eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Neonatal Hypertension: Follow-up

Author: Joseph Flynn, MD, MS, Director of Pediatric Hypertension Program, Division of Nephrology, Children's Hospital and Regional Medical Center; Professor, Department of Pediatrics, University of Washington School of Medicine
Contributor Information and Disclosures

Updated: Dec 4, 2008

Follow-up

Further Inpatient Care

  • Monitor blood pressure (BP) regularly in neonates with hypertension until the infant is ready for discharge from the neonatal ICU (NICU). Infants treated with ACE inhibitors or diuretics should have electrolyte levels and renal function monitored periodically until discharge.
  • Arrangements for home BP monitoring should be part of the discharge plan for any infant sent home on antihypertensive therapy. The optimal device for home BP measurements in an infant is a Dinamap or similar oscillometric device. A second choice is a Doppler device: however, this only measures systolic BP and is difficult to teach parents to use. Therefore, oscillometric devices should be prescribed.

Further Outpatient Care

  • Include BP measurement at all follow-up visits for infants with neonatal hypertension. In addition, monitor infants with bronchopulmonary dysplasia (BPD) at discharge and those who had complicated NICU courses for the development of hypertension following discharge.
  • Ultrasonography should be obtained 6-12 months after discharge in infants with hypertension to ensure that the kidneys are growing normally.

Inpatient & Outpatient Medications

  • Refer to preceding sections.

Transfer

  • Occasionally, infants may need to be transferred to specialized centers for advanced diagnostic or therapeutic procedures, such as angiography or vascular surgery.

Deterrence/Prevention

  • Although several studies have examined the role of placement of umbilical artery catheters (ie, low versus high lines), no definitive proof has emerged that changes in catheter placement can prevent thromboembolism and the subsequent development of hypertension.

Complications

  • As mentioned above, the long-term sequelae of neonatal hypertension on renal growth, renal function, and future BP are unknown at this time. Long-term effects related to certain antihypertensive medications (eg, ACE inhibitors, calcium channel blockers) are also unknown. These infants may need to be monitored closely even after their hypertension has resolved, particularly with respect to renal growth and the redevelopment of hypertension in later childhood.

Prognosis

  • The long-term prognosis for most infants with hypertension is quite good. For infants with hypertension related to an umbilical arterial catheter, the hypertension usually resolves over time. These infants may require increases in their antihypertensive medications in the first several months following discharge from the nursery as they undergo rapid growth. Following this, weaning the patient off antihypertensive therapy is usually possible by making no further dose increases as the infant continues to grow. Home BP monitoring by the parents is a crucially important component of this process. Provide proper equipment, either a Doppler or oscillometric device, for all infants discharged from the NICU on long-term antihypertensive medications. Such infants may benefit from referral to a comprehensive pediatric hypertension clinic if their primary care provider is inexperienced in managing hypertension.
  • Other forms of neonatal hypertension may persist beyond infancy. In particular, polycystic kidney disease (PKD) and other forms of renal parenchymal disease may continue to cause hypertension throughout childhood. Infants with renal venous thrombosis (RVT) may also remain hypertensive, and some of these children ultimately benefit from nephrectomy. Persistent or recurrent hypertension may also be observed in children who have undergone repair of renal arterial stenosis or coarctation of the aorta. Reappearance of hypertension in these situations should prompt a search for restenosis using the appropriate imaging studies.
  • BP in newborns depends on various factors, including gestational age, postnatal age, and birth weight. Hypertension can be observed in various situations in the modern NICU and is especially common in infants who have undergone umbilical arterial catheterization. A careful diagnostic evaluation should lead to determination of the underlying cause of hypertension in most infants. Tailor treatment decisions, which may include intravenous therapy, oral therapy, or both, to the severity of the hypertension. Hypertension resolves in most infants over time, although a small number of infants may have persistent BP elevation throughout childhood.

Patient Education

  • Educate the parents of infants who develop hypertension requiring drug therapy about the expected effects and side effects of their infant's antihypertensive medications. In addition, arrange home BP monitoring equipment and educate the parents in its use prior to the infant's discharge from the NICU. Parents must monitor the BP of all infants discharged on antihypertensive medications on a regular basis (ie, usually daily); parents should call the prescribing clinician if the infant's BP exceeds or falls below the target range.
  • Patient education information on childhood hypertension can be found at the International Pediatric Hypertension Association web site. Also, visit eMedicine's patient education article, High Blood Pressure.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose or treat neonatal hypertension (A major concern is missing an underlying cause of hypertension such as renal disease that might require specific therapy.)
 


More on Neonatal Hypertension

Overview: Neonatal Hypertension
Differential Diagnoses & Workup: Neonatal Hypertension
Treatment & Medication: Neonatal Hypertension
Follow-up: Neonatal Hypertension
References
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Further Reading

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Keywords

neonatal hypertension, high blood pressure, high BP, premature infants, bronchopulmonary dysplasia, BPD, steroids, maternal hypertension, umbilical arterial catheter, postnatal acute renal failure, patent ductus arteriosus, chronic lung disease, congestive heart failure, cardiogenic shock, congenital adrenal hyperplasia, CAH, umbilical artery catheter–associated thromboembolism, renal venous thrombosis, RVT, renal artery stenosis, fibromuscular dysplasia, FMD, rubella, polycystic kidney disease, PKD, hydronephrotic kidney, nephromegaly, multicystic dysplastic kidney, congenital ureteropelvic junction obstruction, ureteral obstruction, hyperaldosteronism, hyperthyroidism, hypercalcemia, neuroblastoma, Wilms tumor, mesoblastic nephroma

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Contributor Information and Disclosures

Author

Joseph Flynn, MD, MS, Director of Pediatric Hypertension Program, Division of Nephrology, Children's Hospital and Regional Medical Center; 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

Medical Editor

Steven M Donn, MD, Professor of Pediatrics, Director, Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan Health System
Steven M Donn, MD is a member of the following medical societies: American Pediatric Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

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.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

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.

 
 
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