Neonatal Hypertension

NEONATAL
HYPERTENSION
Outline of Presentation
• Introduction
• Measuring BP in neonates
• Etiology
• Clinical presentation
• Investigation
• Management
• References
Introduction
• Definition : persistent systolic and/or diastolic blood pressure (BP) that
exceeds the 95th percentile for infants of the same gestational and postnatal
age and similar size.
• The incidence ranged between 0.2% to 3%
• More common in premature infants ( 75% )
• Most of the cases are secondary . Idiopathic hypertension is a diagnosis of

exclusion
Measuring non invasive BP in neonates
1. Site : Right upper arm
2. Size : choose appropriate size
3. Time : left undisturbed for at
least 15 minutes or until the
neonate is asleep or in a quiet
state
4. Three successive blood pressure
readings must be taken, 2
minutes apart from each other
• “Studies investigating measurement location identified the upper arm
as the most accurate and least variable location for oscillometric BP
measurement”
Dionne JM et al ; International Neonatal Consortium. Method of Blood Pressure Measurement in Neonates and Infants:
A Systematic Review and Analysis. J Pediatr. 2020 Jun;221:23-31.e5. doi: 10.1016/j.jpeds.2020.02.072. PMID: 32446487.
Factors Causing Rise in BP
Crying Agitation
Feeding Pain
Table 2. Estimated blood pressure levels at 95th and 99th percentile in
neonates with 2 weeks of age.
Etiology
Renovascular Renal parenchymal disease
• Thromboembolism • cont
• Renal artery stenosis
• Renal artery thrombosis
• Renal vein thrombosis
• Renal artery compression
• Idiopathic arterial calcification
Renal Parenchymal disease
Congenital Acquired
Congenital nephrotic syndrome Acute tubular necrosis
Multicystic-dysplastic kidney Cortical necrosis

Interstitial nephritis
Ureteropelvic junction obstruction
Obstruction (abdominal/ pelvis
Polycystic kidney disease masses, stones)
Unilateral renal hypoplasia Hemolytic-uremic syndrome
Renal tubular dysgenesis
Tuberous sclerosis
Other cause of neonatal hypertension
Clinical presentation
• Hypertension usually found during routine vital signs monitoring
• Usually non specific sign and symptoms present such as :

 Apnea
 Increased tone
 Tachypnea
 Tachycardia
 Cyanosis
 Mottling
 Lethargy
 Vomiting
 Irritability
 Abdominal distension
 Feeding intolerance
Physical examination
• Dysmorphic features
• All 4 limbs BP
• Cardiovascular : murmur, mottling, tachycardia, cyanosis and
suggestive signs of heart failure
• Abdominal examination : palpable mass / epigastric bruit
• Femoral pulses
• Genitourinary assessment : look for anomalies or virilization sign
NOONAN SYNDROME
TURNER SYNDROME
Investigation
GENERALLY USEFUL USEFUL IN SELECTED PATIENTS
FBC TFT
Renal profile Serum aldosterone
Calcium Cortisol
Plasma renin Abdominal/pelvis USG
UFEME VCUG
CXR Angiography
Renal ultrasound with Doppler Renal Angiography
ECHO Nuclear scan ( DTPA/Mag 3 )
Joseph T. Flynn Neonatal hypertension: diagnosis and management , Pediatr

Nephrol (2000) 14:332–341
Management
• Before commencing therapy, assess the infant’s clinical status and
address iatrogenic causes of hypertension first e.g. infusions of
inotropic agents, volume overload, pain .
• In acute hypertensive crisis – infusion of antihypertensive is

recommended
Intravenous agents for acute hypertension and hypertensive emergencies/urgencies
Drug Class Dose Route
Diazoxide Vasodilator ( arteriolar ) 2- 5 mg/kg/dose Rapid bolus injection
Enalapril ACE inhibitor 15±5 ug/kg per dose injection over 5–10
Repeat 8- 24 H min
Esmolol B blocker Drip : 100 - 300 ug/kg per min IV infusion
Hydralazine Vasodilator ( arteriolar ) Bolus: 0.15–0.6 mg/kg) per dose IV bolus / infusion
Drip: 0.75–5.0 µg/kg per min
Labetolol Alpha & Beta Blocker 0.20–1.0 mg/kg per dose IV bolus/ constant
0.25–3.0 mg/kg per h infusion
Nicardipine Ca2+ Channel blocker 1–3 µg/kg per min constant infusion
Sodium nitroprusside Vasodilator ( arteriolar and 0.5–10 µg/kg per minRapid bolus constant infusion
venous ) injection
• Oral antihypertensive agents are reserved for infants with less severe
hypertension or infants whose acute hypertension has been
controlled with intravenous infusions and are ready to be transitioned
to chronic therapy.
Drug Class Dose Interval Comments
Captopril ACE inhibitor < 6 m : 0.01 – 0.5 TDS Drug of choice ,

mg/kg per dose monitor serum creat
Max 6 mg/kg per day and K
Clonidine Central α agonist 0.05–0.1 mg per dose BD–TDS Side effects include dry
mouth & sedation;
rebound hypertension
with abrupt
discontinuation
Hydralazine Vasodilator (arteriolar) 0.25–1.0 mg/kg per TDS–QID Suspension stable up

dose to 1 week; tachycardia
Max 7.5 mg/kg per day & fluid retention
common side-effects;
lupus-like syndrome
may develop in slow
acetylators
Chlorothiazide Thiazide diuretic 5–15 mg/kg per dose BD Monitor electrolytes

Minoxidil Vasodilator (arteriolar) 0.1–0.2 mg/kg per BD – TDS Most potent oral
dose vasodilator; excellent
for refractory HTN
Propranolol β – blocker 0.5–1.0 mg/kg per TDS Maximal dose depends

dose on heart rate; may go
as high as 8–10 mg/kg
per day if no
bradycardia. Avoid in
infants with BPD
Labetolol α and β blocker 1.0 mg/kg per dose BD- TDS Monitor heart rate;
Max. 10 mg/kg per day avoid in infants with
BPD
Spironolactone Aldosterone antagonist 0.5–1.5 mg/kg per BD

dose
HCTZ Thiazide diuretic 1–3 mg/kg per dose QID Monitor electrolytes
• Surgical intervention is indicated for treatment of neonatal
hypertension in a limited set of circumstances such hypertension
caused by ureteral obstruction or aortic coarctation
References
• Dionne JM et al; International Neonatal Consortium. Method of
Blood Pressure Measurement in Neonates and Infants: A Systematic
Review and Analysis. J Pediatr. 2020 Jun;221:23-31.e5. doi:
10.1016/j.jpeds.2020.02.072. PMID: 32446487.
• Joseph T. Flynn Neonatal hypertension: diagnosis and management ,
Pediatr Nephrol (2000) 14:332–341
• Hassan R, Verma RP. Neonatal Hypertension. 2022 Oct 3. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022
Jan–. PMID: 33085370.
• UptoDate website

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NEONATAL

• The incidence ranged between 0.2% to 3%

• More common in premature infants ( 75% )

• Most of the cases are secondary . Idiopathic hypertension is a diagnosis of

Multicystic-dysplastic kidney Cortical necrosis

• Usually non specific sign and symptoms present such as :

Joseph T. Flynn Neonatal hypertension: diagnosis and management , Pediatr

• In acute hypertensive crisis – infusion of antihypertensive is

Drug Class Dose Route

Diazoxide Vasodilator ( arteriolar ) 2- 5 mg/kg/dose Rapid bolus injection

Esmolol B blocker Drip : 100 - 300 ug/kg per min IV infusion

Captopril ACE inhibitor < 6 m : 0.01 – 0.5 TDS Drug of choice ,

Hydralazine Vasodilator (arteriolar) 0.25–1.0 mg/kg per TDS–QID Suspension stable up

Chlorothiazide Thiazide diuretic 5–15 mg/kg per dose BD Monitor electrolytes

Propranolol β – blocker 0.5–1.0 mg/kg per TDS Maximal dose depends

Spironolactone Aldosterone antagonist 0.5–1.5 mg/kg per BD

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