Pediatric hypertension: the year in review

The impact of methylphenidate treatment on the functional and structural properties of the left ventricle: A medium-term prospective study

INTRODUCTION

Although methylphenidate (MPH) used for treatment of attention deficit hyperactivity disorder (ADHD) are considered safe in healthy children and adolescents in the short and medium term, there is a widespread concern about long-term cardiovascular safety.

MATERIAL AND METHODS

Interventional, prospective, longitudinal and comparative study with a crossover design to evaluate the cardiovascular impact of the treatment with MPH in healthy children and adolescents diagnosed with ADHD. A protocol for the cardiovascular evaluation was established at a basal point, after the first and the second year of the beginning with treatment based on the monitoring of blood pressure (BP) and echocardiographic follow-up of the systolic and diastolic functions, and structural cardiac properties.

RESULTS

73 patients completed the study, with an average age of 9 ± 2.6 years, 75.3% were male and the majority were thin (64.4%). We found an increase in Systolic and Diastolic BP of 3.7 ± 9 mmHg (P = 0.004) and 2 ± 11,5 mmHg respectively. There were no severe cardiovascular events. We didn't find any echocardiographic alterations namely on the structural properties or parameters of systolic function. Regarding diastolic function, a significant increase in the isovo-lumic relaxation time (IVRT) (P = 0.046) and deceleration time (P = 0.016) was observed. However, no significant alterations in the parameters related to distensibility of the LV neither in the early diastolic pressure were found.

CONCLUSION

Further studies are needed to evaluate the impact of psychostimulants as a modifiable long-term Cardiovascular Risk Factor.

[The impact of methylphenidate treatment on the functional and structural properties of the left ventricle: A medium-term prospective study]

INTRODUCTION

Although methylphenidate (MPH) used for treatment of Attention deficit hyperactivity disorder (ADHD) are considered safe in healthy children and adolescents in the short and medium term, there is a widespread concern about long-term cardiovascular safety.

MATERIAL AND METHODS

Interventional, prospective, longitudinal and comparative study with a crossover design to evaluate the cardiovascular impact of the treatment with MPH in healthy children and adolescents diagnosed with ADHD. A protocol for the cardiovascular evaluation was established at a basal point, after the first and the second year of the beginning with treatment based on the monitoring of Blood pressure (BP) and echocardiographic follow-up of the systolic and diastolic functions, and structural cardiac properties.

RESULTS

73 patients completed the study, with an average age of 9+/- 2.6 years, 75.3% were male and the majority were thin (64.4%). We found an increase in Systolic and Diastolic BP of 3.7±9mmHg (P).004) and 2±11,5mmHg respectively. There were no severe cardiovascular events. We didn't find any echocardiographic alterations namely on the structural properties or parameters of systolic function. Regarding diastolic function, a significant increase in the isovolumic relaxation time (IVRT) (P=.046) and deceleration time (P=.016) was observed. However, no significant alterations in the parameters related to distensibility of the LV neither in the early diastolic pressure were found.

CONCLUSION

Further studies are needed to evaluate the impact of psychostimulants as a modifiable long-term Cardiovascular Risk Factor.

The Effects of Resistance Training on Blood Pressure in Preadolescents and Adolescents: A Systematic Review and Meta-Analysis

The aim was to systematically review and meta-analyze the current evidence for the effects of resistance training (RT) on blood pressure (BP) as the main outcome and body mass index (BMI) in children and adolescents. Two authors systematically searched the PubMed, SPORTDiscus, Web of Science Core Collection and EMBASE electronic databases. Inclusion criteria were: (1) children and adolescents (aged 8 to 18 years); (2) intervention studies including RT and (3) outcome measures of BP and BMI. The selected studies were analyzed using the Cochrane Risk-of-Bias Tool. Eight articles met inclusion criteria totaling 571 participants. The mean age ranged from 9.3 to 15.9 years and the mean BMI of 29.34 (7.24) kg/m²). Meta-analysis indicated that RT reduced BMI significantly (mean difference (MD): −0.43 kg/m² (95% CI: −0.82, −0.03), P = 0.03; I² = 5%) and a non-significant decrease in systolic BP (SBP) (MD: −1.09 mmHg (95% CI: −3.24, 1.07), P = 0.32; I² = 67%) and diastolic BP (DBP) (MD: −0.93 mmHg (95% CI: −2.05, 0.19), P = 0.10; I² = 37%). Limited evidence suggests that RT has no adverse effects on BP and may positively affect BP in youths. More high-quality studies are needed to clarify the association between RT and BP in light of body composition changes throughout childhood and adolescence.

Haemodynamics of Hypertension in Children

PURPOSE OF REVIEW

To review the haemodynamic characteristics of paediatric hypertension.

RECENT FINDINGS

Pulsatile components of blood pressure are determined by left ventricular dynamics, aortic stiffness, systemic vascular resistance and wave propagation phenomena. Recent studies delineating these factors have identified haemodynamic mechanisms contributing to primary hypertension in children. Studies to date suggest a role of cardiac over activity, characterized by increased heart rate and left ventricular ejection, and increased aortic stiffness as the main haemodynamic determinants of primary hypertension in children.

Pediatric Hypertension and End-Stage Renal Disease

Pediatric hypertension is not an uncommon diagnosis, affecting about 3.5% of all children. Most childhood hypertension is associated with obesity, but elevated blood pressure can also be the presenting symptom of a secondary disease process. Moreover, no matter the cause of hypertension, early identification can improve long-term health outcomes as childhood hypertension predicts hypertension in adulthood. In 2017, the American Academy of Pediatrics revised their 2004 guidelines regarding blood pressure screening for all children. Here, we discuss an illustrative case of a 16-year-old girl with hypertension and underlying nephrotic syndrome whose diagnosis was delayed due to inadequate blood pressure screening. Given the varying practices regarding the interpretation of blood pressure data in the outpatient setting, it is important for primary care providers to understand the updated guidelines and the indications for referral. [Pediatr Ann. 2020;49(6):e258-e261.].

Associations of plasma uric acid and purine metabolites with blood pressure in children: the KOALA Birth Cohort Study

OBJECTIVE

Elevated serum uric acid concentration has been associated with high blood pressure (BP) and hypertension. A putative underlying mechanism is the accumulation of reactive oxygen species when uric acid is generated by an increased enzyme activity of xanthine oxidase (XO). The aims of the present study were to investigate the associations between plasma uric acid concentration, purine metabolite ratios, as proxies for increased XO activity, and SBP and DBP in school-age children.

METHODS

Cross-sectional analyses were performed in 246 children (46% boys; mean age 7.1 years) from the Dutch KOALA Birth Cohort Study. Purine metabolites were determined with ultra-performance liquid chromatography-tandem mass spectrometry. During a home visit, a nurse collected a blood sample and measured BP three times; in addition, parents measured their child's BP on three consecutive days, in the morning and evening. Generalized estimating equations were used for analyses while controlling for variables such as sex, age, BMI, physical activity, and dietary intake.

RESULTS

In multivariable analysis, uric acid (per SD of 38 μmol/l) was associated with DBP z-scores [sβ 0.07; confidence interval (CI), 0.01-1.14], but not with SBP z-scores. Higher ratios of uric acid/xanthine (per SD of 138) (sβ 0.09; CI, 0.01-0.17) and xanthine/hypoxanthine (per SD of 321) (sβ 0.08; CI, 0.02-0.17) were associated with higher DBP z-scores, but not with SBP z-scores.

CONCLUSION

In school-age children, uric acid and the ratios of uric acid/xanthine and xanthine/hypoxanthine were significantly associated with DBP z-scores. Suggesting that, both uric acid concentration and increased XO activity are associated with BP.

Left ventricular hypertrophy and diastolic function in children and adolescents with essential hypertension

Introduction

Left ventricular hypertrophy and diastolic dysfunction in children and adolescents with essential hypertension tend to be underdiagnosed. The aims of this study were to investigate left ventricular hypertrophy and diastolic dysfunction in the subjects with essential hypertension defined by ambulatory blood pressure monitoring.

Methods

A total of 38 Korean subjects aged 9–19 years without secondary causes of hypertension were reviewed. Ambulatory blood pressure monitoring was done in the 38 subjects to diagnose hypertension and gain the information of blood pressure pattern. The subjects were divided into two groups: a group with elevated blood pressure (BP) index (n = 29) and a group with normal BP index (n = 9). Two-dimensional ultrasound with M-mode imaging and tissue Doppler imaging were performed to measure left ventricular mass index and to assess the left ventricular diastolic dysfunction.

Results

Left ventricular mass index(g/m^2.7) was significantly higher in the group with elevated BP index than the group with normal BP index, but there were no differences in left ventricular diastolic dysfunction evaluated by E/A ratio and E/E’ ratio. Left ventricular mass index was related only with body mass index, while any of the ambulatory blood pressure monitoring parameters did not predict left ventricular hypertrophy. In terms of diastolic dysfunction in essential hypertension, E/E’ ratio in the subjects with left ventricular hypertrophy was higher than that in the other subjects without left ventricular hypertrophy.

Discussion

Left ventricular mass index is significantly correlated with body mass index in children and adolescents with essential hypertension, and the diastolic dysfunction could be in higher risk in subjects with left ventricular hypertrophy.

Recognition and Management of Elevated Blood Pressure in Pediatric Patients: Challenges and Disparities in Community Health Centers

The prevalence of childhood elevated blood pressure (EBP)-a single blood pressure recording above the normal range-is increasing in the United States. Recognizing childhood EBP is difficult because classification is a function of age, sex, and height. We assessed the frequency of clinical recognition of EBP and follow-up care in a sample of pediatric patients seen in 2010 and followed up through September 2013 in a network of 8 urban health centers. Of 754 patients with BP measurements, 261 (35 %) had at least 1 EBP reading during the study period. Of those with an EBP reading, 52 (20 %) had at least 1 EBP reading noted in their medical record. Clinicians were more likely to recognize EBP in overweight/obese [OR 3.27 (95 % confidence interval (CI) 1.64-6.51)] and male [OR 2.83 (95 % CI 1.64-4.42)] children. Strategies to support routine monitoring of BP status could improve identification and management of pediatric EBP.

Pediatric hypertension: a growing problem

Hypertension in children and adolescents, once thought to be rare, has been estimated at a current prevalence of between 1% and 5% in the United States. The prevalence of primary hypertension continues to increase with the increasing body mass index of the pediatric population. Who is at risk? If and when to screen? When and how to treat? These controversial questions are important to the physician in primary care practice.