Antihypertensive drug exposure in premature infants from 1997 to 2013

Sequence of antihypertensive medications used in preterm infants with hypertension: A cross-sectional study

BACKGROUND

Hypertension in preterm infants can result in life-threatening outcomes. However, there is limited evidence to guide the pharmacologic management of hypertension in preterm infants. Without population-level studies of the pharmacologic strategies that clinicians currently employ for hypertension in preterm infants, studies investigating the benefits and risks of these strategies cannot be performed.

METHODS

A retrospective, cross-sectional study was conducted at a single academic medical centerto determine the most prevalent antihypertensive medication used for first-line, second-line, and adjunctive pharmacologic management among preterm infants with hypertension. The study sample included patients with a postnatal age less than 1 year at hospital discharge, gestational age at birth less than 37 weeks, and treated with an antihypertensive medication between July 2010 and December 2022. The prevalence of each antihypertensive medication used for each stage of pharmacologic management was estimated, and prevalences were compared using prevalence ratios. Bayesian multinomial regression was used to estimate prevalence ratios and 95% credible intervals (CIs).

RESULTS

Out of 751 possibly eligible patient encounters obtained, 134 encounters were identified across 120 patients that met the inclusion criteria. Second-line and adjunctive pharmacologic management were used in 6 and 12 encounters, respectively. Propranolol had the highest prevalence for each stage of pharmacologic management: 61% for first-line (95% CI: 53-69%); 40% for second-line (95% CI: 14-70%); and 47% for adjunctive pharmacologic management (95% CI: 24-72%). As a first-line pharmacologic management, propranolol was 4.8 times (95% CI: 2.9-7.7) as prevalent as the second most prevalent medication (captopril).

CONCLUSION

In a large academic hospital, propranolol was the most commonly used medication for first-line antihypertensive pharmacologic management among preterm infants. The most prevalent medication used for second-line and adjunctive pharmacologic management was inconclusive.

Neonatal blood pressure by birth weight, gestational age, and postnatal age: a systematic review

BACKGROUND

Blood pressure is a vital hemodynamic marker during the neonatal period. However, normative values are often derived from small observational studies. Understanding the normative range would help to identify ideal thresholds for intervention to treat hypotension or hypertension. Therefore, the aim of this study was to assess observed blood pressure values in neonates who have not received any blood-pressure modifying treatments from birth to three months postnatal age and whether these vary according to birth weight, gestational age and postnatal age.

METHODS

This was a systematic review. A literature search was conducted in MEDLINE, PubMed, Embase, Cochrane Library, and CINAHL from 1946 to 2017 on blood pressure in neonates from birth to 3 months of age (PROSPERO ID CRD42018092886). Unpublished data were included where appropriate.

RESULTS

Of 3,587 non-duplicate publications identified, 30 were included (one unpublished study). Twelve studies contained data grouped by birth weight, while 23 contained data grouped by gestational age. Study and clinical heterogeneity precluded meta-analyses thus results are presented by subgroup. A consistent blood pressure rise was associated with increasing birth weight, gestational age, and postnatal age. In addition, blood pressure seemed to rise more rapidly in the most preterm and low birth weight neonates.

CONCLUSION

Despite blood pressure increasing with birth weight, gestational age, and postnatal age, there was marked blood pressure variability observed throughout. To better define hypotension and hypertension, future studies should develop consistent approaches for factors related to blood pressure variability, including the method and timing of measurement as well as statistical control of relevant patient characteristics.

Neonatal Hypertension

Neonatal hypertension is uncommon but is becoming increasingly recognized. Normative blood pressure data are limited, as is research regarding the risks, treatment, and long-term outcomes. Therefore, there are no clinical practice guidelines and management is based on clinical judgment and expert opinion. Recognition of neonatal hypertension requires proper blood pressure measurement technique. When hypertension is present there should be a thorough clinical, laboratory, and imaging evaluation to promptly diagnose causes needing medical or surgical management. This review provides a practical overview for the practicing clinician regarding the identification, evaluation, and management of neonatal hypertension.

The hypertensive neonate

Hypertension in neonates is increasingly recognized because of improvements in neonatal intensive care that have led to improved survival of premature infants. Although normative data on neonatal blood pressure remain limited, several factors appear to be important in determining blood pressure levels in neonates, especially gestational age, birth weight and maternal factors. Incidence is around 1% in most studies and identification depends on careful blood pressure measurement. Common causes of neonatal hypertension include umbilical catheter associated thrombosis, renal parenchymal disease, and chronic lung disease, and can usually be identified with careful diagnostic evaluation. Given limited data on long-term outcomes and use of antihypertensive medications in these infants, clinical expertise may need to be relied upon to decide the best approach to treatment. This review will discuss these concepts and identify evidence gaps that should be addressed.

Neonatal hypertension: cases, causes, and clinical approach

Neonatal hypertension is increasingly recognized as dramatic improvements in neonatal intensive care, advancements in our understanding of neonatal physiology, and implementation of new therapies have led to improved survival of premature infants. A variety of factors appear to be important in determining blood pressure in neonates, including gestational age, birth weight, and postmenstrual age. Normative data on neonatal blood pressure values remain limited. The cause of hypertension in an affected neonate is often identified with careful diagnostic evaluation, with the most common causes being umbilical catheter-associated thrombosis, renal parenchymal disease, and chronic lung disease. Clinical expertise may need to be relied upon to decide the best approach to treatment in such patients, as data on the use of antihypertensive medications in this age group are extremely limited. Available data suggest that long-term outcomes are usually good, with resolution of hypertension in most infants. In this review, we will take a case-based approach to illustrate these concepts and to point out important evidence gaps that need to be addressed so that management of neonatal hypertension may be improved.