Strengths and limitations of current pediatric blood pressure nomograms: a global overview with a special emphasis on regional differences in neonates and infants

Optimizing vancomycin dosing in pediatrics: a machine learning approach to predict trough concentrations in children under four years of age

BACKGROUND

Vancomycin trough concentration is closely associated with clinical efficacy and toxicity. Predicting vancomycin trough concentrations in pediatric patients is challenging due to significant inter-individual variability and rapid physiological changes during maturation.

AIM

This study aimed to develop a machine learning model to predict vancomycin trough concentrations and determine optimal dosing regimens for pediatric patients < 4 years of age using ML algorithms.

METHOD

A single-center retrospective observational study was conducted from January 2017 to March 2020. Pediatric patients who received intravenous vancomycin and underwent therapeutic drug monitoring were enrolled. Seven ML models [linear regression, gradient boosted decision trees, support vector machine, decision tree, random forest, Bagging, and extreme gradient boosting (XGBoost)] were developed using 31 variables. Performance metrics including R-squared (R2), mean square error (MSE), root mean square error (RMSE), and mean absolute error (MAE) were compared, and important features were ranked.

RESULTS

The study included 120 eligible trough concentration measurements from 112 patients. Of these, 84 measurements were used for training and 36 for testing. Among the seven algorithms tested, XGBoost showed the best performance, with a low prediction error and high goodness of fit (MAE = 2.55, RMSE = 4.13, MSE = 17.12, and R2 = 0.59). Blood urea nitrogen, serum creatinine, and creatinine clearance rate were identified as the most important predictors of vancomycin trough concentration.

CONCLUSION

An XGBoost ML model was developed to predict vancomycin trough concentrations and aid in drug treatment predictions as a decision-support technology.

Establishment of a scoring model for the differential diagnosis of white coat hypertension and sustained hypertension

OBJECTIVES

This study aimed to establish a scoring model for the differential diagnosis of white coat hypertension (WCH) and sustained hypertension (SHT).

METHODS

This study comprised 553 adults with elevated office blood pressure, normal renal function, and no antihypertensive medications. Through questionnaire investigation and biochemical detection, 17 parameters, such as gender and age, were acquired. WCH and SHT were distinguished by 24 h ambulatory blood pressure monitoring. The participants were randomly divided into a training set (445 cases) and a validation set (108 cases). The above parameters were screened using least absolute shrinkage and selection operator regression and univariate logistic regression analysis in the training set. Afterward, a scoring model was constructed through multivariate logistic regression analysis.

RESULTS

Finally, six parameters were selected, including isolated systolic hypertension, office systolic blood pressure, office diastolic blood pressure, triglyceride, serum creatinine, and cardiovascular and cerebrovascular diseases. Multivariate logistic regression was used to establish a scoring model. The R2 and area under the ROC curve (AUC) of the scoring model in the training set were 0.163 and 0.705, respectively. In the validation set, the R2 of the scoring model was 0.206, and AUC was 0.718. The calibration test results revealed that the scoring model had good stability in both the training and validation sets (mean square error = 0.001, mean absolute error = 0.014; mean square error = 0.001, mean absolute error = 0.025).

CONCLUSION

A stable scoring model for distinguishing WCH was established, which can assist clinicians in identifying WCH at the first diagnosis.

Comparison of clinical outcomes between active and permissive blood pressure management in extremely preterm infants

Background

There remains uncertainty about the definition of normal blood pressure (BP), and when to initiate treatment for hypotension for extremely preterm infants. To determine the short-term outcomes of extremely preterm infants managed by active compared with permissive BP support regimens during the first 72 hours of life.

Method

This is a retrospective medical records review of 23 +0-28 +6 weeks' gestational age (GA) infants admitted to neonatal units (NNU) with active BP support (aimed to maintain mean arterial BP (MABP) >30 mmHg irrespective of the GA) and permissive BP support (used medication only when babies developed signs of hypotension) regimens. Babies admitted after 12 hours of age, or whose BP data were not available were excluded.

Results

There were 764 infants admitted to the participating hospitals; 671 (88%) were included in the analysis (263 active BP support and 408 permissive BP support). The mean gestational age, birth weight, admission temperature, clinical risk index for babies (CRIB) score and first haemoglobin of infants were comparable between the groups. Active BP support group infants had consistently higher MABP and systolic BP throughout the first 72 hours of life (p<0.01). In the active group compared to the permissive group 56 (21.3%) vs 104 (25.5%) babies died, and 21 (8%) vs 51 (12.5%) developed >grade 2 intra ventricular haemorrhage (IVH). Death before discharge (adjusted OR 1.38 (0.88 - 2.16)) or IVH (1.38 (0.96 - 1.98)) was similar between the two groups. Necrotising enterocolitis (NEC) ≥stage 2 was significantly higher in permissive BP support group infants (1.65 (1.07 - 2.50)).

Conclusions

There was no difference in mortality or IVH between the two BP management approaches. Active BP support may reduce NEC. This should be investigated prospectively in large multicentre randomised studies.

Adolescent blood pressure classification curves and cardiometabolic risk factors: a comparison of the Brazilian and American references

BACKGROUND

The American Academy of Pediatrics (AAP) adolescent blood pressure (BP) percentiles were updated in 2017, and have been used as reference in Brazil since then. However, specific BP percentiles for Brazilian adolescents were recently proposed based on data from the Study of Cardiovascular Risk in Adolescents (ERICA).

OBJECTIVES

To compare the prevalence of arterial hypertension according to each reference, as well as to assess the cardiometabolic risk associated with the reclassification by Brazilian BP percentiles.

METHODS

Data from 73 399 adolescents aged 12-17 years who participated in the ERICA study were analyzed. To assess cardiometabolic risk, 6185 adolescents who were reclassified upwards by the Brazilian reference were 1 : 1 matched with adolescents that were normotensive by both references and were of the same age, sex and height percentile. The parameters evaluated were: overweight/obesity, waist circumference, total cholesterol, triglycerides, LDL-c, HDL-c, fasting glucose, HbA1c and HOMA-ir.

RESULTS

The classification according to Brazilian BP percentiles resulted in a higher prevalence of arterial hypertension (14%, 95% CI 13.2-14.8), when compared with the AAP percentiles (10.6%, 95% CI 10.0-11.2). The use of the Brazilian reference also resulted in higher prevalence of arterial hypertension in girls, teenagers ranging from 12 to 14 years, and those classified with adequate weight, overweight or obesity. In the case-control analysis, cardiometabolic risk factors were present more often in adolescents reclassified with arterial hypertension by the ERICA reference.

DISCUSSION

The use of the BP percentiles proposed by ERICA is a sensitive method for tracking Brazilian adolescents with hypertension and higher cardiometabolic risk.

Left ventricular vortex analysis by high-frame rate blood speckle tracking echocardiography in healthy children and in congenital heart disease

Background

High-frame rate blood speckle tracking (BST) echocardiography is a new technique for the assessment of intracardiac flow. The purpose of this study was to evaluate the characteristics of left ventricular (LV) vortices in healthy children and in those with congenital heart disease (CHD).

Methods

Characteristics of LV vortices were analyses based on 4-chamber BST images from 118 healthy children (median age 6.84 years, range 0.01-17 years) and 43 children with CHD (median age 0.99 years, range 0.01-14 years). Both groups were compared after propensity matching. Multiple linear regression was used to identify factors that independently influence vortex characteristics.

Results

Feasibility of vortex imaging was 93.7% for healthy children and 95.6% for CHD. After propensity matching, there were no overall significant differences in vortex distance to apex, distance to interventricular septum (IVS), height, width, sphericity index, or area. However, multiple regression analysis revealed significant associations of LV morphology with vortex characteristics. Furthermore, CHD involving LV volume overload and CHD involving LV pressure overload were both associated with vortices localized closer to the IVS.

Conclusions

LV vortex analysis using high-frame rate BST echocardiography is feasible in healthy children and in those with CHD. As they are associated with LV morphology and are modified in some types of CHD, vortices might yield diagnostic and prognostic value. Future studies are warranted to establish applications of vortex imaging in the clinical setting.

Prevalence and Risk Factors for Hypertension in Adolescents Aged 12 to 17 Years: A School-Based Study in China

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Strengths, Limitations, and Geographical Discrepancies in the Eligibility Criteria for Sport Participation in Young Patients With Congenital Heart Disease

OBJECTIVE

Benefits of physical activity has been shown in children with congenital heart disease (CHD). In several forms of CHD, the risk of sudden death remains a major concern both for parents and clinicians, who in turn will have to consider the risk-benefit ratio of sport participation versus restriction.

DATA SOURCE

A literature search was performed within the National Library of Medicine using the keywords: Sport, CHD, and Eligibility. The search was further refined by adding the keywords: Children, Adult, and Criteria.

MAIN RESULTS

Fifteen published studies evaluating sport eligibility criteria in CHD were included. Seven documents from various scientific societies have been published in the past decade but which of them should be adopted remains unclear. Our research highlighted accuracy and consistency of the latest documents; however, differences have emerged between the US and European recommendations. Eligibility criteria were consistent between countries for simple congenital heart defects, whereas there are discrepancies for borderline conditions including moderate valvular lesions and mild or moderate residual defects after CHD repair. Furthermore, some of the more severe defects were not evaluated. Multiple recommendations have been made for the same CHD, and cut-off values used to define disease severity have varied. Published eligibility criteria have mainly focused on competitive sports. Little attention was paid to recreational activities, and the psychosocial consequences of activity restriction were seldom evaluated.

CONCLUSIONS

Comprehensive consensus recommendations for sport eligibility evaluating all CHD types and stages of repair are needed. These should include competitive and recreational activities, use standardized classifications to grade disease severity, and address the consequences of restriction.

Incidence of neonatal hypertension from a large multicenter study [Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates-AWAKEN]

BACKGROUND

Hypertension occurs in up to 3% of neonates admitted to the Neonatal Intensive Care Unit (NICU), and is a potentially under-recognized condition. The aim of this study was to examine the incidence of documented and undiagnosed hypertension from the 24-center Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) database, and to assess risk factors for hypertension according to gestational age.

METHODS

Diagnosed hypertension was documented if an infant had a discharge diagnosis of hypertension and/or discharged on antihypertensive medications. Undiagnosed hypertension was defined when infants did not have a diagnosis of hypertension, but >50% of the lowest mean, diastolic and systolic blood pressure recordings were >95^th percentile for gestational age.

RESULTS

Of the 2162 neonates enrolled in the study, hypertension was documented in 1.8%. An additional 3.7% were defined as having undiagnosed hypertension. There was a significant correlation with neonatal hypertension and acute kidney injury (AKI). Additional risk factors for neonatal hypertension were hyperbilirubinaemia, Caucasian race, outborn, vaginal delivery, and congenital heart disease. Protective factors were small for gestational age, multiple gestations, and steroids for fetal maturation.

CONCLUSIONS

Neonatal hypertension may be an under-recognized condition. AKI and other risk factors predispose infants to hypertension.

Establishment of blood pressure nomograms representative for Egyptian children and adolescents: a cross-sectional study

OBJECTIVE

To define nomograms for blood pressure in Egyptian children and adolescents.

METHODS AND STUDY DESIGN

A total of 60 025 Egyptian children from birth to 19 years were enrolled in this cross-sectional randomised study from December 2015 to March 2017. They were selected from diverse geographical districts in Egypt. Healthy children who fulfilled the inclusion criteria, which included good nutritional history, absence of fever or documented underlying disease at the time of examination, no evidence of haemodynamically significant illness, and no antihypertensive drugs or other chronic drug administration, were included in the study. Body weight, recumbent length (for less than 24 months) and height (from 2 years to 19 years), and blood pressure were measured using standard mercury sphygmomanometers.

RESULTS

Blood pressure increases with age in both boys and girls. The 90th percentile of systolic and diastolic blood pressure among Egyptian children was different from other ethnic populations (American and Turkish children) in both sexes. Systolic and diastolic blood pressure showed a positive correlation with weight and height in both sexes (p<0.001).

CONCLUSION

We assumed that normal blood pressure curves should be used cautiously during childhood, and it is recommended that every population have its own normal standard curve to define measured blood pressure levels in children. These centiles increased our knowledge and awareness of normal blood pressure among Egyptian children and adolescents. The percentiles will distinguish children and young adolescents with increased blood pressure and will be of value to both medical practice and scientific research.

Performance of 4 definitions of childhood elevated blood pressure in predicting subclinical cardiovascular outcomes in adulthood

We aimed to compare the ability of the pediatric blood pressure (BP) standards issued by the US Fourth Report, the recently proposed US, Chinese, and international standards to predict adult hypertension and subclinical cardiovascular disease (CVD). 2296 children were randomly selected from Beijing at baseline. The follow-up survey was conducted among 1177 adults. Subclinical adult CVD was assessed using the carotid-femoral pulse wave velocity (cfPWV), carotid intima-media thickness (CIMT), and left ventricular mass index (LVMI). The prevalence of pediatric elevated BP was significantly higher according to the Chinese standards vs the Fourth Report, the updated US standards, and the international standards (18.7% vs 14.2%, 17.5%, and 18.0%, respectively; all Ps < .001). Children identified as elevated BP using any of the 4 standards were more likely to have adult hypertension, high cfPWV, and high LVMI than children without elevated BP. However, only the Chinese and updated US standards can predict the increased risk of adult high CIMT. Our results indicated that the Chinese standards performed equally or better compared with 3 other standards in predicting adult hypertension and subclinical CVD.

Advances in paediatrics in 2016: current practices and challenges in allergy, autoimmune diseases, cardiology, endocrinology, gastroenterology, infectious diseases, neonatology, nephrology, neurology, nutrition, pulmonology

This review reports main progresses in various pediatric issues published in Italian Journal of Pediatrics and in international journals in 2016. New insights in clinical features or complications of several disorders may be useful for our better understanding. They comprise severe asthma, changing features of lupus erythematosus from birth to adolescence, celiac disease, functional gastrointestinal disorders, Moebius syndrome, recurrent pneumonia. Risk factors for congenital heart defects, Kawasaki disease have been widely investigated. New diagnostic tools are available for ascertaining brucellosis, celiac disease and viral infections. The usefulness of aCGH as first-tier test is confirmed in patients with neurodevelopmental disorders. Novel information have been provided on the safety of milk for infants. Recent advances in the treatment of common disorders, including neonatal respiratory distress syndrome, hypo-glycemia in newborns, atopic dermatitis, constipation, cyclic vomiting syndrome, nephrotic syndrome, diabetes mellitus, regurgitation, short stature, secretions in children with cerebral palsy have been reported. Antipyretics treatment has been updated by national guidelines and studies have excluded side effects (e.g. asthma risk during acetaminophen therapy). Vaccinations are a painful event and several options are reported to prevent this pain. Adverse effects due to metabolic abnormalities are reported for second generation antipsychotic drugs.

Novelty in hypertension in children and adolescents: focus on hypertension during the first year of life, use and interpretation of ambulatory blood pressure monitoring, role of physical activity in prevention and treatment, simple carbohydrates and uric acid as risk factors

The present article intends to provide an update of the article "Focus on prevention, diagnosis and treatment of hypertension in children and adolescents" published in 2013 (Spagnolo et al., Ital J Pediatr 39:20, 2013) in this journal. This revision is justified by the fact that during the last years there have been several new scientific contributions to the problem of hypertension in pediatric age and during adolescence. Nevertheless, for what regards some aspects of the previous article, the newly acquired information did not require substantial changes to what was already published, both from a cultural and from a clinical point of view. We felt, however, the necessity to rewrite and/or to extend other parts in the light of the most recent scientific publications. More specifically, we updated and extended the chapters on the diagnosis and management of hypertension in newborns and unweaned babies, on the use and interpretation of ambulatory blood pressure monitoring, and on the usefulness of and indications for physical activity. Furthermore, we added an entirely new section on the role that simple carbohydrates (fructose in particular) and uric acid may play in the pathogenesis of hypertension in pediatric age.