Differences between office and ambulatory blood pressures in children and adolescents attending a hospital hypertension clinic.

BACKGROUND AND OBJECTIVES: Information on ambulatory blood pressure monitoring (ABPM) in children is scarce. While in adults office BP (OBP) is higher than ABP and the difference increases as OBP increases, information in children suggests that at this young age ABP is no lower and often higher than OBP. This study was aimed at describing OBP-ABP differences in a cohort of children of different ages and BPs, and investigating whether OBP-ABP differences are dependent on age or OBP level. METHODS: We retrospectively compared OBP and 24-h, daytime and night-time ABP in 433 children and adolescents aged 4-18 years, referred to our hospital clinic. RESULTS: OBP was found to be significantly lower than 24-h and daytime ABP in the low age tertile (4-10 years) but not in the medium and high tertiles. OBP was also lower than ABP in normotensive patients (n = 182), but higher than ABP in untreated hypertensive patients (n = 92) despite similar ages. Continuous analyses showed a weak correlation of OBP-ABP differences with age, and a much stronger correlation with OBP so that 24-h ABP was higher than OBP at OBP values less than 117/73 mmHg and lower than OBP at higher OBP values. Logistic regression analysis indicates that also in children OBP accounts for most of the OBP-ABP difference. CONCLUSION: There is a common relation both in children and adults between OBP and ABP. It is only because high OBP is common in the elderly, and the lowest OBP is usually found in young children that large positive OBP-ABP differences have been associated with old age, and negative differences with childhood. OBP-ABP differences, often defined as white-coat effect, can have different directions and are likely to be largely due to regression to the mean.

Bioimpedance analysis and cardiovascular status in pediatric patients on chronic hemodialysis.

Bioimpedance analysis (BIA) is reported to be useful in assessing dry weight (DW) in patients on hemodialysis (HD), but its exact role has never been clearly defined. We reviewed our experience of using the BIA measure of reactance (Xc) in pediatric patients on chronic HD. Our approach is currently based on identifying a range of patient-specific Xc values at which a child can be considered at DW according to a multidisciplinary assessment. Values lower than the patient-specific limit suggests the need for a reduction in DW, whereas values higher than the limit suggest that DW should be increased. The accuracy of our approach was retrospectively assessed by analyzing the left ventricular mass index (LVMI) and the incidence of pulmonary edema (PE) in two groups: The first consisted of 13 patients (median age 15.6 years) on dialysis in 2007, before the introduction of the BIA-based approach; the second included 18 patients (median 14.8 years) on dialysis in 2011. In 2007, three children experienced four episodes of PE, whereas no PE occurred in 2011. The median LVMI was 56.8 g/m(2.7) in 2007, and 44.5 g/m(2.7) in 2011 (P < 0.05). The percentage of patients with LV hypertrophy (LVMI>38.5 g/m(2.7)) was 92.3% in 2007 and 61.1% in 2011 (P < 0.05). There were no between-group differences in terms of blood pressure, antihypertensive medications, percentage of symptomatic sessions, or biochemistry. In conclusion, a simple approach based on BIA may be useful in assessing DW in pediatric patients on HD, and thus improve their cardiovascular status.

Flecainide as first-line treatment for supraventricular tachycardia in newborns.

BACKGROUND: Flecainide for the treatment of supraventricular tachycardia (SVT) in newborns is still controversial because of its potentially severe proarrhythmic effects. METHODS AND RESULTS: Between January 2004 and December 2006, we used flecainide to treat 20 consecutive newborns (15 males) with paroxysmal SVT without any structural heart disease. Their age at hospitalization was 11.5 +/- 11.1 days. The intravenous administration of flecainide (1 mg/kg) effectively restored sinus rhythm in all the patients. Once stable sinus rhythm had been restored, the drug was administered orally at a dose of 2 mg/kg/day twice daily, which was uptitrated as the patients gained weight. The patients were followed up for up to 24 months with clinical evaluations, baseline ECG and 24-h Holter monitoring every 3 months. There were neither deaths nor any episodes of heart failure or sustained ventricular tachycardia during follow-up. SVT were completely controlled in 17 patients (85%), with an oral dose of 3.35 +/- 1.35 mg/kg/day of flecainide; in the remaining three patients with refractory arrhythmias, propranolol was added for optimal treatment. No significant increase in the duration of QRS (70 +/- 1.09 vs. 63.8 +/- 1.87 ms, P = NS) or any significant QTc prolongation (413 +/- 7.4 vs. 412.6 +/- 8.01 ms, P = NS) was observed. One patient developed an incomplete right bundle branch block promptly reverted by reducing the dose. CONCLUSION: This preliminary experience indicates that flecainide is well tolerated and effective as first-line treatment for paroxysmal SVT in newborns without structural heart disease.