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How best to treat UTIs in women who breastfeed?
It’s unclear, as no studies have specifically evaluated therapies for uncomplicated urinary tract infections (UTIs) in breastfeeding women. However, trimethoprim/sulfamethoxazole (TMP/ SMX), β-lactam antibiotics, nitrofurantoin, and fluoroquinolones all produce cure rates of 78% to 95% for uncomplicated UTIs in women who aren’t breastfeeding, and all appear to be equivalent (strength of recommendation [SOR]: A, a systematic review).
Women who take TMP/SMX develop drug concentrations in breast milk that are below recommended maximum safe levels for infants who don’t have glucose-6-phosphate dehydrogenase (G6PD) deficiency (SOR: B, a small observational study and expert opinion); treatment with nitrofurantoin and ciprofloxacin also produces low levels in breast milk (SOR: C, extrapolations from small observational studies and expert opinion). (Though in the case of nitrofurantoin, this does not include patients with G6PD deficiency.)
Some antibiotics taken by breastfeeding mothers may occasionally be associated with adverse effects in their infants: TMP/SMX may cause poor feeding; amoxicillin and cephalexin may cause diarrhea; nitrofurantoin may cause diarrhea or, in infants with G6PD deficiency, hemolytic anemia; and ciprofloxacin may cause pseudomembranous colitis in infants and green teeth in neonates (SOR: C, case reports and expert opinion).
EVIDENCE SUMMARY
Because no randomized controlled trials have evaluated the efficacy of UTI treatment in lactating women, recommendations are extrapolated from studies in other populations and case reports.
Antibiotics: Comparable and effective
A 2010 Cochrane review examined 21 good-quality randomized trials that compared the effectiveness of TMP-SMX, β-lactam antibiotics, nitrofurantoin, and fluoroquinolones for uncomplicated UTIs in 6016 women.1 The authors found no significant differences in short-term symptom cure rates: all antibiotics were very effective. Seven studies reported mixed (clinical and bacteriologic) cure rates.
Symptom cure rates for patients followed for as long as 2 weeks ranged from 78% to 95%; longer-term (as long as 8 weeks) symptom cure rates ranged from 82% to 91%. The review suggested that TMP-SMX may be slightly more likely to cause a rash than other antibiotics.1
Antibiotic concentrations in breast milk
In a case series, TMP/SMX, 160/800 mg, given to 50 lactating women 2 times (40 women) or 3 times (10 women) daily resulted in an average breast milk concentration of 2 μg/mL of TMP and 4.6 μg/mL of SMX, corresponding to respective doses of 0.3 and 0.7 mg/kg/d for infants taking 150 mL breast milk/kg/d.2 The authors state that this dose is safe for infants without G6PD deficiency. The study included only women with UTIs or other infections requiring antibiotic treatment.
A case series of 4 lactating mothers who received a single 100-mg oral dose of nitrofurantoin found that peak breast milk concentration occurred 4 hours later and averaged 2.4 μg/mL (standard deviation=1.7-3.2 μg/mL).3 The authors calculated a mean concentration over 12 hours of 1.3 μg nitrofurantoin/mL breast milk. This level would correspond to an estimated dose of 0.2 mg/kg/d for an infant consuming 150 mL/kg/d of breast milk whose mother takes 100 mg nitrofurantoin twice daily, much lower than the recommended pediatric dose of 5 to 7 mg/kg/d.
Data from a case series and a case report suggest the amount of ciprofloxacin transferred to breastfed infants is low. In the case series, researchers gave 10 lactating women 3 oral doses of ciprofloxacin, 750 mg, at 12-hour intervals and then measured ciprofloxacin levels in breast milk.4 The highest levels occurred 2 hours after the third dose and averaged 3.79 μg/mL. Average levels fell gradually to 0.02 μg/mL 24 hours after the third dose. Assuming a milk intake of 150 mL/kg/d, a breastfed infant would consume approximately 0.3 mg/kg/d, much lower than the 10 to 40 mg/kg/d dose recommended for treating sick infants.
A case report of a woman who took oral ciprofloxacin 500 mg/d for 10 days noted a breast milk ciprofloxacin concentration of 0.98 mg/L at 10.7 hours after the last dose.5 Ofloxacin, norfloxacin, and levofloxacin have been associated with lower milk concentrations than ciprofloxacin.6
Adverse effects
In a cohort study of 838 women from a program for pregnant and lactating women exposed to drugs and other substances, 2 of 12 mothers taking TMP/SMX reported poor feeding in their infants.7
The same program received reports of infants with diarrhea from mothers taking amoxicillin (3 of 25 infants), nitrofurantoin (2 of 6 infants), and cephalexin (2 of 7 infants), but no reports of other adverse effects. Another study demonstrated that nitrofurantoin is actively transported into the mother’s milk, making hemolytic anemia a possibility in G6PD-deficient infants.3
Studies indicate that adverse effects of fluoroquinolones in children are similar to those in adults despite a contraindication in children because of reports of arthropathy in young animals. One case of pseudomembranous colitis in a breastfeeding infant and 2 cases of green teeth in neonates have been reported with ciprofloxacin use.6,8,9
RECOMMENDATIONS
The Infectious Disease Society of America recommends nitrofurantoin, TMP/SMX, or fosfomycin for first-line treatment of uncomplicated UTIs in women, although fosfomycin appears to be inferior to other standard short-course antibiotics based on FDA data. Fluoroquinolones and β-lactams are recommended alternative treatments.10
The American Academy of Pediatrics’ Committee on Drugs says that TMP/SMX (unless G6PD deficiency is present), amoxicillin, nitrofurantoin, ciprofloxacin, and ofloxacin usually are compatible with breastfeeding.11
1. Zalmanovici Trestioreanu A, Green H, Paul M, et al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database of Syst Rev. 2010;(10):CD007182.
2. Miller RD, Salter AJ. The passage of trimethoprim/sulfamethoxazole into breast milk and its significance. Proceedings of the 8th International Congress of Chemotherapy, Athens. Hellenic Soc Chemother. 1974;1:687-691.
3. Gerk PM, Kuhn RJ, Desai NS, et al. Active transport of nitrofurantoin into human milk. Pharmacotherapy. 2001;21:669-675.
4. Giamarellou H, Kolokythas E, Petrikkos G, et al. Pharmacokinetics of three newer quinolones in pregnant and lactating women. Am J Med. 1989;87:49S-51S.
5. Gardner DK, Gabbe SG, Harter C. Simultaneous concentrations of ciprofloxacin in breast milk and in serum in mother and breast-fed infant. Clin Pharm. 1992;11:352-354.
6. Bar-Oz B, Bulkowstein M, Benyamini L, et al. Use of antibiotic and analgesic drugs during lactation. Drug Safety. 2003;26:925-935.
7. Ito S, Blajchman A, Stephenson M, et al. Prospective followup of breast-fed infants exposed to maternal medication. Am J Obstet Gynecol.1993;168:1393-1399.
8. Harmon T, Burkhart G, Applebaum H. Perforated pseudomembranous colitis in the breast-fed infant. J Pediatr Surg. 1992;27:744-746.
9. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 8th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2008.
10. Gupta K, Hooton TM, Naber KG, et al; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International Clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103-e120.
11. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemical into human milk. Pediatrics. 2001;108:776-789.
It’s unclear, as no studies have specifically evaluated therapies for uncomplicated urinary tract infections (UTIs) in breastfeeding women. However, trimethoprim/sulfamethoxazole (TMP/ SMX), β-lactam antibiotics, nitrofurantoin, and fluoroquinolones all produce cure rates of 78% to 95% for uncomplicated UTIs in women who aren’t breastfeeding, and all appear to be equivalent (strength of recommendation [SOR]: A, a systematic review).
Women who take TMP/SMX develop drug concentrations in breast milk that are below recommended maximum safe levels for infants who don’t have glucose-6-phosphate dehydrogenase (G6PD) deficiency (SOR: B, a small observational study and expert opinion); treatment with nitrofurantoin and ciprofloxacin also produces low levels in breast milk (SOR: C, extrapolations from small observational studies and expert opinion). (Though in the case of nitrofurantoin, this does not include patients with G6PD deficiency.)
Some antibiotics taken by breastfeeding mothers may occasionally be associated with adverse effects in their infants: TMP/SMX may cause poor feeding; amoxicillin and cephalexin may cause diarrhea; nitrofurantoin may cause diarrhea or, in infants with G6PD deficiency, hemolytic anemia; and ciprofloxacin may cause pseudomembranous colitis in infants and green teeth in neonates (SOR: C, case reports and expert opinion).
EVIDENCE SUMMARY
Because no randomized controlled trials have evaluated the efficacy of UTI treatment in lactating women, recommendations are extrapolated from studies in other populations and case reports.
Antibiotics: Comparable and effective
A 2010 Cochrane review examined 21 good-quality randomized trials that compared the effectiveness of TMP-SMX, β-lactam antibiotics, nitrofurantoin, and fluoroquinolones for uncomplicated UTIs in 6016 women.1 The authors found no significant differences in short-term symptom cure rates: all antibiotics were very effective. Seven studies reported mixed (clinical and bacteriologic) cure rates.
Symptom cure rates for patients followed for as long as 2 weeks ranged from 78% to 95%; longer-term (as long as 8 weeks) symptom cure rates ranged from 82% to 91%. The review suggested that TMP-SMX may be slightly more likely to cause a rash than other antibiotics.1
Antibiotic concentrations in breast milk
In a case series, TMP/SMX, 160/800 mg, given to 50 lactating women 2 times (40 women) or 3 times (10 women) daily resulted in an average breast milk concentration of 2 μg/mL of TMP and 4.6 μg/mL of SMX, corresponding to respective doses of 0.3 and 0.7 mg/kg/d for infants taking 150 mL breast milk/kg/d.2 The authors state that this dose is safe for infants without G6PD deficiency. The study included only women with UTIs or other infections requiring antibiotic treatment.
A case series of 4 lactating mothers who received a single 100-mg oral dose of nitrofurantoin found that peak breast milk concentration occurred 4 hours later and averaged 2.4 μg/mL (standard deviation=1.7-3.2 μg/mL).3 The authors calculated a mean concentration over 12 hours of 1.3 μg nitrofurantoin/mL breast milk. This level would correspond to an estimated dose of 0.2 mg/kg/d for an infant consuming 150 mL/kg/d of breast milk whose mother takes 100 mg nitrofurantoin twice daily, much lower than the recommended pediatric dose of 5 to 7 mg/kg/d.
Data from a case series and a case report suggest the amount of ciprofloxacin transferred to breastfed infants is low. In the case series, researchers gave 10 lactating women 3 oral doses of ciprofloxacin, 750 mg, at 12-hour intervals and then measured ciprofloxacin levels in breast milk.4 The highest levels occurred 2 hours after the third dose and averaged 3.79 μg/mL. Average levels fell gradually to 0.02 μg/mL 24 hours after the third dose. Assuming a milk intake of 150 mL/kg/d, a breastfed infant would consume approximately 0.3 mg/kg/d, much lower than the 10 to 40 mg/kg/d dose recommended for treating sick infants.
A case report of a woman who took oral ciprofloxacin 500 mg/d for 10 days noted a breast milk ciprofloxacin concentration of 0.98 mg/L at 10.7 hours after the last dose.5 Ofloxacin, norfloxacin, and levofloxacin have been associated with lower milk concentrations than ciprofloxacin.6
Adverse effects
In a cohort study of 838 women from a program for pregnant and lactating women exposed to drugs and other substances, 2 of 12 mothers taking TMP/SMX reported poor feeding in their infants.7
The same program received reports of infants with diarrhea from mothers taking amoxicillin (3 of 25 infants), nitrofurantoin (2 of 6 infants), and cephalexin (2 of 7 infants), but no reports of other adverse effects. Another study demonstrated that nitrofurantoin is actively transported into the mother’s milk, making hemolytic anemia a possibility in G6PD-deficient infants.3
Studies indicate that adverse effects of fluoroquinolones in children are similar to those in adults despite a contraindication in children because of reports of arthropathy in young animals. One case of pseudomembranous colitis in a breastfeeding infant and 2 cases of green teeth in neonates have been reported with ciprofloxacin use.6,8,9
RECOMMENDATIONS
The Infectious Disease Society of America recommends nitrofurantoin, TMP/SMX, or fosfomycin for first-line treatment of uncomplicated UTIs in women, although fosfomycin appears to be inferior to other standard short-course antibiotics based on FDA data. Fluoroquinolones and β-lactams are recommended alternative treatments.10
The American Academy of Pediatrics’ Committee on Drugs says that TMP/SMX (unless G6PD deficiency is present), amoxicillin, nitrofurantoin, ciprofloxacin, and ofloxacin usually are compatible with breastfeeding.11
It’s unclear, as no studies have specifically evaluated therapies for uncomplicated urinary tract infections (UTIs) in breastfeeding women. However, trimethoprim/sulfamethoxazole (TMP/ SMX), β-lactam antibiotics, nitrofurantoin, and fluoroquinolones all produce cure rates of 78% to 95% for uncomplicated UTIs in women who aren’t breastfeeding, and all appear to be equivalent (strength of recommendation [SOR]: A, a systematic review).
Women who take TMP/SMX develop drug concentrations in breast milk that are below recommended maximum safe levels for infants who don’t have glucose-6-phosphate dehydrogenase (G6PD) deficiency (SOR: B, a small observational study and expert opinion); treatment with nitrofurantoin and ciprofloxacin also produces low levels in breast milk (SOR: C, extrapolations from small observational studies and expert opinion). (Though in the case of nitrofurantoin, this does not include patients with G6PD deficiency.)
Some antibiotics taken by breastfeeding mothers may occasionally be associated with adverse effects in their infants: TMP/SMX may cause poor feeding; amoxicillin and cephalexin may cause diarrhea; nitrofurantoin may cause diarrhea or, in infants with G6PD deficiency, hemolytic anemia; and ciprofloxacin may cause pseudomembranous colitis in infants and green teeth in neonates (SOR: C, case reports and expert opinion).
EVIDENCE SUMMARY
Because no randomized controlled trials have evaluated the efficacy of UTI treatment in lactating women, recommendations are extrapolated from studies in other populations and case reports.
Antibiotics: Comparable and effective
A 2010 Cochrane review examined 21 good-quality randomized trials that compared the effectiveness of TMP-SMX, β-lactam antibiotics, nitrofurantoin, and fluoroquinolones for uncomplicated UTIs in 6016 women.1 The authors found no significant differences in short-term symptom cure rates: all antibiotics were very effective. Seven studies reported mixed (clinical and bacteriologic) cure rates.
Symptom cure rates for patients followed for as long as 2 weeks ranged from 78% to 95%; longer-term (as long as 8 weeks) symptom cure rates ranged from 82% to 91%. The review suggested that TMP-SMX may be slightly more likely to cause a rash than other antibiotics.1
Antibiotic concentrations in breast milk
In a case series, TMP/SMX, 160/800 mg, given to 50 lactating women 2 times (40 women) or 3 times (10 women) daily resulted in an average breast milk concentration of 2 μg/mL of TMP and 4.6 μg/mL of SMX, corresponding to respective doses of 0.3 and 0.7 mg/kg/d for infants taking 150 mL breast milk/kg/d.2 The authors state that this dose is safe for infants without G6PD deficiency. The study included only women with UTIs or other infections requiring antibiotic treatment.
A case series of 4 lactating mothers who received a single 100-mg oral dose of nitrofurantoin found that peak breast milk concentration occurred 4 hours later and averaged 2.4 μg/mL (standard deviation=1.7-3.2 μg/mL).3 The authors calculated a mean concentration over 12 hours of 1.3 μg nitrofurantoin/mL breast milk. This level would correspond to an estimated dose of 0.2 mg/kg/d for an infant consuming 150 mL/kg/d of breast milk whose mother takes 100 mg nitrofurantoin twice daily, much lower than the recommended pediatric dose of 5 to 7 mg/kg/d.
Data from a case series and a case report suggest the amount of ciprofloxacin transferred to breastfed infants is low. In the case series, researchers gave 10 lactating women 3 oral doses of ciprofloxacin, 750 mg, at 12-hour intervals and then measured ciprofloxacin levels in breast milk.4 The highest levels occurred 2 hours after the third dose and averaged 3.79 μg/mL. Average levels fell gradually to 0.02 μg/mL 24 hours after the third dose. Assuming a milk intake of 150 mL/kg/d, a breastfed infant would consume approximately 0.3 mg/kg/d, much lower than the 10 to 40 mg/kg/d dose recommended for treating sick infants.
A case report of a woman who took oral ciprofloxacin 500 mg/d for 10 days noted a breast milk ciprofloxacin concentration of 0.98 mg/L at 10.7 hours after the last dose.5 Ofloxacin, norfloxacin, and levofloxacin have been associated with lower milk concentrations than ciprofloxacin.6
Adverse effects
In a cohort study of 838 women from a program for pregnant and lactating women exposed to drugs and other substances, 2 of 12 mothers taking TMP/SMX reported poor feeding in their infants.7
The same program received reports of infants with diarrhea from mothers taking amoxicillin (3 of 25 infants), nitrofurantoin (2 of 6 infants), and cephalexin (2 of 7 infants), but no reports of other adverse effects. Another study demonstrated that nitrofurantoin is actively transported into the mother’s milk, making hemolytic anemia a possibility in G6PD-deficient infants.3
Studies indicate that adverse effects of fluoroquinolones in children are similar to those in adults despite a contraindication in children because of reports of arthropathy in young animals. One case of pseudomembranous colitis in a breastfeeding infant and 2 cases of green teeth in neonates have been reported with ciprofloxacin use.6,8,9
RECOMMENDATIONS
The Infectious Disease Society of America recommends nitrofurantoin, TMP/SMX, or fosfomycin for first-line treatment of uncomplicated UTIs in women, although fosfomycin appears to be inferior to other standard short-course antibiotics based on FDA data. Fluoroquinolones and β-lactams are recommended alternative treatments.10
The American Academy of Pediatrics’ Committee on Drugs says that TMP/SMX (unless G6PD deficiency is present), amoxicillin, nitrofurantoin, ciprofloxacin, and ofloxacin usually are compatible with breastfeeding.11
1. Zalmanovici Trestioreanu A, Green H, Paul M, et al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database of Syst Rev. 2010;(10):CD007182.
2. Miller RD, Salter AJ. The passage of trimethoprim/sulfamethoxazole into breast milk and its significance. Proceedings of the 8th International Congress of Chemotherapy, Athens. Hellenic Soc Chemother. 1974;1:687-691.
3. Gerk PM, Kuhn RJ, Desai NS, et al. Active transport of nitrofurantoin into human milk. Pharmacotherapy. 2001;21:669-675.
4. Giamarellou H, Kolokythas E, Petrikkos G, et al. Pharmacokinetics of three newer quinolones in pregnant and lactating women. Am J Med. 1989;87:49S-51S.
5. Gardner DK, Gabbe SG, Harter C. Simultaneous concentrations of ciprofloxacin in breast milk and in serum in mother and breast-fed infant. Clin Pharm. 1992;11:352-354.
6. Bar-Oz B, Bulkowstein M, Benyamini L, et al. Use of antibiotic and analgesic drugs during lactation. Drug Safety. 2003;26:925-935.
7. Ito S, Blajchman A, Stephenson M, et al. Prospective followup of breast-fed infants exposed to maternal medication. Am J Obstet Gynecol.1993;168:1393-1399.
8. Harmon T, Burkhart G, Applebaum H. Perforated pseudomembranous colitis in the breast-fed infant. J Pediatr Surg. 1992;27:744-746.
9. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 8th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2008.
10. Gupta K, Hooton TM, Naber KG, et al; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International Clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103-e120.
11. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemical into human milk. Pediatrics. 2001;108:776-789.
1. Zalmanovici Trestioreanu A, Green H, Paul M, et al. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database of Syst Rev. 2010;(10):CD007182.
2. Miller RD, Salter AJ. The passage of trimethoprim/sulfamethoxazole into breast milk and its significance. Proceedings of the 8th International Congress of Chemotherapy, Athens. Hellenic Soc Chemother. 1974;1:687-691.
3. Gerk PM, Kuhn RJ, Desai NS, et al. Active transport of nitrofurantoin into human milk. Pharmacotherapy. 2001;21:669-675.
4. Giamarellou H, Kolokythas E, Petrikkos G, et al. Pharmacokinetics of three newer quinolones in pregnant and lactating women. Am J Med. 1989;87:49S-51S.
5. Gardner DK, Gabbe SG, Harter C. Simultaneous concentrations of ciprofloxacin in breast milk and in serum in mother and breast-fed infant. Clin Pharm. 1992;11:352-354.
6. Bar-Oz B, Bulkowstein M, Benyamini L, et al. Use of antibiotic and analgesic drugs during lactation. Drug Safety. 2003;26:925-935.
7. Ito S, Blajchman A, Stephenson M, et al. Prospective followup of breast-fed infants exposed to maternal medication. Am J Obstet Gynecol.1993;168:1393-1399.
8. Harmon T, Burkhart G, Applebaum H. Perforated pseudomembranous colitis in the breast-fed infant. J Pediatr Surg. 1992;27:744-746.
9. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 8th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2008.
10. Gupta K, Hooton TM, Naber KG, et al; Infectious Diseases Society of America; European Society for Microbiology and Infectious Diseases. International Clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103-e120.
11. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemical into human milk. Pediatrics. 2001;108:776-789.
Evidence-based answers from the Family Physicians Inquiries Network
Does blood pressure screening benefit children?
SCREENING MAY NOT SHOW BENEFITS in childhood but could pay off for adults. Although major professional organizations recommend measuring blood pressure (BP) at every clinic visit for all children older than 3 years (strength of recommendation [SOR]: C, expert opinion), scant evidence links earlier detection and treatment of childhood hypertension with improved patient-oriented outcomes.
However, detecting childhood hypertension may help identify adults who would benefit from earlier treatment. Children with elevated BP have a more than 60% chance of being hypertensive as young adults (SOR: B, prospective cohort study). Children with systolic BP above the 95th percentile had a more than 4-fold increase in coronary artery disease as adults compared with children below the 95th percentile (SOR: B, retrospective study).
Identifying hypertension in children is associated with a 15-fold greater likelihood of hypertension in their parents (SOR: B, case series).
Evidence summary
The US Preventive Services Task Force considers screening adults for hypertension a grade A recommendation because it’s known to improve patient outcomes through early diagnosis, treatment, and prevention of serious cardiovascular complications.1
The Fourth Task Force of the National High Blood Pressure Education Program Working Group, endorsed by the American Academy of Pediatrics, states that maintaining a large national database of BP values throughout childhood allows physicians to recognize children and adolescents with elevated BP.2 Data indicate that, in this population, the prevalence of prehypertension is 10% and the prevalence of hypertension is 4%.3
The Task Force suggests that detecting and treating childhood hypertension should be important because of increasing childhood obesity, the risk of developing left ventricular hypertrophy, and other intermediate cardiovascular effects in undiagnosed and untreated children. The Task Force acknowledges, however, that prospective longitudinal outcome studies in untreated children and adolescents are lacking.
Hypertensive children often grow up to be hypertensive adults
A prospective cohort study showed that children with elevated BP had a greater likelihood of adult hypertension than children with normal BP. Investigators followed 2445 children 7 to 18 years of age to determine whether elevated BP in childhood correlated with increased BP in adulthood.
Investigators obtained BP, height, and weight measurements biennially during the children’s school years and when they were young adults between 20 and 30 years of age. Twelve to 13 years later, 24% of children with BP above the 90th percentile still had BP above the 90th percentile (relative risk [RR]=2.4; P<.001) and 39% had BP above the 80th percentile (RR=1.9; P<.001). Ninety-four percent of children with more than 3 normal readings during the study were normotensive as young adults. Children with one or 2 abnormal readings had a 17% and 24% chance, respectively, of having hypertension as adults (P<.001).4
High childhood systolic BP may predict CAD in adulthood
A retrospective study evaluated 126 children 10 to 17 years of age who were admitted to the hospital for an elective surgical procedure between 1950 and 1967. Children with documented BP readings at admission were eligible for the study; children with preexisting cardiac and renal disease were excluded. Investigators reassessed patients as adults (age range 42-68 years); the mean follow-up period was 42 years.
Mean BP was 125/80 mm Hg at admission and 133/75 mm Hg at follow-up. Univariate logistic regression analysis showed a significant association between systolic BP in childhood and coronary artery disease at follow-up (odds ratio [OR]=1.052; 95% confidence interval [CI], 1.005-1.101; P=.027). Children with systolic BP at or above the 95th percentile had a 4-fold increase in coronary artery disease at follow-up compared with children whose systolic BP was below the 95th percentile (29% vs 7%, P=.03). Investigators also found an association between elevated BP in childhood and a diagnosis of hypertension at follow-up (P=.007).
Limitations of the study included small sample size, selection bias, changes in the definition of hypertension during the 4 decades since the study began, and limited childhood BP data (a single measurement at admission for surgery).5
Parents of hypertensive children are likely to be hypertensive themselves
Screening BP in children has the potential to identify families at increased risk for cardiovascular disease. A case series found a high incidence of hypertension among the parents of children with elevated BP. Investigators measured several risk factors, including BP in 141 children (mean age 10.5±3.4 years) and 108 parents (at least one a biological parent, mean age 38.5±7.5 years). They obtained 2 BP readings 15 to 30 minutes apart.
Parents of children with BPs at or above the 95th percentile had a 15-fold greater likelihood of hypertension themselves (OR=14.7; 95% CI, 3.02-71.56; P=.009, positive predictive value=75%; negative predictive value=81%).6 Limitations of the study included small sample size, high prevalence of obesity and black ethnicity in the study population (a population with a greater incidence of hypertension), and only 2 BP measurements in the same day, which isn’t diagnostic for hypertension.
Recommendations
The American College of Obstetricians and Gynecologists recommends screening girls for hypertension between 13 and 15 years of age.7
The American Academy of Family Physicians concludes that the evidence is insufficient to recommend for or against routine screening for hypertension in children and adolescents to reduce the risk of cardiovascular disease.8
The European Society of Hypertension and European Society of Cardiology recommend that children older than 3 years have auscultatory BP measurements at each clinic visit.9
1. US Preventive Services Task Force. Screening for high blood pressure: reaffirmation recommendation statement. December 2007. AHRQ publication 08-05105-EF-2. Available at: http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbprs.htm. Accessed June 19, 2012.
2. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl):555-576.
3. Din-Dzietham R, Liu Y, Bielo MV, et al. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116:1488-1496.
4. Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics. 1989;84:633-641.
5. Erlingsdottir A, Indridason OS, Thorvaldsson O, et al. Blood pressure in children and target-organ damage later in life. Pediatr Nephrol. 2010;25:323-328.
6. Reis EC, Kip KE, Marroquin OC, et al. Screening children to identify families at increased risk for cardiovascular disease. Pediatrics. 2006;118:e1789-e1797.
7. American Congress of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 452: Primary and preventive care: periodic assessments. Obstet Gynecol. 2009;114:1444-1451.
8. American Academy of Family Physicians. Hypertension. Available at http://www.aafp.org/online/en/home/clinical/exam/hypertension.html. Accessed April 16, 2012.
9. Lurbe E, Cifkova R, Cruickshank J, et al. Management of high blood pressure in children and adolescents: recommendation of the European Society of Hypertension. J Hypertens. 2009;27:1719-1742.
SCREENING MAY NOT SHOW BENEFITS in childhood but could pay off for adults. Although major professional organizations recommend measuring blood pressure (BP) at every clinic visit for all children older than 3 years (strength of recommendation [SOR]: C, expert opinion), scant evidence links earlier detection and treatment of childhood hypertension with improved patient-oriented outcomes.
However, detecting childhood hypertension may help identify adults who would benefit from earlier treatment. Children with elevated BP have a more than 60% chance of being hypertensive as young adults (SOR: B, prospective cohort study). Children with systolic BP above the 95th percentile had a more than 4-fold increase in coronary artery disease as adults compared with children below the 95th percentile (SOR: B, retrospective study).
Identifying hypertension in children is associated with a 15-fold greater likelihood of hypertension in their parents (SOR: B, case series).
Evidence summary
The US Preventive Services Task Force considers screening adults for hypertension a grade A recommendation because it’s known to improve patient outcomes through early diagnosis, treatment, and prevention of serious cardiovascular complications.1
The Fourth Task Force of the National High Blood Pressure Education Program Working Group, endorsed by the American Academy of Pediatrics, states that maintaining a large national database of BP values throughout childhood allows physicians to recognize children and adolescents with elevated BP.2 Data indicate that, in this population, the prevalence of prehypertension is 10% and the prevalence of hypertension is 4%.3
The Task Force suggests that detecting and treating childhood hypertension should be important because of increasing childhood obesity, the risk of developing left ventricular hypertrophy, and other intermediate cardiovascular effects in undiagnosed and untreated children. The Task Force acknowledges, however, that prospective longitudinal outcome studies in untreated children and adolescents are lacking.
Hypertensive children often grow up to be hypertensive adults
A prospective cohort study showed that children with elevated BP had a greater likelihood of adult hypertension than children with normal BP. Investigators followed 2445 children 7 to 18 years of age to determine whether elevated BP in childhood correlated with increased BP in adulthood.
Investigators obtained BP, height, and weight measurements biennially during the children’s school years and when they were young adults between 20 and 30 years of age. Twelve to 13 years later, 24% of children with BP above the 90th percentile still had BP above the 90th percentile (relative risk [RR]=2.4; P<.001) and 39% had BP above the 80th percentile (RR=1.9; P<.001). Ninety-four percent of children with more than 3 normal readings during the study were normotensive as young adults. Children with one or 2 abnormal readings had a 17% and 24% chance, respectively, of having hypertension as adults (P<.001).4
High childhood systolic BP may predict CAD in adulthood
A retrospective study evaluated 126 children 10 to 17 years of age who were admitted to the hospital for an elective surgical procedure between 1950 and 1967. Children with documented BP readings at admission were eligible for the study; children with preexisting cardiac and renal disease were excluded. Investigators reassessed patients as adults (age range 42-68 years); the mean follow-up period was 42 years.
Mean BP was 125/80 mm Hg at admission and 133/75 mm Hg at follow-up. Univariate logistic regression analysis showed a significant association between systolic BP in childhood and coronary artery disease at follow-up (odds ratio [OR]=1.052; 95% confidence interval [CI], 1.005-1.101; P=.027). Children with systolic BP at or above the 95th percentile had a 4-fold increase in coronary artery disease at follow-up compared with children whose systolic BP was below the 95th percentile (29% vs 7%, P=.03). Investigators also found an association between elevated BP in childhood and a diagnosis of hypertension at follow-up (P=.007).
Limitations of the study included small sample size, selection bias, changes in the definition of hypertension during the 4 decades since the study began, and limited childhood BP data (a single measurement at admission for surgery).5
Parents of hypertensive children are likely to be hypertensive themselves
Screening BP in children has the potential to identify families at increased risk for cardiovascular disease. A case series found a high incidence of hypertension among the parents of children with elevated BP. Investigators measured several risk factors, including BP in 141 children (mean age 10.5±3.4 years) and 108 parents (at least one a biological parent, mean age 38.5±7.5 years). They obtained 2 BP readings 15 to 30 minutes apart.
Parents of children with BPs at or above the 95th percentile had a 15-fold greater likelihood of hypertension themselves (OR=14.7; 95% CI, 3.02-71.56; P=.009, positive predictive value=75%; negative predictive value=81%).6 Limitations of the study included small sample size, high prevalence of obesity and black ethnicity in the study population (a population with a greater incidence of hypertension), and only 2 BP measurements in the same day, which isn’t diagnostic for hypertension.
Recommendations
The American College of Obstetricians and Gynecologists recommends screening girls for hypertension between 13 and 15 years of age.7
The American Academy of Family Physicians concludes that the evidence is insufficient to recommend for or against routine screening for hypertension in children and adolescents to reduce the risk of cardiovascular disease.8
The European Society of Hypertension and European Society of Cardiology recommend that children older than 3 years have auscultatory BP measurements at each clinic visit.9
SCREENING MAY NOT SHOW BENEFITS in childhood but could pay off for adults. Although major professional organizations recommend measuring blood pressure (BP) at every clinic visit for all children older than 3 years (strength of recommendation [SOR]: C, expert opinion), scant evidence links earlier detection and treatment of childhood hypertension with improved patient-oriented outcomes.
However, detecting childhood hypertension may help identify adults who would benefit from earlier treatment. Children with elevated BP have a more than 60% chance of being hypertensive as young adults (SOR: B, prospective cohort study). Children with systolic BP above the 95th percentile had a more than 4-fold increase in coronary artery disease as adults compared with children below the 95th percentile (SOR: B, retrospective study).
Identifying hypertension in children is associated with a 15-fold greater likelihood of hypertension in their parents (SOR: B, case series).
Evidence summary
The US Preventive Services Task Force considers screening adults for hypertension a grade A recommendation because it’s known to improve patient outcomes through early diagnosis, treatment, and prevention of serious cardiovascular complications.1
The Fourth Task Force of the National High Blood Pressure Education Program Working Group, endorsed by the American Academy of Pediatrics, states that maintaining a large national database of BP values throughout childhood allows physicians to recognize children and adolescents with elevated BP.2 Data indicate that, in this population, the prevalence of prehypertension is 10% and the prevalence of hypertension is 4%.3
The Task Force suggests that detecting and treating childhood hypertension should be important because of increasing childhood obesity, the risk of developing left ventricular hypertrophy, and other intermediate cardiovascular effects in undiagnosed and untreated children. The Task Force acknowledges, however, that prospective longitudinal outcome studies in untreated children and adolescents are lacking.
Hypertensive children often grow up to be hypertensive adults
A prospective cohort study showed that children with elevated BP had a greater likelihood of adult hypertension than children with normal BP. Investigators followed 2445 children 7 to 18 years of age to determine whether elevated BP in childhood correlated with increased BP in adulthood.
Investigators obtained BP, height, and weight measurements biennially during the children’s school years and when they were young adults between 20 and 30 years of age. Twelve to 13 years later, 24% of children with BP above the 90th percentile still had BP above the 90th percentile (relative risk [RR]=2.4; P<.001) and 39% had BP above the 80th percentile (RR=1.9; P<.001). Ninety-four percent of children with more than 3 normal readings during the study were normotensive as young adults. Children with one or 2 abnormal readings had a 17% and 24% chance, respectively, of having hypertension as adults (P<.001).4
High childhood systolic BP may predict CAD in adulthood
A retrospective study evaluated 126 children 10 to 17 years of age who were admitted to the hospital for an elective surgical procedure between 1950 and 1967. Children with documented BP readings at admission were eligible for the study; children with preexisting cardiac and renal disease were excluded. Investigators reassessed patients as adults (age range 42-68 years); the mean follow-up period was 42 years.
Mean BP was 125/80 mm Hg at admission and 133/75 mm Hg at follow-up. Univariate logistic regression analysis showed a significant association between systolic BP in childhood and coronary artery disease at follow-up (odds ratio [OR]=1.052; 95% confidence interval [CI], 1.005-1.101; P=.027). Children with systolic BP at or above the 95th percentile had a 4-fold increase in coronary artery disease at follow-up compared with children whose systolic BP was below the 95th percentile (29% vs 7%, P=.03). Investigators also found an association between elevated BP in childhood and a diagnosis of hypertension at follow-up (P=.007).
Limitations of the study included small sample size, selection bias, changes in the definition of hypertension during the 4 decades since the study began, and limited childhood BP data (a single measurement at admission for surgery).5
Parents of hypertensive children are likely to be hypertensive themselves
Screening BP in children has the potential to identify families at increased risk for cardiovascular disease. A case series found a high incidence of hypertension among the parents of children with elevated BP. Investigators measured several risk factors, including BP in 141 children (mean age 10.5±3.4 years) and 108 parents (at least one a biological parent, mean age 38.5±7.5 years). They obtained 2 BP readings 15 to 30 minutes apart.
Parents of children with BPs at or above the 95th percentile had a 15-fold greater likelihood of hypertension themselves (OR=14.7; 95% CI, 3.02-71.56; P=.009, positive predictive value=75%; negative predictive value=81%).6 Limitations of the study included small sample size, high prevalence of obesity and black ethnicity in the study population (a population with a greater incidence of hypertension), and only 2 BP measurements in the same day, which isn’t diagnostic for hypertension.
Recommendations
The American College of Obstetricians and Gynecologists recommends screening girls for hypertension between 13 and 15 years of age.7
The American Academy of Family Physicians concludes that the evidence is insufficient to recommend for or against routine screening for hypertension in children and adolescents to reduce the risk of cardiovascular disease.8
The European Society of Hypertension and European Society of Cardiology recommend that children older than 3 years have auscultatory BP measurements at each clinic visit.9
1. US Preventive Services Task Force. Screening for high blood pressure: reaffirmation recommendation statement. December 2007. AHRQ publication 08-05105-EF-2. Available at: http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbprs.htm. Accessed June 19, 2012.
2. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl):555-576.
3. Din-Dzietham R, Liu Y, Bielo MV, et al. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116:1488-1496.
4. Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics. 1989;84:633-641.
5. Erlingsdottir A, Indridason OS, Thorvaldsson O, et al. Blood pressure in children and target-organ damage later in life. Pediatr Nephrol. 2010;25:323-328.
6. Reis EC, Kip KE, Marroquin OC, et al. Screening children to identify families at increased risk for cardiovascular disease. Pediatrics. 2006;118:e1789-e1797.
7. American Congress of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 452: Primary and preventive care: periodic assessments. Obstet Gynecol. 2009;114:1444-1451.
8. American Academy of Family Physicians. Hypertension. Available at http://www.aafp.org/online/en/home/clinical/exam/hypertension.html. Accessed April 16, 2012.
9. Lurbe E, Cifkova R, Cruickshank J, et al. Management of high blood pressure in children and adolescents: recommendation of the European Society of Hypertension. J Hypertens. 2009;27:1719-1742.
1. US Preventive Services Task Force. Screening for high blood pressure: reaffirmation recommendation statement. December 2007. AHRQ publication 08-05105-EF-2. Available at: http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbprs.htm. Accessed June 19, 2012.
2. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl):555-576.
3. Din-Dzietham R, Liu Y, Bielo MV, et al. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116:1488-1496.
4. Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics. 1989;84:633-641.
5. Erlingsdottir A, Indridason OS, Thorvaldsson O, et al. Blood pressure in children and target-organ damage later in life. Pediatr Nephrol. 2010;25:323-328.
6. Reis EC, Kip KE, Marroquin OC, et al. Screening children to identify families at increased risk for cardiovascular disease. Pediatrics. 2006;118:e1789-e1797.
7. American Congress of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 452: Primary and preventive care: periodic assessments. Obstet Gynecol. 2009;114:1444-1451.
8. American Academy of Family Physicians. Hypertension. Available at http://www.aafp.org/online/en/home/clinical/exam/hypertension.html. Accessed April 16, 2012.
9. Lurbe E, Cifkova R, Cruickshank J, et al. Management of high blood pressure in children and adolescents: recommendation of the European Society of Hypertension. J Hypertens. 2009;27:1719-1742.
Evidence-based answers from the Family Physicians Inquiries Network