Hypertension (HTN) in children and adolescents has become increasingly common. We sought to identify variability in the approach to HTN among general pediatricians as well as obstacles to care of hypertensive youth by surveying pediatricians referring to an urban children's hospital. Although most pediatricians begin blood pressure measurement at 3 years, there was substantial variability in the initial diagnostic evaluation of hypertensive patients. Just 7% of pediatricians routinely start antihypertensive drug treatment for HTN, whereas 82% refer their hypertensive patients to a specialist; 40% of pediatricians felt uncomfortable evaluating and treating HTN. Pediatricians unfamiliar with The Fourth Report were more likely to be uncomfortable with the care of hypertensive patients than those familiar with it (54% vs 33%, P < .05). Current practice does not appear to follow recent consensus recommendations. Interventions designed to address the issues identified in this survey may lead to improved care for pediatric patients with HTN.