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ACE Inhibitor (Paediatric Heart Failure / Hypertension) Pregnancy: Contraindicated in all trimesters — ACE inhibitors cause foetal renal failure, oligohydramnios, neonatal anuria, skull hypoplasia (black box warning). Paediatric use — pregnancy not applicable.

Enalapril (Paediatric Heart Failure / Hypertension)

Brand names: Innovace

Adult dose

Dose: Heart failure: 2.5 mg once daily (initial); up to 10–20 mg twice daily. Hypertension: 5–20 mg once daily
Route: Oral
Frequency: Once to twice daily
Max: 40 mg/day
Standard adult ACE inhibitor doses — for paediatric doses see below. Source: BNF 90.

Paediatric dose

Dose: Heart failure/cardiomyopathy: 0.1 mg/kg once daily (initial); increase to 0.1 mg/kg twice daily over 2 weeks (max 0.5 mg/kg/day). Hypertension: 0.08–0.6 mg/kg/day in 1–2 divided doses mg/day/kg
Route: Oral (extemporaneous 1 mg/mL suspension available for infants/toddlers)
Frequency: Once to twice daily
Max: 0.5 mg/kg/day or 40 mg/day (whichever lower)
Licensed from neonates for hypertension (caution — profound hypotension in neonates, start very low). Heart failure in CHD and cardiomyopathy — used from neonatal age under specialist cardiology guidance. Extemporaneous 1 mg/mL oral suspension for young children (pharmacy-prepared). Source: BNF for Children 2024.

Dose adjustments

Renal

eGFR <30 mL/min: reduce starting dose by 50% and monitor creatinine and potassium closely after each dose increase. eGFR <10 mL/min: avoid.

Hepatic

Severe hepatic impairment: use with caution — enalaprilat (active form) production may be impaired.

Paediatric weight-based calculator

Licensed from neonates for hypertension (caution — profound hypotension in neonates, start very low). Heart failure in CHD and cardiomyopathy — used from neonatal age under specialist cardiology guidance. Extemporaneous 1 mg/mL oral suspension for young children (pharmacy-prepared). Source: BNF for Children 2024.

Clinical pearls

  • Paediatric CHD heart failure: enalapril is the most commonly used ACEi in paediatric cardiology for ventricular failure, dilated cardiomyopathy, and post-operative Fontan circulation. CONSENSUS and SOLVD trial evidence in adults extrapolated to paediatric use. PICNIC trial (2010) showed enalapril improved somatic growth and cardiac outcomes in infants with large VSD/ASD.
  • Neonatal hypotension warning: enalapril is particularly potent in neonates because neonatal kidney perfusion is highly renin-angiotensin-dependent. Start at 0.05–0.1 mg/kg single dose, observe in hospital for 2–4 hours for hypotension. Profound hypotension (systolic <40 mmHg in neonates) can occur — have IV saline immediately available.
  • Extemporaneous suspension: commercial enalapril 5 mg or 10 mg tablets are not suitable for infants/toddlers. Pharmacy-prepared 1 mg/mL suspension (stable 30–90 days refrigerated with HPMC vehicle) is the standard preparation in UK neonatal/paediatric units. Confirm preparation stability with pharmacy.
  • Cough — switch to ARB: enalapril-related cough (bradykinin accumulation) affects up to 15% of patients — more common in certain ethnicities (East Asian populations higher incidence ~40%). Switch to losartan or candesartan if cough troublesome. ARBs have similar evidence base in paediatric heart failure (ASPEKTE trial: valsartan in paediatric HF).
  • ACE inhibitor in CHD — specific indications: reduced ventricular function (EF <40%), regurgitant valvular lesions (mitral/aortic regurgitation — reduces afterload), single ventricle post-Fontan (reduces systemic resistance). NOT used in outflow obstruction (aortic stenosis, hypertrophic cardiomyopathy) — vasodilation in fixed obstruction is dangerous. Source: BNF for Children 2024; NICE paediatric hypertension guidelines; PICNIC trial 2010.

Contraindications

  • Bilateral renal artery stenosis (or unilateral in single kidney) — acute renal failure
  • History of ACEi-related angioedema
  • Concurrent aliskiren in diabetes (ONTARGET data — increased adverse events)
  • Pregnancy (all trimesters — teratogenic; causes foetal renal failure, oligohydramnios, skull hypoplasia)

Side effects

  • First-dose hypotension (particularly in neonates, salt/volume-depleted patients, or high-dose diuretic use — observe for 2h after first dose)
  • Dry cough (ACEi class — ACE inhibition increases bradykinin; up to 15%; switch to ARB if troublesome)
  • Hyperkalaemia (monitor potassium especially with concurrent diuretics or renal impairment)
  • Renal impairment (check eGFR and creatinine at 1–2 weeks)
  • Angioedema (rare but potentially fatal — stop immediately; do not rechallenge; use ARB instead)

Interactions

  • NSAIDs: reduce ACEi antihypertensive effect and increase nephrotoxicity — avoid
  • Potassium-sparing diuretics (spironolactone): additive hyperkalaemia — monitor potassium
  • Aliskiren: dual RAAS blockade — avoid in diabetes
  • Lithium: ACEi reduces lithium excretion — monitor lithium levels

Monitoring

  • Blood pressure (1–2h post-first dose and after each dose increase — first-dose hypotension)
  • Renal function (creatinine, eGFR) and serum potassium at 1–2 weeks after starting and after dose increases
  • Weight and fluid balance (heart failure — monthly)
  • Echocardiogram (ventricular function — 3–6 monthly in HF)
  • Cough assessment at each visit
  • Serum electrolytes annually when stable

Reference: BNF for Children 2024; BNF 90; PICNIC trial 2010 (enalapril in infant VSD); Bengur et al. J Am Coll Cardiol 1991; MHRA SPC Innovace. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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