The available data concerning childhood blood pressure (BP) have increased substantially over the last four decades. Clinicians can use the available pediatric reference BP data to determine whether BP is in the normal range or is at a level that warrants evaluation or preventive intervention. It has also become possible to refine BP-derived parameters and to identify subclinical end organ damage through measures and markers now far more sensitive than those available years ago. The progress to date should provide an impetus for research advances that may translate into clinical practice. Findings that are becoming ready to incorporate into clinical use include data showing the importance of detecting prehypertension or high-normal BP, the meaning of BP obtained out of the clinic setting and the importance of central BP determinations. Furthermore, new information about large and small vessels during the early stages of BP elevation, the clustering of metabolic abnormalities with BP and the relevance of perinatal programming may lead to better strategies for reducing the impact of BP elevation on cardiovascular health.