children (Table 2). Genetic and Perinatal Factors Familial aggregation of hypertension is well known. Genetic factors significantly contribute, as demonstrated by the stronger association between parent/ child BP than between spouses34 and lack of BP correlation between parents and adopted children.35,36 Familial and twin studies demonstrate that BP heritability is w30% to 50%.37–40 Genome-wide association studies have identified many BP loci, although each individually accounts for small BP differences (120/80 mm Hg (6–11 yr) Or >130/85 mm Hg ($12 yr) Target BP (general pediatric population) 90th percentile) was associated with CKD progression.149 However, using ABPM-based targets for pediatric hypertension management is impractical and limits global applicability. The 2016 guidelines of the European Society of Hypertension instead recommend an office-based BP target of #75th percentile (nonproteinuric CKD) and of #50th percentile (proteinuric CKD).15 Challenges in BP Measurement and Interpretation Standardized, reliable BP measurement is critical to hypertension diagnosis. Unfortunately, pediatric BP measurement is challenging. In North America, pediatric BP screening, elevated BP level follow-up, and hypertension diagnosis are suboptimal (Figure 1). There are minimal data on the extent of pediatric hypertension screening in low- to middle-income countries, where underdiagnosis may be more prevalent. Office-Based BP Measurement Office-based BP was traditionally measured using mercury sphygmomanometers. These have been gradually replaced by aneroid sphygmomanometers, although there are limited pediatric validation data, and these require routine calibration. Oscillometric devices are popular, given their ease of use and consistency. They overcome observer bias and prevent terminal digit preference (i.e., rounding measurements to certain digits). However, oscillometric devices estimate systolic and diastolic BP levels using proprietary formulas by measuring MAP and pulse pressure. Significant differences may exist between oscillometric devices, and they tend to overestimate pediatric BP level by 3 to 10 mm Hg.160–162 Normative BP data are typically derived by auscultatory methods, so abnormal oscillometric BP should be confirmed by auscultation.5,15,16 Repeated or averaged BP measurements are also more reliable, because BP level can decrease during a single visit.163,164 Newer automated devices can repeat BP measurements in clinic without an observer present and have been shown to reduce white coat phenomenon in adults.165 Elevated BP level should be confirmed on 3 separate visits to diagnose hypertension.88,106 Interpretation of pediatric BP is also challenging; with large reference tables, changing normative data, and conflicting definitions of pediatric hypertension. The development of accessible tools, including simple BP screening tables and mobile applications (e.g., PedBP), has simplified diagnosis.5 Although convenient, office-based BP provides only a snapshot of a patient’s BP. In the Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth, office-based BP level $85th percentile was most REVIEW CH Robinson and R Chanchlani: Blood Pressure Management in Children 958 Kidney International Reports (2022) 7, 954–970 predictive of ambulatory hypertension and may be considered as a threshold for ABPM.166 Home and ABPM Ambulatory BP is more reproducible and better associated with target organ damage than office-based BP.167–169 There are limited pediatric data on home BP monitoring (HBPM),170 although it is commonly used (>70% of surveyed German pediatric nephrologists171) and has gained popularity during the COVID19 pandemic.172 HBPM provides a more longitudinal BP assessment than either office-based BP or ABPM, is cost-effective, and is well tolerated.173,174 Although not recommended for pediatric hypertension diagnosis, HBPM can help detect white coat or masked hypertension. HBPM is also useful for BP monitoring in patients with hypertension, especially when strict BP control is desired.5,15 However, there can be reporting bias, the optimal timing of measurements is unknown, and validated pediatric devices and cuff sizes are lacking.15HBPM should be supported by adequate caregiver training and device calibration with office-based auscultatory BP. Telemedicine strategies for hypertension management, including BP telemonitoring, have been shown to be feasible and associated with improved BP control in adults with hypertension.175 However, there are minimal data on the use of BP telemonitoring in children. Incorporation of these strategies could improve access to pediatric hypertension care, may promote disease selfmanagement, and enhance lifestyle modification. However, these potential benefits are balanced against limited access to validated pediatric home BP devices, a lack of standardized protocols for HBPM, few pediatric telemedicine services, regulatory and privacy issues, and provider reimbursement considerations.175 Further research on the clinical application of HBPM in children is needed to facilitate BP telemonitoring programs.170 ABPM is the gold standard for adults and is recommended by the European Society of