Among 71,683 children aged 6–17 tracked across three or more primary care visits from 2017–2024, 4.2% (2,911) exhibited persistent abnormal blood pressure meeting guideline-based hypertension criteria, yet only 1.2% (848) carried a formal diagnosis — a 3.5-fold recognition gap. Neighborhood deprivation (Area Deprivation Index Q3) was associated with 2.48 times higher odds of abnormal BP and nearly 5-fold higher odds of stage 1/2 hypertension. Insurance instability, obesity, male sex, prematurity, and age ≥13 were additional risk factors. Notably, higher educational opportunity within the Child Opportunity Index paradoxically associated with increased abnormal BP odds, a counterintuitive finding warranting further investigation.
This preprint — not yet peer-reviewed — adds meaningful scale and methodological rigor to a persistent clinical blind spot. Prior literature relied heavily on single-visit BP snapshots or diagnostic codes, both of which systematically undercount true hypertension burden. By requiring three abnormal readings, this study more closely mirrors actual clinical diagnostic thresholds, making the diagnosis gap more alarming, not less. Pediatric hypertension is a known accelerant of adult cardiovascular risk; undetected cases in childhood translate directly into earlier atherosclerosis, left ventricular remodeling, and premature mortality. The social determinants findings reinforce that BP screening failures are not random — they cluster in under-resourced communities. System-level interventions, including automated BP flagging in electronic health records and community screening programs, are the logical response. Results should be considered preliminary until peer-reviewed.