what is the first line treatment of pediatric idiopathic high blood pressure

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How is high blood pressure treated in children?

High blood pressure is treated similarly in children and adults, usually starting with lifestyle changes. Even if your child takes medication for high blood pressure, lifestyle changes can make the medication work better. Control your child's weight.

How to manage pediatric idiopathic intracranial hypertension?

Pediatric Idiopathic Intracranial Hypertension Treatment & Management 1 Approach Considerations. The care of patients with pseudotumor cerebri requires a multidisciplinary... 2 Pharmacologic Therapy. Acetazolamide is administered at an initial dosage of 25 mg/kg/day,... 3 Optic Nerve Sheath Fenestration and CSF Diversion.

How to prevent high blood pressure (BP) in pediatric heart transplant recipients?

Use ABPM to evaluate BP in pediatric heart- and kidney-transplant recipients. 26. Reasonable strategies for HTN prevention include the maintenance of a normal BMI, consuming a DASH-type diet, avoidance of excessive sodium consumption, and regular vigorous physical activity. 27.

How is nicardipine used to treat pediatric hypertension?

Nicardipine is largely used intravenously for treatment of severe hypertension. 16 Outside of hypertension associated with renal disease, data are extremely limited regarding the use of ARBs for the treatment of pediatric hypertension.

What is the first line of treatment for high blood pressure?

The strongest body of evidence indicates that for most patients with hypertension, thiazide diuretics are the best proven first-line treatment in reducing morbidity and mortality.

What is the recommended first line in the management of hypertension in middle age patient?

Low-dose thiazide diuretics remain first-line therapy for older patients. Beta blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and calcium channel blockers are second-line medications that should be selected based on comorbidities and risk factors.

Why are ACE inhibitors first line in hypertension?

Introduction. ACE (angiotensin-converting enzyme) inhibitors and angiotensin receptor blockers (ARBs) effectively lower blood pressure (BP) through inhibition of the renin-angiotensin system and are equally recommended as first-line medications in the treatment of hypertension.

Why is amlodipine first line?

Results Amlodipine has good efficacy and safety, in addition to strong evidence from large randomised controlled trials for cardiovascular event reduction. Conclusions Amlodipine should be considered a first-line antihypertensive agent.

What is the best treatment for hypertension in pediatrics?

11 Currently recommended agents for the treatment of hypertension in pediatric patients include angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), and diuretics. 11 Patients should be treated to a goal BP of <95th percentile; in patients with comorbid conditions, however, treatment should aim for a goal of <90th percentile. The choice of initial agent is based largely upon clinician preference or compelling indications, as evidence of the impact on clinical outcomes is lacking. 11 For example, a BB or alpha antagonist would be most beneficial in a patient with high catecholamine levels. 12 For a diabetic patient, an ACE inhibitor would be ideal. 11 Additional conditions to take into consideration when selecting an agent are the presence of symptomatic hypertension, secondary causes of hypertension, target-organ damage, and persistent hypertension despite nonpharmacologic interventions. 11

How to treat hypertension in children?

As with adults, initial therapy for hypertension in children and adolescents includes diet and exercise. 11,12 Weight loss, particularly for the obese child, often will prevent the addition of pharmacologic therapy. 12 Nonpharmacologic dietary interventions recommended for adults (including increased intake of fruits and vegetables, consumption of low-fat dairy products, and sodium restriction) may also be beneficial for children and adolescents. Current recommendations for sodium intake are 1.2 g/day for children aged 4 to 8 years and 1.5 g/day for those older than 8 years. Reducing dietary sodium is expected to provide a decrease in BP of 1 mmHg to 3 mmHg. 11 Additional interventions include the cessation of alcohol and tobacco products, along with increased exercise. 11 Patients should be encouraged to engage in 30 to 60 minutes of physical activity daily and to minimize (i.e., <2 hours) time spent in sedentary activities, including watching television and playing video or computer games. 11 There are limitations on the types of activities children with uncontrolled or severe hypertension should participate in. Currently, it is recommended that patients with severe hypertension (>99th percentile) avoid competitive and high static sports, including, but not limited to, activities such as gymnastics, water skiing, weight lifting, and wrestling. 11,13

What is the definition of prehypertension?

Prehypertension is defined as average SBP or diastolic BP (DBP) between the 90th and 95th percentiles, or BP ≥120/80 mmHg in an adolescent. Guidelines state that if a patient’s BP is >90th percentile, BP should be remeasured during the same visit and an average of the two readings should be used. 11 Hypertension is defined as SBP and/or DBP ≥95th percentile for gender, age, and height on at least three occasions. Once it is recognized that a patient has hypertension, the disease should be staged. Stage 1 hypertension is defined as between the 95th and 99th percentiles plus 5 mmHg; stage 2 hypertension is defined as >99th percentile plus 5 mmHg ( TABLE 3 ). 11

Why is hypertension increasing in children?

The prevalence of hypertension among children has increased in response to the increased prevalence of childhood obesity. Despite this increase, secondary causes remain the most common reason for hypertension in this patient population.

What causes secondary hypertension in children?

Secondary hypertension, which is more common in pediatric patients, is most often caused by renal disease, coarctation of the aorta, or endocrine disease. 9 Primary hypertension usually is associated with a positive family history of hypertension or cardiovascular disease. It has been observed that patients with primary hypertension frequently are ...

Why are beta blockers less used?

Beta-blockers are used less often owing to complications with disease states such as diabetes and asthma and the development of lipid abnormalities after long-term use . 11,12 Consideration should be given to BBs in the presence of severe hypertension or when combination therapy is needed.

What are ACE inhibitors and CCBs?

ACE inhibitors and CCBs are commonly prescribed, owing to a better adverse-effect profile. Additional agents such as ARBs, BBs, and diuretics may be included as part of a multidrug regimen. Pharmacists can play a key role in the treatment of children with hypertension.

How does thiazide affect blood pressure?

The mechanism of these effects is uncertain, as it may involve effects on the whole body, renal autoregulation, or direct vasodilator actions (Hughes 2004). Thiazides act on the kidney to inhibit reab sorption of sodium (Na+) and chloride (Cl‐) ions from the distal convoluted tubules in the kidneys, by blocking the thiazide‐sensitive sodium‐chloride symporter (Duarte 2010). They also increase calcium reabsorption at the distal tubule, and increase the reabsorption of calcium ions (Ca2+), by a mechanism involving the reabsorption of sodium and calcium in the proximal tubule in response to sodium depletion.

What are the different types of antihypertensive drugs?

To quantify the mortality and morbidity effects from different first‐line antihypertensive drug classes: thiazides (low‐dose and high‐dose), beta‐blockers, calcium channel blockers, ACE inhibitors, angiotensin II receptor blockers (ARB), and alpha‐blockers, compared to placebo or no treatment.

How to manage high blood pressure?

High blood pressure should initially be managed with changing life style — eating a healthy diet with less salt, exercising regularly, quitting smoking, and maintaining a healthy weight. When these life‐style changes are not enough, treatment with antihypertensive drugs is recommended. Several different classes of medications are available to reduce blood pressure. The six main drug classes, included in this review, are thiazide diuretics, beta‐blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers, calcium channel blockers, and alpha blockers.

What is secondary objective?

Secondary objectives: when different antihypertensive drug classes are used as the first‐line drug, to quantify the blood pressure lowering effect and the rate of withdrawal due to adverse drug effects, compared to placebo or no treatment.

What is elevated blood pressure?

Elevated blood pressure (hypertension) is a chronic condition in which the blood pressure in the arteries is persistently elevated. It has been divided into three categories, based on resting blood pressures, measured in a standard way: mild hypertension (140 to 159/90‐99 mmHg), moderate hypertension (160 to 179/100 to 109 mmHg), and severe hypertension (180/110 mmHg or higher). Most people with high blood pressure have no signs or symptoms, even if blood pressure readings are very high. For most adults with primary or essential hypertension, there is no identifiable cause for the high blood pressure. Some people have high blood pressure, called secondary hypertension, caused by underlying conditions such as adrenal gland tumours, kidney problems, thyroid problems, excessive alcohol intake, or use of certain medications, such as birth control pills. Isolated systolic hypertension is a condition in which the diastolic pressure is normal (less than 90 mmHg), but systolic pressure is high (160 mmHg or greater). This is a common type of high blood pressure among older people.

How long is a RCT?

Randomized trials (RCT) of at least one year duration , comparing one of six major drug classes with a placebo or no treatment, in adult patients with blood pressure over 140/90 mmHg at baseline. The majority (over 70%) of the patients in the treatment group were taking the drug class of interest after one year. We included trials with both hypertensive and normotensive patients in this review if the majority (over 70%) of patients had elevated blood pressure, or the trial separately reported outcome data on patients with elevated blood pressure.

What databases are used for randomized controlled trials?

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to November 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials ( CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform , and ClinicalTrials.gov. We contacted authors of relevant papers regarding further published and unpublished work.

What is IIH in pediatrics?

IIH can be attributed to certain medications or medical illnesses. In that case, it is referred to as secondary intracranial hypertension (SIH). In a large cohort study of 203 pediatric patients with IIH, (30%) of the cases were classified as SIH [9]. Various systemic diseases have been associated with pediatric IIH, including endocrine conditions such as hypoparathyroidism, thyroid replacement therapy, and treatment with recombinant human growth hormone [22]. Other medical conditions include chiari malformation, prior meningitis, hydrocephalus, craniosynostosis, traumatic brain injury, superior sagittal sinus thrombosis, leukemia, Lyme disease, congestive heart failure, renal failure, and kidney transplantation [9]. Several medications are associated with SIH. The medical conditions and medications associated with IIH are summarized in Table 1[8, 9, 22–24].

What is idiopathic intracranial hypertension?

Idiopathic intracranial hypertension (IIH) is a rare neurological disorder in children. It is characterized by raised intracranial pressure (ICP) in the absence of brain parenchymal lesion, vascular malformations, hydrocephalus, or central nervous system (CNS) infection. The diagnosis is usually confirmed by high opening pressure of cerebrospinal fluid (CSF) with exclusion of secondary causes of intracranial hypertension. If not treated properly, it may lead to severe visual dysfunction. Here we review the etiology, clinical presentation, diagnostic criteria and management of IIH in children through illustration of the clinical and radiological presentation of a 13-year-old overweight girl who presented with severe headache, diplopia and bilateral papilledema. Otherwise, she had unremarkable neurological and systemic examinations. Lumbar puncture showed a high CSF opening pressure (360–540 mmH2O). Her investigations showed normal complete blood count (CBC), normal renal, liver, and thyroid function tests. Cerebrospinal fluid (CSF) and blood chemistry were unremarkable. Magnetic resonant image (MRI) of the brain demonstrated empty sella turcica, tortuous optic nerves, and flattening of the posterior sclera. Magnetic resonant venography (MRV) showed focal narrowing of the distal transverse sinuses and absence of venous sinus thrombosis. She required treatment with acetazolamide and prednisolone. With medical treatment, weight reduction, and exercise, our patient had a remarkable improvement in her symptoms with resolution of papilledema in two months. This review highlights the importance of early recognition and management of IIH to prevent permanent visual loss.

How to treat IIH in children?

The best approach to manage IIH in children is through a multidisciplinary team that includes a pediatrician, pediatric neurologist, ophthalmologist, orthoptist, nutritionist, and neurosurgeon. In asymptomatic patients with normal vision and mild papilledema, no treatment is needed and only serial ophthalmological evaluation is required [40]. Treatment is indicated when there is an evidence of visual loss, moderate to severe papilledema, or persistent headaches [40]. Different treatment modalities can be used. Generally, the selection of medical, surgical, or combined treatments depends on the severity of the visual symptoms and signs. In most cases, medical treatment is used first; surgical intervention is indicated if medical treatment fails or if the visual function is deteriorating. Life style modification such as weight reduction, especially in overweight patients was found to be beneficial. [41]. One case series showed that reversal of papilledema was achieved after reduction of 6% in body weight [42]. Another study showed that weight reduction can improve the symptoms and reduce ICP in overweight women with IIH [43].

What are the symptoms of IIH in children?

The most common presenting symptom in children is headache which has been documented in up to 91% of the cases [7–9]. It is usually throbbing, intermittent, diffuse in nature, and worse upon awakening. Retro-orbital, neck, and back pains may also occur [25]. Nausea and vomiting are very common symptoms. Other complaints are blurred or double vision, transient visual obscurations, tinnitus, and neck stiffness [26, 27]. Atypical presentations of IIH without headache have been reported, and patients might present with some degree of visual loss [28]. In young patients, IIH can present only with irritability [22]. Unlike patients with intracranial mass lesions, the level of consciousness is usually intact in children with IIH [6]. Symptoms such as seizures and focal neurologic deficits are likely to point towards intracranial mass lesions [8].

How long does a carbonic anhydrase inhibitor last?

Treatment should aim at lowering ICP, relieve symptoms, and preserve visual function. The length of treatment varies between cases and may last up to 14 months [32]. Carbonic anhydrase inhibitors have been used to reduce ICP and to treat papilledema in IIH [44]. Acetazolamide is the most commonly used drug as a first-line treatment [8]. Commonly used medications are summarized in (Table 3).

What is the examination for suspected IIH?

Children with suspected IIH should have careful ophthalmological and full neurological examination. The examination of children with IIH is usually normal except for reduced visual acuity, visual fields defects, unilateral or bilateral sixth nerve palsy, and papilledema [8]. Also, children with suspected IIH should undergo detailed general examination, including blood pressure measurement and BMI assessment. The examination should be directed to identify the secondary causes, such as otitis media, mastoiditis, sinusitis, or other causes listed in Table 1.

What is the normal CSF opening pressure for a child?

Interpreting the results of CSF opening pressure in children is difficult. Most of the studies suggest that 280 mmH2O is considered as the upper limit of CSF opening pressure in children between 1 and 18 years [37, 38]. In normal neonates, value above 76 mmH2O is considered abnormal [39]. CSF Samples should always be sent for routine biochemistry and microbiology analysis. The composition of CSF should be unremarkable with respect to cell count, protein, and glucose.

What is hypertension?

Hypertension is the sustained elevation in blood pressure, meaning it is diagnosed when one's blood pressure is higher than normal on repeated measurements over time. In childhood and adolescence, blood pressure normally increases with age and height. So, a normal blood pressure value for your child will change each year, just as the normal values for their height and weight will change.

Why do children with hypertension have to see a nephrologist?

Because of this, all children with hypertension should undergo an evaluation to search for an underlying cause. Kidney disease is a main cause of high blood pressure and hypertension in children, which is why nephrologists are the providers who evaluate and treat this condition in children.

How do you treat hypertension in children?

Treatment of hypertension in children should focus on the underlying cause and on the institution of a heart healthy lifestyle. Children and their families should adopt a lifestyle that includes the following:

How do I know if my child is hypertensive?

Your child should have his or her blood pressure measured at least once yearly, ideally at each health care encounter. If your child’s blood pressure is at or above the 90th percentile, testing should be repeated three times, ideally by manual auscultation (using a stethoscope and a blood pressure cuff inflated by hand). If the average of these three measurements is at or above the 95th percentile, your child should return to his or her health care provider for repeat measurements to confirm that their blood pressure is high. If the average blood pressure is less than the 95th percentile but greater than or equal to the 90th percentile (or greater than or equal to 120/80), then your child is prehypertensive and is at risk for developing hypertension. He or she should return in six months for repeat blood pressure measurements to screen for the development of hypertension.

Does being overweight impact my child’s blood pressure?

Yes. Children who are overweight or obese are more likely to be hypertensive. In addition, being overweight is sometimes the sole cause of a child or adolescent being hypertensive. Individuals who are overweight are also more likely to have other risk factors for heart disease like high cholesterol, diabetes and left ventricular hypertrophy (abnormal thickening of the heart). It is for this reason that ALL children with hypertension should develop heart healthy behaviors.

What is the average blood pressure of a child?

A child or adolescent is diagnosed with hypertension when their average blood pressure is at or above the 95th percentile for their age, sex and height when measured multiple times over three visits or more.

What happens if your blood pressure is less than 95?

If the average blood pressure is less than the 95th percentile but greater than or equal to the 90th percentile (or greater than or equal to 120/80), then your child is prehypertensive and is at risk for developing hypertension. He or she should return in six months for repeat blood pressure measurements to screen for the development ...

What is idiopathic intracranial hypertension?

Idiopathic intracranial hypertension (IIH) is defined as elevated intracranial pressure without clinical, radiologic, or laboratory evidence of a secondary cause. The most frequently cited incidence data for IIH in the general population of the United States is from a study by Durcan, et al, 1 who reported the annual incidence as 1 in 100,000 individuals. When restricting the inclusion criteria to women aged 20–44 years who are 20% or more above their ideal bodyweight, the annual incidence in the US increases to 15–19 cases per 100,000. 1 Although it has historically been described as a condition affecting obese females of childbearing age, IIH can occur in all age groups, both genders, and both obese and non-obese individuals, and is becoming more recognized in the pediatric population.

How rare is IIH in children?

Additionally, the associations with obesity and female gender do not hold true in this population. 9,10 Studies also suggest that IIH is infrequent in children less than 10 years of age 9 and extremely rare in infants less than 3 years old.

What are the symptoms of IIH?

The clinical presentation of pediatric IIH includes many of the same symptoms and objective findings as IIH in the adult patient. Headache is by far the most common symptom of IIH and occurs in over 90% of cases. 14 Other symptoms include neck, shoulder, or arm pain; nausea; vomiting; pulsatile tinnitus; diplopia; blurred vision; and transient obscurations of vision. 15,16 Infrequently, patients may present with no suggestive symptoms at all and are only diagnosed after papilledema is identified on routine eye examination and prompts further workup.

What is the most important clinical finding in IIH?

The ophthalmic exam should include assessing visual acuity, color vision, visual fields, extraocular movements, and a careful anatomic evaluation. Papilledema is the most important clinical finding, as it is associated with vision loss, the most feared consequence of IIH.

What is the opening pressure for lumbar puncture?

Elevated lumbar puncture opening pressure (≥250 mm CSF in adults and ≥280 mm CSF in children [250 mm CSF if the child is not sedated and not obese]) in a properly performed lumbar puncture

Is pseudotumor cerebri syndrome definite?

A diagnosis of pseudotumor cerebri syndrome is definite if the patient fulfills criteria A–E.

Can pseudotumor cerebri be diagnosed?

In the absence of papilledema, a diagnosis of pseudotumor cerebri syndrome can be made if B–E from above are satisfied, and in addition the patient has a unilateral or bilateral abducens nerve palsy.

How many adverse events could have been prevented if the physicians had prescribed thiazide diuretics instead of?

Finally, the authors estimate that 3,100 adverse cardiovascular events could have been prevented if the physicians had prescribed thiazide diuretics instead of ACE inhibitors.

What is the method used to correct biases in observational studies?

Hripcsak, and colleagues used a method developed to correct and prevent the biases of observational studies. The method is called Large-Scale Evidence Generation and Evaluation across a Network of Databases (LEGEND).

How many variables are included in the LEGEND algorithm?

After applying the complex LEGEND algorithm and accounting for approximately 60,000 variables, the researchers identified several cases of heart attacks, heart failure hospitalizations, strokes, and a high number of side effects of first-line hypertension medications.

How many side effects does ACE inhibitor have?

Furthermore, ACE inhibitors caused higher rates of 19 side effects, compared with other first-line treatments. Also, non-dihydropyridine calcium channel blockers were the least effective first-line treatment that the study authors identified. Finally, the authors estimate that 3,100 adverse cardiovascular events could have been prevented if ...

What does Randomized Clinical Trials demonstrate?

He says, “Randomized clinical trials demonstrate a drug’s effectiveness and safety in a highly defined patient population , but they’re not good at making comparisons among multiple drug classes in a diverse group of patients that you would encounter in the real world.”

How many classes of drugs are there for hypertension?

Current guidelines advise about five classes of drugs that physicians can choose from as the first line of treatment for hypertension, but what are the criteria underpinning this range?

Which organization has based their guidelines on randomized clinical trials?

First, the existing literature that organizations such as the American College of Cardiology and the American Heart Association (AHA) have based their guidelines on are randomized clinical trials with an insufficient number of participants, very few of whom are just beginning their treatment, explain Dr. Suchard and colleagues.

How long does it take to taper prednisone?

If acetazolamide is ineffective, prednisone can be given at a dosage of 2 mg/kg/day for 2 weeks, followed by a 2-week taper. Topiramate is now being widely used in the treatment of migraine and IIH in adults.

Why is neurosurgical intervention important?

Neurosurgical interventions are sometimes needed for diagnostic and treatment purposes. Prompt and accurate communication among specialists is necessary to ensure timely treatment and optimal outcomes. [ 27] Medical therapy appeared to be successful in treating pediatric pseudotumor cerebri in most patients.

What is IIH diagnosis?

For IIH to be diagnosed, brain scans (such as MRI) must be performed to ensure there is no underlying cause for the increased pressure around the brain. Left optic disc with moderate chronic papilledema in patient with idiopathic intracranial hypertension (pseudotumor cerebri).

What is the treatment for idiopathic intracranial hypertension?

When medical treatment is required, most children respond to medications such as steroids, acetazolamide, furosemide, or topiramate.

Does intracranial hypertension improve with medical treatment?

Although most cases of pediatric idiopathic intracranial hypertension improve with medical treatment, those who have had visual progression despite medical treatment have undergone optic nerve sheath fenestration and lumboperitoneal shunting.

Is intracranial hypertension increasing?

Specifically, the incidence of idiopathic intracranial hypertension seems to be increasing among adolescent children, and among older children its clinical picture is similar to that of adult idiopathic intracranial hypertension (female and obese).

Etiology

• The doctor will perform a physical exam and ask questions about your child's medical history, family history of high blood pressure, and nutrition and activity level. Your child's blood pressure will be measured. The correct blood pressure cuff size is important for measuring accurately. It i…

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