Version May 2024
INTRODUCTION — The optimal management for hypertension in neonates and older infants remains uncertain due to the lack of evidence regarding long-term outcome and clinical trials evaluating the safety and efficacy of antihypertensive agents in this age group. As a result, therapeutic recommendations generally rely on expert opinion based on clinical experience and judgment.
This topic reviews the management of hypertension in neonates and infants, including a suggested approach for initiating pharmacologic therapy. The etiology, evaluation, and diagnosis of hypertension in neonates and older infants are discussed separately. (See "Etiology, clinical features, and diagnosis of neonatal hypertension" and "Evaluation and diagnosis of hypertension in infants between one month and one year of age".)
DEFINITION
●Neonates are newborn infants between 0 to 30 days of age
●Infants include all individuals who are less than 12 months of age and include neonates
OVERVIEW — Because data are extremely limited regarding the treatment of hypertension in infancy, the approach to management is largely empiric and differs widely from that used in older children. Management decisions depend on the severity of hypertension, underlying cause, and other clinical factors that impact the infant's clinical status.
Treatment consists of identifying and correcting any curable cause of hypertension and, when indicated, initiating pharmacologic therapy to lower blood pressure (BP).
However, clinical criteria (ie, BP thresholds) for starting antihypertensive medications in infancy are not well defined, because of a paucity of robust normative data and long-term outcome data. As a result, indications for initiation of antihypertensive therapy are primarily based on expert clinical opinion [1]. In addition, there is limited information on the efficacy and safety of specific agents to control hypertension in neonates and older infants and most of the available data are from small observational case series [2-7]. Thus, most treatment decisions regarding pharmacologic intervention must rely on clinical experience and judgment. Prior to starting antihypertensive medications in a neonate or infant, consultation with a pediatric nephrologist and/or other clinician with experience in the management of hypertension in this age group is recommended.
CORRECTING UNDERLYING CAUSE — Many causes of hypertension during infancy can be addressed by addressing the underlying cause. These include:
●Sodium and fluid imbalance. (See "Fluid and electrolyte therapy in newborns".)
●Hyperthyroidism. (See "Evaluation and management of neonatal Graves disease" and "Evaluation and management of neonatal Graves disease", section on 'Treatment'.)
●Drugs – Drugs that are known to increase blood pressure (BP; eg, corticosteroids) should be withdrawn, if possible.
●Congenital adrenal hyperplasia – Infants diagnosed with congenital adrenal hyperplasia should be treated with glucocorticoid therapy. (See "Uncommon congenital adrenal hyperplasias", section on '11-beta-hydroxylase deficiency' and "Uncommon congenital adrenal hyperplasias", section on 'CYP17A1 deficiencies'.)
●Pain – Pain should always be assessed and treated. (See "Assessment of pain in neonates" and "Management and prevention of pain in neonates".)
●Congenital anomalies – Surgery may be required to correct anatomic abnormalities, such as urinary obstruction or coarctation of the aorta. Decisions about the timing of the procedure depend on the severity of the hypertension, response to medical therapy, and age and size of the infant [8]. Antihypertensive drug therapy may be needed in patients awaiting corrective surgical intervention. (See "Congenital ureteropelvic junction obstruction" and "Treatment and prognosis of Wilms tumor", section on 'Management' and "Management of coarctation of the aorta", section on 'Procedures' and "Management of coarctation of the aorta".)
●Aortic and/or renal thromboembolism – The management of major aortic and/or renal thromboembolism usually includes administration of antithrombotic agents. The efficacy and safety of such treatment in infancy are unclear, although new insights are emerging [9,10]. These patients may need to be treated with antihypertensive medication.
●Catheter-associated thromboembolism – There are fewer data available on catheter-associated thromboembolic disease, which is felt to be one of the most common causes of neonatal hypertension. These thrombi are difficult, if not impossible, to demonstrate on imaging, especially in neonates. Diagnosis is often surmised, not proven, and the need for treatment is based on clinician judgment.
●Renovascular hypertension secondary to unilateral renal artery stenosis – Unilateral nephrectomy is an option if the function of the affected kidney is poor and endovascular intervention is either impossible or unavailable. In one study, four patients who underwent unilateral nephrectomy for unilateral renovascular disease had normal growth, BP, and kidney function at follow-up 5 to 16 years [11].
APPROACH TO PHARMACOLOGIC TREATMENT
Who should be treated? — The criteria for drug treatment of hypertension in neonates and infants are uncertain as there are no short- or long-term outcome data on the consequences of untreated hypertension in this age group.
The following approach is based on consensus expert opinion and clinical experience [1]. Management decisions are made based on the severity of hypertension and whether symptoms or evidence of end-organ damage are present (figure 1 and figure 2 and figure 3 and table 1). (See "Etiology, clinical features, and diagnosis of neonatal hypertension", section on 'Clinical features' and "Etiology, clinical features, and diagnosis of neonatal hypertension", section on 'Diagnosis' and "Evaluation and diagnosis of hypertension in infants between one month and one year of age", section on 'Diagnosis'.)
Mild asymptomatic hypertension — Observation may be most appropriate for asymptomatic healthy neonates and infants with mild hypertension (systolic blood pressure [BP] 95th to <99th percentile) with no evidence of target-organ involvement (eg, left ventricular hypertrophy [LVH]). Depending on the etiology, the hypertension will likely resolve over time in many such cases.
●Neonates – Neonates (usually hospitalized) with mild hypertension (95th to <99th percentile) who are asymptomatic may be observed closely with ongoing BP monitoring. If the BP elevation is persistent, drug treatment can be considered. Echocardiography is helpful in assessing for target-organ damage. LVH would be an indication for the initiation of drug therapy. Similarly, treatment should be strongly considered if there is proven underlying kidney disease.
●Older infants – Older infants with either systolic or diastolic BP values between the 95th and 99th percentile should be reevaluated to see whether the elevated BP is persistent. In hospitalized infants, this can occur over several days. In the ambulatory setting, repeating BP measurements in two to three weeks is reasonable. If BP elevation remains persistent, the decision whether to institute pharmacologic therapy should be made based on the underlying cause of hypertension and whether there is evidence of target-organ injury. (See "Evaluation and diagnosis of hypertension in infants between one month and one year of age", section on 'Diagnosis'.)
Mild hypertension with evidence of end-organ involvement — Antihypertensive therapy should be started in neonates and infants with persistent asymptomatic mild hypertension with evidence of target-organ involvement, typically LVH detected by echocardiography. There are no clinical trial data to guide medication choice in this age group; therefore, choice of agent is at the discretion of the treating clinician. Similar to patients with asymptomatic hypertension, reasonable choices include calcium channel blockers, diuretics, beta blockers (may wish to avoid in patients with a history of chronic lung disease), and agents blocking the renin-angiotensin-aldosterone system (if the patient is greater than 44 weeks postmenstrual age). (See 'Pharmacologic agents' below.)
Asymptomatic moderate hypertension — Antihypertensive therapy is started in neonates and infants with persistent asymptomatic moderate hypertension, defined as a BP ≥99th percentile [1]. Oral medications may be used if the patient is clinically stable and able to take oral medications, or after initial treatment with intravenous (IV) antihypertensive medications and the patient is ready to be transitioned to oral medication.
Although case series have reported on a wide variety of agents used to treat persistent hypertension in neonates and older infants [1-7], there are no clinical trial data available to guide the choice of medication in these patients. Reasonable choices include calcium channel blockers, diuretics, beta blockers (may wish to avoid in patients with a history of chronic lung disease), and, if the patient is greater than 44 weeks postmenstrual age (gestational age at birth plus chronologic age), agents blocking the renin-angiotensin-aldosterone system. (See 'Pharmacologic agents' below.)
Severe symptomatic hypertension — Severe symptomatic hypertension [8,12], as in older children with hypertensive emergencies, must be managed aggressively but in a controlled and safe manner. Continuous infusions of IV medications should be used as they act quickly and have short onset and offset of action, which allow titration to the desired effect. As in older children, BP should be lowered in a controlled fashion by no more than 25 percent of the planned reduction over the first eight hours. Further reduction to the target BP (usually the 95th percentile for age) can be made over the next 24 to 36 hours. IV bolus infusions and potent oral medications should be avoided because they may lower BP too precipitously and their duration of action may be too long. (See "Initial management of hypertensive emergencies and urgencies in children" and 'Target blood pressure goal' below.)
For patients treated with an IV antihypertensive agent, BP should be measured either continuously through an intraarterial catheter or at frequent intervals by an oscillometric device.
Nicardipine (a calcium channel blocker) is generally considered the drug of choice for the management of severe hypertension in neonates and infants. It should be started as a continuous IV infusion at a dose of 0.5 mcg/kg per minute. If the target BP goal is not achieved within 15 minutes, the infusion can be increased in increments of 0.25 to 0.5 mcg/kg per minute every 15 minutes to a maximum of 3 to 4 mcg/kg per minute. Volume status may be a limiting factor since the medication must be diluted if given via peripheral venous access. In the rare patient whose BP does not respond to nicardipine, or whose BP remains elevated on the maximum dose of nicardipine, infusions of either sodium nitroprusside or esmolol can be added or substituted. Once the target BP is reached, and if the clinical condition permits, transition to oral medication can be considered. (See 'Calcium channel blockers' below.)
Pharmacologic management — When antihypertensive therapy is initiated, it is best to begin with a single drug, increasing the dose in a stepwise fashion to the maximum dose until BP is controlled. If hypertension persists, or adverse effects of the first drug are seen, a second drug should be added.
Choice of pharmacologic agent — However, there is a paucity of data on the use of specific antihypertensive agents to treat neonates and infants with hypertension. Information is derived from small case series reporting use of antihypertensive drugs in newborns and/or older infants [2-7,13,14]. Given the lack of properly conducted clinical trials in this age group, treatment is usually empiric and the choice of therapy relies on clinical experience and judgment and the clinical setting. In addition, the availability of specific agents, especially extemporaneously prepared oral liquid formulations, will vary among institutions. Thus, consultation with a pediatric nephrologist or other clinician with experience in the management of neonatal hypertension is recommended.
The choice of antihypertensive agent depends on the severity of hypertension. For neonates and infants with acute severe hypertension, continuous IV antihypertensive administration (eg, nicardipine) is preferred so that BP can be rapidly modified and safely lowered based on patient response. Oral agents can be used in patients with less severe hypertension. (See "Etiology, clinical features, and diagnosis of neonatal hypertension", section on 'Definition' and 'Approach to pharmacologic treatment' above.)
Despite the paucity of data, all classes of antihypertensive agents have been used in the treatment of hypertension in neonates and older infants, including diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta blockers, calcium channel blockers, and direct vasodilators [15-18]. Suggested doses for antihypertensive medications commonly used in infants can be found in the table (table 2).
Target blood pressure goal — Although target BP goals have not been established for infants treated with antihypertensive therapy, we suggest an ultimate target BP goal less than the 90th percentile, as recommended by the 2017 American Academy of Pediatrics Guidelines for Screening and Management of High Blood Pressure in Children and Adolescents [19]. The 95th percentile may be an appropriate goal for initial management of acute severe hypertension in the intensive care setting, with further reduction to the 90th percentile deferred to later phases of care.
PHARMACOLOGIC AGENTS
Diuretics — Diuretics reduce extracellular and plasma volume, resulting in a modest decrease in blood pressure (BP). Their use in infancy usually is limited to mild hypertension resulting from volume overload or as a second-line medication when BP cannot be controlled using a single agent. Diuretic therapy may also be beneficial in improving lung function in infants with bronchopulmonary dysplasia. (See "Bronchopulmonary dysplasia (BPD): Management and outcome", section on 'Diuretics'.)
If diuretics are used in the treatment of hypertension in infants, thiazide diuretics (eg, chlorothiazide and hydrochlorothiazide) are generally preferred to loop diuretics (eg, furosemide) because of the increased risk of adverse effects with loop diuretics. Loop diuretics are associated with a greater risk of electrolyte abnormalities, particularly hypokalemia, and may also lead to nephrocalcinosis due to hypercalciuria.
If a diuretic is indicated, we suggest starting with a low dose of either chlorothiazide (10 mg/kg per day, divided Q 12 hours) or hydrochlorothiazide (1 mg/kg per day) and making adjustments every three to four days (table 2). Availability of commercial suspensions of chlorothiazide has fluctuated over the past several years [20], leading to reliance on locally compounded suspensions. Electrolytes should be monitored within 72 hours and periodically thereafter when introducing a diuretic.
Potassium-sparing diuretics such as spironolactone were generally not felt to be useful in the management of hypertension in infants; however, the use of spironolactone as monotherapy was reported to be effective in a United States case series of hypertensive neonates [18]. In that study, many infants were found to have low renin and aldosterone, suggestive of volume overload. The results of this study may lead to reexamination of the role of this class of antihypertensive agents in the treatment of neonatal hypertension.
Renin-angiotensin-aldosterone system blockers
●Neonates – We do not recommend the use of angiotensin-converting enzyme (ACE) inhibitors in infants, because of concerns for significant adverse effects.
•Captopril, an oral ACE inhibitor, is effective in lowering BP in infants [4], but it causes a well-known exaggerated fall in BP in premature infants [21]. Seizures and acute kidney injury have been associated with the precipitous fall in BP due to captopril [22].
•Enalaprilat is an intravenously (IV) administered ACE inhibitor that is effective in severe hypertension. There is one case series in neonates that reported that doses even at the lower end of what was used in this cohort may lead to significant, prolonged hypotension and oliguric acute kidney injury [3]. As a result, we do not recommend routine use of enalaprilat. If it is used in a newborn, it should be used with caution, with ongoing monitoring of BP and kidney function. It should be used with caution, if at all, in neonates.
•The use of an ACE inhibitor in neonates may also affect normal kidney development because of its inhibition of the neonatal renin-angiotensin system [23]. Although few data exist on the neonatal effect of ACE inhibitors, the known adverse effects on fetal kidney development with the maternal use of these agents have led to concerns that they may impair the final stages of kidney maturation when given to neonates. (See "Adverse effects of angiotensin converting enzyme inhibitors and receptor blockers in pregnancy".)
●Older infants – Based on the above concerns, we typically avoid use of ACE inhibitors or angiotensin receptor blockers (ARBs) until the infant has reached a corrected postmenstrual age of 44 weeks.
If an ACE inhibitor or ARB is selected for use in an older infant, it should be noted that these agents are contraindicated in patients with bilateral renovascular disease or renovascular disease in a solitary kidney. In these cases, loss of the angiotensin II-mediated maintenance of glomerular capillary pressure can result in acute kidney injury. While enalapril and lisinopril suspensions are commercially available, captopril is only commercially available in a tablet formulation. Although a 1 mg/mL suspension can be compounded, there may be great variability when prepared by local pharmacists [24,25]. Suspension formulations of ARBs can be prepared extemporaneously; several agents have compounding instructions included in their US Food and Drug Administration-approved labels.
Beta blockers — Beta blockers are widely used in the treatment of neonatal hypertension and include both oral and IV preparations (table 2). However, these agents should be avoided in infants with chronic lung disease because of possible bronchoconstriction.
●Propranolol is effective in treating neonatal hypertension, and side effects (aside from bradycardia) are uncommon. It is one of the only agents commercially available as a suspension, making it attractive for use in infants.
●Labetalol is a combined alpha-1 and beta blocker with a rapid onset of action and duration of two to three hours. It is typically administered IV, either as a continuous infusion or in intermittent doses. It may be particularly useful in both catecholamine- and central nervous system-mediated hypertension since it does not cause tachycardia, cerebral vasodilatation, or changes in intracranial pressure.
●Esmolol is an ultra-short-acting IV cardioselective beta-1 adrenergic blocker that is well suited for management of severe symptomatic hypertension because of its rapid onset of action (approximately 60 seconds) and relatively short duration of action (10 to 20 minutes) [26]. It is particularly effective in the management of acute hypertension in infants and children after repair of aortic coarctation [27].
Calcium channel blockers — Dihydropyridine calcium channel blockers, such as nicardipine and isradipine, are potent peripheral vasodilators and are effective in the treatment of neonatal hypertension. IV nicardipine is generally considered the drug of choice for management of severe hypertension. Both oral and IV formulations of calcium channel blockers are available to treat infants (table 2).
●Nicardipine appears to be effective and safe in term and preterm newborns and in older infants with hypertension of a variety of etiologies [2,5,6,28,29]. IV nicardipine is generally considered the drug of choice for management of severe hypertension because its administration decreases BP within minutes. Because of its short half-life of 10 to 15 minutes, it is given as a continuous infusion. Nicardipine is started as a continuous IV infusion at a dose of 0.5 mcg/kg per minute. If the target BP goal is not achieved within 15 minutes, the infusion can be increased in increments of 0.25 to 0.5 mcg/kg per minute every 15 minutes to a maximum of 3 mcg/kg per minute. In the rare patient whose BP does not respond to nicardipine or whose BP remains elevated on the maximum dose of nicardipine, infusions of either sodium nitroprusside or esmolol can be added or substituted. Once the target BP is reached, and if the clinical condition permits, transition to oral medication can be considered. An associated side effect is tachycardia, which is usually clinically insignificant. (See 'Sodium nitroprusside' below and 'Beta blockers' above.)
●Isradipine appears to be an effective oral calcium channel blocker and has been reported effective in both acute and chronic hypertension in two single-center case series that included small numbers of infants [7,30]. It takes effect within one to two hours after administration and may be compounded into a stable 1 mg/mL suspension, facilitating its use in infants.
●Amlodipine is a longer-acting calcium channel blocker that has also found widespread use in the treatment of hypertensive children, including in a case series of hypertensive infants [17]. Its maximal hypotensive effect may not be seen for several days after initiation of therapy, making it best suited for management of chronic hypertension.
●The use of short-acting nifedipine is no longer recommended. It cannot be compounded into a stable, easy-to-administer oral formulation and can cause exaggerated, rapid drops in BP [31].
Vasodilators — Hydralazine, minoxidil, and sodium nitroprusside are antihypertensive agents used in infants that act as direct vasodilators (table 2).
Hydralazine — Hydralazine is a direct vasodilator with an unclear mechanism of action that causes relaxation of vascular smooth muscle, resulting in BP reduction. Oral or IV hydralazine may be useful in the treatment of moderate hypertension in infants. However, significant variation in response to IV hydralazine has been reported [32], which may result in undesirably large drops in BP in the acute setting.
Minoxidil — Minoxidil is a direct vasodilator that opens potassium channels in smooth muscle cells, causing potassium efflux, which, in turn, leads to hyperpolarization and relaxation [33]. It acts primarily on arterioles and does not produce venous dilatation. Although primarily studied in older children with refractory hypertension, minoxidil may be useful in rare infants with severe secondary forms of hypertension. Well-known side effects include hirsutism and fluid retention that are primarily seen with chronic use.
Sodium nitroprusside — IV sodium nitroprusside is a direct vasodilator of both arteriolar and venous smooth muscle cells. It is metabolized to nitric oxide, which dilates both arterioles and venules, thereby reducing total peripheral resistance, accounting for its efficacy in the treatment of severe hypertension. Because of its rapid onset of action and short duration of effect, BP can be carefully titrated. Complications include hypotension and thiocyanate toxicity, which can occur with prolonged administration (>72 hours) or reduced kidney function. Thiocyanate levels should be monitored in these settings.
ONGOING MANAGEMENT — In most cases of neonatal hypertension, blood pressure (BP) control can be readily achieved with antihypertensive medications. In any neonate treated with antihypertensive medications, the infant should not be discharged from the nursery until the desired goals of treatment are determined and the potential adverse effects of the prescribed agents are reviewed with the parents/caregivers.
After discharge from the nursery, infants with chronic hypertension may require increasing doses of their antihypertensive medication as they grow. As a result, ongoing BP monitoring will be needed to assure that BP control is being maintained. In these patients, proper equipment needs to be arranged for home use (usually an oscillometric device) and the parents/caregivers instructed on the use of the equipment. At our center, we routinely provide home oscillometric devices to the families of infants discharged on antihypertensive medications and home BP measurements are used to adjust medication dosing.
Duration of treatment and course — The duration of therapy and long-term outcome may be influenced by the ability to identify and treat the underlying disease. (See "Etiology, clinical features, and diagnosis of neonatal hypertension", section on 'Etiology'.)
●Renovascular hypertension secondary to umbilical catheter-associated thromboembolism is typically transient, with some patients requiring treatment for only a few weeks or months. It is typical for infants to initially require increased dosing of medications as they gain weight after discharge, then for the BP to remain controlled on the same dose despite ongoing growth. When the dosing remains unchanged despite ongoing growth, the medication can be slowly weaned and discontinued. The following two studies illustrate the relatively good prognosis of hypertension due to aortic and/or renal thromboembolism:
•In a study of 11 infants with renovascular hypertension (primarily due to renal artery thrombosis), BP remained normal after antihypertensive therapy was discontinued [34]. At a mean follow-up of 5.75 years, creatinine clearance was normal in all but one patient. However, radionuclide scans were abnormal, with evidence of unilateral kidney atrophy in five patients.
•In a second study of 15 children with neonatal aortic thrombosis and renovascular hypertension, BP was normal at an average age of 26 months [35]. However, five patients who were less than 24 months of age still required antihypertensive medication. All patients had normal serum creatinine concentration and plasma renin activity.
•In a case series of neonates with hypertension of either undermined origin or associated with bronchopulmonary dysplasia [18], hypertension resolved at a median of 25 weeks after treatment initiation.
●Hypertension associated with acute kidney injury should resolve when the kidney function improves. (See "Neonatal acute kidney injury: Pathogenesis, etiology, clinical presentation, and diagnosis", section on 'Tubular and interstitial disease'.)
●Chronic hypertension is observed in infants with persistent kidney dysfunction or kidney parenchymal diseases such as autosomal recessive polycystic kidney disease. (See "Autosomal recessive polycystic kidney disease in children".)
●Hypertension associated with coarctation of the aorta typically resolves following successful correction, although these infants are at risk for recurrence of hypertension later in life. (See "Management of coarctation of the aorta", section on 'Systemic hypertension'.)
LONG-TERM OUTCOME — No data have been published regarding the outcome of hypertensive infants in late childhood, let alone adulthood. For this reason, we recommend that patients with neonatal hypertension should be closely followed. Monitoring of blood pressure (BP) and kidney function should be performed on a regular basis. In our practice, patients are generally seen monthly for the first three to six months after discharge from the neonatal intensive care unit, then every three months after that. Given the high prevalence of renovascular and other kidney parenchymal causes of hypertension, serial kidney imaging should also be considered to monitor kidney growth. There is a great need for long-term outcome studies to better define the prognosis of hypertensive infants.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in children".)
SUMMARY AND RECOMMENDATIONS
●Overview – Data are limited regarding the treatment of hypertension in neonates and older infants. The approach to management is similar to that used in older children, with decisions based on the severity of hypertension, underlying cause, and other clinical factors that impact the wellbeing of the patient.
●Underlying cause – Management includes identifying and correcting underlying causes that are amenable to treatment with resolution of hypertension, including fluid overload, hyperthyroidism, congenital adrenal hyperplasia, pain, abdominal or kidney tumors, obstructive uropathy, and coarctation of the aorta. (See 'Correcting underlying cause' above.)
●Who should be treated – Clinical criteria for starting antihypertensive therapy in neonates and infants, such as blood pressure (BP) thresholds, are not well defined. As a result, indications for initiation of antihypertensive therapy are primarily based on expert clinical opinion. BP percentiles are derived from limited data in neonates and older infants (table 1 and table 3). (See 'Approach to pharmacologic treatment' above and "Etiology, clinical features, and diagnosis of neonatal hypertension" and "Etiology, clinical features, and diagnosis of neonatal hypertension", section on 'Normal blood pressure' and "Evaluation and diagnosis of hypertension in infants between one month and one year of age", section on 'Normal blood pressure'.)
•For asymptomatic neonates and infants with mild hypertension (systolic BP 95th to <99th percentile), we suggest observation and continued monitoring for asymptomatic neonates and infants versus the initiation of pharmacologic therapy (Grade 2C). (See 'Mild asymptomatic hypertension' above.)
•For neonates and infants with mild hypertension with end-organ involvement, we suggest pharmacologic therapy for neonates and infants with mild hypertension who have end-organ involvement versus observation (Grade 2C). (See 'Mild hypertension with evidence of end-organ involvement' above.)
•For neonates and infants with moderate, sustained asymptomatic hypertension (BP ≥99th percentile), we suggest pharmacologic therapy versus observation (Grade 2C). (See 'Asymptomatic moderate hypertension' above.)
•For neonates and infants with severe symptomatic hypertension, we suggest emergency administration of an intravenous (IV) antihypertensive agent (Grade 2C). In our center, nicardipine is administered in a continuous infusion at a dose of 0.5 mcg/kg per minute. BP is lowered in a controlled fashion by no more than 25 percent of the overall planned reduction (ie, target BP of 95th percentile for age) over the first eight hours. (See 'Severe symptomatic hypertension' above.)
●Target BP goal – Although target BP goals have not been established for infants treated with antihypertensive therapy, we suggest a target BP goal of 90th percentile for age (table 1 and table 3) (Grade 2C). (See 'Target blood pressure goal' above.)
●Pharmacologic management – When antihypertensive therapy is initiated, it is best to begin with a single drug, increasing the dose in a stepwise fashion to the maximum dose until the BP is controlled. If hypertension persists, or adverse effects of the first drug are seen, a second drug should be added. (See 'Pharmacologic management' above.)
●Choice of pharmacologic agent – There are no clinical trials to evaluate the comparative effectiveness of specific antihypertensive drugs in infants with hypertension. Classes of antihypertensive agents used in the management of infant hypertension include diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta blockers, calcium channel blockers, and direct vasodilators such as hydralazine, minoxidil, and sodium nitroprusside (table 2). (See 'Pharmacologic agents' above and 'Choice of pharmacologic agent' above.)
The choice of agent generally depends on the experience and judgment of the clinicians caring for the patient and availability of the medication, with the following caveats:
•Neonates and infants with severe symptomatic hypertension should receive IV medication to lower BP. We suggest administration of nicardipine, a calcium channel blocker, as a continuous IV infusion starting at a dose of 0.5 mcg/kg per minute (Grade 2C). (See 'Severe symptomatic hypertension' above and 'Calcium channel blockers' above.)
•We do not recommend the use of an ACE inhibitor or angiotensin receptor blocker (ARB) in neonates and infants <44 weeks postconceptual age, because of potential adverse effects on kidney development, and acute kidney injury and seizures due to precipitous and uncontrolled fall in BP (Grade 1B). (See 'Renin-angiotensin-aldosterone system blockers' above.)
•We suggest not using beta blockers to treat hypertension in infants with chronic lung disease, because of their potential to cause bronchoconstriction (Grade 2C). (See 'Beta blockers' above.)
●Ongoing management – Infants treated with antihypertensive therapy need to have ongoing BP monitoring. These infants may require increasing doses of their medication as they grow. In any neonate treated with antihypertensive medications, the infant should not be discharged from the nursery until the desired goals of treatment are determined and the potential adverse effects of the prescribed agents are reviewed with the parents/caregivers. (See 'Ongoing management' above.)
●Duration of therapy – The duration of therapy is influenced by the underlying cause of hypertension. In many cases, hypertension will resolve with recovery or treatment of the underlying disorder and chronic long-term antihypertensive therapy may not be needed. (See 'Duration of treatment and course' above.)
●Outcome – There are no long-term outcome data on the sequelae of hypertension during infancy. For infants and neonates treated for hypertension, follow-up care includes monitoring of BP as well as renal function and growth on a regular basis. (See 'Long-term outcome' above.)
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