Patient education: Children and heart disease (atherosclerosis) (Beyond the Basics)
- Sarah D de Ferranti, MD, MPH
Sarah D de Ferranti, MD, MPH
- Director, Preventive Cardiology Clinic
- Department of Cardiology
- Boston Children's Hospital
- Jane W Newburger, MD, MPH
Jane W Newburger, MD, MPH
- Commonwealth Professor of Pediatrics
- Harvard Medical School
CHILDREN AND HEART DISEASE OVERVIEW
Atherosclerosis is the medical term used to describe the build-up of fat and cholesterol-filled plaques inside the arteries of the body. Atherosclerosis increases the risk of cardiovascular disease, such as heart attack and stroke, when it affects arteries that supply blood to the heart and brain.
It is unusual for children or teenagers to have a heart attack or stroke as a result of atherosclerosis. This is because vessel narrowing, caused by atherosclerosis, takes many years to develop. However, the process of atherosclerosis begins in childhood. For most children, atherosclerosis is mild and progresses slowly. In some children, atherosclerosis worsens rapidly, increasing the risk of heart disease, and less commonly, stroke in early adult life.
It is often possible to identify which children are at risk for atherosclerosis and to begin making improvements in lifestyle (like eating a healthy diet and exercising). In addition, medications may be prescribed for children with the greatest likelihood of developing early atherosclerosis. In the sections that follow, we will discuss childhood risk factors for early atherosclerosis and cardiovascular disease.
IS MY CHILD AT RISK FOR ATHEROSCLEROSIS?
Risk factors — Certain factors increase a child's risk of developing early atherosclerosis, including the following:
●Obesity − Children and teenagers who are overweight or obese have a higher risk of developing high blood pressure, diabetes, and high cholesterol and lipids. In adults, these factors increase the risk for early atherosclerotic disease. Children who are obese are more likely to be obese as adults. In addition, there is increasing evidence that childhood obesity makes it more likely to have other risk factors that are associated with heart disease in early adulthood, such as high blood pressure or diabetes mellitus. The definitions of obesity and overweight for children and teenagers are described below. (See 'Obesity' below.)
●High blood pressure – Children and adolescents with high blood pressure are more likely to have high blood pressure as adults. High blood pressure in adulthood increases the risk of cardiovascular disease. (See "Patient education: High blood pressure in children (Beyond the Basics)".)
●Family history of cardiovascular disease – Children whose parents or grandparents had a heart attack or stroke at an early age have twice the risk of developing cardiovascular disease. A family history of early-age cardiovascular disease is defined as a parent or grandparent who had a heart attack, a stroke, or peripheral vascular disease (blockages in the large blood vessels of the arms or legs) before the age of 56 years for men or 66 years for women.
●Depressive and bipolar disorders – There is evidence that major depression and bipolar disorder in adolescents are associated with an increased risk of early cardiovascular disease. In addition, other risk factors for cardiovascular disease like obesity, diabetes, and smoking are more common in children and adolescents with major depression or bipolar disorder. As a result, children and adolescents being treated for depression or bipolar disorder should also be monitored for these issues. (See "Patient education: Depression in children and adolescents (Beyond the Basics)" and "Patient education: Bipolar disorder (manic depression) (Beyond the Basics)".)
●Exposure to cigarette smoke – Smoking and exposure to smoking increases the risk of developing early cardiovascular disease. Children/teenagers who smoke themselves are likely to continue smoking into adulthood, thus increasing their risk of early cardiovascular disease.
●Underlying medical problems – Certain underlying medical problems increase the risk of early cardiovascular disease. These include diabetes, chronic kidney disease, heart transplantation, Kawasaki disease with coronary aneurysms, and treatment for cancer during childhood. Children with these problems are treated especially vigorously with lifestyle changes and sometimes medications to lower their risk. (See "Diseases associated with atherosclerosis in childhood".)
Is testing for risk factors recommended? — Screening for cholesterol problems is recommended once for children ages 9 to 11 years and again at ages 17 to 21 years. Additionally, children ages two years and older who have one or more of the following risks should be screened (table 1):
●Family history of high cholesterol or lipids, or early cardiovascular disease. Family history is defined as a parent, sibling, or grandparent with a heart attack, a stroke, or peripheral vascular disease (blockages in the large blood vessels of the arms or legs) before 55 years of age for men and ≤65 years of age for women.
●Obesity and/or high blood pressure
●Medical diseases associated with cardiovascular disease.
Screening tests — The following screening tests are recommended for children who have one or more of the above risk factors:
●Fasting cholesterol and lipid blood testing (drawn before the first meal or drink of the day)
●OR non-fasting total cholesterol and HDL for children screened purely because of age (9 to 11 years and 17 to 21 years)
All children, especially those with a risk factor for atherosclerosis, should have yearly measurement of:
●Height and weight and calculation of body mass index (BMI), which is a way to measure for overweight or obesity (see 'Obesity' below)
●Review of lifestyle issues, such as tobacco smoke exposure, exercise, diet, and sleep
MANAGEMENT OF CHILDREN WITH INCREASED RISK OF ATHEROSCLEROSIS
The management of children with an increased risk of cardiovascular disease includes the following:
●Lifestyle changes, including increased exercise, changes in diet, avoiding exposure to cigarette smoke, or weight loss
●If necessary, one or more medications to treat high cholesterol and/or high blood pressure
Is treatment necessary? — Treatment of atherosclerosis risk factors may prevent or delay the development of cardiovascular disease later in life. The decision about when to start treatment depends upon:
●The severity of risk for future heart disease
●The risk of side effects of the treatment
●The effectiveness of the treatment
Making healthy lifestyle changes (diet, exercise, weight control, avoiding smoking) is effective and has few risks. The use of a medication(s) requires more careful consideration. For each child or teenager, the clinical provider will work to individualize a treatment plan that has the greatest potential benefits and fewest risks.
HIGH CHOLESTEROL AND LIPIDS
Cholesterol and lipids are measured by testing the blood level of several components, including total cholesterol, LDL (bad cholesterol), HDL (good cholesterol), and triglycerides. The most accurate time to measure these levels is before the first meal or drink of the day, 8 to 12 hours after the last meal (called fasting).
The following levels are considered abnormal and may indicate a need for treatment:
●Total cholesterol >200 mg/dL (5.18 mmol/L)
●Low-density lipoprotein (LDL) cholesterol >130 mg/dL (3.36 mmol/L)
●High-density lipoprotein (HDL) cholesterol <40 mg/dL
●Triglycerides (TG) >130 mg/dL
Initial treatment — The initial treatment for high cholesterol includes a combination of changes in diet and increased activity. These treatments are usually recommended for at least 6 to 12 months before considering the use of medication.
Diet — Parents of children with elevated low-density lipoprotein levels should offer their child a low-saturated fat, low-cholesterol diet. Increasing fruits and vegetables, whole grains, low-fat or nonfat dairy products, beans, fish, and lean proteins can help to meet this goal.
Children with high triglycerides should eat a diet without excessive carbohydrates, particularly "refined" carbohydrates (white rice, pasta, bread, desserts), which raise blood sugar and are low in fiber.
Meeting with a dietitian or nutritionist can help families to set realistic, individual goals and make long-lasting changes. In most cases, the entire family should change their diet together to maximize the child's chances of success. More than one visit with a nutritionist is often necessary.
Activity — Increasing daily activity can help to decrease the risk of cardiovascular disease and improve cholesterol levels. Most expert groups recommend that children get 30 to 60 minutes of exercise four to six days per week.
For children who are not already active, the increase in activity should be gradual. For example, the initial goal may be to ride a bicycle outside for 10 minutes 3 times per week. Other options include joining a gym or YMCA, riding an exercise bike, or running on a treadmill; activity should be tailored to the child's age and interests.
Dietary supplements — Dietary supplements containing fiber and omega-3 fatty acids are sometimes used to decrease LDL cholesterol. However, the best source of fiber is from dietary sources, such as fruits, vegetables, and whole grains. The best source of omega-3 fatty acids is fish. (See "Patient education: High-fiber diet (Beyond the Basics)".)
Medications — If changes in diet and activity do not decrease cholesterol levels enough after 6 to 12 months, or if a child's cholesterol or triglyceride levels are very high, one or more medications may be recommended. Medications do not permanently cure the problem but work to lower the child's risk factors.
Statins — The most commonly used medication to treat high cholesterol belongs to a class of drugs called statins. Several statins are approved for use in children. These medications are usually taken in pill form, once per day. More detailed information about use of statins in children is available separately. (See "Overview of the management of the child at risk for atherosclerosis".)
HIGH BLOOD PRESSURE
In children, the normal range for blood pressure (BP) is determined by the child's gender, age, and height. The normal range is expressed as a percentile, similar to charts used to track children's height and weight (table 2 and table 3).
As an example, if a child's BP is at the 90th percentile, this means that 90 percent of children who are that age, gender, and height have a lower BP.
Hypertension is defined as BP >95th percentile.
Blood pressure may change in response to an individual's emotions and environment. Hypertension (sustained high blood pressure) is not usually diagnosed until blood pressure is measured as high on three separate occasions when the child is calm and in a quiet environment. (See "Patient education: High blood pressure in children (Beyond the Basics)".)
When is treatment needed? — Lifestyle changes (diet and increased activity) are initially recommended for most children with hypertension. One or more medications may be recommended if lifestyle changes are not effective, if the blood pressure is very elevated, or if the child has an underlying medical problem that causes high blood pressure.
Treatment of high blood pressure in children is discussed in detail in a separate topic. (See "Patient education: High blood pressure treatment in children (Beyond the Basics)".)
Body mass index (BMI) is a measure of weight in relation to height, and is currently the best way to determine whether a child (>2 years of age) is overweight or obese.
Children whose BMI is ≥85th percentile are considered to be overweight while children whose BMI is ≥95th percentile are considered to be obese.
Treatment is generally recommended for children whose BMI is ≥95th percentile for age and gender. Treatment usually includes making changes in diet, behavior, and increasing physical activity.
All patients and family members who smoke are counseled to quit smoking. Smoking, as well as exposure to second-hand smoke, has many health risks. Approaches to quitting smoking are described separately. (See "Patient education: Quitting smoking (Beyond the Basics)".)
OTHER MEDICAL CONDITIONS THAT INCREASE RISK
A number of medical conditions, such as diabetes, chronic kidney disease, and Kawasaki disease, increase a child's risk of developing cardiovascular disease. Careful management and monitoring of these conditions can reduce the child's risk. More information about these conditions is available separately. (See "Diseases associated with atherosclerosis in childhood".)
WHERE TO GET MORE INFORMATION
Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our Web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: High blood pressure in children (Beyond the Basics)
Patient education: High-fiber diet (Beyond the Basics)
Patient education: High blood pressure treatment in children (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Systemic lupus erythematosus (SLE) in children: Clinical manifestations and diagnosis
Cardiovascular sequelae of Kawasaki disease: Clinical features and evaluation
Comorbidities and complications of type 2 diabetes mellitus in children and adolescents
Definition and diagnosis of hypertension in children and adolescents
Diseases associated with atherosclerosis in childhood
Evaluation of hypertension in children and adolescents
Risk factors and development of atherosclerosis in childhood
Ischemic stroke in children and young adults: Etiology and clinical features
Ischemic stroke in children: Evaluation, initial management, and prognosis
Overview of the management of the child at risk for atherosclerosis
Inherited disorders of LDL-cholesterol metabolism other than familial hypercholesterolemia
The following organizations also provide reliable health information.
●National Library of Medicine
●The American Heart Association
- American Academy of Pediatrics. Cardiovascular risk reduction in high-risk pediatric populations. Pediatrics 2007; 119:618.
- McCrindle BW, Urbina EM, Dennison BA, et al. Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing. Circulation 2007; 115:1948.
- Kavey RE, Allada V, Daniels SR, et al. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation 2006; 114:2710.
- Berenson GS, Srinivasan SR, Bao W, et al. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 1998; 338:1650.
- McGill HC Jr, McMahan CA, Zieske AW, et al. Associations of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler Thromb Vasc Biol 2000; 20:1998.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.