Avoid beta blockers for patients with asthma or other obstructive airway disease

Avoid beta blockers for patients with asthma or other obstructive airway disease: Excerpt from Avoiding Common Pediatric Errors

Author: Lindsey Albrecht, MD

What to Do - Interpret the Data, Make a Decision, Take Action

Hypertension in childhood is defined as a systolic blood pressure and/or diastolic blood pressure greater than the 95th percentile for age, gender, and height on multiple occasions. In the past decade, the detection and management of pediatric hypertension has evolved, partly because normative data has become available and the long-term consequences have been more clearly elucidated. Additionally, given the increasing incidence of childhood obesity and the association with elevated blood pressure, hypertension is being recognized as a major health issue in the pediatric population. Although lifestylemodificationplaysanimportantroleinpediatrichypertension,medical management is often required.

Pharmacologic therapy should be initiated when lifestyle modification fails or in the presence of secondary hypertension, symptomatic hypertension, or end organ damage (often left ventricular hypertrophy). To begin, single drug therapy is recommended. When initiated, treatment may be with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, calcium channel blockers, beta blockers, or diuretics. Specific classes of medication are used preferentially in certain disease states; for example, ACE inhibitors have been shown to be efficacious in preventing disease progression in children with proteinuric renal disease.

Beta-receptor antagonist drugs, or beta blockers, work by competitively reducing receptor occupancy by catecholamines and other beta agonists. Because catecholamines have positive inotropic and chronotropic effects on the heart, beta blockade leads to a reduction in heart rate and a reduction in myocardial contractility. Beta-2 receptor blockade leads initially to increased peripheral vascular resistance, but with chronic use, the resistance returns to normal. Beta blockers do not reduce blood pressure in normotensive individuals but do reduce blood pressure in hypertensive ones. In children, they are safe and effective.

Patients with asthma or underlying airway disease may suffer an increase in airway resistance or bronchoconstriction following treatment with beta blockers. Bronchoconstriction occurs because beta-2 receptor blockade in bronchial smooth muscle leads to smooth muscle contraction. This affect may be subtle, with mild symptoms including wheezing or dyspnea on exertion, but may be life-threatening. More severe bronchoconstriction does not seem to occur in individuals without underlying pulmonary disease. Because of this, nonselective beta blockers (those with no preference for thecardiac or beta-1 subtype of beta receptors), such as propranolol, are contraindicated in children with asthma. Some beta receptor antagonists, such as metoprolol and atenolol, are designed to selectively work on beta-1 receptors, and these medications are considered to be less likely to cause pulmonary side effects. However, because even the selective forms have some affinity for the beta-2 receptors, they should be used with caution in asthmatics and others with obstructive airway disease.

Hypertension in the pediatric population is an increasingly recognized problem. Pharmacologic therapy is often required, and when needed, the patient's underlying health should be taken into consideration. In particular, beta blocker use in asthmatics and others with pulmonary disease may have severe consequences related to a potential for bronchoconstriction.

Suggested Readings

Flynn JT, Daniels SR. Pharmacologic treatment of hypertension in children and adolescents. J Pediatr. 2006;149(6):746–754.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treat ment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl 4th Report):555–576.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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