Elsevier

The Lancet Neurology

Volume 9, Issue 9, September 2010, Pages 933-940
The Lancet Neurology

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The effects of hypertension on the paediatric brain: a justifiable concern

https://doi.org/10.1016/S1474-4422(10)70167-8Get rights and content

Summary

The prevalence of hypertension in children is increasing but its neurological effects are under-recognised. Here, we describe acute and chronic effects of childhood hypertension on the nervous system. Acute neurological involvement ranges from posterior reversible encephalopathy syndrome to, possibly, infarction and haemorrhage. Children with chronic hypertension are likely to have learning disabilities and deficiencies in executive function, which are potentially reversible with antihypertensive treatment. These cognitive defects may be secondary to abnormal regulation of cerebral blood flow. Raised blood pressure in childhood could also contribute to the early development of atherosclerosis, which can have both short-term and long-term adverse effects on vasculature. Clinical studies are needed to better define the full clinical range of paediatric hypertension on a child's nervous system. Furthermore, accurate biomarkers to define cognitive abnormalities and cerebral involvement need to be identified.

Introduction

The prevalence of hypertension in children is rising. In the USA, 5% of all children, and 10% of young people from ethnic minority groups (specifically Hispanic boys), have hypertension.1 This rate is a result of growing awareness and enhanced diagnosis of hypertension and obesity.2, 3 In national surveys, the prevalence of overweight status more than tripled over the past 40 years, from 5% to 17%.4 This rise has led to an increase in type 2 diabetes mellitus and hypertension.5, 6 Obese children have about a threefold amplified risk of hypertension.1, 7

In adults, the definition of hypertension is based on clinical outcomes. Blood pressure greater than 140/90 mm Hg increases the risk of cardiovascular adverse events, including heart attacks and strokes.8 Findings in adults suggest that blood pressure variability, instability, and episodic hypertension might cause a greater risk of hypertension than just raised blood pressure.9

The definition of paediatric hypertension is based on the normative distribution of blood pressure in healthy children and is defined as an average systolic or diastolic blood pressure (or both) above the 95th percentile for sex, age, and height on three or more occasions.10 Urbina and colleagues11 proposed a staging schema for definition of ambulatory hypertension based on both 24-h mean blood pressure levels and blood pressure loads (daily percentage of blood pressure rise). As studies progress, and researchers ascertain the blood pressure levels that result in disease, the definition will be modified.12

Childhood hypertension is underdiagnosed,13 and its effects on the paediatric brain are underappreciated and thought to be confined to acute hypertensive encephalopathy.14 Current textbooks on paediatric neurology do not include information on hypertension and the brain, except for hypertensive encephalopathy.15

Section snippets

Hypertension and the adult brain as a model for paediatric hypertension

Mechanisms of autoregulation and hypertensive vasculopathy overlap between adults and children. Research is ongoing into whether common features exist between adults and children in hypertension-associated stroke (acute ischaemic and haemorrhagic strokes) and in cognitive changes.

Hypertension and the paediatric brain

In the next section, we discuss the many paediatric studies in which neurological issues are assessed. Criteria for diagnosis and details of reports are inconsistent, making interstudy analysis and comparisons difficult (webappendix).

Cognitive effects

In children, the mechanisms by which hypertension affects cognitive function are not understood.65 In the Third US National Health and Nutrition Examination Survey (NHANES III),66 a positive correlation was recorded between blood pressure and cognitive performance in young adults. Lande and colleagues65 analysed test scores of children aged 6–16 years and found that those with hypertension had, on average, decreased scores. Deficits were encountered in the domains of attention, learning, and

Future perspectives

Paediatric hypertension has become one of the most common chronic conditions in childhood.2 Definition and measurement of hypertension in children is an evolving area and, ultimately, 24-h monitoring of blood pressure and variability testing (ie, blood pressure measurements repeated over time) might be the best predictor of secondary cerebrovascular involvement.9, 11

Currently, hypertension as a risk factor for childhood cerebrovascular disease is almost entirely dismissed. However, as data

Search strategy and selection criteria

We searched Pubmed, Embase, and Medline for articles published in English from January, 1980, to January, 2010. Search terms included: “hypertension”, “elevated blood pressure”, “cerebral blood flow and velocity”, “stroke”, “brain infarction and hemorrhage”, “cognitive function”, “cerebrovascular autoregulation”, “posterior reversible encephalopathy syndrome”, “moyamoya”, and “atherosclerosis”. We focused on literature on individuals younger than 21 years. Case reports were included a

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