Heart medication for Children

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This is a NYT article about children with high blood pressure who are now being treated with heart medication. Frightening.

http://www.nytimes.com/2004/08/10/health/10pres.html\

Starting Young in Treating High Blood Pressure

By LINDA CARROLL

hen doctors prescribed blood pressure medication for Adiva Berkovitz at the age of 8, her parents were troubled.

"It was scary to think that this small child who wasn't even 10 years old was going to have to be taking medication for the rest of her life," said Diane Berkovitz, Adiva's mother. "You think about high blood pressure as an illness of adults."

Despite concerns about possible side effects from long-term use of antihypertensive medications, the Berkovitzes eventually decided that the benefits of the drugs outweighed the risks.

As blood pressure levels rise among America's youth, doctors are increasingly prescribing antihypertensive medications to children and teenagers. They hope that by catching and treating hypertension early, they will save lives.

While there are no studies examining the effects of long-term use of antihypertensive drugs in children, recent reports show that many of the medications are safe in the short term.

A study published in May in The Journal of the American Medical Association found that, on average, systolic blood pressures, the top number in the blood pressure ratio, rose by 1.4 millimeters of mercury over the last decade among children ages 8 to 17. Diastolic blood pressures, the bottom number, increased by 3.3 millimeters. The researchers attributed part of this rise to the increasing numbers of overweight children.

The remainder might be explained by the high intake of fast foods among children, said Dr. Bonita Falkner, a professor of medicine and pediatrics at the Jefferson Medical College of the Thomas Jefferson University in Philadelphia.

"It seems like the intake of processed foods has gone up a lot," Dr. Falkner said. "And this raises the intake of sodium. The intake of sugar has gone up too because children are drinking a lot more sodas and less milk than they did 20 years ago."

New guidelines published in the August issue of Pediatrics suggest that doctors start checking blood pressure in children when they are as young as 3.

A diagnosis of higher than normal blood pressure will be made in 1 percent to 3 percent of children, experts say. Children with readings in the 90th percentile up to the 95th, who might previously have been told they were "high normal," will now be considered to have prehypertension. Full hypertension will be diagnosed in children with pressure readings in the 95th percentile and above.

For example, hypertension would be diagnosed in an 8-year-old boy of average height whose systolic blood pressure reading spikes up over 116, said Dr. Falkner, chairman of the group that developed the new guidelines. Prehypertension would be diagnosed with a systolic reading of 112 to 116.

The guidelines also suggest treatment options for children who have higher than normal blood pressure.

Most children with moderate to high blood pressure will be given a prescription for lifestyle modifications, which includes dieting and exercise, Dr. Falkner said

But children with the highest blood pressure levels and those who appear to have organ damage related to their high blood pressure may be put on antihypertensive drugs.

The number of children who will end up with prescriptions for antihypertensive medications is small, 1 percent or less, said Dr. Samuel Gidding, a professor of pediatrics at the Jefferson Medical College and a member of the group that put together the new guidelines.

And doctors may choose not to move to medications immediately.

"Obviously, lifestyle changes are at the base of all therapies, before you get to the medical part," said Dr. Ora Yadin, an associate professor of pediatrics and a pediatric nephrologist at the Mattel Children's Hospital at the University of California, Los Angeles. "We're not advocating that every obese child with high blood pressure be prescribed medication."

But ultimately, if lifestyle changes do not work, a more aggressive approach is needed, experts say. Studies in adults have shown that untreated hypertension can wreak havoc on organs. Kidneys may be scarred. Hearts may enlarge. Eyes can be damaged.

So when doctors get a high blood pressure measurement along with clear signs of damage to an organ, like the heart, they are much more likely to prescribe medication.

The data from adults makes this clear, Dr. Gidding said. With high blood pressure and an enlarged heart, the risk of mortality is two to three times as high as for someone who does not have an enlarged heart, he added.

"Early treatment can delay the onset of significant medical problems for at least five to seven years," Dr. Gidding said. "We know if you start in adulthood that these treatments are effective. In kids, you are further away from an event, but your potential for long-term prevention is greater."

Dr. Yadin agreed.

"I don't want to sound like we're pushing drugs," she said. "But it takes a while to change lifestyle habits, and in the meantime you don't want these kids walking around with such high blood pressure that it puts them at risk for kidney function deterioration or enlarged hearts."

Still, important issues arise when deciding to give children medications that were originally studied in adults and approved for adults.

Calculating dosage, for example, is not simply a matter of adjusting for weight, experts say, because a child's metabolism can process drugs at a different rate than an adult's.

Furthermore, children may have side effects from medications that are not seen in adult patients. Nor do doctors know whether antihypertensives have any long-term side effects in children, experts say.

"It's difficult to extrapolate from adult side-effect profiles," Dr. Yadin said. For example, she noted that a drug might have an effect on growth or on appetite, "or, there could be behavioral effects, like sleepiness or difficulties with concentration, stuff that can affect school performance. The effects can be completely different."

One bit of reassuring news is that over the past five years, some blood-pressure lowering drugs have been studied in children, experts say. These studies have provided doctors with information on how to adjust dosages of the drugs and also on some of the short-term side effects that can be expected in children.

Nevertheless, experts say that the medications should be doled out judiciously and that more long term studies are needed. And doctors need to explain to parents and to children what types of side effects they might encounter.

Each family of antihypertensives has its own list of side effects, Dr. Yadin said.

In some cases, she said, the drugs can cause an increase in blood potassium levels, and in rare cases children can develop a dry cough from the medications.

With teenage girls, pregnancy is also a concern. Some antihypertensive medications can have a negative effect on the development of a fetus, said Dr. Kevin Meyers, a pediatric nephrologist at the Children's Hospital of the University of Pennsylvania.

For parents, it often comes down to the mathematics of risks and benefits, balancing fears about possible long-term side effects with concerns about the long-term damage that high blood pressure can cause.

For Ms. Berkovitz, the decision was easier because Adiva already had signs of organ damage. An ultrasound revealed a small amount of scarring in the organs.

"I think it's a hard line to cross for parents," Ms. Berkovitz said. "The fact that there was already kidney damage made it a bit easier in terms of a long-term commitment to medication."