1) Neonatal hypertension is defined as a systolic blood pressure at or above the 95th percentile, with multiple measurements needed on separate occasions. The most common causes in newborns are issues related to umbilical catheters and renal problems. 2) Proper measurement of blood pressure in infants requires an appropriately sized cuff. Treatment of severe hypertension in neonates involves intravenous antihypertensive drugs to gradually lower blood pressure below the 95th percentile. 3) Common causes of hypertension change with age, from problems like renal artery stenosis in newborns to essential hypertension in adolescence. Many cases resolve by one year of age, but conditions like coarctation of the aorta may require

1. NEONATE AND INFANTILE
HYPERTENSION
Dr.ELHAM EMAMI
PEDIATRIC NEPHROLOGIST

2. NORMAL BLOOD PRESSURE IN NEONATES
Controversia_need clinical trial
 factors significant influence on BP:
gestational age at birth
appropriateness of size for gestational age

4. DEFINITION and incidence :
Neonatal hypertension : systolic blood pressure of at least
the 95th percentile incidence :1.3 % - 2 % in nicu
multiple BP measurements are needed( 3 separate
occasions)
 Dress Giri and Roth have disclosed no financial relationships relevant to this article.
This commentary does not contain a discussion of an unapproved/investigative use
of a commercial product/device.

5. Severe htn (defined by systolic BP >99th percentile):
end organ damage: vascular injury, left ventricular hypertrophy, encephalopathy, and
hypertensive retinopathy
complications from, linked to hypertension beyond infancy
diagnose and aggressively manage severe or persistent hypertension

6. ROUTINE EVALUATION OF BP IS NOT RECOMMENDED IN ALL
NEONATES (AAP)
 routinely screening in the absence of symptoms does not usually apply
 do not recommend routine screening, which should begin annually only at 3 years of
age.
recent AAP guidelines (Pediatrics. 2017;140[3]:e20171904
Hypertension was considerably more common in infants with:
bronchopulmonary dysplasia
patent ductus arteriosus
and intraventricular hemorrhage
with indwelling umbilical arterial catheters
Antenatal steroids

9. ETIOLOGIES:

10. The most common causes of hypertension by age:
Newborn:### Renal artery thrombosis or embolus (umbilical artery catheter) Renal vein
thrombosis Congenital renal malformations Coarctation of aorta Renal artery stenosis
Bronchopulmonary dysplasia
Infancy to 6 years: Renal parenchymal disease، Renal artery stenosis، Coarctation of the aorta
Medications، Endocrine causes
6–10 years : Renal parenchymal disease، Renal artery stenosis، Primary (essential) ،Endocrine causes
Adolescence: Primary (essential) hypertension، White coat hypertension، Renal parenchymal
disease Substance abuse (cocaine, amphetamines, methamphetamines, phencyclidine,
methylphenidate, caffeine) Teen pregnancy Endocrine cause

13. Drug in etiology:

 dexamethasone and other corticosteroids used to treat chronic pulmonary
diseases
 catecholamines (dopamine, adrenaline)
 xanthines (caffeine and theophylline)
 curare-mimetics (pancuronium)
 mydriatic eye drops (phenylephrine)

14. VOGT M, KUHN A, BAUMGARTNER D, BAUMGARTNER C, BUSCH R, KOSTOLNY M, HESS J. IMPAIRED ELASTIC PROPERTIES OF
THE ASCENDING AORTA IN NEWBORNS BEFORE AND EARLY AFTER SUCCESSFUL COARCTATION REPAIR—PROOF OF A
SYSTEMIC VASCULAR DISEASE OF THE PRESTENOTIC ARTERIES? CIRCULATION 2005; 111: 3269–3273.
POLSON JW, MCCALLION N, WAKI H, THORNE G, TOOLEY MA, PATON JFR, WOLF AR. EVIDENCE FOR CARDIOVASCULAR
AUTONOMIC DYSFUNCTION IN NEONATES WITH COARCTATION OF THE AORTA. CIRCULATION 2006; 113: 2844–2850
Hypertension and coarctation of the aorta :
increased aortic stiffnes
alteration in autonomic cardiac balance
maladaptive response to mechanisms responsible for longer term blood pressure
control
Endothelial dysfunction

15. MAXIMUM AORTIC THICKNESS WAS SIGNIFICANTLY HIGHER STIFFNESS INDEX
CONCLUSION: THE AORTIC WALL THICKNESS AND VASOMOTOR FUNCTION ARE SIGNIFICANTLY
ALTERED IN PRETERM INFANTS WITH SEVERE BPD..
Systemic arterial stiffness in infants with bronchopulmonary
dysplasia: potential cause of systemic hypertension:
Damien Kenny1, Jaimie W Polson2, Robin P Martin1, Julian FR Paton3 and Andrew R Wolf 4 Patients with
coarctation of the aorta develop early onset hypertension in spite of early effective repair. (2011) 34, 543–
547; doi:10.1038/hr.2011.22; published online 17 March 2011

17. 1. oscillometric methods
2. intra-arterial transducer

19. The majority of measuring errors :
inappropriate cuffs
 in children: width of the cuff 40 %
of the circumference of the arm.
 in newborn babies: width 50 %
of the arm circumference

20. Oscillometric devices : proper cuff size
a cuff too small gives falsely high BP reading
 measurement in the right upper arm
 infant in the supine position
 minimizing infant activity
 ****at least 1.5 hours after feeding
medical intervention

21. DIAGNOSIS:

28. Plasma renin activity is very high in newborns
little data normal values for infants
particularly for preterm
typically quite high in infancy
particularly in premature
renal artery stenosis and thromboembolism are high renin states, peripheral plasma renin activity may not
be elevated in such infants
methylxanthines, caffeine, and aminophylline
these limitations

29.  angiography gold standard renal artery stenosis
fibrodysplasia

30. TREATMENTs

36.  Neonates with severe HTN (>99th percentile) managed
with continuous short-acting intravenous agents which
can be readily titrated to gradually reduce BP below
the 95th percentile.
 Other agents : NICARDIPIN، esmolol ، labetalol, and
sodium nitroprusside
Wiest DB, Garner SS, Uber WE, Sade RM.

38. CALCIUM CHANNEL BLOCKER:
• THE SHORT-ACTING ISRADIPINE (DOSAGE OF 0.05–
0.1 MG/KG/ DOSE EVERY 6–8 H) PARTICULARLY IN
BRONCHOPULMONARY DYSPLASIA OR STEROID
INDUCED HTN
• AMLODIPINE LONGER DURATION OF ACTION
DELAYED ONSET OF ACTION

39. ACE-inhibitors :
not to use ACE-inhibitors in preterm neonate :
1. negative effects of the development of the kidney.
2. the reaction unpredictable
3. risk of profound hypotension with possible renal failure and severe
neurological consequences
captopril dosage in neonates are much lower than those used in full-term
babies

40. ACE-inhibitors :

 acute oliguric kidney injury
renal artery stenosis

42. BETA-BLOCKERS CAUTION
avoided:
***in sick newborns adversely affect and
stressed cardiovascular system
in all preterm neonates with cardiorespiratory
instability
apnea bradycardia

43. DIURETICS
(HYDROCHLOROTHIAZIDE, FUROSEMIDE, SPIRONOLACTONE)
first choice bronchodysplasia
positive effects on pulmonary mechanics
Reduce extracellular and plasma
Guron G, Friberg P. An intact renin-angiotensin system is a prerequisite for normal renal development. J Hypertens.
2000;18(2):123–37. Epub 29 Feb 2000.

44.  Many causes of HTN that begin in the newborn period resolve spontaneously by 1 year
of age. Thus, “step-down” care should be anticipated. Also, most infants tend to
outgrow their medication dosages due to rapid body growth during infancy.
conditions can be treated surgically:
1. coarctation of the aorta
2. some neoplasias
3. urologic diseases

48. Thanks for your attention