CC BY
9
Section 7. Medicine
Agzamova S. A.,
DM, professor, Tashkent Pediatric Medical Institute,
Akhmedova F.,
assistant, Tashkent Pediatric Medical Institute, Shamansurova E. A., DM, professor, Chief of Department Tashkent Pediatric Medical Institute E-mail: mbshakur@mail.ru
EVALUATION OF POTENTIALLY REMOVABLE RISK FACTORS OF ARTERIAL HYPERTENSION IN CHILDREN OF UZBEKISTAN
Abstract: Arterial hypertension (AH) is one of the topical problems in the modern medicine not only due to high prevalence in the population, but also high risk of vascular complications and invalidation. Late diagnostics and inadequate prognosis in children and adolescents serve the basis for high morbidity and lethality rates in elder age groups, while the success of prophylactic programs is directly dependent on the early implementation. Positive experience in the countries with low rate of lethality due to CVP demonstrates that the success of the strugle against that pathology is strongly dependent on its detection, treatment, and prevention in early childhood. That dictates the necessity of the designing of effective prophylactic programs, including screening in the risk groups and prevention of the formation of resistant forms of the disease.
Keywords: Arterial hypertension, late diagnostics, children.
Arterial hypertension (AH) is one of the topical problems tion mostly in adolescence, according to some authors opinion in the modern medicine not only due to high prevalence in the [3]. There are data that 17-25% of teenagers have progression population, but also high risk of vascular complications and of EAH with further formation of hypertonic disease [12]. invalidation. AH became significantly "younger", and its de- Scientists from the University of North Carolina (USA) re-velopment in children and teenagers is not rare anymore. The ported that predictors of cardiac pathologies were revealed in performed multiple massive studies of children's population 60% of adolescents. The pathology develops slowly for years, showed that the frequency of AH varied from 2.4% to 18% increasing the risk of vascular or cardiac death. In the structure [2; 11], while according to the results of foreign researches it of adult population morbidity in Russia cardiac-vascular pa-varies from 0.7% to 33.0% [4; 6]. thology is of the second rank (12-15%). Prevalence of these
A systematic review of school-based cross-sectional stud- diseases among children in 2006 reached the value of 912.4 ies was conducted to estimate the prevalence of hypertension cases per 100000 children in the age from 0 to 14 years old and among 14115 adolescent Brazilian students, (the articles were 1576.9 per 100000 children in the age from 15 to 17 years old searched in the databases MEDLINE, Embase, Scopus, LI- [8]. In our republic there is no data about the prevalence of LACS, SciELO, Web of Science, CAPES thesis database and EAH among children. That's why the design and implemen-Trip Database. Was retrieved 1,577 articles from the search tation of normative criteria of AH diagnosis dependently on and included 22 in the review) among them 51.2% (n = 7.230) the age, gender, and height of children in the primary line of female. The prevalence of hypertension was 8.0% (95%CI health care system is extremely important. 5.0-11.0; I = 97.6%), 9.3% (95%CI 5.6-13.6; I = 96.4%) in It is true that the results of multiple researches demon-
males and 6.5% (95%CI 4 .2-9.1; I= 94.2%) in females [10]. strated that pediatric hypertension was followed till adult life.
Within the last decades there was notable growth in the In other words, children with increased arterial pressure (AP) prevalence of essential AH (EAH), which had its manifesta- have more chances to become adults with hypertension. That
shows the importance of AP control among children and adolescents in the conditions of the primary line of health care system. In the process of aging arterial pressure (AP) gradually increases, and that is conditioned by increase of body mass and growth. That is why there is no common normative value of AP in children and adolescents. The criterion for AH diagnosis is the level of systolic AP (SAP) and\or diastolic AP (DAP) equal to or above 95 percentile for the given age, gender, and height. The normal AP corresponds to the values below 90th percentile; the values of SAP or DAP between 90th and 95th percentiles are considered to be high normal AP, and the child with that kind of pressure requires further follow up. Doctoral monitoring of children's health is performed both in our republic and abroad, but there are significant defects in the system ofAP control taking into account the age, gender, and height. Absence of a standard strategy for the assessment of the AP makes it impossible to evaluate real situation of AH prevalence among children. Urgency of the problem of AH in children and adolescents is determined by the importance and significance of the control of arterial pressure at home within everyday clinical practice of GP in developed countries. That method is included into the list of checkings, the management of which is compensated by insurance companies, in case of both state and private forms of help provision in the system of health carea [1; 7; 12].
There are detailed pediatric standards worked out for the United States based on the data of clinical studies performed by means of auscultation in more than 70000 children. AP percentiles were calculated for each gender, age group, and seven height percentile categories (Center for Disease Control and Prevention).
Because of the great volume of available data on the study of arterial pressure in children, the problem is still studied in the whole world. Besides that, it should be taken into account that, the results of the corresponding American Task Force are not applicable to European population, and for all age groups these data are just several millimeters of mercury column below the values, received by means of auscultation in the standard Italian, and about 10 mm below the values, received by oscilographic method in Norway. In the developed countries of Europe, USA, and Japan, even now that problem persists. Multicenter meta analysis shows certain tendencies. The search for the works in the system of Pubmed database demonstrated heterogeneity of the analyzed randomized groups of patients, which caused less definite results [5; 9].
In the modern time there is a justified opinion, according to which a greater part of adults with hypertonic disease are those who had high AP in childhood and adolescence. In this field it is very important to reveal early, treat, and prevent AH. The prophylaxis is based on the concept of common risk factors (RF), which can be relatively classified to congenital,
non-modulated, and potentially removable. Congenital RF are genetically conditioned ones, which make us classify the child as a member of high risk group; non-modulated ones are age, gender, suffered diseases, biochemical markers, etc. Removable RF are unbalanced nutrition, excessive body mass, insufficient physical activity, eating too much salt, smoking, alcohol, stress, 'chronic negative emotions', and so on. Exactly these ones are the most important for the prevention of AH. Our research of RF and evaluation of its impact on the development of EAH among 425 children of 13-15 years old based on the results of screening showed that distribution of the examined children dependently on the AP rate determined the prevailing of number of children with normal arterial pressure, while the number of children with high normal AP (HNAP) was equal to 16.9%, and with AH to 7.1%. According to the age and gender criteria there was a reliable prevailing of 15 years old children with AH, while HNAP was reliably more often registered in 14 years old, and in both groups the number of boys prevailed over girls [5].
The prevailing risk among girls according to the integration risk coefficient (IRC) of "physical development" was attributed to the factors such as 'low height risk' in all age groups, 'excessive weight risk' only in the age of13 years old, 'exhaustion risk' also in all age groups. In 14 and 15 years old 'low height' factor was registered. Among boys reliable RF were 'excessive weight risk' and 'low height risk' in all age groups, but there was no 'low height'. 'Complicated gynecological history' factor was more often registered among boys. There are gradually decreasing in prevalence factors such as endemic goiter, obesity, which were characteristic for both men and women, and high rate gaining weight in pregnant women.
Both genders had prevailing factor of 'complications of CVD of the I stage relativity. 'First-born syndrome' was met more often among boys, than girls. Presence of relatives with CVD was an important factor for the prognosis ofAH development in children [5; 7]. And the prevalence of arterial hypertension in the family, where there were relatives with arterial hypertension was 15 folds higher, than in the families with normal AP [1]. For the evaluation of the risk of AH and cardiac-vascular pathologies development in children and grandchildren the important criterion is not only presence of cardiac-vascular pathologies in parents, but also the age when these pathologies occurred. So, when we checked a group of children, whose parents had cardiac-vascular pathologies acquired before 45 years old, and a group of children, with "healthy" parents, it was noted, that the children, whose parents had "early" onset of cardiac-vascular diseases, had higher AP values, thickness of vascular wall, and metabolic alterations (increase cholesterol, prostaglandin B2-alfa, and glucose) compared to the children, whose parents were "healthy" [1; 6; 8].
But family predisposition to AH is not absolute [4]. Performed study demonstrated that, among the two groups with AH diagnosis, the first group had relatives with AH and worse results of AP, while the second group had no relatives with AH in history and better values of AP. During 6 years the group with family hypertension lived a healthy style of life (no smoking, moderate physical activity, etc) and their values of AP improved. At the same time the group without family history ofAH lived a worse life and the values ofAP also deteriorated [4; 11; 12]. IRC of "feeding", to be more exactly "formula feeding prior to 6 months" was more reliable risk factor of AH onset among boys (IRC = 12.3), than among girls (IRC = = 10.8). According to chance correlation (CC) the distribution of that risk factor was almost identical to integration values: CC = 4.1 for boys and CC = 3.8 for girls.
The impact of nutrition on the human genotype was linked with the trigger action of many nutrients on the start of alteration of the functions of certain genes, by these means changing metabolism, hormonal pathways, direction of signaling molecules. Critical periods in the alteration of the functions of genes correspond to the period of early development, and exactly 1000 days of existence, including antenatal period and initial two years of life. During postnatal period the speed of gaining weight or growth are the most important. Breastfeeding is the best method for provision of ideal nutrition for a healthy growth and development of infants; it is also a part of health with important consequences in adult life. The global recommendation of civil health care for optimal growth, development, and health of infants is the necessity of exclusive breastfeeding for initial six months of life.
3 months old breastfed baby receives average 1.2g\kg of protein a day, while a baby on formula receiving a standard mixture (containing 1.4 g protein per 100ml) gets 2.5g\kg a day; i. e. the amount of protein consumed with formula is actually 2 times more, than in case of breastfeeding. Increase in the protein consumption stimulates high level of amino acids with branched chains, so called insulinogenic amino acids, which in their turn increase the secretion of insulin and insulin-like growth factor 1 (IGF-1), intensifying baby's growth and possessing adipogenic activity.
IRC of "excessive body mass in initial 2 years of life" (between + 2SD and + 3SD - standard deviations of BMI)
was equal to 10.6 for boys and 9.2 for girls. IRC of "obesity" (above + 3SD - standard deviation of BMI) was 12.7 and 12.8 for boys and girls, respectively. An important predictor of increased arterial pressure is body mass.
The processes leading to the rise of AP in children with obesity and excessive body mass are complex and have multi-factor character. Children with obesity have not only increase in body mass, which can occur even without pathological process, like in case of physical training, but increase in the amount of fat.
Ranks of the leading risk factors of the development of AH among the examined children for integration risk (X) independently of the age distributed as follows gradually decreasing: "complicated with CVS with the I stage relativity" among both genders was the most important factor (X = = 17.3 for girls and X = 15.8 for boys); while the lowest one was "little iron amount" (X = 11.4 and 11.8, respectively). Only for the boys there was significant risk of "excessive weight", "GIT pathologies" and "formula feeding" (X = 13.1, 13.1 and 12.8, respectively), while for the girls these were "carriage disorder and flat-footedness" (X = 12.7).
Ranking of the leading risk factors for the development of arterial hypertension in children according to chance correlation (CC) was almost identical to integration values. Difference was conditioned by the factors such as gender (male) and age (15 years old), "little body mass at birth" was the third important factor, while retardation of fetal development the fifth one. Thus, screening of school-age children showed that, 16.9% of them from 13 to 15 years old had high normal AP and 7.1% had arterial hypertension.
Complicated heredity history with cardiac-vascular pathologies, formula feeding prior to 6 months, and disharmonic physical development within initial 2 years of life can 6.5 folds increase the chance of AH formation in children. Exclusive breastfeeding during initial six months is necessary not only for physical health and development of young children, but also for the diminishing of the risk of CD, including AH, with long-term perspectives. In relation to that, design and implementation of prophylactic actions among school-age children is a topical and important social-economical problem, the salvation of which will provide decrease of the risk of development and onset of AH in children and adolescents.
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