The pediatric patient most likely to present with hypertension will be the obese adolescent.

Life-style changes are initially recommended. Weight loss, increased exercise, and avoidance of high fat high carbohydrate foods should be attempted first before the introduction of medications.

Oral diuretics remain the first choice for most patients with hypertension.

Since many of the patients one would see in pediatrics with hypertension will be the obese adolescent, this is usually the agent of choice.

Other agents may be added in a step-wise fashion until the desired blood pressure goal is reached.

Calcium channel blockers are useful and are preferred in African-Americans. Diltiazem can be formulated as a liquid for small children and has a pediatric dosing schedule. Nifedipine is available in a sustained release formulation and may be used in adolescents. Amlodipine has the advantage of being given once a day. A pediatric dosing schedule is not available.

"Ace" inhibitors may be useful if hypertension is related to high renin states.

Renal function may deteriorate if there is a single kidney with renal artery stenosis or there is already decreased renal function. They should be used with caution in the adolescent female who is not or will not practice birth control. Enalapril is very useful since it can be given once or twice a day, there is a pediatric dose schedule, and the generic formulation is inexpensive. Captopril must be given more frequently but has an established dosing schedule for neonates, infants and children.

There are other newer calcium channel blockers,"ace" inhibitors, and angiotensin II receptor antagonists that are more costly, have little or no information on pediatric dose schedules and may really not be any more effective in the average situation.

It is useful to know a few drugs very well.

Beta blockers are useful in pediatrics.

Propranolol has a pediatric dosing schedule and is available in a long acting form. Labetalol has been used in children and is recommended to treat hypertensive emergencies. Atenolol has a pediatric dosing schedule and may be given once a day. Remember, the Beta blockers are contraindicated in asthmatic patients. They may interfere with athletic performance.

There are centrally acting drugs such as clonidine that have a pediatric dosing schedule for hypertension.

Sedation and drowsiness may be a problem for students. There can also be rebound hypertension if the drug is not tapered.

Peripheral vasodilators such as prazosin, minoxidil, and hydralazine may be useful.

Only hydralazine has an established pediatric dosing schedule. Prazosin and minoxidil have been used in children but are of limited usefulness because of more effective agents and side effects, e.g. hirsutism.