儿童及青少年高血压漏诊原因分析

美国学者Hansen等指出，由于现行儿童及青少年高血压诊断标准复杂难记，具体实施难度较大，因此，在临床实践中儿童及青少年高血压、高血压前期的漏诊率较高。     

儿童及青少年高血压的研究概况

随着生活水平的提高和饮食模式的改变,儿童及青少年高血压的发病率有逐渐增加的趋势。高血压的防治重在预防,在儿童及青少年时期识别高血压高危人群有助于早期进行有效干预和治疗,降低成人高血压的发生率。该文从儿童及青少年高血压的流行病学特点、诊断标准、危险因素、靶器官损害等方面的研究进展作一综述。     

2009 ESC/ESH儿童、青少年高血压指南概述

2009年9月,欧洲心脏学会（ESC）及欧洲高血压学会（ESH）共同制订了儿童、青少年高血压的诊治指南。这是ESC／ESH首次发布有关儿童及青少年高血压的诊治指南。其内容对我国儿童及青少年高血压的诊治有一定借鉴意义。现对该指南作一解读。     

《儿童青少年高血压筛查和管理的临床实践指南》主要更新内容

<正>2017年9月,美国儿科学会对2004年《儿童青少年高血压诊断、评估和治疗的第四次报告》进行了更新,并发布了《儿童青少年高血压筛查和管理的临床实践指南》,该指南主要更新内容如下。(1)使用术语"血压升高"代替"高血压前期";(2)基于正常体质量儿童青少年,制定了新的儿童青少年血压数据表格;(3)制定了简化筛查表,用于识别需进一步评估的儿童青少年;     

1991-2015年中国儿童青少年血压水平及高血压检出率的变化趋势

正中华流行病学杂志,2020,41(2):178-183.本文采用4类儿童血压标准分析1991-2015年中国年龄7～17岁儿童青少年血压水平和高血压检出率的变化趋势,为儿童青少年高血压的防控提供参考数据。方法:基于"中国健康与营养调查"1991-2015年数据,选取资料完整的年龄7～17岁儿童青少年14 622人。儿童高血压的诊断分别采用2018年国家卫生行业儿童血压标准(行业标准)、2018年中国高血压防治指南儿童血压标准(指南标准)、2016年国际儿童血压参考值(国际标准)和2017年美国儿科协会血压参考值(美国标准)。     

青少年高血压评估及管理

·青年肥胖的流行使高血压患病率不断增加,主要与代谢综合征有关,可以促进动脉粥样硬化、增加靶器官损害的发生风险.·原发性高血压常见于年长儿童和青少年,继发性高血压常见于婴儿、幼童及血压重度升高者.·对儿童的血压测量应注意测量技术,特别是要使用与儿童四肢相匹配的袖带.·儿童诊断高血压前期和高血压需要把血压测量值与同性别、年...     

海口市年龄6～11岁儿童青少年血压分布情况

目的探讨海口市儿童青少年高血压的参考诊断标准。方法采用分层随机整群抽样法获取海口市4个行政辖区内15所小学、159个班级的7363名学生样本,问卷调查血压相关影响因素,并测量身高、体质量、收缩压、柯氏音第4、第5时相舒张压(DBPK4/K5)水平。结果入选儿童青少年的年龄分布以6~11岁为主,占93.46%。收缩压、DBPK4/K5随年龄增长而升高。无论男女,各个年龄段儿童青少年的身高与收缩压、DBPK5呈正相关(均P0.05);男生所有年龄段体质量指数均与收缩压、DBPK4、DBPK5呈正相关(均P0.05)。6~11岁儿童青少年高血压参考诊断标准有本市特色:(1)男、女共用一个标准;(2)收缩压诊断标准市区较城郊高1~8 mm Hg。结论海口市6~11岁儿童青少年的高血压诊断标准有自己的特点。     

儿童及青少年单纯收缩期高血压发病机制研究进展

单纯收缩期高血压(ISH)是老年人高血压最为常见的类型,其对心血管事件的发生有重要影响。值得注意的是,ISH在儿童及青少年中也很常见。与儿童及青少年ISH发病机制不同,大动脉僵硬度增加是老年人ISH的主要发病机制。多项研究表明,儿童及青少年ISH的主要发病机制为交感神经活动亢进,可表现为:高动力状态、肾素-血管紧张素-醛固酮系统激活等。现从儿童及青少年ISH发病机制的研究进展做一综述。     

安徽省儿童青少年高血压与体脂百分比关联性研究

正本文了解安徽省儿童青少年高血压的检出情况,分析其与体脂百分比的关联性。方法:对安徽省年龄7~17岁的中小学生8890人进行了血压和皮褶厚度的测量,参考《中国高血压防治指南2010》中儿童高血压诊断标准评价儿童高血压情况,通过皮褶厚度计算体脂百分比。采用t检验、χ~2检验和Logistic回归分析体脂百分比与高血压的关联。结果:安徽省年龄7~     

儿童及青少年2型糖尿病的诊断和治疗

儿童及青少年糖尿病一直是威胁儿童及青少年健康成长的重要危险因素,目前儿童及青少年糖尿病中2型糖尿病占很大一部分.对儿童及青少年2型糖尿病的诊断主要是与1型糖尿病的鉴别.儿童及青少年2型糖尿病多伴有肥胖、多囊卵巢综合征（PCOS）、黑棘皮病等,可以通过临床症状、空腹血糖、口服葡萄糖耐量试验（OGTT）、胰岛素自身抗体和C肽水平来诊断儿童及青少年2型糖尿病.儿童及青少年2型糖尿病与1型糖尿病相比,更早、更易出现糖尿病微血管并发症.目前的治疗方案主要有糖尿病健康教育、饮食控制、运动疗法、口服药物和胰岛素治疗.     

Management of systemic hypertension in children and adolescents: An update

Opinion statement  Identification and treatment of hypertension should be an important focus of physicians caring for children. Ultimately, a link between hypertension in children and the risk of cardiovascular disease will be established. Further long-term studies are likely to show that morbidity and mortality will be decreased by the institution of treatment of hypertension in children. Additional risk factors such as obesity and lipid disorders should be sought and targeted for treatment as well. Lifestyle modifications are advised for all patients and can be tried solely for those with blood pressures between the 95th and 99th percentiles. Drug therapy is indicated in children with blood pressures greater than the 99th percentile, secondary hypertension, coexisting diabetes, left ventricular hypertrophy, or those who fail a trial of nonpharmacologic treatment. Children with white coat hypertension should not be treated with drugs. Children with renal artery stenosis and drug-refractory hypertension should be considered for percutaneous angioplasty or surgery depending on the anatomy of the lesion and operator experience. Children requiring multiple drug classes for control of blood pressure and older adolescents on one drug with renal artery lesions amenable to a percutaneous procedure may elect intervention in an attempt to reduce or eliminate drug therapy. Infants and children with hypertension due to native coarctation of the aorta should undergo surgical repair. Older children and adolescents with native coarctation should have surgical repair or percutaneous angioplasty/stenting. Hypertension secondary to recurrent coarctation is usually treated with a percutaneous intervention.     

Treatment of Obesity-Related Hypertension in Children and Adolescents

The obesity epidemic has become a common concern among pediatricians, with an estimated 32 % of US children and adolescents classified as overweight and 18 % as obese. Along with the increase in obesity, a growing body of evidence demonstrates that chronic diseases, such as Type 2 diabetes, primary hypertension, and hyperlipidemia, once thought to be confined solely to adulthood, are commonly seen among the obese in childhood. Following a brief summary of the diagnosis and evaluation of hypertension in obese children and adolescents, this review will highlight recent research on the treatment of obesity-related hypertension. Pharmacologic and non-pharmacologic treatment will be discussed. Additionally, current and emerging therapies for the primary treatment of obesity in children and adolescents, which have been gaining in popularity, will be reviewed.     

Systemic Hypertension: Management in Children and Adolescents

Opinion statement Recognition of systemic hypertension in children and adolescents requires careful blood pressure measurement using proper technique to compare with appropriate normative data. Selected use of ambulatory blood pressure monitoring can identify children with "white coat" hypertension, thus avoiding unnecessary diagnostic testing and treatment in these children. Nonpharmacologic therapies including dietary sodium restriction, weight loss, and exercise may benefit children and adolescents with borderline hypertension and mild essential hypertension. These therapies may be important adjunctive agents in children requiring antihypertensive therapy as well. Historically, pharmacologic management of hypertension in children has been limited by a lack of controlled studies and age-appropriate formulations. Recent clinical trials have provided new information regarding a number of antihypertensive agents in this age group.     

Pediatric hypertension: An update on a burning problem

A large number of adults worldwide suffer from essen-tial hypertension, and because blood pressures(BPs) tend to remain within the same percentiles throughout life, it has been postulated that hypertensive pressures can be tracked from childhood to adulthood. Thus, chil-dren with higher BPs are more likely to become hyper-tensive adults. These "pre-hypertensive" subjects can be identified by measuring arterial BP at a young age, and compared with age, gender and height-specific references. The majority of studies report that 1 to 5% of children and adolescents are hypertensive, defined as a BP 95th percentile, with higher prevalence rates reported for some isolated geographic areas. However, the actual prevalence of hypertension in children and adolescents remains to be fully elucidated. In addition to these young "pre-hypertensive" subjects, there are also children and adolescents with a normal-high BP(90th-95th percentile). Early intervention may help pre-vent the development of essential hypertension as they age. An initial attempt should be made to lower their BP by non-pharmacologic measures, such as weight re-duction, aerobic physical exercise, and lowered sodium intake. A pharmacological treatment is usually needed should these measures fail to lower BP. The majority of antihypertensive drugs are not formulated for pediatricpatients, and have thus not been investigated in great detail. The purpose of this review is to provide an up-date concerning juvenile hypertension, and highlight recent developments in epidemiology, diagnostic meth-ods, and relevant therapies.     

Diagnosis and Treatment of Hypertension in Children

Hypertension is a global problem, affecting both developed and developing nations. In children and adolescents, hypertension has gained ground in cardiovascular medicine, thanks to the progress made in several areas of pathophysiologic and clinical research. Childhood hypertension is often asymptomatic and is easily missed, even by health professionals. Target organ damage is detectable in children and adolescents. Management of hypertension includes lifestyle changes and pharmacologic treatment. In the case of secondary hypertension, pharmacologic treatment usually is required. In essential hypertension, assessment of early organ damage provides a useful tool for treatment decisions.     

Children and adolescents with obesity-associated high blood pressure

Hypertension and obesity are both common health problems in children and adolescents. More than 17% of children are obese and even more children are overweight. Hypertension, although defined differently in children than in adults, can be detected in 3% to 4% of children, and approximately 30% of obese adolescents have high blood pressure (BP) associated with obesity. Children with high BP and obesity frequently have other risk factors that are components of the metabolic syndrome. Evidence of target organ damage, including left ventricular hypertrophy, is detectable in many children with hypertension and is more commonly found in children with high BP and obesity. Both obesity and hypertension are considered inflammatory conditions. There are some emerging data in the young that show an association of insulin resistance, obesity, and high BP with inflammatory markers. Children and adolescents with hypertension and especially obesity-associated hypertension can be identified and should be evaluated for additional metabolic risk factors. Considering the heightened risk for premature cardiovascular (CV) disease, therapeutic interventions, including lifestyle changes and medications, when indicated, are important for all children and adolescents with obesity-associated hypertension.     

Office and out-of-office blood pressure measurement in children and adolescents

Office and out-of-office blood pressure measurements are being used for the diagnosis of hypertension in children and adolescents. The US National Heart, Lung, and Blood Institute have recently presented a new classification of blood pressure. On the basis of office measurements the 90th, 95th and 99th percentile for gender, age and height are used to classify children and adolescents as normotensive, pre-hypertensive and stage-1 or stage-2 hypertensive. Although auscultation using a standard mercury sphygmomanometer remains the recommended method, accumulating evidence suggests that ambulatory blood pressure monitoring is useful for the detection of white-coat hypertension and the prediction of target organ damage in children and adolescents. Studies have shown ambulatory blood pressure to be more reproducible than office measurements and normative tables for ambulatory measurements have been developed from cross-sectional studies in children and adolescents. In regard to home measurements in children, there are limited data from small trials showing lower blood pressure levels than daytime ambulatory blood pressure. In conclusion, ambulatory blood pressure monitoring is already finding a role as a supplementary source of information in children and adolescents, whereas at present home measurements should not be used for decision making in this population.     

Significance of heritability in primary and secondary pediatric hypertension

BACKGROUND: Patient weight and family history are significant risk factors for the development of hypertension in children. Multiple genetic factors have been identified in primary (essential) hypertension in adults; however, the delineation of genetic factors in the separate populations of children with primary or secondary hypertension are not well understood. Heritability is the proportion of observed variation in a particular trait that can be attributed to an inherited genetic factor in contrast to environmental factors. In the consideration of hypertension, heritability can be assessed in terms of an underlying continuous gradient of the liability for developing hypertension. With this assumption it is possible to compute heritability using hypertension incidence among relatives and described by Falconer. Heritability values range from 0 (no genetic contribution) to 1 (complete genetic contribution). The aim of this study was to determine the genetic contribution to primary and secondary hypertension in a pediatric population through heritability analysis. METHODS: This was a retrospective case-control analysis of medical records of children (n=276) followed in the Pediatric Nephrology Clinic over a 4-year period from 1999 to 2002. There were 192 children and adolescents with primary hypertension (124 male, 68 female, age 0 to 21 years) and 84 children and adolescents with secondary hypertension (46 male, 38 female, age 0 to 21 years). Each hypertensive group served as the control for the other. Estimates of heritability were made using Falconer's method 2. The model assumes independence between the environment and genetic factors and that the joint distribution of liabilities between parent and child are normally distributed. Problems can arise from computing heritability due to dominance within loci, correlations between nongenetic familial effects, or the presence of a major gene. RESULTS: Of the children and adolescents with primary hypertension, 49% had parents with primary hypertension; and of the children and adolescents with secondary hypertension, 24% had parents with primary hypertension. Of the children and adolescents with primary hypertension, 10% had parents with secondary hypertension; and of the children and adolescents with secondary hypertension, 46% had parents with secondary hypertension. The estimated heritability for primary hypertension was 0.84 (SE=0.21). The estimated heritability for secondary hypertension was 1.14 (SE=0.21). As the value was >1, this indicates that the fit of the liability model is poor and that a few genes, or even one major gene, were significantly involved in the causes of secondary hypertension in the children and adolescents studied. CONCLUSIONS: The results suggest that primary and secondary hypertension do not share the same type of genetic profile. Primary hypertension in children and adolescents is likely due to a large number of additive contributions of genes, although a highly correlated environmental component can not be excluded. The continuous liability model is inappropriate for secondary hypertension because the estimate was substantially greater than one. This study supports the model that secondary hypertension in children and adolescents may be related to just a few genes.     

Cirrhosis in children and adolescents: An overview

Several conditions, especially chronic liver diseases, can lead to cirrhosis in children and adolescents. Most cases in clinical practice are caused by similar etiologies. In infants, cirrhosis is most often caused by biliary atresia and genetic-metabolic diseases, while in older children, it tends to result from autoimmune hepatitis, Wilson’s disease, alpha-1-antitrypsin deficiency and primary sclerosing cholangitis. The symptoms of cirrhosis in children and adolescents are similar to those of adults. However, in pediatric patients, the first sign of cirrhosis is often poor weight gain. The complications of pediatric cirrhosis are similar to those observed in adult patients, and include gastrointestinal bleeding caused by gastroesophageal varices, ascites and spontaneous bacterial peritonitis. In pediatric patients, special attention should be paid to the nutritional alterations caused by cirrhosis, since children and adolescents have higher nutritional requirements for growth and development. Children and adolescents with chronic cholestasis are at risk for several nutritional deficiencies. Malnutrition can have severe consequences for both pre- and post-liver transplant patients. The treatment of cirrhosis-induced portal hypertension in children and adolescents is mostly based on methods developed for adults. The present article will review the diagnostic and differential diagnostic aspects of end-stage liver disease in children, as well as the major treatment options for this condition.     

Hypertension in children and adolescents: An approach to management of complex hyper tension in pediatric patients

Although primary (essential) hypertension is detectable in childhood, secondary causes of hypertension must be considered in evaluating and managing hypertension in children and adolescents. Very young children and children with severe hypertension may have an underlying cause of the hypertension. Interventions to control elevated blood pressure (BP) are clinically important for all children with high BP. Nonpharmacologic approaches are recommended for all asymptomatic children with hypertension and prehypertension. Some children and adolescents will require pharmacologic therapy to control BP and to optimize organ protection. Recent advancements in pediatric clinical trials of antihypertensive agents have provided data on BP-lowering effects and safety in children. Little has been published on the choice and use of various classes of antihypertensive drugs for management of secondary hypertension in children and adolescents. This review focuses on the clinical management of specific types of secondary hypertension in pediatric patients.