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Am Fam Physician. 2012;86(8):776-781

Guideline source: National Heart, Lung, and Blood Institute

Evidence rating system used? Yes

Literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? No

Published source: Pediatrics, December 2011

Although it is rare for cardiovascular disease (CVD) to manifest in children and adolescents, risk factors and behaviors do start in childhood. Evidence indicates that reducing risk can slow the progression of CVD; therefore, the National Heart, Lung, and Blood Institute (NHBLI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents developed guidelines to help health care professionals promote cardiovascular health and to identify and manage risk factors in children and adolescents. These guidelines were based on evidence that atherosclerosis begins, and its risk factors can be identified, in childhood; that atherosclerosis development and progression are associated with these risk factors; that risk factors track from childhood into adulthood; and that there are options for managing these risk factors.

Prevention goals in young persons should be separate from prevention goals in older persons in whom atherosclerosis is well established. Historically, preventing the development of risk factors and preventing CVD through effective management of risk factors have been the two main goals in young persons. Research supports the theory that childhood populations with lower levels of cardiovascular risk factors will have less atherosclerosis and CVD as adults.

Table 1 provides the integrated cardiovascular health schedule.

Risk factorAge
Birth to 12 months1 to 4 years5 to 9 years9 to 11 years12 to 17 years18 to 21 years
Family history of early CVDAt 3 years, evaluate family history for early CVD: parents, grandparents, aunts/uncles, men ≤ 55 years, women ≤ 65 years; review with parents and refer as needed; positive family history identifies children for intensive CVD risk factor attentionUpdate at each nonurgent health encounterReevaluate family history for early CVD in parents, grandparents, aunts/uncles, men ≤ 55 years, women ≤ 65 yearsUpdate at each nonurgent health encounterRepeat family history evaluation with patient
Tobacco exposureAdvise smoke-free home; offer smoking cessation assistance or referral to parentsContinue active antismoking advice with parents; offer smoking cessation assistance and referral as neededObtain smoke exposure history from child; begin active antismoking advice with childAssess smoking status of child; active antismoking counseling or referral as neededContinue active antismoking counseling with patient; offer smoking cessation assistance or referral as neededReinforce strong antismoking message; offer smoking cessation assistance or referral as needed
Nutrition/dietSupport breastfeeding as optimal to 12 months of age if possible; add formula if breastfeeding decreases or stops before 12 months of ageAt age 12 to 24 months, may change to cow's milk with 2% fat decided by family and children's health care professional; after 2 years of age, fat-free milk for all; juice ≤ 4 oz per day; transition to CHILD-1* by 2 years of ageReinforce CHILD-1* messagesReinforce CHILD-1* messages as neededObtain diet information from child and use to reinforce healthy diet and limitations; provide counseling as neededReview healthy diet with patient
Growth, overweight/obesityReview family history for obesity; discuss weight-for-height tracking, growth chart, and healthy dietChart height/weight/BMI; classify weight by BMI from age 2 years; review with parentChart height/weight/BMI and review with parent; BMI ≥ 85th percentile, crossing percentiles: intensify diet/activity focus for 6 months; if no change, registered dietitian referral, manage per obesity algorithms; BMI ≥ 95th percentile: manage per obesity algorithmsChart height/weight/BMI and review with parent and child; BMI ≥ 85th percentile, crossing percentiles: intensify diet/activity focus for 6 months; if no change, registered dietitian referral, manage per obesity algorithms; BMI ≥ 95th percentile: manage per obesity algorithmsChart height/weight/BMI and review with child and parent; BMI ≥ 85th percentile, crossing percentiles: intensify diet/activity focus for 6 months; if no change, registered dietitian referral, manage per obesity algorithms; BMI ≥ 95th percentile: manage per obesity algorithmsReview height/weight/BMI and norms for health with patient; BMI ≥ 85th percentile, crossing percentiles: intensify diet/activity focus for 6 months; if no change, registered dietitian referral, manage per obesity algorithms; BMI ≥ 95th percentile: manage per obesity algorithms
LipidsNo routine lipid screeningObtain fasting lipid profile only if family history for CVD is positive, parent has dyslipidemia, child has any other risk factors or high-risk conditionObtain fasting lipid profile only if family history for CVD is positive, parent has dyslipidemia, child has any other risk factors or high-risk conditionObtain universal lipid screen with nonfasting non-HDL cholesterol (total cholesterol minus HDL cholesterol), or fasting lipid profile; manage per lipid algorithms as neededObtain fasting lipid profile if family history newly positive, parent has dyslipidemia, child has any other risk factors or high-risk condition; manage per lipid algorithms as neededMeasure one nonfasting non-HDL cholesterol or fasting lipid profile in all: review with patient; manage with lipid algorithms per Adult Treatment Panel guidelines as needed
Blood pressureMeasure blood pressure in infants with renal/urologic/cardiac diagnosis or history of neonatal intensive care unitCheck blood pressure annually in all from the age of 3 years; chart for age/sex/height percentile and review with parentCheck blood pressure annually and chart for age/sex/height: review with parent; workup or management per blood pressure algorithm as neededCheck blood pressure annually and chart for age/sex/height: review with parent; workup or management per blood pressure algorithm as neededCheck blood pressure annually and chart for age/sex/height: review with parent; workup and/or management per blood pressure algorithm as neededCheck blood pressure: review with patient; evaluate and treat per Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines
Physical activityEncourage parents to model routine activity; no screen time before the age of 2 yearsEncourage active play; limit sedentary/screen time to ≤ 2 hours per day; no television in bedroomRecommend moderate-to-vigorous physical activity of ≥ 1 hour per day; limit screen/sedentary time to ≤ 2 hours per dayObtain activity history from child: recommend moderate-to-vigorous physical activity of ≥ 1 hour per day and leisure screen time of ≤ 2 hours per dayUse activity history with adolescent to reinforce moderate-to-vigorous physical activity of ≥ 1 hour per day and leisure screen time of ≤ 2 hours per dayDiscuss lifelong activity, sedentary time limits with patient
Diabetes mellitusMeasure fasting glucose level per American Diabetes Association guidelines; refer to endocrinologist as neededMeasure fasting glucose level per American Diabetes Association guidelines; refer to endocrinologist as neededMeasure fasting glucose level if indicated; refer to endocrinologist as needed

Lipid and lipoprotein levels in childhood are predictive of levels in adulthood, with the strongest relationship occurring between levels in late childhood and at age 20 to 40 years. Table 2 lists normal lipid and lipoprotein distributions in children and adolescents. Total and low-density lipoprotein (LDL) cholesterol levels can decrease by 10 to 20 percent or more during puberty. Based on this, a stable time for lipid evaluation would be 10 years of age, which is before puberty in most children.

CategoryLow (mg per dL)*Acceptable (mg per dL)Borderline-high (mg per dL)*High (mg per dL)*
Total cholesterol< 170170 to 199≥ 200
LDL cholesterol< 110110 to 129≥ 130
Non-HDL cholesterol< 120120 to 144≥ 145
Apolipoprotein B< 9090 to 109≥ 110
Triglycerides
0 to 9 years of age< 7575 to 99≥ 100
10 to 19 years of age< 9090 to 129≥ 130
HDL cholesterol< 40> 4540 to 45
Apolipoprotein A-1< 115> 120115 to 120

To reduce total and LDL cholesterol levels, children should eat a diet made up of 25 to 30 percent of calories from fat, with less than 10 percent from saturated fat, and less than 300 mg of cholesterol per day (e.g., CHILD-1 [cardiovascular health integrated lifestyle diet]). Some evidence indicates that this type of diet also reduces total and LDL cholesterol levels if started in infancy and continued through adolescence. A diet that has no more than 7 percent of calories from saturated fat and less than 200 mg of cholesterol per day (CHILD-2-LDL) has been shown to decrease LDL cholesterol levels in children diagnosed with hypercholesterolemia and an elevated LDL cholesterol level. Table 3 briefly summarizes the various recommended diets.

AgeRecommendationGrade and recommendation levels
Birth to 10 yearsPharmacologic treatment is limited to children with severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia*), a high-risk condition, or evident cardiovascular disease, all under the care of a lipid specialistC; recommend
≥ 10 to21 yearsDetailed family history and risk factor assessment required before initiation of drug therapyC; strongly recommend
LDL cholesterol:
  • If average LDL cholesterol ≥ 250 mg per dL, consult lipid specialist

B; strongly recommend
  • If average LDL cholesterol ≥ 130 to 250 mg per dL, or non-HDL cholesterol ≥ 145 mg per dL, refer to dietitian for medical nutrition therapy with CHILD-1 then CHILD-2–LDL§ for 6 months; repeat fasting lipid profile

A; strongly recommend
Repeat fasting lipid profile:
  • LDL cholesterol < 130 mg per dL, continue CHILD-2–LDL,§ reevaluate in 12 months

A; strongly recommend
  • LDL cholesterol ≥ 190 mg per dL,|| consider initiation of statin therapy

A; strongly recommend
  • LDL cholesterol ≥ 130 to 189 mg per dL, negative family history, no other risk factor or risk condition, continue CHILD-2–LDL,§ reevaluate every 6 months

B; recommend
  • LDL cholesterol is 160 to 189 mg per dL with a positive family history or at least one high-level risk factor/condition or at least two moderate-level risk factors/conditions, consider statin therapy

B; recommend
  • LDL cholesterol ≥ 130 to 159 mg per dL and at least two high-level risk factors/conditions, or one high-level risk factor and two moderate-level risk factors/conditions, consider statin therapy

B; recommend
  • Children on statin therapy should be counseled and carefully monitored

A; strongly recommend
≥ 10 to 21 yearsDetailed family history and risk factor/condition assessment required before initiation of drug therapyC; strongly recommend
Triglycerides:
  • If average triglycerides ≥ 500 mg per dL, consult lipid specialist

B; recommend
  • If average triglycerides ≥ 100 mg per dL in a child younger than 10 years, ≥ 130 mg per dL in a child 10 to 19 years of age, or < 500 mg per dL, refer to dietitian for medical nutrition therapy with CHILD-1, then CHILD-2–TG** for 6 months

B; recommend
Repeat fasting lipid profile:
  • Triglycerides < 100 (130) mg per dL, continue CHILD-2–TG,** monitor every 6 to 12 months

B; strongly recommend
  • Triglycerides > 100 (130) mg per dL, reconsult dietitian for intensified CHILD-2–TG** counseling

C; recommend
  • Triglycerides ≥ 200 to 499 mg per dL, non-HDL cholesterol ≥ 145 mg per dL, consider fish oil and/or consult lipid specialist

D; recommend
Non-HDL cholesterol:
  • Children at least 10 years of age with non-HDL cholesterol ≥ 145 mg per dL after LDL cholesterol goal is achieved may be considered for additional treatment with statins, fibrates, or niacin in conjunction with a lipid specialist consultation

D; optional

In children with familial hypercholesterolemia, up to 20 g per day of a dietary supplement (e.g., plant sterol or stanol esters) can augment LDL cholesterol–lowering effects in the short term. Long-term trials have not been performed; therefore, these types of dietary supplements are typically used only for children in whom LDL cholesterol goals cannot be achieved with dietary therapy alone, with the hope that they may lower LDL cholesterol levels enough to avoid using medication. Consuming a diet with fewer simple carbohydrates (and with more complex carbohydrates and less saturated fat) and losing weight are associated with lower triglyceride levels. Children with elevated triglyceride levels and obesity should eat fewer calories, with the CHILD-2–TG being the recommended diet. It is also important that these children get more physical activity.

Table 3 provides the recommendations for pharmacologic treatment of dyslipidemia.

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