Background
Hypertension in newborns and unweaned babies
GA (weeks) | 50th percentile | 95th percentile | 99th percentile | ||||||
---|---|---|---|---|---|---|---|---|---|
SBP | DBP | MBP | SBP | DBP | MBP | SBP | DBP | MBP | |
44 | 88 | 50 | 63 | 105 | 68 | 80 | 110 | 73 | 85 |
42 | 85 | 50 | 62 | 98 | 65 | 76 | 102 | 70 | 81 |
40 | 80 | 50 | 60 | 95 | 65 | 75 | 100 | 70 | 80 |
38 | 77 | 50 | 59 | 92 | 65 | 74 | 97 | 70 | 79 |
36 | 72 | 50 | 57 | 87 | 65 | 72 | 92 | 70 | 77 |
34 | 70 | 40 | 50 | 85 | 55 | 65 | 90 | 60 | 70 |
32 | 68 | 40 | 49 | 83 | 55 | 64 | 88 | 60 | 69 |
30 | 65 | 40 | 48 | 80 | 55 | 63 | 85 | 60 | 68 |
28 | 60 | 38 | 45 | 75 | 50 | 58 | 80 | 54 | 63 |
26 | 55 | 30 | 38 | 72 | 50 | 57 | 77 | 56 | 63 |
Causes of hypertension in neonates
Renovascular |
Renal artery stenosis |
Renal artery thrombosis |
Renal venous thrombosis |
Renal parenchymal disease/obstructive uropathy |
Polycystic kidney disease |
Acute tubular necrosis |
Nephrocalcinosis |
Severe vesicoureteral reflux |
Stenosis of ureteropelvic junction |
Posterior urethral valve |
Ureterocele |
Other causes of acute and chronic renal insufficiency |
Cardiac |
Aortic coarctation |
Aortic arch reconstruction |
Patent ductus arteriosus |
Endocrine |
Congenital adrenal hyperplasia (17 alpha or 11 beta hydroxylase deficiency) |
Hyperthyroidism |
Hyperaldosteronism |
Hypercalcemia |
Neurologic |
Intracranial hypertension |
Seizures |
Intraventricular hemorrhage |
Abstinence syndrome from opioid withdrawal |
Pain |
Neoplasia |
Neuroblastoma |
Wilms tumor |
Pheochromocytoma |
Closure of abdominal wall defect |
Gastroschisis |
Giant omphalocele |
Iatrogenic |
Dexamethasone and other corticosteroids |
Methylxanthines (caffeine, theophylline) |
Vasoactive amines (dopamine, adrenaline) |
Bronchodilators |
Phenylephrine |
Parenteral nutrition (volume overload, sodium, calcium) |
Extracorporeal respiratory assistance |
Malformation syndromes |
DiGeorge |
Potter |
Congenital Rubella |
CHARGE |
VACTERL |
Clinical approach
The most frequent prenatal causes of neonatal hypertension are: |
1. repeated use of steroids by mother |
2. maternal diabetes mellitus |
3. maternal hypertension |
The most frequent postnatal causes of neonatal hypertensione are: |
1. thromboembolism associated with the placement of an umbilical cathether, involving an acute risk presumably due to endothelial damage and a chronic risk related to the time the cathether stays in place |
2. renal parenchymal disease, both congenital (eg. polycystic kidney disease) and acquired |
3. bronchopulmonary dysplasia (CLD) |
Treatment
Drug | Class | Dose | Route | Comments |
Intravenous agentsa: | ||||
Diazoxide | Vasodilator (arteriolar) | 2–5 mg/kg/dose | Rapid bolus injection | Slow injection is ineffective. Duration unpredictable. May cause rapid hypotension. |
Enalaprilat | ACE-inhibitor | 15 ± 5 μg/kg/dose; repeat after 8–24 h | Injection over 5–10 min | May cause prolonged hypotension and acute renal insufficiency. |
Esmolol | β-blocker | 100–300 μg/kg/min | IV infusion | Very short-acting. Constant infusion necessary. |
Hydralazine | Vasodilator (arteriolar) | Bolus: 0.15–0.6 mg/kg/dose every 4 h. Drip: 0.75–5.0 μg/kg/min | IV bolus or infusion | Frequently causes tachycardia. |
Labetalol | α- and β-blocker | 0.20–1.0 mg/kg/dose 0.25–3.0 mg/kg/h | IV bolus or constant infusion | Heart failure and BPD are relative contraindications. |
Nicardipine | Calcium antagonist | 1–3 μg/kg/min | Constant infusion | May cause reflex tachycardia. |
Sodium nitroprusside | Vasodilator (arteriolar and venous) | 0.5–10 μg/kg/min | Constant infusion | In case of prolonged therapy (>72 h) or renal failure thiocyanate toxicity may occur. |
Drug | Class | Dose | Interval | Comments |
Oral agentsa
| ||||
Captopril | ACE-inhibitor | 0.01–0.5 mg/kg | TID | Monitor serum creatinine and potassium. |
Clonidine | Central α-agonist | 0.05–0.1 mg/kg? | BID-TID | Side effects: sedation, dryness of the mucosa. Abrupt interruption may cause rebound hypertension. |
Hydralazine | Vasodilator (arteriolar) | 0.25–1.0 mg/kg (max 7.5 mg/kg per day) | TID-QID | Frequent side effects: fluid retention and tachycardia. Lupus-like syndrome may occur in slow acetylators. |
Isradipine | Calcium antagonist | 0.05–0.15 mg/kg | QID | Useful for both chronic and acute hypertension. |
Amlodipine | Calcium antagonist | 0.1-0.3 mg/kg | BID | Causes sudden hypertension less frequently than isradipine. |
Nifedipine | Calcium antagonist | 0,25–0,5 mg/kg Max. dose: 1–2 mg/kg per day | Repeat every 4–6 h | Hypotensive response poorly predictable. |
Minoxidil | Vasodilator (arteriolar) | 0.1–0.2 mg/kg | BID-TID | The most potent oral vasodilator. Hypertrichosis in case of prolonged use. |
Propranolol | β-blocker | 0.5–1.0 mg/kg | TID | Maximum dose to be defined according to heart rate (up to 8–10 mg/kg if no bradycardia). Not to be used in infants with BPD. |
Atenolol | β-blocker | 0.8–1 mg/kg Max. dose 2 mg/kg per day | QD | |
Labetalol | α- and β-blocker | 1.0 mg/kg | BID-TID | Monitor heart rate. Not to be used in infants with BPD. |
Spironolactone | Aldosterone antagonist | 0.5–1.5 mg/kg | BID | Potassium-sparing. Check serum electrolytes. May take several days to reach maximum effectiveness. |
Hydrochlorothiazide | Thiazide diuretic | 1–3 mg/kg | QID | Check serum electrolytes. |
Chlorothiazide | Thiazide diuretic | 5–15 mg/kg | BID | Check serum electrolytes. |
Organ damage
Prevention of primary hypertension: programming
Ambulatory blood pressure monitoring in pediatric hypertension: how and when to use it
Classification | Office SBP/DBP a
| 24-h ambulatory SBP/DBP b
| SBP or DBP load (%) b
|
---|---|---|---|
Normal blood pressure | <90th percentile | <95th percentile | <25 |
White coat hypertension | ≥95th percentile | <95th percentile | <25 |
Prehypertension | ≥90th percentile | <95th percentile | ≥25 |
Masked hypertension | <95th percentile | >95th percentile | ≥25 |
Hypertension | >95th percentile | >95th percentile | 25–50 |
Severe hypertension | >95th percentile | >95th percentile | >50 |
Dipping subjects: mean nocturnal values at least 10 % lower than diurnal values |
Height (cm) | 24 h | Day | Night | |||
---|---|---|---|---|---|---|
90th p | 95th p | 90th p | 95th p | 90th p | 95th p | |
120 | 112/71 | 114/72 | 118/80 | 120/82 | 103/63 | 106/65 |
125 | 113/71 | 116/73 | 119/80 | 121/82 | 104/63 | 107/66 |
130 | 114/72 | 117/72 | 120/80 | 122/82 | 106/63 | 108/66 |
135 | 115/72 | 118/74 | 120/80 | 123/82 | 107/63 | 109/66 |
140 | 116/73 | 119/75 | 121/80 | 124/82 | 108/63 | 110/66 |
145 | 117/73 | 120/75 | 122/80 | 125/82 | 109/63 | 112/66 |
150 | 119/74 | 121/76 | 124/80 | 127/82 | 110/63 | 113/66 |
155 | 120/74 | 123/76 | 125/80 | 128/82 | 111/63 | 114/66 |
160 | 121/74 | 123/76 | 126/80 | 129/82 | 111/63 | 114/66 |
165 | 122/74 | 124/76 | 127/80 | 130/82 | 112/63 | 114/66 |
170 | 123/74 | 125/76 | 128/80 | 131/82 | 112/67 | 115/71 |
175 | 124/75 | 126/76 | 129/81 | 131/82 | 113/63 | 115/66 |
Height (cm) | 24 h | Day | Night | |||
---|---|---|---|---|---|---|
90th p | 95th p | 90th p | 90th p | 95th p | ||
120 | 114/74 | 117/77 | 122/80 | 125/82 | 103/61 | 106/63 |
125 | 115/74 | 118/77 | 122/80 | 125/82 | 105/61 | 108/61 |
130 | 116/74 | 119/77 | 122/80 | 122/82 | 106/62 | 110/64 |
135 | 117/74 | 120/77 | 123/80 | 126/82 | 108/63 | 111/65 |
140 | 118/75 | 121/77 | 123/80 | 126/82 | 109/63 | 113/65 |
145 | 120/75 | 123/77 | 124/79 | 127/81 | 111/64 | 114/66 |
150 | 121/75 | 124/77 | 125/79 | 128/81 | 112/64 | 116/66 |
155 | 123/75 | 126/77 | 127/79 | 130/81 | 113/64 | 117/66 |
160 | 124/75 | 127/77 | 129/79 | 133/81 | 114/64 | 118/66 |
165 | 126/75 | 129/78 | 132/80 | 135/82 | 116/64 | 119/66 |
170 | 128/75 | 131/78 | 134/80 | 138/82 | 117/64 | 121/66 |
175 | 130/75 | 133/78 | 136/80 | 140/83 | 119/64 | 122/66 |
180 | 131/76 | 134/78 | 138/81 | 142/83 | 120/64 | 124/66 |
185 | 133/76 | 136/78 | 140/81 | 144/84 | 122/64 | 125/66 |
Age (years) | 24 h | Day | Night | |||
---|---|---|---|---|---|---|
90th p | 95th p | 90th p | 90th p | 95th p | ||
5 | 112/72 | 115/74 | 118/80 | 121/82 | 105/66 | 109/69 |
6 | 114/72 | 116/74 | 120/80 | 122/82 | 106/65 | 110/68 |
7 | 115/72 | 118/74 | 121/80 | 123/82 | 107/65 | 111/67 |
8 | 116/72 | 119/74 | 122/80 | 124/82 | 108/64 | 112/67 |
9 | 117/73 | 120/74 | 122/80 | 125/82 | 109/64 | 112/67 |
10 | 118/73 | 121/75 | 123/79 | 126/81 | 110/64 | 113/66 |
11 | 119/73 | 122/75 | 124/79 | 127/81 | 110/63 | 114/66 |
12 | 120/74 | 123/76 | 125/80 | 128/82 | 110/63 | 114/66 |
13 | 121/74 | 124/76 | 126/80 | 129/82 | 111/63 | 114/66 |
14 | 122/74 | 125/76 | 127/80 | 130/82 | 111/63 | 114/65 |
15 | 123/75 | 125/77 | 128/80 | 130/82 | 111/63 | 114/65 |
16 | 123/75 | 126/77 | 129/82 | 131/82 | 111/63 | 114/65 |
Age (years) | 24 h | Day | Night | |||
---|---|---|---|---|---|---|
90th p | 95th p | 90th p | 90th p | 95th p | ||
5 | 114/72 | 116/74 | 120/79 | 123/81 | 103/62 | 106/65 |
6 | 115/73 | 118/75 | 121/79 | 124/81 | 105/63 | 108/66 |
7 | 116/73 | 119/75 | 122/80 | 125/82 | 106/64 | 110/67 |
8 | 117/73 | 120/75 | 122/80 | 125/82 | 108/64 | 111/67 |
9 | 118/73 | 121/75 | 123/80 | 126/82 | 109/64 | 112/67 |
10 | 119/73 | 123/75 | 124/80 | 127/82 | 110/64 | 113/67 |
11 | 121/74 | 125/76 | 126/80 | 129/82 | 111/64 | 115/67 |
12 | 124/74 | 127/76 | 128/80 | 132/82 | 113/64 | 116/67 |
13 | 126/74 | 130/76 | 131/80 | 135/82 | 115/64 | 119/67 |
14 | 129/75 | 133/77 | 134/80 | 138/82 | 118/64 | 121/67 |
15 | 132/75 | 136/77 | 137/81 | 141/83 | 120/64 | 123/66 |
16 | 135/76 | 138/78 | 140/81 | 144/84 | 123/64 | 126/66 |
ABPM and organ damage
Indications for the use of ABPM
ABPM and clinical condition
Technical problems regarding the correct use of Ambulatory Blood Pressure Monitoring in children
Systolic blood pressure | < 60 or > 220 mm Hg |
Diastolic blood pressure | < 35 or > 120 mm Hg |
Heart rate | < 40 or > 180 beats per minute |
Pulse pressure | < 40 or > 120 mm Hg |
Conclusions
Hypertension and physical activity: about prevention, therapy and certifications
Introduction
Prevention of hypertension and its risk factors by physical activity
Physical activity in the treatment of children and adolescents with hypertension
Aspects related to the certification for physical activities and contraindications for sports activities in hypertensive children and adolescents
Mountaineering, Climbing |
Athletics: speed, jumps, leaps, heptathlon, decathlon |
Bobsledding, Luge |
Weight lifting, Bodybuidling |
Speed cycling, Mountain bike downhill, BMX |
Artistic gymnastics |
Synchronized swimming |
Motorcycling (Motocross, Enduro, Trial) |
Water skiing |
Skiing: slalom, giant slalom, super G, downhill, alpine, snowboard, carving, grass skiing. |
Surfing |
Tug-of-war |
Simple carbohydrates, fructose, uric acid and hypertension
Foods at very high purine content (avoid) |
Anchovies, brains, game, gravy, herring, kidney, liver, sardines, shellfish, sweetbread. |
Foods at high purine content (limit) |
Asparagus, beef stock, cauliflower, eel, legumes (beans, lentils, peas), meat (beef, lamb, pork, veal), mushrooms, oatmeal, wheat bran, wheat germ. |