Ambulatory blood pressure monitoring: a versatile tool for evaluating and managing hypertension in children.

In recent years, pediatric practitioners have increasingly used ambulatory blood pressure (ABP) monitoring for evaluating blood pressure (BP) abnormalities in children. ABP monitoring in adults is superior to casual BP measurements for predicting cardiovascular morbidity and mortality, and whereas the association with target-organ damage in children is not as definitive, early evidence does seem to parallel the adult data. In addition to confirming hypertension at diagnosis, ABP monitoring may be useful for identifying isolated nocturnal hypertension, characterizing BP patterns, and assessing response to therapeutic interventions. This article reviews current evidence supporting the use of ABP monitoring in children and discusses limitations in our understanding of this technology, specifically focusing on indications for its use and interpretation of the large quantity of data obtained by ABP monitoring.

Left ventricular hypertrophy in hypertensive adolescents: analysis of risk by 2004 National High Blood Pressure Education Program Working Group staging criteria.

The National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents recently recommended staging hypertension (HTN) in children and adolescents based on blood pressure severity. The use of blood pressure staging and its corresponding therapeutic approach was examined in this pooled analysis assessing the risk for end-organ damage, specifically left ventricular hypertrophy among hypertensive adolescents stratified by working group criteria. Newly diagnosed hypertensive adolescents and normotensive control subjects similar in age, race/ethnicity, gender, and body mass index completed casual and 24-hour ambulatory blood pressure measurements, M-mode echocardiography, and fasting serum laboratories. Hypertensive subjects had higher insulin and cholesterol but similar glucose levels as compared with control subjects. Among subjects with stage 1 HTN by casual blood pressure, 34% had white-coat HTN as opposed to 15% of stage 2 hypertensive subjects. Of the subjects with normal casual measurements, 20% had HTN by ambulatory monitoring. Subjects with stage 2 HTN by casual measurement alone (odds ratio: 4.13; 95% CI: 1.04 to 16.48) and after 24-hour ambulatory confirmation (odds ratio: 7.23; 95% CI: 1.28 to 40.68) had increased odds for left ventricular hypertrophy. In addition, the risk for left ventricular hypertrophy was similar for subjects with masked and confirmed stage 1 HTN, whereas subjects with white-coat HTN had a risk comparable to normotensive subjects. Thus, recommendations that adolescents with stage 2 HTN by casual measurements alone receive medication initially along with therapeutic lifestyle counseling are reasonable, though ambulatory blood pressure monitoring remains a valuable tool for evaluating children with stage 2 HTN, because >10% have white-coat HTN.

Ambulatory blood pressure monitoring: what a pediatrician should know.

PURPOSE OF REVIEW: Ambulatory blood pressure monitoring is a useful tool for the evaluation and management of hypertension in children and adolescents. This review provides a basic overview of ambulatory blood pressure monitoring and summarizes the most recent available knowledge regarding its use in the pediatric population. RECENT FINDINGS: Evaluation and validation of ambulatory blood pressure monitoring equipment in children remains limited, although advances in the interpretation of results for this age group have been reported specifically in the area of circadian (24 h) and ultradian (<24 h) variability. Blood pressure is a dynamic phenomenon that varies not only with time but also with changing patient and environmental circumstances. Growing evidence regarding conditions identified when this variability is considered, specifically white coat and masked hypertension, suggests that office blood pressure measurement may not be a sufficient screening test for hypertension-related target-organ damage. SUMMARY: Information regarding ambulatory blood pressure monitoring use in children is increasing, although due to its limitations and expense, it remains a tool primarily utilized by the pediatric sub-specialist.

Prevalence of hypertension and pre-hypertension among adolescents.

OBJECTIVE: To determine the prevalence of hypertension and pre-hypertension on the basis of the 2004 National High Blood Pressure Education Program Working Group guidelines in an adolescent school-screening population. STUDY DESIGN: Cross-sectional assessment of blood pressure (BP) in 6790 adolescents (11-17 years) in Houston schools was conducted from 2003 to 2005. Initial measurements included height, weight, and 4 oscillometric BP readings. Repeat measurements were obtained on 2 subsequent occasions in students with persistently elevated BP. Final prevalence was adjusted for loss to follow-up and logistic regression used to assess risk factors. RESULTS: BP distribution at initial screen was 81.1% normal, 9.5% pre-hypertension, and 9.4% hypertension (8.4% Stage 1; 1% Stage 2). Prevalence after 3 screenings was 81.1% normal, 15.7% pre-hypertension, and 3.2% hypertension (2.6% Stage 1; 0.6% Stage 2). Hypertension and pre-hypertension increased with increasing body mass index. Sex, race, and classification as either at-risk for overweight or overweight were independently associated with pre-hypertension. Only classification as overweight was associated with hypertension. CONCLUSIONS: Application of new classification guidelines for adolescents with elevated BP reveals approximately 20% are at risk for hypertension. Further research determining the significance of each BP category and refining definitions to account for BP variability is warranted.

Adequacy of peritoneal dialysis in children following cardiopulmonary bypass surgery.

Acute renal failure requiring renal replacement therapy can complicate cardiopulmonary bypass in children. Peritoneal dialysis has been shown to stabilize electrolytes and improve fluid status in these patients. To assess dialysis adequacy in this setting, we prospectively measured Kt/V and creatinine clearance in five patients (6-839 days of age) requiring renal replacement therapy at our institution. Median dialysis creatinine clearance was 74.25 L/week/1.73m(2) (range 28.28-96.63 L/week/1.73m(2)). Residual renal function provided additional solute clearance as total creatinine clearance was 215.97 L/week/1.73m(2) (range 108.04-323.25 L/week/1.73m(2)). Dialysis Kt/V of >2.1 (median 4.84 [range 2.12-5.59]) was achieved in all patients. No dialysis-associated complications were observed. We conclude that peritoneal dialysis is a safe, simple method of providing adequate clearance in children who develop acute renal failure following exposure to cardiopulmonary bypass.