When to withhold antihypertensive (blood pressure) medications in pediatric patients?

From the Guidelines

Blood pressure medications in pediatric patients should be withheld when the child's blood pressure is significantly below their target range, typically if systolic blood pressure is less than 70 + (2 × age in years) mmHg or if the child is experiencing symptoms of hypotension such as dizziness, lightheadedness, or syncope, as recommended by the U.S. Preventive Services Task Force 1.

Key Considerations

• The decision to withhold antihypertensive medications should be based on the individual child's condition and medical history.
• Common antihypertensive medications used in children include ACE inhibitors (like enalapril, lisinopril), calcium channel blockers (amlodipine), and beta-blockers (propranolol, metoprolol) 1.
• These medications should also be temporarily withheld if the child is experiencing acute illness with dehydration, vomiting, or diarrhea, as these conditions can exacerbate hypotension.
• Additionally, hold blood pressure medications before surgical procedures as directed by the anesthesiologist, usually 12-24 hours before surgery.

Monitoring and Resuming Treatment

• After holding medication, it's essential to monitor the child's blood pressure closely and resume treatment once blood pressure returns to target range and any acute illness resolves.
• The rationale for holding these medications is to prevent dangerous hypotension, which can lead to inadequate perfusion of vital organs, particularly the brain and kidneys, potentially causing organ damage in developing children.

Evidence-Based Recommendations

• The U.S. Preventive Services Task Force recommends that medications are not used as first-line therapy for stage 1 hypertension in children, but rather lifestyle interventions such as weight reduction, increased physical activity, and restricted sodium intake 1.
• The American Academy of Pediatrics also provides guidance on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents, including recommendations for antihypertensive medication use 1.

From the FDA Drug Label

The usual recommended starting dose is 0. 08 mg/kg (up to 5 mg) once daily. Dosage should be adjusted according to blood pressure response. Enalapril maleate is not recommended in neonates and in pediatric patients with glomerular filtration rate <30 mL/min/1. 73 m 2, as no data are available. The effective antihypertensive oral dose in pediatric patients ages 6 to 17 years is 2.5 mg to 5 mg once daily. Doses in excess of 5 mg daily have not been studied in pediatric patients

Withholding Antihypertensive Medications in Pediatric Patients:

• Neonates: Withhold antihypertensive medications, such as enalapril, as no data are available.
• Pediatric patients with glomerular filtration rate <30 mL/min/1. 73 m 2: Withhold antihypertensive medications, such as enalapril, as no data are available.
• Hypotension: Withhold or adjust antihypertensive medications if hypotension occurs. 2 3

From the Research

Withholding Antihypertensive Medications in Pediatric Patients

• There is no direct evidence to suggest when to withhold antihypertensive medications in pediatric patients 4, 5, 6, 7, 8.
• However, studies suggest that lifestyle modifications such as weight management, dietary changes, and daily physical activity can be effective in lowering blood pressure in pediatric patients, and may be considered before initiating antihypertensive medication 4.
• The decision to withhold antihypertensive medication in pediatric patients may depend on various factors, including the severity of hypertension, the presence of underlying medical conditions, and the patient's response to lifestyle modifications.
• Further research is needed to determine the optimal approach to managing hypertension in pediatric patients, including the use of antihypertensive medications and lifestyle modifications 5, 6.

Considerations for Antihypertensive Medication Use in Pediatric Patients

• Antihypertensive medications such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and beta-blockers may be effective in lowering blood pressure in pediatric patients 5, 6, 7, 8.
• However, the use of these medications in pediatric patients should be carefully considered, taking into account the potential risks and benefits, as well as the availability of alternative treatments such as lifestyle modifications 4, 5, 6.
• The choice of antihypertensive medication and the decision to withhold medication should be individualized based on the patient's specific needs and circumstances 5, 6, 7, 8.