Neonatal Hypertension Differential Diagnoses

  • Author: Joseph Flynn, MD, MS; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Jan 3, 2012
 
 

Diagnostic Considerations

Cardiac conditions to consider in the differential diagnosis of neonatal hypertension include thoracic aortic coarctation. Renovascular conditions to consider in the differential diagnosis include the following:

  • Thromboembolism
  • Renal artery stenosis
  • Midabdominal aortic coarctation
  • Renal venous thrombosis
  • Compression of renal artery
  • Idiopathic arterial calcification
  • Congenital rubella syndrome

Renal parenchymal diseases to consider in the differential diagnosis of neonatal hypertension include the following:

  • Polycystic kidney disease
  • Multicystic dysplastic kidney disease
  • Tuberous sclerosis
  • Ureteropelvic junction obstruction
  • Acute tubular necrosis
  • Cortical necrosis
  • Interstitial nephritis
  • Hemolytic-uremic syndrome

Pulmonary conditions to consider in the differential diagnosis of neonatal hypertension include the following:

  • Bronchopulmonary dysplasia
  • Pneumothorax

Endocrine conditions to consider in the differential diagnosis of neonatal hypertension include the following:

  • Congenital adrenal hyperplasia
  • Hyperaldosteronism
  • Hyperthyroidism
  • Pseudohypoaldosteronism type II

Medications/intoxications to consider in the differential diagnosis of neonatal hypertension include the following:

  • Dexamethasone
  • Adrenergic agents
  • Vitamin D intoxication
  • Theophylline
  • Caffeine
  • Pancuronium
  • Phenylephrine
  • Maternal cocaine or heroin use

Tumors that should be considered in the differential diagnosis of neonatal hypertension include the following:

  • Neoplasia
  • Wilms tumor
  • Mesoblastic nephroma
  • Neuroblastoma
  • Pheochromocytoma

Neurologic conditions to consider in the differential diagnosis of neonatal hypertension include the following:

  • Pain
  • Intracranial hypertension
  • Seizures
  • Familial dysautonomia
  • Subdural hematoma

Miscellaneous conditions to consider in the differential diagnosis of neonatal hypertension include the following:

  • Closure of abdominal wall defect
  • Adrenal hemorrhage
  • Hypercalcemia
  • Traction
  • Extracorporeal membrane oxygenation
  • Birth asphyxia
  • Urologic neoplasms

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Joseph Flynn, MD, MS  Director of Pediatric Hypertension Program, 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, and Phi Beta Kappa

Disclosure: Novartis Pharmaceuticals Consulting fee Consulting; Pfizer, Inc Consulting fee Review panel membership

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 Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

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. Feb 1992;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. Jan 1987;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. Sep 17 2011;[Medline].

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

  5. Abman SH, Warady BA, Lum GM, Koops BL. Systemic hypertension in infants with bronchopulmonary dysplasia. J Pediatr. Jun 1984;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. Jan 1998;15(1):3-8. [Medline].

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

  8. 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. Nov-Dec 1995;15(6):470-9. [Medline].

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

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

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

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

  13. 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. Jan 1987;79(1):1-25. [Medline].

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

  15. Brierley J, Marks SD. Treating the causes of paediatric hypertension using non-invasive physiological parameters. Med Hypotheses. May 3 2010;[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 Age50th Percentile95th Percentile99th Percentile
44 weeks
SBP88105110
DBP506873
MAP638085
42 weeks
SBP8598102
DBP506570
MAP627681
40 weeks
SBP8095100
DBP506570
MAP607580
38 weeks
SBP779297
DBP506570
MAP597479
36 weeks
SBP728792
DBP506570
MAP577277
34 weeks
SBP708590
DBP405560
MAP506570
32 weeks
SBP688388
DBP405560
MAP496469
30 weeks
SBP658085
DBP405560
MAP486368
28 weeks
SBP607580
DBP385054
MAP455863
26 weeks
SBP557277
DBP305056
MAP385763
Table 2. Intravenous Drugs for Severe Hypertension in Neonates[11]
DrugClassIntravenous (IV) DosageComments
EsmololBeta blocker100-300 mcg/kg/min IV infusionVery short acting; constant IV infusion necessary
HydralazineVasodilator (arteriolar)0.15-0.6 mg/kg/dose IV bolus or 0.75-5mcg/kg/min IV constant infusionTachycardia is frequent adverse effect; must administer every 4 hours when administered as IV bolus
LabetalolAlpha blocker and beta blocker0.2-1 mg/kg/dose IV bolus or 0.25-3 mg/kg/h IV constant infusionHeart failure, bronchopulmonary dysplasia (BPD), relative contraindications
NicardipineCalcium channel blocker1-5 mcg/kg/min IV constant infusionMay cause reflex tachycardia
Sodium nitroprussideVasodilator (arteriolar and venous)0.5-10 mcg/kg/min IV constant infusionThiocyanate 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[11]
DrugClassOral DosageComments
CaptoprilAngiotensin-converting enzyme (ACE) inhibitorUnder 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
ClonidineCentral agonist0.05-0.1 mg/dose 2-3 times dailyAdverse effects include dry mouth and sedation; rebound hypertension with abrupt discontinuation
EnalaprilACE inhibitor0.08-0.6 mg/kg/day, given once or twice dailyMonitor serum creatinine and potassium levels
HydralazineVasodilator (arteriolar)0.25-1 mg/kg/dose 3-4 times daily; not to exceed 7.5 mg/kg/daySuspension stable up to 1 wk; tachycardia and fluid retention are common adverse effects; lupuslike syndrome may develop in slow acetylators
IsradipineCalcium channel blocker0.05-0.15 mg/kg/dose 4 times daily; not to exceed 0.8 mg/kg/d or 20 mg/daySuspension may be compounded; useful for both acute and chronic hypertension
AmlodipineCalcium channel blocker0.1-0.3 mg/kg/dose twice daily; not to exceed 0.6 mg/kg/d or 20 mg/dLess likely to cause sudden hypotension than isradipine
MinoxidilVasodilator (arteriolar)0.1-0.2 mg/kg/dose 2-3 times dailyMost potent oral vasodilator; excellent for refractory hypertension
PropranololBeta-blocker0.5-1 mg/kg/dose 3 times dailyMaximal dose depends on heart rate; may administer as much as 8-10 mg/kg/d if no bradycardia; avoid in infants with BPD
LabetalolAlpha and beta blocker1 mg/kg/dose 2-3 times daily, up to 12 mg/kg/dMonitor heart rate; avoid in infants with BPD
SpironolactoneAldosterone antagonist0.5-1.5 mg/kg/dose twice dailyPotassium-sparing diuretic; monitor electrolytes; several days necessary to observe maximum effectiveness
HydrochlorothiazideThiazide diuretic2-3 mg/kg/d orally every day or divided twice dailyMonitor electrolytes
ChlorothiazideThiazide diuretic5-15 mg/kg/dose twice dailyMonitor electrolytes
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