Hypertension Linked With Learning and Attention Problems in Children

Reference: Adams H, Szilagyi P, Gebhardt L, Lande M. Learning and attention problems among children with pediatric hypertension. Pediatrics. 2010;126(6):e1425-9. [Epub ahead of print]

By Erin Psota, ND

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Design

Cross-sectional, retrospective review.

Participants

Data was collected on 201 patients 10 to 18 years of age, referred to the pediatric hypertension clinic at the University of Rochester Medical Center over a 3-year period. Subjects were assessed as either having or not having primary hypertension. Patients were considered hypertensive if either systolic or diastolic measurements were above the 95th percentile at the initial visit with subsequent confirmation by 24-hour ambulatory blood pressure monitoring, assessment by a school nurse, or home monitoring. Provider-confirmed learning disabilities (LDs) and/or formal treatment for attention deficit/hyperactivity disorder (ADHD) were assessed per parent report. Patients with secondary hypertension, known developmental delay or those receiving anti-hypertensive medication were excluded from the study.

Key Findings

Of the children evaluated, 18% (n=37) had LDs, which is significantly higher than the estimated 5% of the general population. Compared to the normotensive group, the hypertensive group was significantly more likely to have LDs, (28% vs 9%, P < 0.001), regardless of comorbid ADHD. The rate of LDs among the hypertensive group remained elevated when adjusted for age, gender, low socio-economic status and obesity.

Practice Implications

According to the International Pediatric Hypertension Association up to 5% of children have primary hypertension.1 The epidemic of pediatric obesity further highlights this concern as obese children have a 3-fold risk for developing hypertension.2 Studies indicate that lifetime prevalence of LDs in US children is nearly 10%.3 The CDC reports that the prevalence of parent-reported ADHD among children has increased by more than 20% from 2003 to 2007.4 It is clear that hypertension, LDs and ADHD are major challenges faced by this generation of children and their healthcare providers.

Treatment strategies for hypertension outlined by the American Academy of Pediatrics focus first on lifestyle modifications, reserving pharmacologic intervention for cases with insufficient response to lifestyle changes and for secondary hypertension.5 While recent clinical trials have expanded the number of anti-hypertensive drugs with pediatric dosing information, these trials also showed a number of commonly used anti-hypertensive medications to be ineffective in the pediatric population.6,7 It should also be noted that there is no data available on the long-term effects of these drugs on growth and development, yet they are still routinely prescribed to children.8,9

There is no data available on the long-term effects of these drugs on growth and development, yet they are still routinely prescribed to children.

Current treatment strategies for ADHD focus on stimulant medication and/or behavior therapy.10 The authors recognize that the inclusion of children taking stimulant medication for ADHD is a limitation of the study because of the potential side effect of elevated blood pressure. Interestingly, guanfacine (Tenex), an alpha-2-adrenoceptor agonist prescribed as an anti-hypertensive medication in adults, has been used in the management of ADHD in recent years either alone or in conjunction with stimulant medications. While the mechanism of action of guanfacine in ADHD is thought to be due to the binding of adrenoceptors in the pre-frontal cortex, perhaps its effectiveness may be attributed to its hypotensive properties as well.11

From a naturopathic perspective this study encourages practitioners to find and treat the cause. The mechanism linking primary hypertension to LDs in children has not yet been investigated. However, inflammation, toxic and heavy metal burden, nutrient deficiencies and an exaggerated stress response should be evaluated. When reviewing successful treatments widely used by naturopathic physicians for both hypertension and supporting cognitive function, an overlap is immediately apparent. Dietary changes, weight reduction and exercise would be the initial recommendations given by most, if not all naturopathic physicians. Following this, anti-oxidant and essential fatty acid status, as well as B vitamins, calcium and magnesium would all be important considerations for both of these conditions; as would the use of botanical medicines with cardiotonic, adaptogen and nervine qualities.

By linking neurocognitive function in the pediatric population with hypertension, this study may help to direct the diagnosis, treatment and ultimately the prevention of these conditions. A causative relationship has not yet been established, and further research is warranted. However, investigating the occurrence of one when presented with the other in a clinical setting seems justified and easily implemented.

About the Author

Erin Psota, ND, completed her medical studies at the Canadian College of Naturopathic Medicine (CCNM) in 2005 after obtaining her bachelor of science degree from the University of Waterloo. In 2010, her passion for pediatric medicine led her to the Southwest College of Naturopathic Medicine in Arizona to pursue a pediatric residency. In addition to maintaining a private practice in downtown Toronto, Psota is a clinical supervisor at CCNM and is actively involved with the College of Naturopaths of Ontario, the provincial regulatory body for naturopathic medicine.

References

1. International Pediatric Hypertension Association. International Pediatric Hypertension Association Website. Accessed January 24, 2011.

2. Sorof J, Daniels S. Obesity hypertension in children: a problem of epidemic proportions.
Hypertension. 2002;40(4):441-447.

3. Altarac M, Saroha E. Lifetime prevalence of learning disability among US children. Pediatrics. 2007;119(suppl):77S-83S.

4. Centers for Disease Control and Prevention. Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children–United States, 2003 and 2007. MMWR Weekly Report. 2010;59(44);1439-1443.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w. Accessed January 24, 2011.

5. National Heart, Lung and Blood Institute. 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(suppl 2):555S-576S.

6. Ibid.

7. Benjamin D, Smith P, Jadhav P, et al. Pediatric antihypertensive trial failures: Analysis of end points and dose range. Hypertension. 2008;51(4):834-840.

8. Sinaiko A. Antihypertensive therapy in children: Implications for future studies.
Hypertension. 2008;52(2):201-202.

9. National Heart, Lung and Blood Institute. 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(suppl 2):555S-576S.

10. American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. Clinical practice guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108(4):1033-1044.

11. Biederman J, Melmed R, Patel A, et al. A randomized, double-blind, placebo-controlled study of guanfacine extended release in children and adolescents with attention-deficit/hyperactivity disorder. Pediatrics 2008;121(1);e73-e84.