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Neonatal Hypertension Clinical Presentation

  • Author: Joseph Flynn, MD, MS; Chief Editor: Ted Rosenkrantz, MD  more...
 
Updated: Jan 03, 2016
 

History

In most newborns, hypertension is discovered on routine monitoring of vital signs. Other presentations of neonatal hypertension to be aware of in acutely ill infants include congestive heart failure (CHF) and cardiogenic shock, which are potentially life threatening. Fortunately, these consequences of hypertension gradually resolve with appropriate blood pressure (BP) reduction.

In the less acutely ill infant, feeding difficulties, unexplained tachypnea, apnea, lethargy, irritability, or seizures may constitute symptoms of unsuspected hypertension. In older infants who have been discharged from the nursery, unexplained irritability or failure to thrive may be the only manifestations of hypertension.

Focus the history on discovering any pertinent prenatal or postnatal exposures, as well as to the particulars of the infant's nursery course and any concurrent conditions. Review the procedures that the infant has undergone, especially umbilical catheter placement, and analyze the baby's current medication list. If the infant has been discharged from the nursery, the history should also cover symptoms related to possible underlying causes of hypertension (similar to the evaluation of hypertension in older children).

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Physical Examination

The physical examination should begin with 4-extremity blood pressure (BP) measurements in order to rule out aortic coarctation. Assess the general appearance of the infant and pay particular attention to the presence of dysmorphic features that may indicate an underlying genetic syndrome. Perform careful cardiac and abdominal examinations to rule out congestive heart failure (CHF) or renal anomalies. Examine the genitalia to rule out congenital adrenal hyperplasia (CAH). Neurologic examination may also be helpful, particularly in infants with intraventricular hemorrhage.

Normal blood pressure levels

BP in newborn infants is influenced by various factors, including birth weight, gestational age, and postconceptual age. Excellent data illustrating the importance of these factors were generated by Zubrow et al, who prospectively obtained serial BP measurements from nearly 700 infants admitted to several NICUs in a large metropolitan area over 3 months.[9] The investigators used these data to define the mean plus upper and lower 95% confidence limits for BP; their data clearly demonstrated increases in BP with increasing gestational age, birth weight, and postconceptual age.

A more recent study of hemodynamically stable premature and term infants admitted to the NICU showed that BPs on day 1 of life correlated with gestational age and birth weight.[10] However, another study of more than 400 term infants admitted to a postnatal ward in Australia showed no difference in BP on day 1 of life based on birth weight, length, or gestational age.[11] Thus, there appears to be physiologic differences in premature infants with respect to BP level that need to be taken into consideration when considering whether a particular BP value is normal or elevated.

Data from these studies have recently been summarized by Dionne et al,[12, 13] who generated a table of BP values that can be used in assessing if a neonate’s BP is normal or elevated (see Table 1 below). For older infants, the percentile curves generated by the 1987 Second Task Force on Blood Pressure Control in Childhood remain the most useful reference of normal BP values (see the image below).[14] These curves allow BP to be characterized as normal or elevated not only by age and sex but also by size, albeit to a somewhat limited extent.

Normal blood pressure percentile curves for older Normal blood pressure percentile curves for older infants. From the Second (1987) Task Force on Blood Pressure Control in Childhood; National Heart, Lung, and Blood Institute.

Defining hypertensive-level BP

Hypertension in adults is defined based upon occurrence of hard cardiovascular endpoints such as myocardial infarction, stroke, and death. Since these events occur rarely in the pediatric age group, the definition of hypertension in infants, children, and adolescents is a statistical one based on databases of BP readings obtained in healthy subjects. Thus, BP in the young is considered normal if less than the 90th percentile for age, sex, and height, and is considered hypertensive if it is greater than or equal to the 95th percentile.

For infants, the same definitions should probably be applied, although the available data on normal BP values in infancy is limited. The table summarized below is a useful reference for premature infants, while the Second Task Force curves (see image above) can be used for term and older infants. However, there are obvious shortcomings for both of these references, highlighting the need for additional studies of normal BP in infancy.

Table 1. Neonatal Blood Pressures and Potential Treatment Parameters. Adapted from Dionne et al.* (Open Table in a new window)

Postconceptual Age 50th Percentile 95th Percentile 99th Percentile
44 weeks      
SBP 88 105 110
DBP 50 68 73
MAP 63 80 85
42 weeks      
SBP 85 98 102
DBP 50 65 70
MAP 62 76 81
40 weeks      
SBP 80 95 100
DBP 50 65 70
MAP 60 75 80
38 weeks      
SBP 77 92 97
DBP 50 65 70
MAP 59 74 79
36 weeks      
SBP 72 87 92
DBP 50 65 70
MAP 57 72 77
34 weeks      
SBP 70 85 90
DBP 40 55 60
MAP 50 65 70
32 weeks      
SBP 68 83 88
DBP 40 55 60
MAP 49 64 69
30 weeks      
SBP 65 80 85
DBP 40 55 60
MAP 48 63 68
28 weeks      
SBP 60 75 80
DBP 38 50 54
MAP 45 58 63
26 weeks      
SBP 55 72 77
DBP 30 50 56
MAP 38 57 63

 

*Estimated values for blood pressures after age 2 weeks in infants from 26-44 weeks postconceptual age. The 95th and 99th percentile values serve as a reference to identify infants with persistent hypertension that may require treatment. SBP, systolic blood pressure; DBP, diastolic blood pressure; MAP, mean arterial pressure.

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Contributor Information and Disclosures
Author

Joseph Flynn, MD, MS Chief, Division of Nephrology, Seattle Children's Hospital; Professor, Department of Pediatrics, University of Washington School of Medicine

Joseph Flynn, MD, MS is a member of the following medical societies: American Academy of Pediatrics, American Heart Association, American Society of Hypertension, American Society of Nephrology, American Society of Pediatric Nephrology, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received consulting fee from Pfizer, Inc for review panel membership; Received royalty from UpToDate, Inc. for author; Received royalty from Spronger, Inc for authoring.

Chief Editor

Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

Arun K Pramanik, MD, MBBS Professor of Pediatrics, Director of Neonatal Fellowship, Louisiana State University Health Sciences Center

Arun K Pramanik, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, National Perinatal Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

References
  1. Singh HP, Hurley RM, Myers TF. Neonatal hypertension. Incidence and risk factors. Am J Hypertens. 1992 Feb. 5(2):51-5. [Medline].

  2. Friedman AL, Hustead VA. Hypertension in babies following discharge from a neonatal intensive care unit. A 3-year follow-up. Pediatr Nephrol. 1987 Jan. 1(1):30-4. [Medline].

  3. Blowey DL, Duda PJ, Stokes P, Hall M. Incidence and treatment of hypertension in the neonatal intensive care unit. J Am Soc Hypertens. 2011 Sep 17. [Medline].

  4. Neal WA, Reynolds JW, Jarvis CW, Williams HJ. Umbilical artery catheterization: demonstration of arterial thrombosis by aortography. Pediatrics. 1972 Jul. 50(1):6-13. [Medline].

  5. Abman SH, Warady BA, Lum GM, Koops BL. Systemic hypertension in infants with bronchopulmonary dysplasia. J Pediatr. 1984 Jun. 104(6):928-31. [Medline].

  6. Alagappan A, Malloy MH. Systemic hypertension in very low-birth weight infants with bronchopulmonary dysplasia: incidence and risk factors. Am J Perinatol. 1998 Jan. 15(1):3-8. [Medline].

  7. Sahu R, Pannu H, Yu R, Shete S, Bricker JT, Gupta-Malhotra M. Systemic hypertension requiring treatment in the neonatal intensive care unit. J Pediatr. 2013 Jul. 163(1):84-8. [Medline].

  8. Seliem WA, Falk MC, Shadbolt B, Kent AL. Antenatal and postnatal risk factors for neonatal hypertension and infant follow-up. Pediatr Nephrol. 2007 Dec. 22(12):2081-7. [Medline].

  9. Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. J Perinatol. 1995 Nov-Dec. 15(6):470-9. [Medline].

  10. Pejovic B, Peco-Antic A, Marinkovic-Eric J. Blood pressure in non-critically ill preterm and full-term neonates. Pediatr Nephrol. 2007 Feb. 22(2):249-57. [Medline].

  11. Kent AL, Kecskes Z, Shadbolt B, Falk MC. Normative blood pressure data in the early neonatal period. Pediatr Nephrol. 2007 Sep. 22(9):1335-41. [Medline].

  12. Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol. 2012 Jan. 27(1):17-32. [Medline].

  13. Dionne JM, Abitbol CL, Flynn JT. Erratum to: Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol. 2012 Jan. 27(1):159-60. [Medline].

  14. Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics. 1987 Jan. 79(1):1-25. [Medline].

  15. Crossland DS, Furness JC, Abu-Harb M, et al. Variability of four limb blood pressure in normal neonates. Arch Dis Child Fetal Neonatal Ed. 2004 Jul. 89(4):F325-7. [Medline].

  16. Brierley J, Marks SD. Treating the causes of paediatric hypertension using non-invasive physiological parameters. Med Hypotheses. 2010 May 3. [Medline].

  17. Batisky DL. Neonatal hypertension. Clin Perinatol. 2014 Sep. 41(3):529-42. [Medline].

  18. Nickavar A, Assadi F. Managing hypertension in the newborn infants. Int J Prev Med. 2014 Mar. 5(Suppl 1):S39-43. [Medline].

 
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Normal blood pressure percentile curves for older infants. From the Second (1987) Task Force on Blood Pressure Control in Childhood; National Heart, Lung, and Blood Institute.
Table 1. Neonatal Blood Pressures and Potential Treatment Parameters. Adapted from Dionne et al.*
Postconceptual Age 50th Percentile 95th Percentile 99th Percentile
44 weeks      
SBP 88 105 110
DBP 50 68 73
MAP 63 80 85
42 weeks      
SBP 85 98 102
DBP 50 65 70
MAP 62 76 81
40 weeks      
SBP 80 95 100
DBP 50 65 70
MAP 60 75 80
38 weeks      
SBP 77 92 97
DBP 50 65 70
MAP 59 74 79
36 weeks      
SBP 72 87 92
DBP 50 65 70
MAP 57 72 77
34 weeks      
SBP 70 85 90
DBP 40 55 60
MAP 50 65 70
32 weeks      
SBP 68 83 88
DBP 40 55 60
MAP 49 64 69
30 weeks      
SBP 65 80 85
DBP 40 55 60
MAP 48 63 68
28 weeks      
SBP 60 75 80
DBP 38 50 54
MAP 45 58 63
26 weeks      
SBP 55 72 77
DBP 30 50 56
MAP 38 57 63
Table 2. Intravenous Drugs for Severe Hypertension in Neonates [12]
Drug Class Intravenous (IV) Dosage Comments
Esmolol Beta blocker 100-300 mcg/kg/min IV infusion Very short acting; constant IV infusion necessary
Hydralazine Vasodilator (arteriolar) 0.15-0.6 mg/kg/dose IV bolus or 0.75-5mcg/kg/min IV constant infusion Tachycardia is frequent adverse effect; must administer every 4 hours when administered as IV bolus
Labetalol Alpha blocker and beta blocker 0.2-1 mg/kg/dose IV bolus or 0.25-3 mg/kg/h IV constant infusion Heart failure, bronchopulmonary dysplasia (BPD), relative contraindications
Nicardipine Calcium channel blocker 1-5 mcg/kg/min IV constant infusion May cause reflex tachycardia
Sodium nitroprusside Vasodilator (arteriolar and venous) 0.5-10 mcg/kg/min IV constant infusion Thiocyanate toxicity can occur with prolonged use (>72 h) or in renal failure; usual maintenance dose is below 2 mcg/kg/min; may use 10 mcg/kg/min for short duration (ie, < 10-15 min)
Table 3. Oral Antihypertensive Agents Useful for Treatment of Neonatal Hypertension [12]
Drug Class Oral Dosage Comments
Captopril Angiotensin-converting enzyme (ACE) inhibitor Under age 3 months: 0.01-0.5 mg/kg/dose 3 times daily; not to exceed 2 mg/kg/day



At or above age 3 months: 0.15-0.3 mg/kg/dose 3 times daily; not to exceed 6 mg/kg/day



Monitor serum creatinine and potassium levels
Clonidine Central agonist 0.05-0.1 mg/dose 2-3 times daily Adverse effects include dry mouth and sedation; rebound hypertension with abrupt discontinuation
Enalapril ACE inhibitor 0.08-0.6 mg/kg/day, given once or twice daily Monitor serum creatinine and potassium levels
Hydralazine Vasodilator (arteriolar) 0.25-1 mg/kg/dose 3-4 times daily; not to exceed 7.5 mg/kg/day Suspension stable up to 1 wk; tachycardia and fluid retention are common adverse effects; lupuslike syndrome may develop in slow acetylators
Isradipine Calcium channel blocker 0.05-0.15 mg/kg/dose 4 times daily; not to exceed 0.8 mg/kg/d or 20 mg/day Suspension may be compounded; useful for both acute and chronic hypertension
Amlodipine Calcium channel blocker 0.1-0.3 mg/kg/dose twice daily; not to exceed 0.6 mg/kg/d or 20 mg/d Less likely to cause sudden hypotension than isradipine
Minoxidil Vasodilator (arteriolar) 0.1-0.2 mg/kg/dose 2-3 times daily Most potent oral vasodilator; excellent for refractory hypertension
Propranolol Beta-blocker 0.5-1 mg/kg/dose 3 times daily Maximal dose depends on heart rate; may administer as much as 8-10 mg/kg/d if no bradycardia; avoid in infants with BPD
Labetalol Alpha and beta blocker 1 mg/kg/dose 2-3 times daily, up to 12 mg/kg/d Monitor heart rate; avoid in infants with BPD
Spironolactone Aldosterone antagonist 0.5-1.5 mg/kg/dose twice daily Potassium-sparing diuretic; monitor electrolytes; several days necessary to observe maximum effectiveness
Hydrochlorothiazide Thiazide diuretic 2-3 mg/kg/d orally every day or divided twice daily Monitor electrolytes
Chlorothiazide Thiazide diuretic 5-15 mg/kg/dose twice daily Monitor electrolytes
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