Considerable advances have been made in the detection, evaluation and management of hypertension as well as in obesity‐related hypertension in children and adolescents. Clinically, we have moved from an era of mercury sphygmomanometers to newer devices, although the gold standard in confirming or refuting the diagnosis of hypertension is by undertaking 24‐h ambulatory blood pressure monitoring,42
and if present, searching for evidence of end‐organ damage. Although some evidence exists in the literature that obesity limited to childhood has little effect on adult outcomes, persistent obesity is associated with socioeconomic and psychosocial problems, and there is a global focus on preventing the persistence of obesity from childhood into adulthood.43
Childhood obesity contributes to the development of adult obesity and subsequent cardiovascular disease, with morbid obesity, arterial hypertension, subclinical inflammation and low physical fitness forming a risk profile associated with the risk of early atherosclerosis in these children.44
For paediatric nephrologists, this is clinically relevant as children with CRF and ESRF are at an increased risk of developing atherosclerosis, arterial stiffness and vascular calcification independent of hypertension, resulting in increased cardiovascular morbidity and mortality.45,46,47
The fourth report on the diagnosis, evaluation and treatment of high blood pressure in children and adolescents updated clinicians on blood pressure in children and provided recommendations for the management of hypertension based on available evidence and consensus expert opinion of the working group when evidence was lacking.48
The additional data from the 1999–2000 National Health and Nutrition Examination Survey were added to the childhood blood pressure database, and the blood pressure data were re‐examined with revised blood pressure tables including the 50th, 90th, 95th and 99th centiles by sex, age and height centiles. Hypertension in children and adolescents continues to be defined as systolic and/or diastolic blood pressures, that are, on repeated measurement,
95th centile. However, a change in clinical management is that blood pressure between the 90th and 95th centiles in childhood had been designated “high normal” to be consistent with the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. This level of blood pressure is now termed “prehypertensive” and is an indication for continued monitoring and lifestyle modifications.49
This adds an additional resource requirement for the National Health Service as the implication is that 10% of all children in the UK require blood pressure monitoring, which may occur at primary, secondary or tertiary care services (depending on age of the child, degree of hypertension and local care providers).
The optimal treatment of hypertension is unknown, although there is little debate that ACEi should be used in children with CRF and proteinuria. In the absence of renal dysfunction, proteinuria and renovascular disease, extrapolation from the adult studies may not be relevant. The Anglo‐Scandinavian Cardiac Outcomes Trial—Blood Pressure Lowering Arm is the multicentre randomised controlled trial in adults in which the amlodipine‐based regimen prevented more major cardiovascular events and induced less diabetes than the atenolol‐based regimen.50
However, there is emerging evidence that this applied to the older adults in this study.