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INTRODUCTION

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Systemic hypertension occurs in approximately 3% to 4% of the pediatric population, and there is ample evidence that the roots of adult primary hypertension extend back to childhood. In young children, hypertension is often secondary to an underlying renal or cardiac disease, but with the rise in childhood obesity, primary hypertension is now recognized as the most frequent cause of hypertension in adolescents. Perhaps more concerning, blood pressure (BP) problems among children seem to be more common in recent cohorts than among historical populations. Management of systemic hypertension in the pediatric population begins with correct BP measurement using a standardized technique, categorization of BP using current normative standards, appropriate evaluation of the etiology of the hypertension, assessment of end-organ damage, and control of BP using both nonpharmacologic and pharmacologic means as appropriate.

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EPIDEMIOLOGY

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Although the prevalence of hypertension in children (3–4%) is much lower than in adults, recent data suggest that BP has risen among children and adolescents over recent decades. Much of the increase is thought to be attributable to an increase in weight in the pediatric population. Longitudinal studies begun in the 1970s in Muscatine, Iowa, and Bogalusa, Louisiana, established a relationship between body size and BP. Although height relates strongly to BP, weight remains a major determinant of BP even after adjustment for height. BP increases with age throughout childhood. Beginning with puberty, it is greater in boys than in girls. Ethnic differences in BP have also been described in some studies.

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Longitudinal studies have established that the pattern of BP tracks over time. Systolic BP levels track from childhood better than diastolic BP levels. In the Bogalusa study, 40% of those with systolic BP and 37% of those with diastolic BP in the upper 20% in childhood continued to have BP above the 80th percentile 15 years later. Children in Muscatine, Iowa, with systolic BP levels above the 90th percentile for age and gender were at 2.5 times the risk for high adult BP than children with levels at the 50th percentile. Initial BP levels are the most predictive measure of the follow-up level, especially when combined with change in weight. In an illustrative BP screening study, children with even just 1 day of elevated BP at screening were subsequently found 2 years later to have a much higher risk of sustained hypertension.

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Obesity has risen dramatically in the United States. Among children and adolescents, rates of overweight have increased from 13.9% from 1999 to 2000 to 16% from 2003 to 2004. In a more recent study, it was projected that the increase in childhood obesity in the United States will result in a significant increase in obesity among 35-year-olds by 2020, which could then translate into a significant increase in adult coronary heart disease. Although only future investigation will reveal the true trend, it appears that the obesity epidemic in the United States may ...

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