High altitude disease: Unique pediatric considerations
- Peter Hackett, MD
Peter Hackett, MD
- Clinical Professor of Emergency Medicine
- University of Colorado Denver School of Medicine
- Director, Institute for Altitude Medicine, Telluride, Colorado
- Scott A Gallagher, MD
Scott A Gallagher, MD
- Senior Clinical Instructor, Department of Surgery
- University of Colorado Denver School of Medicine
- Section Editor
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will review the unique pediatric aspects of high altitude illness (HAI).
The different types of HAI, their pathophysiology, and methods for prevention and treatment are discussed separately. (See "High altitude illness: Physiology, risk factors, and general prevention" and "Acute mountain sickness and high altitude cerebral edema" and "High altitude pulmonary edema" and "High altitude, air travel, and heart disease".)
Every year the beauty and recreational opportunities of the mountains attract millions of visitors from lowland elevations to high-altitude destinations worldwide. Resort towns in the Western United States alone attract over 30 million visitors annually, generally to sleeping elevations of 2000 to 3000 m (6560 to 9840 feet). Many more millions visit cities at these elevations, including several large cities in South America and Asia situated above 3000 m (9840 feet) . Most of these destinations can be reached within a day using modern means of transportation. Many of these mountain travelers are children.
Rapid ascents to high altitude place the unacclimatized child at risk for developing high altitude illness (HAI). Clinicians working in mountainous areas must familiarize themselves with the presentation and management of HAI in children, while all health care workers who advise travelers need to understand the best prevention strategies and treatment options. The clinician advising families with children on wilderness and high-altitude trips should offer an organized pre-trip evaluation that evaluates individual risk factors, provides recommendations for measures to prevent HAI, and determines whether prophylactic medication is appropriate . (See 'Patient risk assessment and mitigation' below and 'Prevention and pharmacologic prophylaxis' below and 'Travel advice for parents' below.)
HIGH ALTITUDE PHYSIOLOGY
Diminished inspired partial pressure of oxygen (PIO2) at altitude is the direct result of lower barometric pressure. As PIO2 decreases, so does the partial pressure of alveolar oxygen (PAO2), arterial PO2 (PaO2), and arterial oxygen saturation (SpO2), resulting in tissue hypoxia. This form of hypoxia is termed hypobaric hypoxia, and it represents the initial cause of high altitude illness (HAI). The physiology of HAI is discussed in more detail separately. (See "High altitude illness: Physiology, risk factors, and general prevention", section on 'High altitude physiology'.)
- Hackett PH, Luks AM, Lawley JS, Roach RC. High-altitude medicine and pathophysiology. In: Auerbach's Wildnerness Medicine, 7th ed, Auerbach PS, Cushing TA, Harris SN (Eds), Elsevier, Philadelphia 2017. p.8.
- Joy E, Van Baak K, Dec KL, et al. Wilderness Preparticipation Evaluation and Considerations for Special Populations. Wilderness Environ Med 2015; 26:S76.
- Durmowicz AG. Pulmonary edema in 6 children with Down syndrome during travel to moderate altitudes. Pediatrics 2001; 108:443.
- Fasules JW, Wiggins JW, Wolfe RR. Increased lung vasoreactivity in children from Leadville, Colorado, after recovery from high-altitude pulmonary edema. Circulation 1985; 72:957.
- Durmowicz AG, Noordeweir E, Nicholas R, Reeves JT. Inflammatory processes may predispose children to high-altitude pulmonary edema. J Pediatr 1997; 130:838.
- Duster MC, Derlet MN. High-altitude illness in children. Pediatr Ann 2009; 38:218.
- Choudhuri JA, Ogden LG, Ruttenber AJ, et al. Effect of altitude on hospitalizations for respiratory syncytial virus infection. Pediatrics 2006; 117:349.
- Lovering AT, Romer LM, Haverkamp HC, et al. Excessive gas exchange impairment during exercise in a subject with a history of bronchopulmonary dysplasia and high altitude pulmonary edema. High Alt Med Biol 2007; 8:62.
- Das BB, Wolfe RR, Chan KC, et al. High-altitude pulmonary edema in children with underlying cardiopulmonary disorders and pulmonary hypertension living at altitude. Arch Pediatr Adolesc Med 2004; 158:1170.
- Rios B, Driscoll DJ, McNamara DG. High-altitude pulmonary edema with absent right pulmonary artery. Pediatrics 1985; 75:314.
- Sebbane M, Wuyam B, Pin I, et al. Unilateral agenesis of the pulmonary artery and high-altitude pulmonary edema (HAPE) at moderate altitude. Pediatr Pulmonol 1997; 24:111.
- Niermeyer S. Going to high altitude with a newborn infant. High Alt Med Biol 2007; 8:117.
- Oades PJ, Buchdahl RM, Bush A. Prediction of hypoxaemia at high altitude in children with cystic fibrosis. BMJ 1994; 308:15.
- Pashankar FD, Carbonella J, Bazzy-Asaad A, Friedman A. Prevalence and risk factors of elevated pulmonary artery pressures in children with sickle cell disease. Pediatrics 2008; 121:777.
- Hultgren HN, Honigman B, Theis K, Nicholas D. High-altitude pulmonary edema at a ski resort. West J Med 1996; 164:222.
- Yaron M, Niermeyer S. Travel to high altitude with young children: an approach for clinicians. High Alt Med Biol 2008; 9:265.
- KHOURY GH, HAWES CR. Primary pulmonary hypertension in children living at high altitude. J Pediatr 1963; 62:177.
- Cosby RL, Sophocles AM, Durr JA, et al. Elevated plasma atrial natriuretic factor and vasopressin in high-altitude pulmonary edema. Ann Intern Med 1988; 109:796.
- Rennie D, Morrissey J. Retinal changes in Himalayan climbers. Arch Ophthalmol 1975; 93:395.
- Neumann K. Children at altitude. Travel Med Infect Dis 2007; 5:138.
- Cook AL. Splenic infarction in a high-altitude traveler with undiagnosed sickle cell trait. Wilderness Environ Med 2008; 19:318.
- López de Guimaraes D, Menacho López J, Villanueva Palacios J, Mosquera Vásquez V. [Splenic infarction at high altitude, Huaraz-Peru (3,100 masl)]. Rev Gastroenterol Peru 2009; 29:179.
- Harris MD, Terrio J, Miser WF, Yetter JF 3rd. High-altitude medicine. Am Fam Physician 1998; 57:1907.
- Pollard AJ, Niermeyer S, Barry P, et al. Children at high altitude: an international consensus statement by an ad hoc committee of the International Society for Mountain Medicine, March 12, 2001. High Alt Med Biol 2001; 2:389.
- Luks AM, Swenson ER. Travel to high altitude with pre-existing lung disease. Eur Respir J 2007; 29:770.
- Carpenter TC, Niermeyer S, Durmowicz AG. Altitude-related illness in children. Curr Probl Pediatr 1998; 28:181.
- Smith KM. High altitude illness and dysbarism. In: Pediatric Emergency Medicine: Concepts and Clinical Practice, Barkin RM. (Ed), Mosby, St. Louis 1997. p.511.
- Hultgren HN. High-altitude pulmonary edema: current concepts. Annu Rev Med 1996; 47:267.
- Hackett PH, Creagh CE, Grover RF, et al. High-altitude pulmonary edema in persons without the right pulmonary artery. N Engl J Med 1980; 302:1070.
- Hackett PH, Luks AM. High altitude and preexisting medical conditions. In: Auerbach's Wilderness Medicine, 7th ed, Auerbach PS, Cushing TA, Harris NS. (Eds), Elsevier, Philadelphia 2017. p.29.
- Pollard AJ, Murdoch DR, Bärtsch P. Children in the mountains. BMJ 1998; 316:874.
- Kohler M, Kriemler S, Wilhelm EM, et al. Children at high altitude have less nocturnal periodic breathing than adults. Eur Respir J 2008; 32:189.
- Yaron M, Waldman N, Niermeyer S, et al. The diagnosis of acute mountain sickness in preverbal children. Arch Pediatr Adolesc Med 1998; 152:683.
- Yaron M, Niermeyer S, Lindgren KN, Honigman B. Evaluation of diagnostic criteria and incidence of acute mountain sickness in preverbal children. Wilderness Environ Med 2002; 13:21.
- Theis MK, Honigman B, Yip R, et al. Acute mountain sickness in children at 2835 meters. Am J Dis Child 1993; 147:143.
- Moraga FA, Osorio JD, Vargas ME. Acute mountain sickness in tourists with children at Lake Chungará (4400 m) in northern Chile. Wilderness Environ Med 2002; 13:31.
- Moraga FA, Pedreros CP, Rodríguez CE. Acute mountain sickness in children and their parents after rapid ascent to 3500 m (Putre, Chile). Wilderness Environ Med 2008; 19:287.
- Kriemler S, Bürgi F, Wick C, et al. Prevalence of acute mountain sickness at 3500 m within and between families: a prospective cohort study. High Alt Med Biol 2014; 15:28.
- Bloch J, Duplain H, Rimoldi SF, et al. Prevalence and time course of acute mountain sickness in older children and adolescents after rapid ascent to 3450 meters. Pediatrics 2009; 123:1.
- Allemann Y, Stuber T, de Marchi SF, et al. Pulmonary artery pressure and cardiac function in children and adolescents after rapid ascent to 3,450 m. Am J Physiol Heart Circ Physiol 2012; 302:H2646.
- Major SA, Hogan RJ, Yeates E, Imray CH. Peripheral arterial desaturation is further exacerbated by exercise in adolescents with acute mountain sickness. Wilderness Environ Med 2012; 23:15.
- Luks AM, McIntosh SE, Grissom CK, et al. Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness. Wilderness Environ Med 2010; 21:146.
- Bezruchka, S. Altitude Illness: Prevention and Treatment, The Mountaineers, Seattle 1994.
- Scoggin CH, Hyers TM, Reeves JT, Grover RF. High-altitude pulmonary edema in the children and young adults of Leadville, Colorado. N Engl J Med 1977; 297:1269.
- Hultgren HN, Marticorena EA. High altitude pulmonary edema. Epidemiologic observations in Peru. Chest 1978; 74:372.
- Sui GJ, Liu YH, Cheng XS, et al. Subacute infantile mountain sickness. J Pathol 1988; 155:161.
- Miao CY, Zuberbuhler JS, Zuberbuhler JR. Prevalence of congenital cardiac anomalies at high altitude. J Am Coll Cardiol 1988; 12:224.
- Rexhaj E, Garcin S, Rimoldi SF, et al. Reproducibility of acute mountain sickness in children and adults: a prospective study. Pediatrics 2011; 127:e1445.
- HIGH ALTITUDE PHYSIOLOGY
- PATIENT RISK ASSESSMENT AND MITIGATION
- Risk factors
- Recommendations for ascent
- Recommendations for children with pre-existing illnesses
- HIGH ALTITUDE ILLNESS IN CHILDREN
- Acute mountain sickness
- - Clinical manifestations
- - Diagnosis
- - Treatment
- - Prevention and pharmacologic prophylaxis
- Acetazolamide prophylaxis
- High altitude cerebral edema
- High altitude pulmonary edema
- - Clinical manifestations
- - Diagnosis
- - Treatment
- - Prevention
- Other altitude-related illness
- - High altitude pulmonary hypertension
- - High altitude retinal hemorrhage
- - High altitude periodic breathing of sleep
- TRAVEL ADVICE FOR PARENTS
- Healthy infants and children
- Susceptible infants and children
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS