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:

• Overweight – 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 overweight/obese are more likely to be overweight/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 information: 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.
• 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, early cardiovascular disease, or diabetes. 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.
• Medical diseases associated with cardiovascular disease.
• Overweight/obesity, high blood pressure, or high cholesterol or lipids (see below).

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:

• Blood pressure
• 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, such as fiber and omega-3 fatty acids, are sometimes recommended to decrease LDL cholesterol and triglyceride levels. 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 information: 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.

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.

A child's blood pressure percentile can be calculated here for boys (calculator 1) or here for girls (calculator 2). Hypertension is defined as BP >95th percentile. Prehypertension is defined as BP >90th to the 95th percentile or if BP exceeds 120/80 mmHg.

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 information: 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 or prehypertension. 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 information: High blood pressure treatment in children (Beyond the Basics)".)

OBESITY

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.

Because children grow in height as well as weight, a "normal" BMI depends upon the child's age and sex. A tool that calculates BMI for boys (calculator 3) and girls (calculator 4) is available here.

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.

CIGARETTE SMOKING

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 information: 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.

Patient information: Atherosclerosis (The Basics)

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 information: High blood pressure in children (Beyond the Basics)
Patient information: High-fiber diet (Beyond the Basics)
Patient information: High blood pressure treatment in children (Beyond the Basics)
Patient information: 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.

Cardiac abnormalities in children and adolescents with systemic lupus erythematosus
Cardiovascular sequelae of Kawasaki disease
Cerebrotendinous xanthomatosis
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

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The American Heart Association

     (www.heart.org/HEARTORG/GettingHealthy/HealthierKids/Healthier-Kids_UCM_304156_SubHomePage.jsp)

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