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Table of Contents
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 65-71

Use of continuous holter of blood pressure in pediatric population: Single-center experience and review of literature

1 Department of Cardiology, Paediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2 Department of Cardiology, General Hospital ‘'Prim. Dr Abdulah Nakaš''; Department of Pharmacology, School of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
3 Department for Pathophysiology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
4 Department of Anesthesiology, General Hospital ‘'Prim. Dr Abdulah Nakaš''; Sarajevo, Bosnia and Herzegovina

Date of Submission04-Aug-2020
Date of Decision13-Aug-2020
Date of Acceptance19-Sep-2020
Date of Web Publication26-Oct-2020

Correspondence Address:
Dr. Zijo Begic
Department of Cardiology, Pediatric Clinic, Clinical Center University of Sarajevo, Patriotske Lige 81, Sarajevo 71000
Bosnia and Herzegovina
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_31_20

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Introduction: A Holter blood pressure monitoring is a basic method for the diagnosis and evaluation of hypertension therapy. Hypertension in children and adolescents is defined as an increase of systolic/diastolic pressure, which is equal, or above 95th percentile blood pressure for sex, age, and height. Aim: The aim of this study is to analyze the etiology of arterial hypertension (AH) in the pediatric population. Methods: Research had descriptive and retrospective character. During the period from March 2006 to April 2020, 1527 registered continuous Holters of blood pressure were analyzed. Data were taken from the medical documentation of patients that were hospitalized on Pediatric Clinic (register of continuous Holter of blood pressure). Results: Out of the total number of registered and analyzed patients 833 were male (54.5%) with dominant age 15–19 years of life 774 (50.6%), school-age children 660 (43.2%), preschool children 93 (6.1%). We had 902 (59%) first registrations and 626 (41%) control registrations. AH was verified in 52 patients (387 records of continuous Holter of blood pressure were performed to them). Primary AH was verified in 27 patients and secondary AH in 25 patients. Forty patients (76.9%) were treated with monotherapy while combined therapy was used in 12 (23.1%) of cases. Renal cause was in 28% patients, endocrine in 24%, cardiovascular in 24%, neurological in 16%, and rheumatic in 8% of patients with secondary AH. Conclusion: Continuous Holter of blood pressure represents useful diagnostic method and method of control of high blood pressure in children and adolescents. It should be routine method in everyday pediatric clinical practice especially in pediatric cardiology.

Keywords: Diagnosis, hypertension, pediatrics

How to cite this article:
Begic Z, Begic N, Begic E, Secic D, Begic S. Use of continuous holter of blood pressure in pediatric population: Single-center experience and review of literature. Res Cardiovasc Med 2020;9:65-71

How to cite this URL:
Begic Z, Begic N, Begic E, Secic D, Begic S. Use of continuous holter of blood pressure in pediatric population: Single-center experience and review of literature. Res Cardiovasc Med [serial online] 2020 [cited 2022 May 23];9:65-71. Available from: https://www.rcvmonline.com/text.asp?2020/9/3/65/298990

  Introduction Top

Arterial hypertension (AH) is a risk factor for the development of atherosclerosis, which represents the main risk factor of the development of coronary, cerebrovascular, and renovascular diseases.[1],[2] AH in children is defined as an increase of systolic/diastolic blood pressure, which is equal, or higher than 95th percentile of blood pressure for sex, age, and height measured at least in three separate measurements.[3] Borderline AH (prehypertension) is average systolic and/or diastolic tension on 90th percentile or higher, but below 95th percentile. Since 16th year and above borderline blood pressure is the same as in adults 130–139/85–89 mmHg, and hypertension is blood pressure equal or higher than 140/90 mmHg. AH of first degree in children is 95–99 percentile + 5 mmHg, and second degree above 99 percentile + 5 mmHg.[1] In adolescents above 16 years, AH is classified as for adult patients.[4],[5] Special kind of AH is isolated systolic hypertension.[2] Elevated blood pressure in childhood is the strongest predictor of AH in adult age.[6] This definition is arbitrary and is based on the normal distribution of blood pressure in healthy children.

AH effects heart, kidneys, and central nervous system leading to functional and structural changes.[2] Cardiovascular renal sequelae of AH that started in childhood and adolescence can be manifested in the adult period.[7] Expected prevalence of AH in healthy children and adolescents population is about 5%. After 10 years of life primary hypertension is dominant, and 81% of adolescents with hypertension has isolated systolic hypertension.[8] Epidemic of obesity contributes to the increase of prevalence, so AH is present in 1.4% of adolescents of normal weight, 7.1 preobese, and 25% of obese adolescents.[8],[9] Unfortunately, knowledge and recognition of the problem by the medical professionals remains poor. Diagnostic begins with confirmation of AH by measurement (auscultation and oscillometric) and continuous Holter blood pressure monitoring.[10],[11] Anamnesis is significant for the diagnosis so that targeted individualized approach could be enabled and that expensive and inadequate diagnostic methods could be avoided.[11] Family history includes AH, diabetes mellitus, dyslipidemia, cardiovascular diseases, hereditary renal diseases and hereditary disease of endocrine system, syndrome associated with AH, and obesity.[11],[12] Personal history means actual or earlier symptoms of secondary AH (perinatal anamnesis and medication use) and anamnesis about the symptoms of damaging the target organs. Risk factors include diabetes mellitus, dyslipidemia, obesity, physical inactivity, poor dietary habits, smoking, alcohol, inadequate birth weight and gestational age, anamnesis about snoring and sleep apnea, headache, visual disturbances, nose bleeding, nausea, lack of sleep, and unhealthy lifestyle.[2],[11] In these data, it is important to know the time of onset of AH, treatment modality related to age, and co-operation in the treatment and side effects of drugs. For the onset of cardiometabolic diseases in adults, the development in utero and in the 1st year of life is important as well.[13] Physical examination is started with accurately measured height and weight related to percentiles and accurately measured arterial tension, along with palpation of femoral arteries. The basic examination records growth retardation, pallor, edemas, obesity, signs of Cushing, but also signs of many syndromes.[14],[15],[16],[17] On the skin, rash, neurofibromas, acanthosis, pseudoxanthoma should be checked. Eye fundus examination along with the examination of signs of cataract, hemangioblastoma, and ptosis should be performed. During the examination of the abdomen, medical doctor has to check abdomen level, possible palpable, tumorous changes, and signs of venous thrombosis. In the neurological examination, the presence of cranial nerve palsy, hemiparesis, and reflex changes should be noted. Cardiovascular system is checked through the auscultation of heart rhythm, tones, and murmurs. Inspection of the genitals (virilization), joints, and muscles has to be also a part of examination. Laboratory findings of urine (presence of albuminuria), urea, creatinine, uric acid, electrolytes, glucose, cholesterol, renin (plasma renin activity), aldosterone, thyroid hormones, sex hormones, levels of drugs in the blood, catecholamines and vanillylmandelic acid in urine, cortisol (along with Iodine-131 Metaiodobenzylguanidine scintigraphy), and adrenocorticotropic hormone (ACTH) in the plasma (circadian rhythm pattern) and urine has to be a methods in diagnostic modality. Tumor markers (alpha-fetoprotein, beta human chorionic gonadotropin, neuron-specific enolase, carcinoembryonic antigen, and ferritin), echocardiography, abdominal and renal ultrasound are also a part of diagnostic algorithm. Additional tests are recommended for children who are obese (glycated hemoglobin, aspartate transaminase, alanine transaminase, and fasting lipid profile). When the diagnosis of AH is determined, the assessment of target organ damage is useful. The target organs that can be damaged are the heart (left ventricular hypertrophy), blood vessels (atherosclerosis), kidneys (parenchymal tissue and vessels), fundus (retinal blood vessels), and brain (microhemorrhage).[2],[18] Therapy is nonpharmacological (conservative-reduced salt intake, weight loss, physical activity, alcohol and cigarette avoiding, and treatment of associated metabolic-type diseases such as diabetes mellitus, hyperlipidemia, hypercholesterolemia, and pharmacological therapy (angiotensin-converting enzyme [ACE] inhibitors, calcium channel inhibitors, and beta-blockers).[2],[19],[20],[21] Usually, we start therapy with ACE inhibitors, most commonly captopril, enalapril and lisinopril, less frequently with calcium blockers nifedipine or amlodipine, and very rarely beta-blockers propranolol and atenolol. Alpha-blockers and angiotensin receptor antagonists, vasodilators, and diuretics are very rarely given and monotherapy is preferred. Antihypertensive drugs may be combined only in certain cases.[2],[22],[23],[24] There are the specificities of the use of antihypertensive drugs in diabetes mellitus, heart failure, nondiabetic kidney disease, metabolic syndrome with the problem of therapy-resistant AH and urgent and/or malignant hypertension.[2] The treatment of associated risk factors is with anti-hyperlipidemia and glycemic control drugs.[2],[23] Monitoring for AH in children is probably lifelong.[23],[25]


The aim of this article was to analyze the etiology of AH in the pediatric population.

  Methods Top

Research had descriptive and retrospective character. During the period March 2006–April 2020, 1528 registered continuous holters of blood pressure were analyzed. Data were taken from the medical documentation of patients that were hospitalized on Department of Cardiology, Pediatric Clinic, Clinical Center University of Sarajevo (register of continuous Holter of blood pressure).

  Results Top

Out of the total number of registered and analyzed patients, 833 were male (54.5%) with dominant age 15–19 years of life 774 (50.6%), school-age children 660 (43.2%), preschool children 93 (6.1%). We had 902 (59%) first registrations and 626 (41%) control registrations. AH was verified in 52 patients (387 records of continuous Holter of blood pressure were performed to them). Primary AH was verified in 27 patients and secondary AH in 25 patients. Forty patients (76.9%) were treated with monotherapy while combined therapy was used in 12 (23.1%) of cases. Renal cause was in 28% patients, endocrine in 24%, cardiovascular in 24%, neurological in 16%, and rheumatic in 8% of patients with secondary AH [Figure 1].
Figure 1: Etiology of secondary hypertension (n = 25)

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  Discussion Top

Considering the guidelines (European Society of Hypertension in 2016 and American Academy of Pediatrics in 2017), there are some new features in the form of clear recommendations for both the diagnosis and treatment of these patients. AH classifications have also been supplemented, and there are also the changes in the form of a proper way to measure blood pressure. In addition, the concept of understanding of primary AH, which are actually more prevalent in the pediatric age, has been expanded. The causes of AH generally depend on the age of the children and are divided into two large groups: primary (idiopathic and essential) AH, which usually has no underlying organic disease, is most commonly seen in adolescents and secondary AH with a known cause and occurrence in preschool and school age.[26],[27] The basic characteristics of primary and secondary AH are accurately defined, with clear recommendations for the diagnosis and treatment. The importance of the continuous blood pressure monitoring and its value in terms of diagnosis, therapy, monitoring, and prognosis is emphasized.[28] The guidelines should not be part of academic knowledge but an useful starting point for better prevention, diagnosis and therapy of childhood AH. The incidence of pediatric AH is clearly higher than previously thought and is becoming a growing public health problem.

The main characteristics of primary AH are that patients are mainly children above 8 years of age or in the adolescent age. These patients are often overweight, have a positive family history of AH, usually have first-degree hypertension, are usually asymptomatic and have more often elevated systolic tension than diastolic.[29],[30] There are two types of factors that affect the occurrence of primary AH and these are preventable or variable factors (obesity, poor dietary habits, excessive salt intake, smoking, stress exposure, sedentary lifestyle, and poor quality of sleep), while invariable factors are race, gender, genetics, prematurity, and low birth weight.[30],[31] Pregnancy factors are increasingly being mentioned in terms of maternal nutrition, maternal obesity, diabetes and hypertension, and corticosteroids during pregnancy (endogenous and exogenous), maternal infections, and placental dysfunction.[32],[33] Primary AH is often associated with dyslipidemia, insulin resistance, sympathetic activation, impaired sodium and renin-angiotensin homeostasis, coagulation disorders, and target organ damage. The most common factors for early manifestation of essential AH are borderline blood pressure (90–95 percentiles), obesity, and hypertension in the family.[34] Probably, 30%–50% of hypertensive adolescents are adipose.[34],[35]

It is essential to identify and register children with metabolic syndrome (AH, dyslipidemia, and glucose intolerance with insulin resistance).[34],[36] Treatment of primary AH rests on the principle of treatment of risk factors which imply primarily normalization of body weight, diet with less salt, increased physical activity most often during the first 12 months, followed by the introduction of drug therapy.[37] Nonpharmacological therapy should be initiated in all children with borderline hypertension and hypertension, and this therapy should be continued after the possible initiation of pharmacological therapy. Evidence of the effectiveness of hypertension therapy procedures are mainly based on studies with randomization based on intermediate outcomes with respect to the heart and improvement in left ventricular function, and with regard to kidney function and kidney disease, antihypertensive therapy could have a significant impact on delaying renal failure. Predictors of future cardioprotection and nephroprotection are probably more complex than we know so far.

The treatment of AH must also be based on the overall risk for cardiovascular and renal complications, not just the on the height of blood pressure. In primary hypertension, the goal should be to prevent damage to the target organs-heart, kidney, endocrine system (in secondary hypertension treatment of the underlying disease). Pharmacological therapy should be initiated in all children symptomatic hypertension, hypertensive target organ damage, secondary hypertension, diabetes mellitus Type 1 and Type 2, and in children who have persistent hypertension for at least 1 year, although undergoing nonpharmacological therapy.[37],[38],[39] It is likely that medications should also be given to some children with borderline AH who have hypertensive damage to the target organs. Blood pressure control in hypertensive patients has two main therapeutic goals: preventing cardiovascular complications and preventing kidney damage. Comorbidity with AH has been mostly researched related to obesity and metabolic syndrome, but also in diabetes mellitus and chronic kidney disease where there are direct correlations in all three cases and these diseases should be seen in complementarity of treatment. The target blood pressure value should be below the 95th percentile (although it should strive to achieve a value below the 90th percentile to prevent damage to the target organs), and in children with a higher risk score and proteinuric chronic kidney disease below the 50th percentile.[8],[26],[40] The optimal management for AH in 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. Although data are limited, the approach to management is similar to that used in older children, except for nonpharmacological management, which is important in older children but has very limited role in infants. Treatment consists of identifying and correcting any curable cause of hypertension, and when indicated, initiating pharmacological therapy to lower blood pressure. Continuous holter blood pressure monitoring is a noninvasive full-day monitoring of blood pressure during day and night, during daily activities, and sleep. It is done with standard cuffs placed on the upper arm of the left arm, which automatically measures the blood pressure during the day every 15–30 and during the night every 30–60 min with registration of systolic, diastolic, mean blood pressure, and frequency.[41],[42],[43] The maximum and minimum values are verified and the percentage of deviation from normal values.[42] It has been used in this form since the 1970s.[42],[43],[44],[45] This method significantly contributes to the diagnosis and monitoring of AH (detection of white coat hypertension and masked AH), enables a good assessment of circadian rhythm, monitors therapeutic response (during the sleep and early morning hours), reveals possible resistance to therapy.[42] Continuous Holter blood pressure monitoring must come to life as a basic method for determining the value of blood pressure even with the smallest suspicion of AH. It shows daily pressure fluctuations depending on the child's activity. AH is considered to be present if more than 25% of the measurements exceed the 95th percentile predicted for age, gender, and height. AH can be diagnosed in children if there is no normal lowering of 10% in blood pressure during the night. In the form of hypertension, we have an increase in diastolic daily pressure of 25% and nocturnal systolic pressure of 50% or more. In clinical practice, continuous holter blood pressure monitoring can be performed children after the age of 6 years. In particular, continuous holter blood pressure monitoring should be used frequently in chronic renal patients, where the blood pressure should strictly be kept below the 50th percentile. Diabetic nephropathy is rarely seen in children, but it also requires strict blood pressure control.[46] The indications for the use are both types of diabetes mellitus, kidney, liver and heart transplants, severe obesity with or without breathing disturbances during sleep, and responding with hypertension to exercise tests as well as discrepancies between blood pressure measured at the hospital and at home. During drug antihypertensive therapy itself, it is necessary to exclude or evaluate the possible resistance of hypertension to drugs, to evaluate the regulation of blood pressure in children with target organ damage and the existence of symptoms of hypotension.[42],[47] In addition to indications during diagnosis and during antihypertensive therapy, there are indications related to the evaluation of autonomic dysfunctions and suspected catecholamine-secreting tumors.[47] Today, continuous Holter blood pressure monitoring is preferred at home environment. White coat hypertension is defined as elevated blood pressure at the doctor's office, and normal blood pressure when measured outside the office.[48] An inverse phenomenon is masked hypertension when blood pressure is normal in the doctor's office but increased outside. Blood pressure during physical activity as a method has not been widely used as a method of assessment of blood pressure in children, but it is significant in ergometry.[49] In the future, biomarkers could be good for risk stratification in patients on the individual level or as a determinant for the outcome, especially for cardiovascular complications. Secondary hypertension is usually suspected if AH is found in children less than 8 years of age, if there is second degree hypertension, along with secondary complications such as hypertensive encephalopathy, cranial nerve paresis and heart failure.[50] With standard pharmacotherapy, this hypertension is difficult to control, and numerous medical history and clinical signs may indicate the cause of secondary hypertension itself. The causes of the mentioned hypertension are seen in renal diseases (more often renoparenchymal than renovascular), endocrine diseases, cardiovascular, pulmonary, neurological, and iatrogenic. The leading causes of secondary hypertension are kidney diseases (67%–80%), which may be parenchymal diseases such as glomerulopathy (30%–40%), parenchymal damage (vesicoureteral reflux and pyelonephritis) (15%–30%), hemolytic-uremic syndrome (6%–14%), polycystosis (5%–10%), chronic kidney failure, transplantation, obstructive hydronephrosis, tumor (nephroblastoma-Wilms tumor), or kidney blood vessels diseases (8%–12%) such as renal artery stenosis (fibromuscular dysplasia and Williams-Beuren syndrome), multiple vascular lesions (diffuse arterial calcified elastopathy, neurofibromatosis, and panarteritis), and renal artery thrombosis.[20],[25],[38],[40],[48] It is a silent disease with isolated hypertension as its primary clinical manifestation.[51] Secondary hypertension caused by diseases of the endocrine glands (1%–8%) such as pheochromocytoma, congenital adrenal hyperplasia, hyperthyroidism, primary aldosteronism, Cushing's syndrome are relatively common as well as cardiovascular diseases, coarctation of aorta and hypoplastic aorta, angiodysplasia, arterio-venous fistulas, patent arterial ductus, aortic valvular insufficiency, and mitral insufficiency [52],[53],[54],[55],[56] [Table 1]. Neuropediatric diseases may also be a cause of secondary hypertension; encephalitis, increased intracranial pressure, familial dysautonomia, neurofibromatosis, Guillain-Barre syndrome, poliomyelitis, and metabolic diseases (hyperkalcemia, hypernatremia, and acute intermittent porphyria).[54],[57],[58] Secondary hypertension can also occur as hereditary “monogenic hypertension” (should be suspected in case of dyskalemia), which may be autosomal dominant (Liddle's syndrome, Gordon's syndrome, and hyperaldosteronism sensitive to dexamethasone) and autosomal recessive (Ulrich syndrome).[54],[55],[59] The cause can also be exogenous or medicamentous (corticotherapy, Vitamin D, vasoconstrictors, cyclosporins, amphetamine, heavy metal poisoning, and burns).[53],[60],[61],[62] Glucocorticoids and disease-modifying antirheumatic drugs can lead to increased blood pressure.[52] The cause of AH also depends on the age of the child. Newborns usually have renal artery and vein thrombosis, congenital renal abnormalities, coarctation of the aorta, and bronchopulmonary dysplasia. In preschool age, stenosis of renal artery with renal parenchymal diseases, nephroblastoma, neuroblastoma, and coarctation of aorta.[63] Between 7 and 12 years, usually, renal diseases are present, less frequently endocrine. In adolescent age, primary hypertension is dominant.[64] Earlier epidemiology has highlighted the view that hypertension in children is relatively rare and most commonly caused by kidney diseases.[65]
Table 1: Causes of secondary hypertension[66],[67]

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The diagnostic procedure and differential diagnosis of hypertension in children in the first step include complete blood count, analysis of glucose, creatinine, urea, uric acid, cholesterol, triglycerides, urine, urine culture, determination of albuminuria and proteinuria, renal ultrasound, echocardiography, determination of carotid intima-media thickness, continuous measurement of arterial pressure, and measurement of pulse-wave velocity.[66],[67] The second step would be analysis of renin and aldosterone or plasma renin activity, metanephrines and normetanephrines in 24-h urine, cortisol and ACTHs in plasma, free cortisol in 24-h urine, urinary steroid profile, thyroid hormones, thyroid steroids and Vitamin D metabolites, corticosterone, 18-hydroxycorticosterone, and 11 deoxycortisol.[66],[67] In the third step, renal scintigraphy (captopril test) is performed, along with noninvasive and invasive imaging of renal arteries, imaging of the adrenal gland/paraganglioma and molecular genetic testing.[66],[67]

There was an orientation toward the detection and treatment of secondary hypertension. Today, it has been realized that blood pressure measurement should be an integral part of ongoing health monitoring, leading to the conclusion that mild or moderate asymptomatic hypertension is much more common than previously thought. With this, the prevalence and incidence, with already present pandemic of obesity in children and adolescents, has brought to the highlight the primary hypertension, which in childhood can cause damage to the target organs.[68] Familial screening is done due to the knowledge that hypertension is a polygenic condition. It would be very important for pediatricians and especially pediatric cardiologists to recognize children and adolescents who are at risk or already have AH and to take preventative therapeutic measures in a timely manner. The basis for this assignment must be taken by a pediatric cardiology service with mandatory blood pressure measurement as part of a regular pediatric examination. The method of measuring the pressure, the place where the pressure is measured, the size of the cuff, but also the measuring method itself is important. In principle, pressure is measured for children from the age of three, although depending on the occasion and the present diagnosis, it can be done in the infant and young child. Measurements below the age of 3 are performed under special circumstances in neonatology as intensive care monitoring, congenital heart diseases, kidney diseases, medications with known effects on blood pressure, and increased intracranial pressure.[69],[70],[71],[72],[73]

  Conclusion Top

Measurement of blood pressure as a mandatory part of the examination of the child must be established from birth and at the latest from the period of the young child. Early diagnosis of AH is the best prevention of chronic diseases in adults. The diagnosis of hypertension in children should not be established unless there is no evidence that blood pressure elevation is continuous (continuous holter blood pressure monitoring). The initiation of pharmacological therapy in primary hypertension is usually after the age of 12, after at least 1 year of nonpharmacological therapy, and in secondary hypertension, the treatment depends on the cause. Therapy should be initiated in childhood as these diseases are also transmitted into adulthood. It is desirable to have a salutogenic approach. There is good evidence that identifying children with AH and successfully treating their hypertension has an important impact on the long-term outcome of cardiovascular diseases. Continuous Holter blood pressure monitoring is a good diagnostic method for the evaluation of hypertension existence, but also for estimating the effect of antihypertensive therapy, which in principle should be monotherapy in childhood. Continuous Holter blood pressure monitoring must be a routine method in everyday pediatric clinical practice, especially pediatric cardiology. Priorities to improve clinical practice include more education among clinicians about diagnosis and management, clinical decision support to aid in diagnosis, routine use of ambulatory holter blood pressure monitoring, and to monitor response in treatment. The European and American guidelines for the diagnosis, therapy and monitoring of high blood pressure in children and adolescents should be the basis of our daily work. Pediatric AH is becoming a growing public health problem. It is likely that a multidisciplinary team of pediatricians (cardiologists, nephrologists, endocrinologists, neuropediatricians, nutritionists, psychologists, etc.,) should be formed in Bosnia and Herzegovina to present and adapt the latest guidelines to everyday pediatric practice.

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Ethical approval was obtained from Ethics Committee Clinical Center University of Sarajevo.

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Conflicts of interest

There are no conflicts of interest.

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