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Although systemic hypertension occurs in less than 4% of the pediatric population, there is ample evidence that the roots of primary hypertension extend back to childhood. In young children, hypertension is often a sign of underlying renal or cardiac disease, but with the rise in childhood obesity, primary hypertension is now recognized as a frequent cause of hypertension in adolescents. Management of systemic hypertension in the pediatric population begins with correct blood pressure (BP) measurement using a standardized technique, categorization using current normative standards, evaluation of the etiology of the hypertension, and use of nonpharmacologic and pharmacologic therapies.

Until more recently, the prevalence of hypertension in children has been low (1–2%). More recent data suggests, however, that blood pressure (BP) has risen among children and adolescents over the past decade attributable to an increase in weight in the pediatric population.1 Longitudinal studies begun in the 1970s in Muscatine, Iowa, and Bogalusa, Louisiana, established a relationship between body size and BP.2,3 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.

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.3 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.2 Initial BP levels are the most predictive measure of the follow-up level, especially when combined with change in weight.

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 2004.4 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.5

Weight-related disorders such as hypertension, type 2 diabetes mellitus, hyperlipidemia, sleep disorders, and orthopedic problems are now commonly identified within pediatric practice. National survey data show a rise in the prevalence of hypertension from 2.7% from 1988 to 1994 to 3.7% from 1999 to 2002.6 Prehypertension is now reported to be present in approximately 10% of children and adolescents. National surveys have relied, however, on measurements of BP on a single occasion. More recent data from school-based screening in Houston confirm a ~3% prevalence of hypertension after measurement ...

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