascular risk in their mid-life will likely have an increased risk of clinical cardiovascular and renal outcomes in old age. This article summarizes the current status for the prevalence and consequences of obesity and hypertension in Latin America, with the aim of initiating a call to action to all stakeholders for greater implementation of primary prevention strategies, particularly in the young.

Spontaneously Resolving Hyperreninemic Hypertension Caused by Accessory Renal Artery Stenosis in a 13-Year-Old Girl: A Case Report

The authors describe the clinical investigation and progress of a 13-year-old girl diagnosed with hypertension 4 years prior to her admission. A thorough history was taken and physical examination performed. Laboratory analysis and relevant radiological evaluation were obtained in order to determine the etiology for suspected secondary hypertension, and later to differentiate between the possible causes of hyperreninemic hypertension. The patient had an accessory left renal artery, presumptively leading to renin secretion by the underperfused kidney. The patient was treated medically with spontaneous resolution of her hypertension and near normalization of plasma renin activity. On repeat imaging, the artery was not demonstrated. The authors concluded that the diagnosis of hyperreninemic hypertension in young ages should prompt investigation for the etiology. However, cautious observation is a valid option that might lead to spontaneous resolution.

Dietary pattern and blood pressure levels of adolescents in Sohag, Egypt

BACKGROUND

Poor eating patterns formed early in life may lead to health problems in later years. These poor dietary habits are carried over into adolescence in Upper Egypt. The study aimed to assess the relationship between dietary pattern and blood pressure levels of adolescents in Sohag as one of Upper Egypt Governorates.

PARTICIPANTS AND METHODS

A comparative cross-sectional study was carried out on 300 school students of both sexes between 12 and 18 years of age in Sohag. Schools from one educational district were stratified into private or public and boys or girls sectors. From each stratum, about 35-40 students were selected from one class at random. Data on sociodemographic characteristics, medical history, lifestyle, and dietary habits and intake were collected from each student. Anthropometric measurements and both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken at the time of the interview.

RESULTS

Hypertension was detected among 7.7% of the adolescents studied and prehypertension was detected among 34% of the adolescents. The entire studied sample consumed energy, protein, and sodium that exceeded their daily requirements, whereas their intake of potassium was less, with no statistically significant difference. The prehypertensive group consumed the highest daily intake of energy, macronutrients, sodium, and potassium. High BMI and low consumption of fruits and vegetables were associated with increased SBP and DBP. High consumption of chips was a predictor for increased SBP, whereas daily consumption of soft drinks was a predictor for increased DBP.

CONCLUSION AND RECOMMENDATION

The study revealed significant association between the unhealthy dietary pattern and the risk of hypertension and prehypertension among adolescents in Sohag. Changes in their eating habits and dietary intake are highly recommended. Implementing a comprehensive nutrition promotion program has the potential to decrease the risk of hypertension during adulthood.

Documented lifestyle education among young adults with incident hypertension

BACKGROUND

Only 38% of young adults with hypertension have controlled blood pressure. Lifestyle education is a critical initial step for hypertension control. Previous studies have not assessed the type and frequency of lifestyle education in young adults with incident hypertension.

OBJECTIVE

The purpose of this study was to determine patient, provider, and visit predictors of documented lifestyle education among young adults with incident hypertension.

DESIGN

We conducted a retrospective analysis of manually abstracted electronic health record data.

PARTICIPANTS

A random selection of adults 18-39 years old (n = 500), managed by a large academic practice from 2008 to 2011 and who met JNC 7 clinical criteria for incident hypertension, participated in the study.

MAIN MEASURES

The primary outcome was the presence of any documented lifestyle education during one year after meeting criteria for incident hypertension. Abstracted topics included documented patient education for exercise, tobacco cessation, alcohol use, stress management/stress reduction, Dietary Approaches to Stop Hypertension (DASH) diet, and weight loss. Clinic visits were categorized based upon a modified established taxonomy to characterize patients' patterns of outpatient service. We excluded patients with previous hypertension diagnoses, previous antihypertensive medications, or pregnancy. Logistic regression was used to identify predictors of documented education.

KEY RESULTS

Overall, 55% (n = 275) of patients had documented lifestyle education within one year of incident hypertension. Exercise was the most frequent topic (64%). Young adult males had significantly decreased odds of receiving documented education. Patients with a previous diagnosis of hyperlipidemia or a family history of hypertension or coronary artery disease had increased odds of documented education. Among visit types, chronic disease visits predicted documented lifestyle education, but not acute or other/preventive visits.

CONCLUSIONS

Among young adults with incident hypertension, only 55% had documented lifestyle education within one year. Knowledge of patient, provider, and visit predictors of education can help better target the development of interventions to improve young adult health education and hypertension control.

The natural history of the multicystic dysplastic kidney--is limited follow-up warranted?

OBJECTIVE

Imaging of patients with multicystic dysplastic kidney (MCDK) has increased over the past three decades. This increased use of imaging has provided additional insights into the natural history of MCDK. The present study looked at this data for predictors of involution and associated anomalies.

METHODS AND MATERIALS

Institutional review board approval was obtained for this retrospective study. The University of Michigan Departments of Urology and Radiology records were searched to identify unilateral MCDK patients during 1980-2012. Available clinical, radiological and surgical records were reviewed, and pertinent data were recorded. The log-rank test and a Cox proportional regression analysis were performed to identify predictors of MCDK involution. Probability of involution over time was assessed using Kaplan-Meier methodology.

RESULTS

301 unilateral MCDKs were identified; 195 (64.8%) were detected antenatally. Of the MCDKs found, 136 (45.2%) were in girls; 160 (53.2%) were right-sided. Mean size at baseline was 5.0 ± 0.2 cm (Mean ± SE). Associated abnormalities included: contralateral ureteropelvic junction obstruction (n = 10; 3.3%); contralateral ureterovesical junction obstruction/primary megaureter (n = 6; 2.0%); ipsilateral VUR (n = 21; 7.0%); contralateral VUR (n = 63; 20.1%); and renal fusion anomaly (n = 4; 1.3%). The cumulative probability of involution was: 9.8% at one year, 38.5% at five years, and 53.5% at ten years of age. Baseline MCDK size was the only significant predictor of involution at bivariate (p < 0.0001) and multivariate (p < 0.0001; HR 0.58 [95% CI: 0.49, 0.69]) analyses. No MCDK developed malignancy during the follow-up period.

CONCLUSION

As many MCDKs eventually involute and the risk of associated malignancy appears to be very low, there is no absolute indication for nephrectomy. Based on the data and other recent studies, it is believed that pediatric MCDK patients with no other urologic abnormalities can safely tolerate more limited urological and radiological follow-up.

Associations among blood pressure, salt consumption and body weight status of students from south-western Ontario

OBJECTIVE

The purpose was to examine the associations among body weight status, blood pressure and daily Na intake among grade 7 students from south-western Ontario, Canada.

DESIGN

Cross-sectional. Data were collected using the Food Behaviour Questionnaire, including a 24 h diet recall. Measured height and weight were used to determine BMI. Blood pressure was taken manually using mercury sphygmomanometers.

SETTING

Twenty-six schools in south-western Ontario, Canada.

SUBJECTS

Grade 7 students (n 1068).

RESULTS

Body weight status indicated 1 % were underweight, 56 % normal weight, 23 % overweight and 20 % were obese. Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 108·3 (sd 10·3) mmHg and 66·0 (sd 7·5) mmHg, respectively, and mean Na intake was 2799 (sd 1539) mg/d. Bivariate analyses suggested that SBP (P < 0·001) and DBP (P < 0·001) were significantly different by body weight status, yet no associations were observed for Na. Adjusted for gender, ethnicity and under-reporting, participants were more likely to be overweight/obese if they had higher SBP (v. lower: OR = 1·06, 95 % CI 1·05, 1·08, P < 0·001), higher DBP (v. lower: OR = 1·02, 95 % CI 1·00, 1·04, P = 0·043) and higher intakes of Na (3rd v. 1st quartile: OR = 1·72, 95 % CI 1·14, 2·59, P = 0·009; 4th v. 1st quartile: OR = 2·88, 95 % CI, 1·76, 4·73, P < 0·001).

CONCLUSIONS

High intakes of Na, coupled with high SBP and DBP, were associated with overweight and obesity status among the grade 7 sample from south-western Ontario, Canada.

Renal sonography with Doppler for detecting suspected pediatric renin-mediated hypertension - is it adequate?

BACKGROUND

Renal Doppler US is used to evaluate suspected vascular causes of hypertension in children, despite mostly unknown diagnostic performance characteristics.

OBJECTIVE

To evaluate renal Doppler US for detecting vascular causes of hypertension in children with high clinical suspicion of aortic or renal artery narrowing.

MATERIALS AND METHODS

We identified pediatric renal Doppler US examinations performed for hypertension between January 1995 and June 2010 at our institution. We excluded children without follow-up angiography (CT-, MR-, or catheter-based). Two pediatric radiologists reviewed imaging studies and documented relevant findings. Intrarenal spectral Doppler resistive index measurement <0.5 or tardus parvus waveform constituted a positive examination.

RESULTS

Thirty-five boys and 13 girls underwent renal Doppler US and confirmatory imaging (mean age  =  9.0 years). Nineteen US examinations were truly negative, two were falsely negative, 18 were truly positive (16 involved narrowing of the aorta or main renal artery) and nine were falsely positive. Sonography had a sensitivity and specificity of 90% and 68%, respectively, for detecting a vascular cause of hypertension.

CONCLUSION

Renal Doppler sonography reliably detects renin-mediated hypertension caused by aortic or main renal artery narrowing in children. More studies are needed to determine its ability to detect intrarenal and accessory renal artery stenoses.

[Anesthesia for coronary revascularization in patients with Kawasaki disease: case report]

Kawasaki disease is a self-limited vasculitis that occurs predominantly in infants and young children, that is characterized by coronary artery lesions (especially aneurysms). It is one of the leading causes of acquired heart disease in children. The etiology of Kawasaki disease still remains unknown. A hypothesis is that an infectious agent produces clinically apparent disease only in certain genetically predisposed individuals. It also is possible that the disease results from an immunologic response and is triggered by different microbial agents. For unknown reason it dominates in Asians. Treatment is directed to prevent coronary thrombosis and reduce inflammation; it is based on high-dose intravenous immunoglobulin and acetyl salicylic acid, which significantly reduce the risk of coronary artery aneurysms from 25 to 4%. In order to reduce myocardial ischemia, percutaneous coronary interventions and coronary artery bypass graft can be used. There is a lot of information about surgical techniques for coronary artery complications linked to Kawasaki disease, but minimal information about anesthetic techniques; for this reason, we describe the anesthetic management of a patient who required coronary artery bypass graft, and we present a literature review on the topic.

Imaging of renin-mediated hypertension in children

OBJECTIVE

The purpose of this article is to review the imaging findings of common and uncommon causes of renin-mediated hypertension in children using a multimodality radiologic approach.

CONCLUSION

Pediatric hypertension, although uncommon, is often due to aortic or renal artery narrowing. Imaging plays an important role in the diagnosis and characterization of pediatric renin-mediated causes of hypertension.

Hypertension in children and adolescents: epidemiology and pathogenesis

High blood pressure is one among the leading contributors to burden of disease globally. Approximately 54 % of stroke and 47 % of ischemic heart disease events worldwide were attributable to high blood pressure in the year 2001. There is deficiency of data on the long-term outcome of hypertension in children. In spite of this, there is sufficient evidence to suspect that the health risks of hypertension in pediatric patients are substantial. Hypertension in childhood is known to result in hypertension in young adulthood. The epidemiology of hypertension in children is well represented from various studies conducted across continents. Factors like methodological issues in measurement, socio demographic differences, adiposity levels and ethnicity appear to influence the distribution of blood pressure as well as prevalence of hypertension in children. The etio-pathogenesis of essential (primary) hypertension is multi-factorial in origin. Obesity, insulin resistance, activation of sympathetic nervous system, alterations in sodium homeostasis, renin-angiotensin system changes, changes in vascular smooth muscle structure and reactivity, high serum uric acid levels, genetic factors and fetal programming have been reported to contribute to this disorder. The causes of secondary hypertension vary with age. Renal disorders and coarctation of the aorta are the most common causes of hypertension in children up to age 6 y. In older children, renal parenchymal disease remains the most frequent cause of increased blood pressure. Other causes of hypertension in children are relatively rare and include systemic arteritis and certain tumours, endocrine dysfunction, and neurologic disorders.

Association between adiposity and blood pressure levels between the ages of 6 and 16 years. Analysis in a student population from Madrid, Spain

INTRODUCTION AND OBJECTIVES

The increase in the incidence of hypertension in children can be attributed to the rising prevalence of obesity. The objective is to analyze the impact of overweight and the degree or distribution of adiposity on blood pressure levels in a population of Spanish schoolchildren.

METHODS

A cross-sectional study was carried out in 1511 schoolchildren between 6 years and 16 years of age. We measured weight, height, waist circumference, subcutaneous skinfolds, and blood pressure. Nutritional categories were established on the basis of body mass index, waist-to-height ratio, and percent body fat. According to the National High Blood Pressure Education Program Working Group, subjects whose blood pressure was above the 90th percentile of the standard normal distribution were considered to have high blood pressure.

RESULTS

In all, 3.17% of the boys and 3.05% of the girls had high blood pressure. According to odds ratio analysis, the risk of high blood pressure increased in individuals with a body mass index indicative of obesity (7.87-fold in boys, 12.32-fold in girls), with a percent body fat>97th percentile (6.98-fold in boys, 18.51-fold in girls), or with a waist-to-height ratio ≥0.5 (10.56-fold in boys, 7.82-fold in girls).

CONCLUSIONS

Overweight and obesity increase the risk of high blood pressure in children between 6 years and 16 years of age, although the risk level varies depending on the amount and distribution of adipose tissue. Anthropometric indicators of relative adiposity and fat distribution are especially useful in the identification of children and adolescents with high blood pressure.

Hypertension screening during ambulatory pediatric visits in the United States, 2000-2009

BACKGROUND AND OBJECTIVE

Hypertension occurs in 2% to 5% of children in the United States, and its prevalence has increased during the obesity epidemic. There is no consensus among professional organizations about how frequently blood pressure should be measured in children >3 years old. The purpose of this study was to estimate the frequency of hypertension screening during ambulatory pediatric visits in the United States and to determine patient- and provider-level factors associated with screening during visits specifically for preventive care.

METHODS

We analyzed data from a nationally representative sample of ambulatory visits by using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2000 through 2009. In the subset of visits involving patients aged 3 to 18 years, we estimated the frequency of screening during all visits, preventive visits, and preventive visits in which overweight/obesity was diagnosed. We used multivariable logistic regression to identify patient- and provider-level factors associated with screening.

RESULTS

Hypertension screening occurred during 35% of ambulatory pediatric visits, 67% of preventive visits, and 84% of preventive visits in which overweight/obesity was diagnosed. Between 2000 and 2009, the frequency of screening increased in all visits and in preventive visits. Factors independently associated with screening included older age and overweight/obesity diagnosis.

CONCLUSIONS

Providers do not measure blood pressure in two-thirds of pediatric visits and one-third of pediatric preventive visits. Providers may understand the importance of screening among overweight/obese children; however, efforts to encourage routine screening, particularly in young children, may be needed.

Valsartan: in children and adolescents with hypertension

Valsartan is an oral angiotensin II subtype 1 receptor antagonist with well established antihypertensive efficacy in adults. It is now approved in the EU and the US for the treatment of hypertension in children and adolescents. In two, randomized, double-blind trials, a once-daily regimen of valsartan reduced the blood pressure (BP) of children and adolescents with hypertension. In one trial in hypertensive children and adolescents aged 6-16 years, significant dose-dependent reductions from baseline in mean sitting systolic BP (msSBP) were observed for recipients of valsartan following 2 weeks' treatment (primary endpoint). There were corresponding dose-dependent and significant reductions in mean sitting diastolic BP. Following 2 further weeks of treatment, the reduction in msSBP was maintained in patients who were re-randomized to continue receiving the same dosage of valsartan but not in those re-randomized to placebo. In the other trial in hypertensive children and adolescents aged 6-17 years, valsartan was no less effective than enalapril in reducing BP. Following 12 weeks' treatment, the least square mean reduction from baseline in msSBP (primary endpoint) in recipients of valsartan was noninferior to that in recipients of enalapril. In addition, the proportion of patients achieving an msSBP <95th percentile for age, sex, and height at week 12 was not significantly different between recipients of valsartan and enalapril (67% vs 70%). Treatment with valsartan for up to 52 weeks was well tolerated in children and adolescents with hypertension.

Emergency management of hypertension in children

Systemic arterial hypertension in children has traditionally been thought to be secondary in origin. Increased incidence of risk factors like obesity, sedentary life-styles, and faulty dietary habits has led to increased prevalence of the primary arterial hypertension (PAH), particularly in adolescent age children. PAH has become a global epidemic worldwide imposing huge economic constraint on health care. Sudden acute increase in systolic and diastolic blood pressure can lead to hypertensive crisis. While it generally pertains to secondary hypertension, occurrence of hypertensive crisis in PAH is however rare in children. Hypertensive crisis has been further subclassified depending on presence or absence of end-organ damage into hypertensive emergency or urgency. Both hypertensive emergencies and urgencies are known to cause significant morbidity and mortality. Increasing awareness among the physicians, targeted at investigation of the pathophysiology of hypertension and its complications, better screening methods, generation, and implementation of novel treatment modalities will impact overall outcomes. In this paper, we discuss the etiology, pathogenesis, and management of hypertensive crisis in children. An extensive database search using keywords was done to obtain the information.

Investigation of thyroid function and blood pressure in school-aged subjects without overt thyroid disease

This study was performed to ascertain whether a relationship exists between thyroid function and blood pressure in school-aged Chinese subjects without overt thyroid disease. A cross-sectional survey of 880 subjects (541 females and 339 males) aged 7-18 years in Bengbu, Anhui province was conducted. The investigation, which was based on a stratified random cluster sampling method, included a questionnaire and measurements of blood pressure, height, and body weight. Fasting blood samples were taken for measurements of thyroid-stimulating hormone (TSH), free 3,5,3'-triiodothyronine (FT(3)) and free thyroxine (FT(4)). Serum TSH and FT(3) were positively correlated with systolic and diastolic blood pressure Z scores (SBP-Z and DBP-Z) even after adjusting for body mass index (BMI) (P < 0.05) but no correlation was observed between FT(4) and SBP-Z or DBP-Z after comparable adjustments (P > 0.05). SBP-Z and DBP-Z in subjects with subclinical hypothyroidism were significant higher than in euthyroid subjects (P < 0.05). Both SBP-Z and DBP-Z increased linearly with TSH concentration in boys after adjusting BMI (P < 0.05); however, a similar linear trend was not observed in girls. Our findings support the hypothesis that elevated TSH and FT(3) concentrations increase blood pressure in school-aged Chinese subjects without overt thyroid disease; this increase may be even more significant in boys.

Aortic dissection and rupture in a child

After developing sudden severe chest pain, an 11-year-old boy presented to the emergency room with chest pain and palpitations and was unable to stand up. The sudden onset of chest pain was first reported while swimming at school about 30 minutes prior to presentation. Arterial blood pressure (BP) was 150/90 mmHg, heart rate was 120/minute, and the chest pain was combined with shortness of breath and diaphoresis. During the evaluation in the emergency room, the chest pain worsened and abdominal pain developed. An aortic dissection was suspected and a chest and abdomen CT was obtained. The diagnosis of aortic dissection type B was established by CT imaging. The patient went to surgery immediately with BP control. He died prior to surgery due to aortic rupture. Here we present this rare case of aortic dissection type B with rupture, reported in an 11-year-old Korean child.

Primary versus secondary hypertension in children followed up at an outpatient tertiary unit

Childhood hypertension has classically been recognized as a secondary disease. However, primary hypertension also occurs in children. The aim of this study was to compare clinical features of pediatric patients with elevated blood pressure, which were referred to an outpatient tertiary unit, and to detect variables associated with the identification of primary hypertension. The records of 220 patients with hypertension followed between 1996 and 2006 were analyzed. The variable of interest was primary hypertension. Logistic regression analysis was applied to identify clinical variables that were independently associated with primary hypertension. Of 220 patients, 33 (15%) had primary hypertension, and 187 (85%) exhibited secondary hypertension. No statistically significant differences were detected in gender, race, age at diagnosis, and systolic/diastolic blood pressure levels between both groups. After adjustment, four variables at baseline remained independently associated with primary hypertension: absence of signs/symptoms (OR 18.87, 95% CI 6.32-56.29), normal serum creatinine (OR 0.02, 95% CI 0.00-0.27), family history of hypertension (OR 3.03, 95% CI 1.04-8.79), and elevated body weight (OR 1.06, 95% CI 1.02-1.10). The absence of signs/symptoms, normal serum creatinine, family history of hypertension, and overweight/obesity at admission are clues to diagnose primary hypertension in childhood.

Aortic dissection and rupture in an 11-year-old child: A case report

We present the case of an 11-year-old boy who developed sudden severe chest pain. When he was referred to the emergency department with this chest pain and palpitation, he could not even stand up. The sudden onset of chest pain was first complained about while he was swimming at school about 30 min previously. His arterial blood pressure was 150/90 mm Hg, heart rate was 120/min, and the chest pain was combined with shortness of breath and diaphoresis. During the evaluation in the emergency room, he complained of much severer chest pain and newly developed abdominal pain. We suspected aortic dissection and took computed tomography (CT) images of his chest and abdomen. The diagnosis of aortic dissection type B was established with the help of CT imaging. The patient went to surgery immediately with blood pressure control. He was lost before the operation because of aortic rupture. We report one rare case of aortic dissection type B with rupture in an eleven-year-old child in Korea.

Superior palatability of crushed lercanidipine compared with amlodipine among children

AIMS

To compare the taste of equivalent doses of pulverized amlodipine and lercanidipine, two calcium channel blockers, among children with kidney disease.

METHODS

Each child received a test dose of 1 mg of amlodipine besylate and 2 mg of lercanidipine in a single-blinded fashion. Children indicated their preference by pointing to the appropriate face on a visual analogue scale (VAS) that depicts five degrees of pleasure.

RESULTS

The VAS palatability score assigned to lercanidipine was higher than that assigned to amlodipine both in nine children 4-7 years of age (P < 0.005) and in 10 children 8-11 years of age (P < 0.005). The preference for lercanidipine was statistically significant in both girls (P < 0.02) and boys (P < 0.001) and in both children initially presented amlodipine (P < 0.005) and children initially presented lercanidipine (P < 0.005).

CONCLUSIONS

There is a lack of appropriate formulations for children prescribed drugs originally designed for adults, such as calcium channel blockers. Parents therefore crush available tablets and administer the medication mixed with solid food or a palatable drink. From the perspective of the child, the taste of pulverized lercanidipine is superior to that of pulverized amlodipine.

Sources of sodium in Australian children's diets and the effect of the application of sodium targets to food products to reduce sodium intake

The average reported dietary Na intake of children in Australia is high: 2694 mg/d (9-13 years). No data exist describing food sources of Na in Australian children's diets and potential impact of Na reduction targets for processed foods. The aim of the present study was to determine sources of dietary Na in a nationally representative sample of Australian children aged 2-16 years and to assess the impact of application of the UK Food Standards Agency (FSA) Na reduction targets on Na intake. Na intake and use of discretionary salt (note: conversion of salt to Na, 1 g of NaCl (salt) = 390 mg Na) were assessed from 24-h dietary recall in 4487 children participating in the Australian 2007 Children's Nutrition and Physical Activity Survey. Greatest contributors to Na intake across all ages were cereals and cereal-based products/dishes (43%), including bread (13%) and breakfast cereals (4%). Other moderate sources were meat, poultry products (16%), including processed meats (8%) and sausages (3%); milk products/dishes (11%) and savoury sauces and condiments (7%). Between 37 and 42% reported that the person who prepares their meal adds salt when cooking and between 11 and 39% added salt at the table. Those over the age of 9 years were more likely to report adding salt at the table (χ2 199·5, df 6, P < 0·001). Attainment of the UK FSA Na reduction targets, within the present food supply, would result in a 20% reduction in daily Na intake in children aged 2-16 years. Incremental reductions of this magnitude over a period of years could significantly reduce the Na intake of this group and further reductions could be achieved by reducing discretionary salt use.

Suitability of buttermilk for fermentation with Lactobacillus helveticus and production of a functional peptide-enriched powder by spray-drying

AIM

To ferment buttermilk, a low-cost by-product of the manufacture of butter, with a proteolytic strain of Lactobacillus helveticus, to enhance its value by the production of a functional peptide-enriched powder.

METHODS AND RESULTS

Buttermilk was fermented with Lact. helveticus 209, a strain chosen for its high proteolytic activity. To enhance the release of peptidic fractions, during fermentation pH was kept at 6 by using NaOH, Ca(CO)(3) or Ca(OH)(2). Cell-free supernatant was recovered by centrifugation, supplemented or not with maltodextrin and spray-dried. The profile of peptidic fractions released was studied by RP-HPLC. The lactose, Na and Ca content was also determined. The powder obtained was administered to BALB/c mice for 5 or 7 consecutive days, resulting in the proliferation of IgA-producing cells in the small intestine mucosa of the animals.

CONCLUSIONS

Buttermilk is a suitable substrate for the fermentation with Lact. helveticus 209 and the release of peptide fractions able to be spray-dried and to modulate the gut mucosa in vivo.

SIGNIFICANCE AND IMPACT OF THE STUDY

A powder enriched with peptides released from buttermilk proteins, with potential applications as a functional food additive, was obtained by spray-drying. A novel use of buttermilk as substrate for lactic fermentation is reported.

Primary hyperparathyroidism in a young adult presenting with severe hypertension

Hypertension is a significant cause of morbidity and mortality in childhood. Endocrine-related hypertension is rare in children. Hypercalcmia due to hyperparathyroidism is a rare cause of endocrine-related hypertension in childhood. We present a patient with severe headache, who was diagnosed with hypertension due to hyperparathyroidism. Hyperparathyroidism should be kept in mind in children with hypertension accompanied by hypercalcemia and hypophosphatemia.

Efficacy of a school-based cardiac health promotion intervention program for African-American adolescents

OBJECTIVE

African-American adolescents are twice as likely to develop hypertension in early adulthood than adolescents from other racial groups. The purpose of this study was to determine the efficacy of a school-based health promotion intervention.

METHOD

Participants were African-American adolescents aged between 14 and 17 years attending an urban high school. The 9-week intervention program focused on the participants' knowledge, diet, exercise, and blood pressure.

CONCLUSIONS

The intervention program was efficacious in knowledge (p = .0001), exercise (p = .0001), as well as fruit and vegetable intake (p = .0001). Differences in systolic (p = .5548) and diastolic (p = .9719) blood pressure levels were not significant.

Long-term outcome of chronic dialysis in children

As the prevalence of children on renal replacement therapy (RRT) increases world wide and such therapy comprises at least 2% of any national dialysis or transplant programme, it is essential that paediatric nephrologists are able to advise families on the possible outcome for their child on dialysis. Most children start dialysis with the expectation that successful renal transplantation is an achievable goal and will provide the best survival and quality of life. However, some will require long-term dialysis or may return intermittently to dialysis during the course of their chronic kidney disease (CKD). This article reviews the available outcome data for children on chronic dialysis as well as extrapolating data from the larger adult dialysis experience to inform our paediatric practice. The multiple factors that may influence outcome, and, particularly, those that can potentially be modified, are discussed.

Dimercaptosuccinic acid (DMSA) renal scan in the evaluation of hypertension in children

Renal scarring is known to be associated with hypertension. The primary objective of this study was to investigate the prevalence of renal scarring in children referred to our clinic with hypertension. The secondary objective was to compare renal ultrasound (US) examination with dimercaptosuccinic acid (DMSA) renal scan in diagnosing renal scars in these patients. The study included 159 patients who underwent DMSA renal scan as well as renal US for the evaluation of hypertension of unknown etiology. Thirty-three (21%) patients were found to have renal scars; their demographic details, including mean age and gender distribution, were not significantly different from those without renal scars. In comparison with the DMSA renal scan, sensitivity and specificity of renal US in diagnosing renal scars were 36% and 94%, respectively. In our study, in which the prevalence of scarring was 21%, this gave positive predictive and negative predictive values of 63% and 85%, respectively. In conclusion, our study indicates that renal scarring is present in 21% of otherwise healthy children who are evaluated for newly diagnosed hypertension, and renal US is not a sensitive imaging modality to rule out renal scarring.

Preeclampsia: exposing future cardiovascular risk in mothers and their children

There is an increased risk for future cardiovascular disease in women who have had preeclampsia. In infants born to mothers with preeclampsia, there is growing evidence of increased risk for both cardiovascular disease and preeclampsia. Epidemiologic and experimental data provide a strong link between intrauterine exposure to preeclampsia and subsequent risk for the development of cardiovascular disease in women.

Hypertension in children: an update on treatment strategies

PURPOSE OF REVIEW

Hypertension is among the more prevalent treatable diseases that afflict children. Pediatric hypertension carries significant short-term morbidity and long-term risk for the development of cardiovascular disease. This review addresses issues significant to the chronic management of hypertension and discusses common pharmacological agents currently used to treat elevated blood pressure in children.

RECENT FINDINGS

The recent change in the Federal 2002 Best Pharmaceuticals for Children Act has led to the study and approval of new antihypertensive medications for use in pediatrics. Several antihypertensive medications are commercially available in liquid form or can be extemporaneously compounded for flexible dosing and ease of administration.

SUMMARY

The availability of normative blood pressure data and several pharmacologic antihypertensive agents makes early detection and treatment of hypertension in children a realizable goal. The long-term effect of chronic antihypertensive therapy on growth, as well as the prevention of future development of cardiovascular disease, is not fully understood.