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INTRODUCTION — Although cardiovascular disease (CVD) is generally manifest in adulthood, the process of atherosclerosis can begin early in childhood . For most children, atherosclerotic vascular changes are minor and can be minimized or even prevented with adherence to a healthy lifestyle. However, in some children, the atherosclerotic process is accelerated because of the presence of identifiable risk factors (eg, obesity and hypertension) and/or specific diseases that are associated with premature CVD (eg, diabetes mellitus and Kawasaki disease [KD]) (table 1) [1,2].
Primary prevention measures to minimize the risk of developing atherosclerosis in childhood will be reviewed here. In addition, the primary care assessment to identify the child at risk for premature atherosclerosis, and, by extension, CVD, will also be discussed. Risk factors for early atherosclerosis in childhood and the management of the child at risk for atherosclerosis are reviewed separately. (See "Risk factors and development of atherosclerosis in childhood" and "Overview of the management of the child at risk for atherosclerosis".)
CARDIOVASCULAR HEALTH PROMOTION — The two primary goals of cardiovascular health promotion in children are [1,3]:
●Prevention of the development of risk factors associated with atherosclerosis (primordial prevention) based on general measures that focus on adherence to a healthy lifestyle.
●Identification and management of the child at risk for early atherosclerosis based on the presence of established risk factors including hypertension, obesity, dyslipidemia, insulin resistance, physical inactivity, and smoke exposure. (See "Risk factors and development of atherosclerosis in childhood", section on 'Risk factors'.)
PROMOTION OF HEALTHY LIFESTYLE
Overview — Prevention of the development of CVD risk factors should be addressed in the pediatric primary care office by promoting a healthy lifestyle for the individual child, and on a population level through advocacy (eg, promoting healthier school lunch, smaller portion sizes, and increasing public awareness on healthy dietary choices). The rationale for these approaches is that an adult population with a lower burden of atherosclerosis, as a result of pediatric preventive care, will have a lower rate of CVD [1,3,4].
In the 2011 National Heart, Lung, and Blood Institute (NHLBI) guidelines, specific measures for preventing atherosclerosis were reviewed and graded based on the available literature . These guidelines recommend that pediatric routine health care supervision should promote and reinforce positive cardiovascular behaviors. Age- and developmental stage-based recommendations were developed using the health care supervision framework of Bright Futures of the American Academy of Pediatrics (AAP) and are focused on the following areas to reduce the risk of developing atherosclerosis:
The construct of ideal cardiovascular health, well developed in the adult literature, has been adapted for children and adolescents and includes smoke exposure, weight status (body mass index [BMI] (calculator 1 and calculator 2)), physical activity, nutrition (healthy diet score), cholesterol, fasting blood sugar, and blood pressure . Ideal cardiovascular health in childhood and young adulthood has been associated with lower prevalence of CVD factors in adulthood in several large pediatric and young adult cohorts with several decades of follow-up [5-8]. Increasing numbers of ideal CV measures was associated with reduced risk of hypertension, metabolic syndrome, and dyslipidemia (ie, elevated low-density lipoprotein cholesterol [LDL-C]), and decreased carotid artery and aortic intima-media thickness (IMT).
Nutrition — Good nutrition beginning at birth has profound health benefits, including a potential to decrease the risk of CVD by preventing or ameliorating obesity, dyslipidemia, hypertension, and insulin resistance/diabetes mellitus. Several United States health organizations (AAP, the American Heart Association, the American Dietetic Association, and the United States Departments of Agriculture and Health and Human Services [USDA/HHS]) have issued dietary guidelines for children and adolescents that are generally consistent with one another and are discussed in greater detail separately (table 2). (See "Dietary recommendations for toddlers, preschool, and school-age children", section on 'Dietary guidelines'.)
The 2011 NHLBI expert panel endorsed the USDA/HHS dietary recommendations for children aged two years and older . In addition, the panel also provided the following age-specific guidelines for a cardiac healthy diet for all pediatric patients from birth to 21 years of age (table 3).
●In accordance with the World Health Organization (WHO), AAP, the United States Surgeon General Office, and the American Academy of Family Physicians, exclusive breastfeeding is recommended for the first six months of life and continued breastfeeding to at least 12 months of age. Breastfeeding appears to decrease the risk of future dyslipidemia and obesity, two CVD risk factors. (See "Breastfeeding: Parental education and support" and "Infant benefits of breastfeeding", section on 'Cardiovascular risk factors'.)
●Within appropriate age- and gender-based requirements for growth and nutrition, the total fat intake is limited to 30 percent of total calories, saturated fat to 7 to 10 percent of total calories, and dietary cholesterol to less than 300 mg/day. However, fat intake should not be restricted in infants younger than 12 months of age without medical indication.
Support for this recommendation is based on the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) trial that demonstrated modest improvements in fasting lipid profiles in infants whose parents received counseling regarding a low-saturated-fat, low-cholesterol diet compared with those whose parents did not receive any dietary counseling [7,9-12]. At 14 and 19 years of age, the group that received repeated dietary counseling for a low-fat diet had lower saturated fat intakes and serum LDL-C than the control group [13,14]. As noted above, the intervention group was more likely to have ideal CV metrics than the control group, which correlated with decreased aortic IMT and improved elasticity . Importantly, there was no difference in neurodevelopmental outcome, which effectively addressed an initial concern that a low-fat diet may adversely affect development. This diet primarily relied on fruit and vegetables, whole grains, low-fat and nonfat dairy products, beans, fish, and lean meat .
●The remaining 20 percent of fat intake should be composed of a combination of monosaturated and polyunsaturated fat. Additive trans fats should be eliminated from the diet.
●The remaining 70 percent of total calories should include 15 to 20 percent derived from protein intake, and 50 to 55 percent from carbohydrates primarily in the form of whole grains.
●The caloric intake should match the growth demands and physical activity of each individual child. Estimated calorie requirements are based on gender, age, and level of activity (table 4).
●Ongoing nutritional counseling for families with children with identified CVD risk factors by a registered dietician is recommended to assist in the adoption and sustainability of a diet that provides adequate nutrition and reduces CVD risk. A behavioral approach that engages the child and family has been shown to be the most effective method for achieving dietary change . Dietary counseling should be tailored to each child and family based on diet patterns, social setting, and patient sensitivities, such as lactose intolerance and food allergy.
●Other recommendations include:
•Increased intake of vegetables and fruits, as supported by longitudinal data following children into adolescence and young adults into middle adulthood [16,17]. The NHLBI panel provided a pediatric version of the DASH (Dietary Approaches to Stop Hypertension) diet, based on total daily caloric intake. This diet is rich in fruits and vegetables, whole grains, and lean proteins (table 5).
•Reduce the intake of sugar-sweetened beverages and foods. In infants between 6 and 12 months of age, only 100 percent juice should be allowed, and the intake should not exceed 4 ounces per day.
•In children older than 12 months, if cow's milk is introduced, decide with the parents on the fat content of milk based on the child's growth, appetite, BMI, CVD risk factors, and intake of other sources of fat and calorie-dense foods. The medical provider may decide that low fat dairy is appropriate as early as 12 months. By two years of age, saturated fat should be limited to 8 to 10 percent of the daily caloric intake and milk should be provided as 1 percent fat or skim (table 3).
•In children greater than two years of age, encourage the intake of dietary fiber in the form of naturally fiber-rich foods such as fruits, vegetables, and whole grains.
•A daily minimum intake of vitamin D supplementation (600 international units/day) is recommended for all children. No other vitamin, mineral, or dietary supplementation is recommended. (See "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Targets for vitamin D intake'.)
Physical activity — In adults, evidence demonstrates that daily vigorous activity decreases the risk of CVD and diabetes mellitus type 2, reduces blood pressure, and improves fasting lipid profiles. Although data similar in quality are limited in children, there are several reports that demonstrate the beneficial effect of increased physical activity and reduction of sedentary behavior on reducing the risk of atherosclerosis and CVD. (See "Exercise and fitness in the prevention of cardiovascular disease".)
●In the STRIP study, multivariate analysis demonstrated lower amounts of physical activity for adolescents (determined by questionnaire) correlated with subclinical atherosclerosis (ie, increased mean aortic IMT and decreased endothelial function measured by flow-mediated dilation [FMD]) [18,19]. Sedentary adolescents who increased their level of physical activity decreased the progression of IMT compared with adolescents who remained sedentary. In persistently active adolescents, the progression of IMT was attenuated compared with those who became sedentary. (See "Risk factors and development of atherosclerosis in childhood", section on 'Indirect evidence'.)
●In another report from the STRIP study, sedentary adolescents were at an increased risk for clustered metabolic risk factors compared with more physically active peers . Physical activity was based on self-report and the cluster risk factors were BMI, lipid profile, and blood pressure.
●In a report from the longitudinal Cardiovascular Risk in Young Finns study that recruited children from ages 3 to 18 years, low physical activity was associated with accelerated IMT progression over 27 years of follow-up .
●Data from the International Children's Accelerometry Database demonstrated that increasing time for moderate to vigorous activity (MVA) was associated with better cardiometabolic risk factors regardless of the amount of sedentary time . Higher mean time spent in MVA correlated with reductions in mean waist circumference, systolic blood pressure, fasting insulin, and fasting triglycerides, and increases in HDL-C (high-density lipoprotein cholesterol).
●In the Dietary Intervention Study in Childhood, higher self-reported levels of physical activity were associated with lower systolic blood pressure .
●Several small studies have shown exercise programs that improve physical fitness resulted in a reduction of CVD risk factors including lowering BMI, blood pressure, and arterial stiffness, and improving lipid profiles [24-27].
There is also evidence that physical activity patterns established in childhood are continued through adulthood .
Based on the above evidence and data from adult studies, routine physical activity should be encouraged, as it is associated with a decreased risk of atherosclerosis and CVD. However, the type and level of activity for optimum cardiovascular health are unknown.
●All children >5 years of age should participate in MVA for at least 60 minutes per day, which is in accordance with the recommendations by the United States Centers for Disease Control and Prevention (CDC, Youth physical activity guide). In addition, the activity should be vigorous on three days of the week, which is in agreement with the 2008 Physical Activity Guidelines Advisory Committee Report from the United States Department of Health and Human Services (2008 HHS Physical Activity Guide for Americans). Examples of moderate activity are jogging or playing baseball, and examples of vigorous activity are running, playing singles tennis, or playing soccer.
●In younger children and infants, parents should allow for unlimited active playtime in a safe and supportive environment.
●Limiting leisure screen time to less than two hours a day in children. In children under the age of two years, screen viewing should be entirely discouraged.
Additional benefits of physical activity in children are discussed separately. (See "Physical activity and strength training in children and adolescents: An overview", section on 'Physical activity'.)
Avoid smoke exposure — Pediatric health care clinicians should provide ongoing counseling on the benefits of a smoke-free environment for the child and family. Patients and parents should be informed about the addictive and adverse health effects of smoking, including the risk of CVD, for themselves and for their children. (See "Secondhand smoke exposure: Effects in children" and "Prevention of smoking initiation in children and adolescents" and "Overview of smoking cessation management in adults" and "Cardiovascular effects of nicotine".)
IDENTIFYING CHILDREN AT RISK FOR CVD
Rationale — Screening is common in regular pediatric care and is designed to identify conditions that, if untreated, increase risk of disease sequelae, and for which there is an available cost-effective intervention. When deciding whether screening should be performed, the test's sensitivity and specificity, prevalence of the screened condition, cost of the screening test, and the potential benefits and harms of screening and intervention must be considered. In pediatrics, evidence is often lacking from randomized controlled trials to determine whether or not screening and treatment are beneficial and cost-effective. (See "Screening tests in children and adolescents", section on 'Overview'.)
Data are not available regarding whether and how to best assess individual risk for CVD in clinical pediatric practice. Because premature CVD occurs decades after suspected exposures, and premature atherosclerosis is generally asymptomatic, there have been no randomized controlled trials of different screening practices examining risks, benefits, costs, and effectiveness. Based on the lack of long-term randomized clinical trials, the US Preventive Services Task Force has not found sufficient data to recommend for or against screening children for lipid or blood pressure abnormalities [28-32]. (See "Dyslipidemia in children: Definition, screening, and diagnosis".)
In contrast, there are large prospective population-based studies for adults that assess individual risk for cardiovascular events and guide therapeutic choices aimed at risk reduction (eg, Framingham or Reynolds Risk Score). This approach directly links risk factors to cardiovascular events and is discussed in greater detail separately. (See "Estimation of cardiovascular risk in an individual patient without known cardiovascular disease".)
Despite the paucity of evidence from randomized controlled trials in children, pediatric risk factors for accelerated atherosclerosis (and, by extension, CVD) have been identified through direct evidence from autopsy studies and indirect evidence using methods that detect vascular changes that have been associated with increased risk of CVD in adults (table 1). Screening for these risk factors is recommended by the American Academy of Pediatrics (AAP), American Heart Association (AHA), and National Heart, Lung, and Blood Institute (NHLBI). (See "Risk factors and development of atherosclerosis in childhood".)
Although long-term outcome data are not available to demonstrate that identification and treatment of risk factors in childhood will reduce the prevalence of clinical disease and opinions differ widely, many experts (including the authors of this review) believe it is reasonable to assume based on data from adult studies that timely intervention to prevent (primordial prevention), decrease, and possibly eliminate CVD risk factor(s) in children will decelerate the atherosclerotic process (primary prevention), and prevent or delay the onset of CVD [2,33,34]. (See "Overview of the management of the child at risk for atherosclerosis".)
Risk factors and special conditions — Specific conditions are associated with early cardiovascular disease (CVD) and accelerated atherosclerosis (table 1). In a scientific statement from the AHA, a panel of experts reviewed the literature on premature cardiovascular disease in children and established a disease risk stratification schema for coronary artery disease (CAD), which was revised into a two-tier schema by the NHLBI panel in 2011 (algorithm 1) [2,34] (see "Diseases associated with atherosclerosis in childhood"):
●High-risk conditions – High-risk conditions are associated with pathologic or clinical evidence of CAD before 30 years of age and include types 1 and 2 diabetes mellitus, chronic kidney disease, having received a heart transplant, and Kawasaki disease (KD) with current coronary aneurysms. (See "Diseases associated with atherosclerosis in childhood", section on 'High-risk conditions'.)
●Moderate-risk conditions – Moderate-risk conditions are associated with pathophysiologic evidence for accelerated atherosclerosis before 30 years of age and include KD with regressed coronary aneurysms, chronic inflammatory disease, human immunodeficiency virus (HIV) infection, and nephrotic syndrome. In addition, major depressive disorder and bipolar disorder have been proposed as potential moderate-risk conditions . (See "Diseases associated with atherosclerosis in childhood", section on 'Moderate-risk conditions'.)
Similar to adults in whom multiple risk factors are considered in evaluation of risk for CVD, the following additional risk factors are considered when making treatment decisions (algorithm 1) (see "Risk factors and development of atherosclerosis in childhood", section on 'Risk factors'):
●Abnormal fasting lipid profile (table 7)
●Fasting blood glucose >100 mg/dL (5.6 mmol/L)
●Family history of early CAD (defined as heart attack, treated angina, interventions for coronary artery disease, stroke, or sudden cardiac disease in a male parent or sibling before 55 years of age, or a female parent or sibling before 65 years of age)
Routine screening — During routine health supervision visits, screening is recommended by the AAP, the AHA, and NHLBI to identify children with any of the above risk factors associated with atherosclerosis.
Routine screening consists of the following:
●Obtain history for possible smoke exposure including both personal and second-hand smoke. (See "Prevention of smoking initiation in children and adolescents" and "Secondhand smoke exposure: Effects in children".)
●Review sleep history. Sleep duration and quality is an emerging cardiovascular risk factor. Specifically, obstructive sleep apnea is a risk factor for CVD and is discussed separately. (See "Assessment of sleep disorders in children" and "Obstructive sleep apnea and cardiovascular disease".)
●Review the family history for premature CAD (ie, heart attack, treated angina, interventions for CAD, stroke, or sudden cardiac disease in a male parent or sibling before 55 years of age, or a female parent or sibling before 65 years of age). The NHLBI guidelines suggest that the family history for premature CVD be reviewed at the prenatal or first visit, and again at routine visits at 3 and 10 years of age.
●Measure blood pressure. Age- and height-specific blood pressure percentiles may be determined using calculators for girls (calculator 3) or boys (calculator 4). (See "Evaluation of hypertension in children and adolescents".)
●Measure weight and height and calculate body mass index (BMI). BMI and BMI percentiles may be determined using linked calculators for girls (calculator 1) or boys (calculator 2). (See "Measurement of growth in children".)
●Perform lipid screening in all children and adolescents (table 8). For children without risk factors, the first screening is performed at 9 to 11 years of age, with a second screening between 17 and 21 years of age. Earlier and more frequent monitoring may be warranted in children with risk factors for early CVD. (See "Dyslipidemia in children: Definition, screening, and diagnosis", section on 'Lipid screening'.)
●Perform screening for type 2 diabetes in at-risk children and adolescents (table 9). Guidelines suggest screening using fasting plasma glucose or hemoglobin A1C level be performed every three years in patients ≥10 years old who are overweight or obese (ie, BMI is ≥85th percentile) and have two additional risk factors for diabetes. (See "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Screening'.)
The severity of childhood atherosclerosis (and by extension the risk of CVD) increases as the number of CVD risk factors increases. Thus, it is important to consider all cardiovascular risk factors together in making management decisions (algorithm 1).
Management of children who are judged to be at increased risk for atherosclerosis includes nonpharmacologic and pharmacologic interventions which are discussed in detail separately. (See "Overview of the management of the child at risk for atherosclerosis" and "Dyslipidemia in children: Management" and "Nonemergent treatment of hypertension in children and adolescents".)
SUMMARY AND RECOMMENDATIONS
●Pediatric prevention to reduce the risk of adult cardiovascular disease (CVD) consists of the following:
•General measures for adherence to a healthy lifestyle that would prevent or reduce the development of risk factors associated with atherosclerosis. (See 'Promotion of healthy lifestyle' above.)
•Identification and management of the child at risk for early atherosclerosis based on the presence of established risk factors including hypertension, obesity, dyslipidemia, insulin resistance, physical inactivity, smoke exposure, or high-risk conditions (algorithm 1 and table 1). (See 'Identifying children at risk for CVD' above.)
●During routine care visits, we suggest that care providers promote positive cardiovascular behaviors and a healthy lifestyle to reduce the development of risk factors associated with early atherosclerosis (Grade 2B). In particular, pediatric care providers should supply age-appropriate information and support to children and their families regarding nutrition (ie, a diet low in saturated fat and refined carbohydrates, and rich in vegetables, fruits, and whole grains) (table 3), physical activity (table 6), and avoidance of smoke exposure. (See 'Promotion of healthy lifestyle' above.)
●Long-term outcome data are not available to demonstrate that identification and treatment of risk factors in childhood will reduce or prevent premature CVD in adults. Nevertheless, it is reasonable to assume based on data from pediatric, young adult, and other adult studies that timely intervention that reduces and possibly eliminates these risk factor(s) in children will decelerate the atherosclerotic process (primary prevention), and prevent or delay the early onset of CVD. As a result, we suggest that all children during routine health care visits be screened for CVD and atherosclerotic risk factors (Grade 2B). Screening consists of reviewing the child's diet, physical activity level, risk of smoke exposure, and family history for premature CVD; measuring blood pressure, weight, and height; calculating body mass index (BMI); lipid screening; screening for type 2 diabetes in at-risk children; and identifying other conditions associated with accelerated atherosclerosis in childhood (table 1 and algorithm 1). (See 'Routine screening' above.)
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