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Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics
SUPPLEMENT ARTICLE

Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report

EXPERT PANEL ON INTEGRATED GUIDELINES FOR CARDIOVASCULAR HEALTH AND RISK REDUCTION IN CHILDREN AND ADOLESCENTS
Pediatrics December 2011, 128 (Supplement 5) S213-S256; DOI: https://doi.org/10.1542/peds.2009-2107C
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  • FIGURE 8-1
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    FIGURE 8-1

    BP measurement and categorization. HT indicates height; WT, weight; HTN, hypertension; %ile, percentile. a See Table 8-2; b see “Nutrition and Diet”Table 5-1; c see “Physical Activity”; c see “Overweight and Obesity.” Adapted from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):555–576.

  • FIGURE 8-2
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    FIGURE 8-2

    BP management according to category. HTN indicates hypertension; CV, cardiovascular; Hx, history; PEx, physical examination; CBC, complete blood count; U/A, urinalysis; U/S, ultrasound; Ped, pediatric; LVH, left ventricular hypertrophy; Q, every; Rx, prescription; 2°, secondary; W/U, workup; TOD, target organ damage; s/p, status post; CKD, chronic kidney disease; %ile, percentile. a Workup for target organ damage/left ventricular hypertrophy if obese or positive for other cardiovascular risk factors; b see “Nutrition and Diet”; c see “Physical Activity”; d see “Overweight and Obesity.” Adapted from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):555–576.

  • FIGURE 9-1
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    FIGURE 9-1

    Dyslipidemia algorithm: target LDL cholesterol. Values given are in mg/dL. To convert to SI units, divide results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. TG indicates triglycerides; C, cholesterol; RF, risk factor; FHx, family history; a Obtain FLPs at least 2 weeks but no more than 3 months apart. b Per Table 9-9, use of drug therapy is limited to children aged 10 years and older with defined risk profiles. c In a child with an LDL cholesterol level of >190 mg/dL and other risk factors, a trial of the CHILD-2–LDL may be abbreviated.

  • FIGURE 9-2
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    FIGURE 9-2

    Dyslipidemia algorithm: target triglycerides. Values given are in mg/dL. To convert to SI units, divide results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. C indicates cholesterol; a Obtain FLPs at least 2 weeks but no more than 3 months apart. b The FDA and the Environmental Protection Agency advise women of childbearing age who may become pregnant, pregnant women, nursing mothers, and young children to avoid some types of fish and shellfish and to eat fish and shellfish that are lower in mercury. For more information, call the FDA's food information line toll-free at 1-888-SAFEFOOD or visit www.cfsan.fda.gov/∼dms/admehg3.html.

  • FIGURE 11-1
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    FIGURE 11-1

    Risk stratification and management for children with conditions predisposing to accelerated atherosclerosis and early CVD. CV indicates cardiovascular; RF, risk factor; HT, height; WT, weight; TG, triglycerides; %ile, percentile; C, cholesterol; FG, fasting glucose; Rx, recommendation. a See “Nutrition and Diet”; b see “Physical Activity”; c see “Overweight and Obesity.” Adapted from Kavey RE, Allada V, Daniels SR, et al; American Heart Association, Expert Panel on Population and Prevention Science; American Heart Association, Council on Cardiovascular Disease in the Young; American Heart Association, Council on Epidemiology and Prevention; American Heart Association, Council on Nutrition, Physical Activity and Metabolism; American Heart Association, Council on High Blood Pressure Research; American Heart Association, Council on Cardiovascular Nursing; American Heart Association, Council on the Kidney in Heart Disease; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2006;114(24):2710–2738.

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    TABLE 1-1

    Evaluated Risk Factors

    Family history
    Age
    Gender
    Nutrition/diet
    Physical inactivity
    Tobacco exposure
    BP
    Lipid levels
    Overweight/obesity
    Diabetes mellitus
    Predisposing conditions
    Metabolic syndrome
    Inflammatory markers
    Perinatal factors
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    TABLE 1-2

    Evidence Grading System: Quality Grades

    GradeEvidence
    AWell-designed RCTs or diagnostic studies performed on a population similar to the guideline's target population
    BRCTs or diagnostic studies with minor limitations; genetic natural history studies; overwhelmingly consistent evidence from observational studies
    CObservational studies (case-control and cohort design)
    DExpert opinion, case reports, or reasoning from first principles (bench research or animal studies)
    • Adapted from American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Pediatrics. 2004;114(3):874–877.

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    TABLE 1-3

    Evidence Grading System: Strength of Recommendations

    Statement TypeDefinitionImplication
    Strong recommendationThe expert panel believes that the benefits of the recommended approach clearly exceed the harms and that the quality of the supporting evidence is excellent (grade A or B). In some clearly defined circumstances, strong recommendations may be made on the basis of lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits clearly outweigh the harms.Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
    RecommendationThe expert panel feels that the benefits exceed the harms but that the quality of the evidence is not as strong (grade B or C). In some clearly defined circumstances, recommendations may be made on the basis of lesser evidence when high-quality evidence is impossible to obtain and when the anticipated benefits clearly outweigh the harms.Clinicians should generally follow a recommendation but remain alert to new information and sensitive to patient preferences.
    OptionalEither the quality of the evidence that exists is suspect (grade D) or well-performed studies (grade A, B, or C) have found little clear advantage to one approach versus another.Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set boundaries on alternatives; patient and family preference should have a substantial influencing role.
    No recommendationThere is both a lack of pertinent evidence (grade D) and an unclear balance between benefits and harms.Clinicians should not be constrained in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient and family preference should have a substantial influencing role.
    • Adapted from American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Pediatrics. 2004;114(3):874–877.

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    3. INTEGRATED CARDIOVASCULAR HEALTH SCHEDULE

    Risk FactorAge
    Birth to 12 mo1–4 y5–9 y9–11 y12–17 y18–21 y
    Family history of early CVD—At 3 y, evaluate family history for early CVD: parents, grand parents, aunts/uncles, men ≤55 y old, women ≤65 y old; review with parents and refer as needed; positive family history identifies children for intensive CVD RF attentionUpdate at each nonurgent health encounterReevaluate family history for early CVD in parents, grandparents, aunts/uncles, men ≤55 y old, women ≤65 y oldUpdate 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 mo of age if possible; add formula if breastfeeding decreases or stops before 12 mo of ageAt age 12–24 mo, may change to cow's milk with 2% percentage of fat decided by family and pediatric care provider; after 2 y of age, fat-free milk for all; juice ≤4 oz/d; transition to CHILD-1 diet by the age of 2 yReinforce CHILD-1 diet messagesReinforce CHILD-1 diet messages as neededObtain diet information from child and use to reinforce healthy diet and limitations and 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 y; review with parentChart height/weight/BMI and review with parent; BMI ≥ 85th percentile, crossing percentiles: Intensify diet/activity focus for 6 mo; if no change: RD referral, manage per obesity algorithmsChart height/weight/BMI and review with parent and child; BMI ≥ 85th percentile, crossing percentiles: Intensify diet/activity focus for 6 mo; if no change: RD 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 mo; if no change: RD 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 mo; if no change: RD referral, manage per obesity algorithms; BMI ≥ 95th percentile, manage per obesity algorithms
    BMI ≥ 95th percentile, manage per obesity algorithms
    LipidsNo routine lipid screeningObtain FLP only if family history for CVD is positive, parent has dyslipidemia, child has any other RFs or high-risk conditionObtain FLP only if family history for CVD is positive, parent has dyslipidemia, child has any other RFs or high-risk conditionObtain universal lipid screen with nonfasting non-HDL = TC − HDL, or FLP: manage per lipid algorithms as neededObtain FLP if family history newly positive, parent has dyslipidemia, child has any other RFs or high-risk condition; manage per lipid algorithms as neededMeasure 1 nonfasting non–HDL or FLP in all: review with patient; manage with lipid algorithms per ATP as needed
    BPMeasure BP in infants with renal/urologic/cardiac diagnosis or history of neonatal ICUMeasure BP annually in all from the age of 3 y; chart for age/gender/height percentile and review with parentCheck BP annually and chart for age/gender/height: review with parent; workup and/or management per BP algorithm as neededCheck BP annually and chart for age/gender/height: review with parent, workup and/or management per BP algorithm as neededCheck BP annually and chart for age/gender/height: review with adolescent and parent, workup and/or management per BP algorithm as neededMeasure BP: review with patient; evaluate and treat per JNC guidelines
    Physical activityEncourage parents to model routine activity; no screen time before the age of 2 yEncourage active play; limit sedentary/screen time to ≤2 h/d; no TV in bedroomRecommend MVPA of ≥1 h/d; limit screen/sedentary time to ≤2 h/dObtain activity history from child: recommend MVPA of ≥1 h/d and screen/sedentary time of ≤2 h/dUse activity history with adolescent to reinforce MVPA of ≥1 h/d and leisure screen time of ≤2 h/dDiscuss lifelong activity, sedentary time limits with patient
    Diabetes———Measure fasting glucose level per ADA guidelines; refer to endocrinologist as neededMeasure fasting glucose level per ADA guidelines; refer to endocrinologist as neededObtain fasting glucose level if indicated; refer to endocrinologist as needed
    • All algorithms and guidelines in this schedule are included in this summary report. RF indicates risk factor; RD, registered dietitian; ATP, Adult Treatment Panel III (“Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults”); JNC, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; MVPA, moderate-to-vigorous physical activity; ADA, American Diabetes Association.

    • The full and summary reports of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents can also be found on the NHLBI Web site (www.nhlbi.nih.gov).

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    TABLE 4-1

    Evidence-Based Recommendations for Use of Family History in Cardiovascular Health Promotion

    Birth to 18 yTake detailed family history of CVD at initial encounter and/or at 3, 9–11, and 18 yaGrade B Recommend
    If positive family history identified, evaluate patient for other cardiovascular risk factors, including dyslipidemia, hypertension, DM, obesity, history of smoking, and sedentary lifestyle
    If positive family history and/or cardiovascular risk factors identified, evaluate family, especially parents, for cardiovascular risk factorsGrade B Recommend
    Update family history at each nonurgent health encounterGrade D Recommend
    Use family history to stratify risk for CVD risk as risk profile evolvesGrade D Recommend
    Supportive action: educate parents about the importance of family history in estimating future health risks for all family members
    18 to 21 yReview family history of heart disease with young adult patientGrade B Strongly recommend
    Supportive action: educate patient about family/personal risk for early heart disease, including the need for evaluation for all cardiovascular risk factors
    • Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support implementation of the recommendations (they are not graded).

    • ↵a “Family” includes parent, grandparent, aunt, uncle, or sibling with heart attack, treated angina, coronary artery bypass graft/stent/angioplasty, stroke, or sudden cardiac death at <55 y in males and <65 y in females.

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    TABLE 5-1

    Evidence-Based Recommendations for Diet and Nutrition: CHILD-1

    Birth to 6 moInfants should be exclusively breastfed (no supplemental formula or other foods) until the age of 6 moaGrade B Strongly recommend
    6 to 12 moContinue breastfeeding until at least 12 mo of age while gradually adding solids; transition to iron-fortified formula until 12 mo if reducing breastfeedingaGrade B Strongly recommend
    Fat intake in infants <12 mo of age should not be restricted without medical indicationGrade D Recommend
    Limit other drinks to 100% fruit juice (≤4 oz/d); no sweetened beverages; encourage waterGrade D recommend
    12 to 24 moTransition to reduced-fatb (2% to fat-free) unflavored cow's milkc (see supportive actions)Grade B Recommend
    Limit/avoid sugar-sweetened beverage intake; encourage waterGrade B Strongly recommend
    Transition to table food with:
        Total fat 30% of daily kcal/EERdGrade B Recommend
        Saturated fat 8%–10% of daily kcal/EERGrade B Recommend
        Avoid trans fat as much as possibleGrade D Strongly recommend
        Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EERGrade D recommend
        Cholesterol < 300 mg/dGrade B Strongly recommend
    Supportive actions
        The fat content of cow's milk to introduce at 12–24 mo of age should be decided together by parents and health care providers on the basis of the child's growth, appetite, intake of other nutrient-dense foods, intake of other sources of fat, and potential risk for obesity and CVD
        100% fruit juice (from a cup), no more than 4 oz/d
        Limit sodium intake
        Consider DASH-type diet rich in fruits, vegetables, whole grains, and low-fat/fat-free milk and milk products and lower in sugar (Table 5-3)
    2 to 10 yPrimary beverage: fat-free unflavored milkGrade A Strongly recommend
    Limit/avoid sugar-sweetened beverages; encourage waterGrade B Recommend
    Fat content:
        Total fat 25%–30% of daily kcal/EERGrade A Strongly recommend
        Saturated fat 8%–10% of daily kcal/EERGrade A Strongly recommend
        Avoid trans fats as much as possibleGrade D, recommend
        Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EERGrade D Recommend
        Cholesterol < 300 mg/dGrade A Strongly Recommend
    Encourage high dietary fiber intake from foodseGrade B recommend
    Supportive actions:
        Teach portions based on EER for age/gender/age (Table 5-2)
        Encourage moderately increased energy intake during periods of rapid growth and/or regular moderate-to-vigorous physical activity
        Encourage dietary fiber from foods: age + 5 g/de
        Limit naturally sweetened juice (no added sugar) to 4 oz/d
        Limit sodium intake
        Support DASH-style eating plan (Table 5-3)
    11 to 21 yPrimary beverage: fat-free unflavored milkGrade A Strongly recommend
    Limit/avoid sugar-sweetened beverages; encourage waterGrade B Recommend
    Fat content:
        Total fat 25%–30% of daily kcal/EERdGrade A Strongly recommend
        Saturated fat 8%–10% of daily kcal/EERGrade A Strongly recommend
        Avoid trans fat as much as possibleGrade D Recommend
        Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EERGrade D Recommend
    Cholesterol < 300 mg/dGrade A Strongly recommend
    Encourage high dietary fiber intake from foodseGrade B Recommend
    Supportive actions:
        Teach portions based on EER for age/gender/activity (Table 5-2)
        Encourage moderately increased energy intake during periods of rapid growth and/or regular moderate-to-vigorous physical activity
        Advocate dietary fiber: goal of 14 g/1000 kcale
        Limit naturally sweetened juice (no added sugar) to 4–6 oz/d
        Limit sodium intake
        Encourage healthy eating habits: breakfast every day, eating meals as a family, limiting fast-food meals
        Support DASH-style eating plan (Table 5-3)
    • Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel. Supportive actions represent expert consensus suggestions from the expert panel provided to support implementation of the recommendations; they are not graded. EER indicates estimated energy requirement.

    • ↵a Infants who cannot be fed directly at the breast should be fed expressed milk. Infants for whom expressed milk is not available should be fed iron-fortified infant formula.

    • ↵b For toddlers 12 to 24 mo of age with a family history of obesity, heart disease, or high cholesterol, parents should discuss transition to reduced-fat milk with pediatric care provider after 12 months of age.

    • ↵c Continued breastfeeding is still appropriate and nutritionally superior to cow's milk. Reduced-fat milk should be used only in the context of an overall diet that supplies 30% of calories from fat.

    • ↵d Estimated energy requirements per day for age/gender (Table 5-2).

    • ↵e Naturally fiber-rich foods are recommended (fruits, vegetables, whole grains); fiber supplements are not advised. Limit refined carbohydrates (sugars, white rice, and white bread).

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    TABLE 5-2

    Estimated Calorie Needs per Day by Age, Gender, and Physical Activity Levela

    GenderAge (Years)Calorie Requirements (kcals) by Activity Levelb
    SedentaryModerately ActiveActive
    Child2–31000–12001000–1400c1000–1400c
    Femaled4–81200–14001400–16001400–1800
    9–131400–16001600–20001800–2200
    14–18180020002400
    19–301800–20002000–22002400
    Male4–81200–14001400–16001600–2000
    9–131600–20001800–22002000–2600
    14–182000–24002400–28002800–3200
    19–302400–26002600–28003000
    • Estimated amounts of calories needed to maintain caloric balance for various gender and age groups at three different levels of physical activity. The estimates are rounded to the nearest 200 calories. An individual's calorie needs may be higher or lower than these average estimates.

    • ↵a Based on Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights (health) for each age/gender group. For children and adolescents, reference height and weight vary. For adults, the reference man is 5 feet 10 inches tall and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. EER equations are from the Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): The National Academies Press; 2002.

    • ↵b Sedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately active means a lifestyle that includes physical activity equivalent to walking ∼1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life. Active means a lifestyle that includes physical activity equivalent to walking >3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life.

    • ↵c The calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents, more calories are needed at older ages. For adults, fewer calories are needed at older ages.

    • ↵d Estimates for females do not include women who are pregnant or breastfeeding.

    • Reproduced with permission from Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002:175–182.

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    TABLE 5-3

    DASH Eating Plan: Servings per Day According to Food Group and Total Energy Intake

    Food GroupNo. of ServingsServing SizeExamples and NotesSignificance of Each Food Group to the DASH Eating Plan
    1200 cal1400 cal1600 cal1800 cal2000 cal2600 cal
    Grainsa4–5/d5–6/d6/d6/d6–8/d10–11/d1 slice bread; 1 oz dry cerealb; ½ cup cooked rice, pasta, or cerealbWhole-wheat bread and rolls, whole-wheat pasta, English muffin, pita bread, bagel, cereals, grits, oatmeal, brown rice, unsalted pretzels and popcornMajor sources of energy and fiber
    Vegetables3–4/d3–4/d3–4/d4–5/d4–5/d5–6/d1 cup raw leafy vegetable; ½ cup cut-up raw or cooked vegetable; ½ cup vegetable juiceBroccoli, carrots, collards, green beans, green peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoesRich sources of potassium, magnesium, and fiber
    Fruits3–4/d4/d4/d4–5/d4–5/d5–6/d1 medium fruit; ¼ cup dried fruit; ½ cup fresh, frozen, or canned fruit; ½ cup fruit juiceApples, apricots, bananas, dates, grapes, oranges, grapefruit, grapefruit juice, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerinesImportant sources of potassium, magnesium, and fiber
    Fat-free or low-fat milk and milk products2–3/d2–3/d2–3/d2–3/d2–3/d3/d1 cup milk or yogurt; 1½ oz cheeseFat-free milk or buttermilk, fat-free, low-fat, or reduced-fat cheese, fat-free/low-fat regular or frozen yogurtMajor sources of calcium and protein
    Lean meats, poultry, and fish≤3/d≤3–4/d≤3–4/d≤6/d≤6/d≤6/d1 oz cooked meats, poultry, or fish; 1 eggcSelect only lean; trim away visible fats; broil, roast, or poach; remove skin from poultryRich sources of protein and magnesium
    Nuts, seeds, and legumes3/wk3/wk3–4/wk4/wk4–5/wk1/d⅓ cup or 1½ oz nuts; 2 tbsp peanut butter; 2 tbsp or ½ oz seeds; ½ cup cooked legumes (dry beans and peas)Almonds, filberts, mixed nuts, peanuts, walnuts, sunflower seeds, peanut butter, kidney beans, lentils, split peasRich sources of energy, magnesium, protein, and fiber
    Fats and oilsd1/d1/d2/d2–3/d2–3/d3/d1 tsp soft margarine; 1 tsp vegetable oil; 1 tbsp mayonnaise; 2 tbsp salad dressingSoft margarine, vegetable oil (such as canola, corn, olive, or safflower), low-fat mayonnaise, light salad dressingThe DASH study had 27% of calories as fat, including fat in or added to foods
    Sweets and added sugars≤3/wk≤3/wk≤3/wk≤5/wk≤5/wk≤2/d1 tbsp sugar; 1 tbsp jelly or jam; ½ cup sorbet, gelatin; 1 cup lemonadeFruit-flavored gelatin, fruit punch, hard candy, jelly, maple syrup, sorbet and ices, sugarSweets should be low in fat
    • Table 5-2 provides estimated energy requirements according to age, gender, and activity level for use with this table. The FDA and the Environmental Protection Agency advise women of childbearing age who may become pregnant, pregnant women, nursing mothers, and young children to avoid some types of fish and shellfish and eat fish and shellfish that are low in mercury. For more information, call the FDA's food information line toll free at 1-888-SAFEFOOD or visit www.cfsan.fda.gov/∼dms/admehg3.html.

    • ↵a Whole grains are recommended for most grain servings as a good source of fiber and nutrients.

    • ↵b Serving sizes vary between a ½ and 1¼ cups, depending on cereal type. Check the product's nutrition-facts label.

    • ↵c Because eggs are high in cholesterol, limit egg yolk intake to no more than 4 per week; 2 egg whites have the same protein content as 1 oz of meat.

    • ↵d Fat content changes serving amount for fats and oils. For example, 1 tbsp of regular salad dressing = 1 serving; 1 tbsp of low-fat dressing = ½ serving; 1 tbsp fat-free dressing = 0 servings.

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    TABLE 6-1

    Evidence-Based Activity Recommendations for Cardiovascular Health

    Newborn to 12 moParents should create an environment that promotes and models physical activity and limits sedentary timeGrade D Recommend
    Supportive actions:
        Discourage TV viewing altogether
    1 to 4 yAllow unlimited active playtime in safe, supportive environmentsGrade D Recommend
    Limit sedentary time, especially TV/videoGrade D Recommend
    Supportive actions:
        Limit total media time to no more than 1-2 hours of quality programming per day
        For children ≤2 y old, discourage TV viewing altogether
        No TV in child's bedroom
        Encourage family activity at least once per week
        Counsel routine activity for parents as role models for children
    5 to 10 yModerate-to-vigorous physical activity every dayaGrade A Strongly recommend
    Limit daily leisure screen time (TV/video/computer)Grade B Strongly recommend
    Supportive actions:
        Prescribe moderate-to-vigorous activity 1 h/da with vigorous-intensity physical activity 3 d/wkb
        Limit total media time to no more than 1–2 h/d of quality programming
        No TV in child's bedroom
        Take activity and screen-time history from child once per year
        Match physical activity recommendations with energy intake
        Recommend appropriate safety equipment relative to each sport
        Support recommendations for daily physical education in schools
    11 to 17 yModerate-to-vigorous physical activity every dayaGrade A Strongly recommend
    Limit leisure time TV/video/computer useGrade B Strongly recommend
    Supportive actions:
        Encourage adolescents to aim for 1 h/d of moderate-to-vigorous daily activitya with vigorous intense physical activityb 3 d/wk
        Encourage no TV in bedroom
        Limit total media time to no more than 1–2 h/d of quality programming
        Match activity recommendations with energy intake
        Take activity and screen-time history from adolescent at health supervision visits
        Encourage involvement in year-round physical activities
        Support continued family activity once per week and/or family support of adolescent's physical activity program
        Endorse appropriate safety equipment relative to each sport
    18 to 21 yModerate-to-vigorous physical activity every dayaGrade A Strongly recommend
    Limit leisure time TV/video/computerGrade B Strongly recommend
    Supportive actions:
        Support goal of 1 h/d of moderate-to-vigorous activity with vigorous intense physical activity 3 d/wk
        Recommend that combined leisure screen time not exceed 2 h/d
        Activity and screen-time history at health supervision visits
        Encourage involvement in year-round, lifelong physical activities
    • Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support implementation of the recommendations (they are not graded).

    • ↵a Examples of moderate-to-vigorous physical activities are jogging and playing baseball.

    • ↵b Examples of vigorous physical activities are running, playing singles tennis, and playing soccer.

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    TABLE 7-1

    Evidence-Based Recommendations to Prevent Tobacco Exposure

    PrenatalObtain smoking history from mothers; provide explicit smoking-cessation message before and during pregnancyGrade A Strongly recommend
    Supportive actions:
        Identify resources to support maternal smoking-cessation efforts.
        Advocate for school and community-based smoke-free interventions
        See “Perinatal Factors” section
    0 to 4 ySmoke-free home environmentGrade B Strongly recommend
    Reinforce this message at every encounter, including urgent visits for respiratory problemsGrade C Recommend
    Supportive actions:
        Provide information about health benefits of a smoke-free home to parents and children
        Advocate for school- and community-based smoke-free interventions
    5 to 10 yObtain smoke-exposure history from child, including personal history of tobacco useGrade C Recommend
    Counsel patients strongly about not smoking, including providing explicit information about the addictive and adverse health effects of smokingGrade C Recommend
    11 to 21 yObtain personal smoking history at every nonurgent health encounterGrade B Strongly recommend
    Explicitly recommend against smokingGrade B Strongly recommend
    Provide specific smoking-cessation guidanceGrade B Strongly recommend
    Supportive actions:
        Use 5 A questions to assess readiness to quit
        Establish your health care practice as a resource for smoking cessation
        Provide quit-line phone number
        Identify community cessation resources
        Provide information about pharmacotherapy for cessation
        Advocate for school and community-based smoke-free interventions
    • Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support implementation of the recommendations (they are not graded).

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    TABLE 8-1

    Age-Specific Recommendations for BP Measurement and Diagnosis of Hypertension

    Birth to 3 yNo routine BP measurement
    Measure BP if history (+) for neonatal complications, congenital heart disease, urinary/renal abnormality, solid-organ transplant, malignancy, drug prescription, or condition known to raise BP or increase intracranial pressure (Table 8-2)
    If BP ≥90th percentile by oscillometry, confirm by auscultation → If BP confirmed ≥90th percentile, initiate evaluation for etiology and treatment per algorithm (Figure 8-2)
    3 to 11 yAnnual BP measurement in all, interpreted for age/gender/height per Tables 8-3 and 8-4
    If BP <90th percentile, repeat in 1 y
    If BP ≥90th percentile:
            Repeat BP × 2 by auscultation
            Average replicate measurements and reevaluate BP category (Fig 8-1)
    If BP confirmed >90th percentile, <95th percentile = prehypertension (HTN):
            Recommend weight management if indicated
            Repeat BP in 6 mo
    If BP ≥95th percentile, <99th percentile + 5 mm Hg:
            Repeat BP in 1–2 wk, average all BP measurements and reevaluate BP category (Fig 8-1)
    If BP confirmed >95th percentile, <99th percentile + 5 mm Hg = stage 1 HTN:
            Basic work-up per Fig 8-2
    If BP ≥99th percentile + 5 mm Hg
            Repeat BP by auscultation × 3 at that visit, average all BP measurements and reevaluate BP category
    If BP confirmed >99th percentile + 5 mm Hg = stage 2 HTN:
            Refer to pediatric HTN expert within 1 wk OR
            Begin BP treatment and initiate basic work-up, per Fig 8-2
    12 to 17 yAnnual BP measurement in all, interpreted for age/gender/height per Tables 8-3 and 8-4
    If BP <90th percentile, counsel on CHILD-1 diet, activity recommendations, and repeat BP in 1 y
    If BP ≥90th percentile or ≥120/80 mm Hg:
            Repeat BP × 2 by auscultation
            Average replicate measurements and reevaluate BP category (Fig 8-1)
    If BP confirmed >90th percentile, < 95th percentile or >120/80 = pre-HTN:
            CHILD-1 diet, activity recommendations, weight management if indicated
            Repeat BP in 6 mo
    If BP ≥95th percentile, <99th percentile + 5 mm Hg
            Repeat BP in 1–2 wk, average all BP measurements and reevaluate BP category (Fig 8-1)
    If BP confirmed ≥95th percentile, <99th percentile + 5 mm Hg = stage 1 HTN:
            Basic workup per Fig 2
    If BP ≥99th percentile + 5 mm Hg:
            Repeat BP by auscultation × 3 at that visit, average all BP measurements and reevaluate BP category
    If BP confirmed >99th percentile + 5 mm Hg = stage 2 HTN:
            Refer to pediatric HTN expert within 1 wk OR
            Begin BP treatment and initiate work-up per Fig 8-2
    18 to 21 yMeasure BP at all health care visits
            BP ≥120/80 to 139/89 = pre-HTN
            BP ≥140/90 to 159/99 = stage 1 HTN
            BP ≥160/100 = stage 2 HTN
    • BP recommendations are based on the NHLBI's “The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents” with the evidence review updated from 2003. Recommendations are all graded as expert opinion (grade D) because they are based on the expert consensus conclusions of the Fourth Report.

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    TABLE 8-2

    Conditions Under Which Children <3 Years Old Should Have BP Measured

    History of prematurity, very low birth weight, or other neonatal complication requiring intensive care
    Congenital heart disease (repaired or unrepaired)
    Recurrent urinary tract infections, hematuria, or proteinuria
    Known renal disease or urologic malformations
    Family history of congenital renal disease
    Solid-organ transplant
    Malignancy or bone marrow transplant
    Treatment with drugs known to raise BP
    Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc)
    Evidence of increased intracranial pressure
    • Reproduced with permission from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):556.

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    TABLE 8-3

    BP Norms for Boys by Age and Height Percentile

    Age, yBP %ileSBP, mm HgDBP, mm Hg
    Percentile of HeightPercentile of Height
    5th10th25th50th75th90th95th5th10th25th50th75th90th95th
    150th8081838587888934353637383939
    90th9495979910010210349505152535354
    95th989910110310410610654545556575858
    99th10510610811011211311461626364656666
    250th8485878890929239404142434444
    90th979910010210410510654555657585859
    95th10110210410610810911059596061626363
    99th10911011111311511711766676869707171
    350th8687899193949544444546474848
    90th10010110310510710810959596061626363
    95th10410510710911011211363636465666767
    99th11111211411611811912071717273747575
    450th8889919395969747484950515152
    90th10210310510710911011162636465666667
    95th10610710911111211411566676869707171
    99th11311411611812012112274757677787879
    550th9091939596989850515253545555
    90th10410510610811011111265666768696970
    95th10810911011211411511669707172737474
    99th11511611812012112312377787980818182
    650th91929496989910053535455565757
    90th10510610811011111311368686970717272
    95th10911011211411511711772727374757676
    99th11611711912112312412580808182838484
    750th929495979910010155555657585959
    90th10610710911111311411570707172737474
    95th11011111311511711811974747576777878
    99th11711812012212412512682828384858686
    850th9495979910010210256575859606061
    90th10710911011211411511671727273747576
    95th11111211411611811912075767778797980
    99th11912012212312512712783848586878788
    950th95969810010210310457585960616162
    90th10911011211411511711872737475767677
    95th11311411611811912112176777879808181
    99th12012112312512712812984858687888889
    1050th979810010210310510658596061616263
    90th11111211411511711911973737475767778
    95th11511611711912112212377787980818182
    99th12212312512712813013085868688888990
    1150th9910010210410510710759596061626363
    90th11311411511711912012174747576777878
    95th11711811912112312412578787980818282
    99th12412512712913013213286868788899090
    1250th10110210410610810911059606162636364
    90th11511611812012112312374757576777879
    95th11912012212312512712778798081828283
    99th12612712913113313413586878889909091
    1350th10410510610811011111260606162636464
    90th11711812012212412512675757677787979
    95th12112212412612812913079798081828383
    99th12813013113313513613787878889909191
    1450th10610710911111311411560616263646565
    90th12012112312512612812875767778797980
    95th12412512712813013213280808182838484
    99th13113213413613813914087888990919292
    1550th10911011211311511711761626364656666
    90th12212412512712913013176777879808081
    95th12612712913113313413581818283848585
    99th13413513613814014214288899091929393
    1650th11111211411611811912063636465666767
    90th12512612813013113313478787980818282
    95th12913013213413513713782838384858687
    99th13613713914114314414590909192939494
    1750th11411511611812012112265666667686970
    90th12712813013213413513680808182838484
    95th13113213413613813914084858687878889
    99th13914014114314514614792939394959697
    • The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.

    • Reproduced with permission from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):558.

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    TABLE 8-4

    BP Norms for Girls by Age and Height Percentile

    Age, yBP %ileSBP, mm HgDBP, mm Hg
    Percentile of HeightPercentile of Height
    5th10th25th50th75th90th95th5th10th25th50th75th90th95th
    150th8384858688899038393940414142
    90th97979810010110210352535354555556
    95th10010110210410510610756575758595960
    99th10810810911111211311464646565666767
    250th8585878889919143444445464647
    90th989910010110310410557585859606161
    95th10210310410510710810961626263646565
    99th10911011111211411511669697070717272
    350th8687888991929347484849505051
    90th10010010210310410610661626263646465
    95th10410410510710810911065666667686869
    99th11111111311411511611773737474757676
    450th8888909192949450505152525354
    90th10110210310410610710864646566676768
    95th10510610710811011111268686970717172
    99th11211311411511711811976767677787979
    550th8990919394959652535354555556
    90th10310310510610710910966676768696970
    95th10710710811011111211370717172737374
    99th11411411611711812012078787979808181
    650th9192939496979854545556565758
    90th10410510610810911011168686970707172
    95th10810911011111311411572727374747576
    99th11511611711912012112280808081828383
    750th9393959697999955565657585859
    90th10610710810911111211369707071727273
    95th11011111211311511611673747475767677
    99th11711811912012212312481818282838484
    850th959596989910010157575758596060
    90th10810911011111311411471717172737474
    95th11211211411511611811875757576777878
    99th11912012112212312512582828383848586
    950th96979810010110210358585859606161
    90th11011011211311411611672727273747575
    95th11411411511711811912076767677787979
    99th12112112312412512712783838484858687
    1050th989910010210310410559595960616262
    90th11211211411511611811873737374757676
    95th11611611711912012112277777778798080
    99th12312312512612712912984848586868788
    1150th10010110210310510610760606061626363
    90th11411411611711811912074747475767777
    95th11811811912112212312478787879808181
    99th12512512612812913013185858687878889
    1250th10210310410510710810961616162636464
    90th11611611711912012112275757576777878
    95th11912012112312412512679797980818282
    99th12712712813013113213386868788888990
    1350th10410510610710911011062626263646565
    90th11711811912112212312476767677787979
    95th12112212312412612712880808081828383
    99th12812913013213313413587878889899091
    1450th10610610710911011111263636364656666
    90th11912012112212412512577777778798080
    95th12312312512612712912981818182838484
    99th13013113213313513613688888990909192
    1550th10710810911011111311364646465666767
    90th12012112212312512612778787879808181
    95th12412512612712913013182828283848585
    99th13113213313413613713889899091919293
    1650th10810811011111211411464646566666768
    90th12112212312412612712878787980818182
    95th12512612712813013113282828384858586
    99th13213313413513713813990909091929393
    1750th10810911011111311411564656566676768
    90th12212212312512612712878797980818182
    95th12512612712913013113282838384858586
    99th13313313413613713813990909191929393
    • The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.

    • Reproduced with permission from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):559.

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    TABLE 8-5

    Antihypertensive Medications With Pediatric Experience

    ClassDrugInitial DoseaMaximal DoseDosing IntervalEvidencebFDAcCommentsd
    ACE inhibitorsBenazepril0.2 mg/kg per d up to 10 mg/d0.6 mg/kg per d up to 40 mg/dQDRCTYes1. All ACE inhibitors are contraindicated in pregnancy; women of childbearing age should use reliable contraception
    Captopril0.3–0.5 mg/kg per dose (>12 mo)6 mg/kg per dTIDRCT, CSNo2. Check serum potassium and creatinine periodically to monitor for hyperkalemia and azotemia
    3. Cough and angioedema are reportedly less common with newer members of this class than with captopril
    FosinoprileChildren >50 kg: 5–10 mg/d40 mg/dQDRCTYes4. Benazepril, enalapril, and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension
    Lisinoprile0.07 mg/kg per d up to 5 mg/d0.6 mg/kg per d up to 40 mg/dQDRCTYes5. FDA approval for ACE inhibitors with pediatric labeling is limited to children ≥6 y of age and to children with creatinine clearance rate of ≥30 mL/min per 1.73 m2
    Quinapril5–10 mg/d80 mg/dQDRCT, EONo6. Initial dose of fosinopril of 0.1 mg/kg per d may be effective, although black patients might require a higher dose
    ARBsIrbesartan6–12 y: 75–150 mg/d; ≥13 y: 150–300 mg/d300 mg/dQDCSYes1. All ARBs are contraindicated in pregnancy; women of childbearing age should use reliable contraception
    Losartane0.7 mg/kg per d up to 50 mg/d1.4 mg/kg per d up to 100 mg/dQD–BIDRCTYes2. Check serum potassium and creatinine levels periodically to monitor for hyperkalemia and azotemia
    Valsartane5–10 mg/d; 0.4 mg/kg per d40–80 mg/d; 3.4 mg/kg per dQDRCTNo3. Losartan label contains information on the preparation of a suspension
    4. FDA approval for ARBs is limited to children ≥6 y of age and to children with creatinine clearance rate of ≥30 mL/min per 1.73 m2
    α- and β-antagonistLabetalol1–3 mg/kg per d10–12 mg/kg per d up to 1200 mg/dBIDCS, EONo1. Asthma and overt heart failure are relative contraindications
    2. Heart rate is dose-limiting
    3. May impair athletic performance in athletes
    4. Should not be used in insulin-dependent diabetic patients
    β-antagonistsAtenolol0.5–1 mg/kg per d2 mg/kg per d up to 100 mg/dQD–BIDCSNo1. Noncardioselective agents (propranolol) are contraindicated in asthma and heart failure
    Bisoprolol/hydrochlorothiazide2.5–6.25 mg/d10/6.25 mg/dQDRCTNo2. Heart rate is dose-limiting
    MetoprololeChildren >6 y: 1 mg/kg per d (12.5–50 mg/d)2 mg/kg per d up to 200 mg/dBIDCSYesf3. May impair athletic performance in athletes
    Propranolol1–2 mg/kg per d4 mg/kg per d up to 640 mg/dBID–TIDRCT, EOYes4. Should not be used in insulin-dependent diabetic patients
    5. A sustained-release, once-daily formulation of propranolol is available
    Calcium-channel blockersAmlodipineeChildren 6–17 y: 2.5 mg/d5 mg/dQDRCTYes1. Amlodipine and isradipine can be compounded into stable extemporaneous suspensions
    Felodipine2.5 mg/d10 mg/dQDRCT, EONo2. Felodipine and extended-release nifedipine tablets must be swallowed whole
    Isradipine0.15–0.2 mg/kg per d0.8 mg/kg per d up to 20 mg/dTID–QIDCS, EONo3. Isradipine is available in both immediate- and sustained-release formulations; sustained release form is dosed QD or BID
    Extended-release nifedipine0.25–0.5 mg/kg per d3 mg/kg per d up to 120 mg/dQD–BIDCS, EONo4. May cause tachycardia
    5. Doses up to 10 mg of amlodipine have been evaluated in children
    6. Contraindicated for children <1 y of age
    Central α-agonistClonidineChildren ≥12 y: 0.2 mg/d2.4 mg/dBIDEOYes1. May cause dry mouth and/or sedation
    2. Transdermal preparation is available
    3. Sudden cessation of therapy can lead to severe rebound hypertension
    DiureticsHydrochlorothiazide1 mg/kg per d3 mg/kg per d up to 50 mg/dQDEOYes1. All patients treated with diuretics should have their electrolytes monitored shortly after initiating therapy and periodically thereafter
    Chlorthalidone0.3 mg/kg per d2 mg/kg per d up to 50 mg/dQDEONo2. Useful as add-on therapy in patients being treated with drugs from other drug classes
    Furosemide0.5–2.0 mg/kg per dose6 mg/kg per dQD–BIDEONo3. Potassium-sparing diuretics (spironolactone, triamterene, amiloride) may cause severe hyperkalemia, especially if given with an ACE inhibitor or ARB
    Spironolactone1 mg/kg per d3.3 mg/kg per d up to 100 mg/dQD–BIDEONo4. Furosemide is labeled only for treatment of edema but may be useful as add-on therapy in children with resistant hypertension, particularly in children with renal disease
    Triamterene1–2 mg/kg per d3–4 mg/kg per d up to 300 mg/dBIDEONo5. Chlorthalidone may precipitate azotemia in patients with renal diseases and should be used with caution in those with severe renal impairment
    Amiloride0.4–0.625 mg/kg per d20 mg/dQDEONo
    Peripheral α-antagonistsDoxazosin1 mg/d4 mg/dQDEONo1. May cause first-dose hypotension
    Prazosin0.05–0.1 mg/kg per day0.5 mg/kg per dTIDEONo
    Terazosin1 mg/d20 mg/dQDEONo
    VasodilatorsHydralazine0.75 mg/kg per d7.5 mg/kg per d up to 200 mg/dQIDEOYes1. Tachycardia and fluid retention are common adverse effects
    MinoxidilChildren <12 y: 0.2 mg/kg per d;Children <12 y: 50 mg/d; childrenQD–TIDCS, EOYes2. Hydralazine can cause a lupus-like syndrome in slow acetylators
        children >12 y: 5 mg/d    ≥12 y: 100 mg/d3. Prolonged use of minoxidil can cause hypertrichosis
    4. Minoxidil is usually reserved for patients with hypertension that is resistant to multiple drugs
    • ACE indicates angiotensin-converting enzyme; QD, every day; BID, 2 times daily; TID, 3 times daily; QID, 4 times daily; CS, case series; EO, expert opinion; ARB, angiotensin-receptor blocker.

    • ↵a The maximal recommended adult dose should not be exceeded in routine clinical practice.

    • ↵b Level of evidence on which recommendations are based.

    • ↵c FDA-approved pediatric labeling information is available for treatment of hypertension. Recommended doses for agents with FDA-approved pediatric labels contained in this table are the doses contained in the approved labels. Even when pediatric labeling information is not available, the FDA-approved label should be consulted for additional safety information.

    • ↵d Comments apply to all members of each drug class except where otherwise stated.

    • ↵e Indicates drug added since “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents” (2004).

    • ↵f Study did not reach the primary end point (dose response for reduction in systolic BP). Some prespecified secondary end points demonstrated effectiveness.

    • Adapted from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):555–576.

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    TABLE 9-1

    Acceptable, Borderline-High, and High Plasma Lipid, Lipoprotein, and Apolipoprotein Concentrations for Children and Adolescents

    CategoryLow, mg/dLaAcceptable, mg/dLBorderline-High, mg/dLHigh, mg/dLa
    TC—<170170–199≥200
    LDL cholesterol—<110110–129≥130
    Non-HDL cholesterol—<120120–144≥145
    Apolipoprotein B—<9090–109≥110
    Triglycerides
        0–9 y—<7575–99≥100
        10–19 y—<9090–129≥130
    HDL cholesterol<40>4540–45—
    Apolipoprotein A-1<115>120115–120—
    • Values for plasma lipid and lipoprotein levels are from the NCEP Expert Panel on Cholesterol Levels in Children. Non-HDL cholesterol values from the Bogalusa Heart Study are equivalent to the NCEP Pediatric Panel cut points for LDL cholesterol. Values for plasma apolipoprotein B and apolipoprotein A-1 are from the National Health and Nutrition Examination Survey III. Note that values shown are in mg/dL; to convert to SI units, divide the results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6.

    • ↵a Low cut points for HDL cholesterol and apolipoprotein A-1 represent approximately the 10th percentile. The cut points for high and borderline-high represent approximately the 95th and 75th percentiles, respectively.

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    TABLE 9-2

    Recommended Cut Points for Lipid and Lipoprotein Levels in Young Adults

    CategoryLow, mg/dLBorderline-Low, mg/dLAcceptable, mg/dLBorderline-High, mg/dLHigh, mg/dL
    TC——<190190–224≥225
    LDL cholesterol——<120120–159≥160
    Non-HDL cholesterol——<150150–189≥190
    Triglycerides——<115115–149≥150
    HDL cholesterol<4040–44>45——
    • Values provided are from the Lipid Research Clinics Prevalence Study. The cut points for TC, LDL cholesterol, and non-HDL cholesterol represent the 95th percentile for 20- to 24-year-old subjects and are not identical with the cut points used in the most recent NHLBI adult guidelines, Adult Treatment Panel III (“Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults”), which are derived from combined data on adults of all ages. The age-specific cut points given here are provided for pediatric care providers to use in managing this young adult age group. For TC, LDL cholesterol, and non-HDL cholesterol, borderline-high values are between the 75th and 94th percentiles, whereas acceptable value are at the <75th percentile. The high triglyceride cut point represents approximately the 90th percentile; borderline-high values are between the 75th and 89th percentiles, and acceptable values are at the <75th percentile. The low HDL cholesterol cut point represents approximately the 25th percentile; borderline-low values are between the 26th and 50th percentiles, and acceptable values are at the >50th percentile.

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    TABLE 9-3

    Causes of Secondary Dyslipidemia

    Exogenous
        Alcohol
        Drug therapy: corticosteroids
            Isoretinoin
            β-blockers
            Some oral contraceptives
            Select chemotherapeutic agents
            Select antiretroviral agents
    Endocrine/metabolic
        Hypothyroidism/hypopituitarism
        T1DM and T2DM
        Pregnancy
        Polycystic ovary syndrome
        Lipodystrophy
        Acute intermittent porphyria
    Renal
        Chronic renal disease
        Hemolytic uremic syndrome
        Nephrotic syndrome
    Infectious
        Acute viral/bacterial infectiona
        HIV
        Hepatitis
    Hepatic
        Obstructive liver disease/cholestatic conditions
        Biliary cirrhosis
        Alagille syndrome
    Inflammatory disease
        Systemic lupus erythematosis
        Juvenile rheumatoid arthritis
    Storage disease
        Glycogen-storage disease
        Gaucher disease
        Cystine-storage disease
        Juvenile Tay-Sachs disease
        Niemann-Pick disease
    Other
        Kawasaki disease
        Anorexia nervosa
        Post–solid organ transplantation
        Childhood cancer survivor
        Progeria
        Idiopathic hypercalcemia
        Klinefelter syndrome
        Werner syndrome
    • ↵a Delay measurement until ≥3 weeks after infection.

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    TABLE 9-4

    Summary of Major Lipid Disorders in Children and Adolescents

    Primary Lipid DisordersLipid/Lipoprotein Abnormality
    Familial hypercholesterolemia
        Homozygous↑↑ LDL cholesterol
        Heterozygous↑ LDL cholesterola
    Familial defective apolipoprotein B↑ LDL cholesterol
    Familial combined hyperlipidemiaa
        Type IIa↑ LDL cholesterol
        Type IV↑ VLDL cholesterol, ↑ triglycerides
        Type IIb↑ LDL cholesterol, ↑ VLDL cholesterol, ↑ triglycerides
        Types IIb and IV↓ HDL cholesterol (often)
    Polygenic hypercholesterolemia↑ LDL cholesterol
    Familial hypertriglyceridemia (200–1000 mg/dL)↑ VLDL cholesterol, ↑ triglycerides
    Severe hypertriglyceridemia (≥1000 mg/dL)↑ chylomicrons, ↑ VLDL cholesterol, ↑↑ triglycerides
    Familial hypoalphalipoproteinemia↓ HDL cholesterol
    Dysbetalipoproteinemia (TC: 250–500 mg/dL; triglycerides: 250–600 mg/dL)↑ IDL cholesterol, ↑ chylomicron remnants
    • ↑ indicates increased; ↓, decreased; IDL indicates intermediate-density lipoprotein; VLDL, very low density lipoprotein.

    • ↵a These are the 2 lipid and lipoprotein disorders seen most frequently in childhood and adolescence; familial combined hyperlipidemia most often manifests with obesity.

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    TABLE 9-5

    Evidence-Based Recommendations for Lipid Assessment

    Birth to 2 yNo lipid screeningGrade C
    Recommend
    2 to 8 yNo routine lipid screeningGrade B
    Recommend
    Measure fasting lipid profile twice,a average results if:
        Parent, grandparent, aunt/uncle, or sibling withGrade B
        MI, angina, stroke, CABG/stent/angioplasty at <55 y in males, <65 y in femalesStrongly recommend
        Parent with TC ≥ 240 mg/dL or known dyslipidemiaGrade B
        Parent with TC ≥ 240 mg/dL or known dyslipidemiaStrongly recommend
        Child has diabetes, hypertension, BMI ≥ 95th percentile or smokes cigarettesGrade B Strongly recommend
        Child has a moderate- or high-risk medical condition (Table 5-2)Grade B Strongly recommend
        Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
    9 to 11 yUniversal screeningGrade B
    Strongly recommend
        Non-FLP: Calculate non–HDL cholesterol:
        Non–HDL cholesterol = TC − HDL cholesterol
        If non-HDL ≥ 145 mg/dL ± HDL < 40 mg/dLb:
        Obtain FLP twice,a average results
        OR
        FLP:
        If LDL cholesterol ≥ 130 mg/dL ± non-HDL cholesterol ≥ 145 mg/dL ± HDL cholesterol < 40 mg/dL ± triglycerides ≥ 100 mg/dL if <10 y, ≥130 mg/dL if ≥10 y:
        Repeat FLP, average results
        Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
    12 to 16 yNo routine screeningcGrade B
    Recommend
    Measure FLP twice,a average results, if new knowledge of:
        Parent, grandparent with MI, angina, stroke, CABG/stent/angioplasty, sudden death at <55 y in male, <65 y in femaleGrade B
    Strongly recommend
        Parent with TC ≥ 240 mg/dL or known dyslipidemiaGrade B
    Strongly recommend
        Patient has diabetes, hypertension, BMI ≥ 85th percentile or smokes cigarettesGrade B
    Strongly recommend
        Patient has a moderate- or high-risk medical condition (Table 5-2)Grade B
    Strongly recommend
        Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
    17 to 21 yUniversal screening once in this time period:Grade B
    Recommend
        Non-FLP: Calculate non–HDL cholesterol:
        Non–HDL cholesterol = TC − HDL cholesterol*
        17–19 y:
        If non–HDL cholesterol ≥145 mg/dL ± HDL cholesterol < 40 mg/dLb
        Measure FLP twice,a average results
        OR
        FLP:
        If LDL cholesterol ≥ 130 mg/dL ± non–HDL cholesterol ≥ 145 mg/dL ± HDL cholesterol < 40 mg/dL ± triglycerides ≥ 130 mg/dL
        Repeat FLP, average results
        Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
        20–21 y:
        Non–HDL cholesterol ≥ 190 mg/dL ± HDL cholesterol < 40 mg/dL
        Measure FLP twice, average results
        OR
        FLP:
        If LDL cholesterol ≥ 160 mg/dL ± non–HDL cholesterol ≥ 190 mg/dL ± HDL cholesterol < 40 mg/dL ± triglycerides ≥ 150 mg/dL
        Repeat FLP, average results
        Use Table 9-2 for interpretation of results, Adult Treatment Panel (ATP III) algorithm for management.
    • Grades reflect the findings of the evidence review, recommendation levels reflect the consensus opinion of the expert panel. Note that the values given are in mg/dL. To convert to SI units, divide the results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. MI indicates myocardial infarction; CABG, coronary artery bypass graft; ATP III, Adult Treatment Panel III.

    • ↵a Interval between FLP measurements: after 2 weeks but within 3 months.

    • ↵b Use Table 9-1 for interpretation of results; use lipid algorithms in Figs 9-1 and 9.2 for management of results.

    • ↵c Disregard triglyceride and LDL cholesterol levels in nonfasting sample.

    • d Lipid screening is not recommended for those aged 12 to 16 years because of significantly decreased sensitivity and specificity for predicting adult LDL cholesterol levels and significantly increased false-negative results in this age group. Selective screening is recommended for those with the clinical indications outlined.

    • eUse Table 9-1 for interpretation of results of 7- to 19-year-olds and lipid algorithms in Figs 9-1 and 9-2 for management. Use Table 17 for interpretation of results of 20- to 21-year-olds and ATP III algorithms for management.

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    TABLE 9-6

    Risk-Factor Definitions for Dyslipidemia Algorithms

    Positive family history: myocardial infarction, angina, coronary artery bypass graft/stent/angioplasty, sudden cardiac death in parent, grandparent, aunt, or uncle at <55 y for males, <65 y for females
    High-level RFs
        Hypertension that requires drug therapy (BP ≥ 99th percentile + 5 mm Hg)
        Current cigarette smoker
        BMI at the ≥97th percentile
        Presence of high-risk conditions (Table 9-7)
        (DM is also a high-level RF, but it is classified here as a high-risk condition to correspond with Adult Treatment Panel III recommendations for adults that DM be considered a CVD equivalent.)
    Moderate-level RFs
        Hypertension that does not require drug therapy
        BMI at the ≥95th percentile, <97th percentile
        HDL cholesterol < 40 mg/dL
        Presence of moderate-risk conditions (Table 9-7)
    • RF indicates risk factor.

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    TABLE 9-7

    Special Risk Conditions

    High risk
        T1DM and T2DM
        Chronic kidney disease/end-stage renal disease/post–renal transplant
        Post–orthotopic heart transplant
        Kawasaki disease with current aneurysms
    Moderate risk
        Kawasaki disease with regressed coronary aneurysms
        Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
        HIV infection
        Nephrotic syndrome
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    TABLE 9-8

    Evidence-Based Recommendations for Dietary Management of Elevated LDL Cholesterol, Non-HDL Cholesterol, and Triglyceride Levels

    2 to 21 yElevated LDL cholesterol: CHILD-2–LDL
        Refer to a registered dietitian for family medical nutrition therapyGrade B Strongly recommend
            25%–30% of calories from fat, ≤7% from saturated fat, ∼10% from monounsaturated fat; <200 mg/d of cholesterol; avoid trans fats as much as possibleGrade A Recommend
        Supportive actions:
            Plant sterol esters and/or plant stanol estersa up to 2 g/d as replacement for usual fat sources can be used after 2 y of age in children with familial hypercholesterolemia
            Plant stanol esters as part of a regular diet are marketed directly to the public; short-term studies have found no harmful effects in healthy children
            The water-soluble fiber psyllium can be added to a low-fat, low-saturated-fat diet as cereal enriched with psyllium at a dose of 6 g/d for children 2–12 y of age and 12 g/d for those ≥12 y of age
            As for all children, 1 h/d of moderate-to-vigorous physical activity and <2 h/d of sedentary screen time are recommended.
    Elevated triglycerides or non-HDL cholesterol: CHILD-2–TG
        Refer to a registered dietitian for family medical nutrition therapybGrade B Strongly recommend
            25%–30% of calories from fat, ≤7% from saturated fat, ∼10% from monounsaturated fat; <200 mg/d of cholesterol; avoid trans fats as much as possibleGrade A Recommend
            Decrease sugar intakeGrade B Recommend
                Replace simple with complex carbohydrates
                No sugar-sweetened beverages
            Increase dietary fish to increase ω-3 fatty acidscGrade D Recommend
    • Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support implementation of the recommendations (they are not graded). Values given are in mg/dL. To convert to SI units, divide the results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6.

    • ↵a Can be found added to some foods, such as some margarines.

    • ↵b If the child is obese, nutrition therapy should include calorie restriction, and increased activity (beyond that recommended for all children) should be prescribed. See “Overweight and Obesity” for additional age-specific recommendations.

    • ↵c The FDA and the Environmental Protection Agency advise women of childbearing age who may become pregnant, pregnant women, nursing mothers, and young children to avoid some types of fish and shellfish and eat fish and shellfish that are low in mercury. For more information, call the FDA's food information line toll-free at 1-888-SAFEFOOD or visit www.cfsan.fda.gov/∼dms/admehg3.html.

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    TABLE 9-9

    Evidence-Based Recommendations for Pharmacologic Treatment of Dyslipidemia

    Birth to 10 yPharmacologic treatment is limited to children with severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia [triglycerides ≥ 500 mg/dL]), a high-risk condition (Tables 9-6 and 9-7), or evident cardiovascular disease, all under the care of a lipid specialistGrade C Recommend
    ≥10 to 21 yDetailed family history and RF assessment required before initiation of drug therapya (high- to moderate-level RFs and RCs are listed in Tables 9-6 and 9-7)Grade C Strongly recommend
        LDL cholesterol
            If average LDL cholesterol ≥ 250 mg/dLa, consult lipid specialistGrade B Strongly recommend
            If average LDL cholesterol ≥ 130–250 mg/dL, or non-HDL ≥ 145 mg/dL:
                Refer to dietitian for medical nutrition therapy with CHILD-1 → CHILD-2–LDL (Table 9-8) for 6 mo; repeat FLPGrade A Strongly recommend
        Repeat FLP
            LDL cholesterol < 130 mg/dL, continue CHILD-2–LDL, reevaluate in 12 moGrade A Strongly recommend
            LDL cholesterol ≥ 190 mg/dL,b consider initiation of statin therapy per Tables 9-11 and 9-12Grade A Strongly recommend
            LDL cholesterol ≥ 130–189 mg/dL, negative family history, no other RF or RC, continue CHILD-2–LDL, reevaluate every 6 moGrade B Recommend
            LDL cholesterol = 160–189 mg/dL + positive family history or ≥1 high-level RF/RC or ≥2 moderate-level RFs/RCs, consider statin therapy per Tables 9-11 and 9-12Grade B Recommend
            LDL cholesterol ≥ 130–159 mg/dL + ≥2 high-level RFs/RCs or 1 high-level + 2 moderate-level RFs/RCs, consider statin therapy per Tables 9-11 and 9-12Grade B Recommend
            Children on statin therapy should be counseled and carefully monitored per Table 9-12Grade A Strongly recommend
    ≥10 to 21 yDetailed family history and RF/RC assessment required before initiation of drug therapya (high- and moderate-level RFs/RCs in Tables 9-6 and 9-7c)Grade C Strongly recommend
        Triglycerides
            If average triglycerides ≥ 500 mg/dL, consult lipid specialistGrade B Recommend
            If average triglycerides ≥ 100 mg/dL in a child aged <10 y, ≥130 mg/dL in a child aged 10–19 y, or <500 mg/dL:
                Refer to dietitian for medical nutrition therapy with CHILD-1 → CHILD-2–TG (Table 9-8) for 6 moGrade B Strongly recommend
            Repeat FLP
                Triglycerides < 100 (130) mg/dL, continue CHILD-2–TG, monitor every 6–12 moGrade B Strongly recommend
                Triglycerides > 100 (130) mg/dL, reconsult dietitian for intensified CHILD-2–TG diet counselingGrade C Recommend
                Triglycerides ≥ 200–499 mg/dL, non-HDL ≥ 145 mg/dL, consider fish oil ± consult lipid specialistGrade D Recommend
        Non-HDL cholesterol
            Children aged ≥10 y with non-HDL cholesterol ≥ 145 mg/dL after LDL cholesterol goal is achieved may be considered for additional treatment with statins, fibrates, or niacin in conjunction with a lipid specialist consultationGrade D Optional
    • Grades reflect the findings of the evidence review, and recommendation levels reflect the consensus opinion of the expert panel. When medication is recommended, it should always be in the context of the complete cardiovascular risk profile of the patient and in consultation with the patient and the family. Values given are in mg/dL. To convert to SI units, divide the results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. RF indicates risk factor; RC, risk condition.

    • ↵a Consideration of drug therapy is based on the average of ≥2 FLPs, obtained at least 2 weeks but no more than 3 months apart.

    • ↵b If average LDL cholesterol ≥ 190 mg/dL after CHILD-2–LDL and child is 8 to 9 years old with a positive family history or ≥1 high-level risk factor/risk condition or ≥2 moderate-level risk factors/risk conditions, statin therapy may be considered.

    • ↵c If the child is obese, nutrition therapy should include calorie restriction and increased activity beyond that recommended for all children. See “Overweight and Obesity” for additional age-specific recommendations.

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    TABLE 9-10

    Medications for Managing Hyperlipidemia

    Type of MedicationMechanism of ActionMajor EffectsExamplesAdverse ReactionsFDA Approval in Youths (as of This Writing)
    HMG-CoA reductase inhibitors (statins)Inhibits cholesterol synthesis in hepatic cells; decreases cholesterol pool, resulting in upregulation of LDL receptorsMainly lowers LDL cholesterol; some decrease in triglycerides and modest increase in HDL cholesterolAtorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatinRaised hepatic enzymes, raised creatine kinase, myopathy possibly progressing to rhabdomyolysisAll statins listed are approved as an adjunct to diet to lower LDL cholesterol in adolescent boys and postmenarcheal girls aged 10–18 y (≥8 y for pravastatin) with heFH and LDL cholesterol ≥190 mg/dL, or ≥160 mg/dL with family history of premature CVD and ≥2 CVD risk factors in the pediatric patient
    Bile acid sequestrantsBinds intestinal bile acids, interrupting enterohepatic recirculation; more cholesterol converted into bile acids; decreases hepatic cholesterol pool; upregulates LDL receptorsLowers LDL cholesterol; small increase in HDL cholesterol; raises triglyceridesCholestyramine, colestipol, colesevelamLimited to gastrointestinal tract: gas, bloating, constipation, crampsNo pediatric indication listed for cholestyramine or colestipol; colesevelam indicated as monotherapy or with statin for LDL cholesterol reduction in boys and postmenarcheal girls aged 10–17 y with family history after diet trial if LDL cholesterol ≥ 190 mg/dL or if LDL cholesterol ≥ 160 mg/dL with family history of premature CVD or ≥2 CVD risk factors in the pediatric patient
    Cholesterol absorption inhibitorsInhibits intestinal absorption of cholesterol and plant sterols; decreases hepatic cholesterol pool; upregulates LDL receptorsMainly lowers LDL cholesterol; some decrease in triglycerides and small increase in HDL cholesterolEzetimibeMyopathy, gastrointestinal upset, headacheNot approved
    Fibric acid derivativesAgonist for PPAR-α nuclear receptors that upregulate LPL and downregulate apolipoprotein C-III, both increasing degradation of VLDL cholesterol and triglycerides; hepatic synthesis of VLDL cholesterol may also be decreasedMainly lowers triglycerides and raises HDL cholesterol; little effect on LDL cholesterolFenofibrate, gemfibrozilDyspepsia, constipation, myositis, anemiaNot approved
    Nicotinic acid (extended release)Inhibits release of FFA from adipose tissue; decreases VLDL and LDL cholesterol production and HDL cholesterol degradationLowers triglycerides and LDL cholesterol and raises HDL cholesterol; can decrease lipoprotein(a)Niacin, extended releaseFlushing, hepatic toxicity, can increase fasting blood glucose, uric acid; can cause hyperacidityUse not recommended in children <2 y old
    ω-3 fish oilDecreases hepatic FA and triglycerides synthesis while enhancing FA degradation/oxidation, with subsequent reduced VLDL cholesterol releaseLowers triglycerides; raises HDL cholesterol; increases LDL cholesterol and LDL cholesterol particle sizeω-3 acid ethyl estersOccasional adverse gastrointestinal effects but no adverse effect on glucose levels or muscle or liver enzymes or bleedingOnly 1 fish-oil preparation is FDA-approved for adults, but many generic fish-oil capsules are commercially available
    • HMG-CoA indicates hydroxymethylglutaryl coenzyme A; heFH, heterozygous hypercholesterolemia; PPAR-α, peroxisome proliferator-activated receptor; LPL, lipoprotein lipase; VLDL, very low density lipoprotein; FFA, free fatty acid; FA, fatty acid.

    • Adapted from McCrindle BW, Urbina EM, Dennison BA, et al; American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee; American Heart Association, Council of Cardiovascular Disease in the Young; American Heart Association, Council on Cardiovascular Nursing. Circulation. 2007;115(14):1948–1967.

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    TABLE 9-11

    Clinical Trials of Lipid-Lowering Medication Therapy in Children and Adolescents

    Study Authors, Type, and DurationMedicationNo. of Subjects, Gender, ConditionDaily DoseEffect on Lipid Profile, %
    TCLDL CholesterolHDL CholesterolTriglycerides
    Bile acid–binding resins
        Tonstad et al, RCT, 1 yCholestyramine72, male and female, FH (LDL ≥ 190 mg/dL without family history of premature CVD or LDL ≥ 160 with family history after 1-y diet; ages 6–11 y)8 g−12−178NA
        McCrindle et al, RCT crossover, 2 × 8 wkCholestyramine40, male and female, FH (1 parent with FH; LDL cholesterol ≥ 131 mg/dL; on diet; ages 10–18 y)8 g−7 to −11−10 to −152 to 46 to 9
        Tonstad et al, RCT, 8 wk; open label, 44–52 wkColestipol66, male and female, FH (TC ≥ 239 mg/dL and triglycerides ≤ 115 mg/dL; ages 10–16 y)2–12 g−17−20−7−13
        McCrindle et al, RCT crossover, 2 × 18 wkColestipol36, male and female, FH/FCHL (LDL ≥ 160 mg/dL after 6 mo of diet counseling; ages 8–18 y)10 g−7−10212
        Stein et al, RCT, 8 wk; open label, 18 wkColesevelam191, male and female, FH (LDL ≥ 190 mg/dL or LDL ≥ plus 2 additional risk factors after 6 mo of diet counseling; ages 10–17 y1.87 g−3−656
    3.75 g−7−1385
    HMG-CoA reductase inhibitors (statins)
        McCrindle et al, RCT; open label, 26 wkAtorvastatin187, male and female, FH/severe hyperlipidemia (LDL cholesterol ≥ 190 mg/dL or LDL cholesterol ≥ 160 mg/dL with family history; triglycerides < 400 mg/dL; ages 10 – 17 y)10–20 mg−30−406−13
        Van der Graaf et al, open label, 2 yFluvastatin85, male and female, FH (LDL cholesterol ≥ 190 mg/dL or LDL cholesterol ≥ 160 mg/dL and ≥1 risk factor or LDL receptor mutation; ages 10–16 y)80 mg−27−345−5
        Lambert et al, RCT, 8 wkLovastatin69, male, FH (LDL cholesterol > 95th percentile, family history of atherosclerosis and hyperlipidemia; on diet; mean age: 13 y)10 mg−17−219−18
    20 mg−19−2429
    30 mg−21−27113
    40 mg−29−363−9
        Stein et al, RCT, 48 wkLovastatin132, male, FH (LDL 189–503 mg/dL + family history of high LDL; or 220–503 mg/dL + family history of CAD death; AHA diet ≥4 mo; ages 10–17 y)10 mg−13−1744
    20 mg−19−2448
    40 mg−21−2756
        Clauss et al, RCT, 24 wkLovastatin54, female, FH (family history of FH; LDL 160–400 mg/dL and triglycerides < 350 mg/dL; 4-wk diet placebo run-in and 20-wk treatment; ages 10–17 y, postmenarcheal)40 mg−22−273−23
        Knipscheer et al, RCT, 12 wkPravastatin72, male and female, FH (family history hypercholesterolemia or premature atherosclerosis; LDL > 95th percentile; diet for 8 wk; ages 8–16 y)5 mg−18−2342
    10 mg−17−2467
    20 mg−25−33113
        Wiegman et al, RCT, 2 yPravastatin214, male and female, FH (LDL cholesterol ≥ 155 mg/dL and triglycerides ≤ 350 mg/dL; diet for 3 mo; ages 8–18 y)20–40 mg−19−246−17
        Rodenburg et al, open-label, 2-y RCT; 4.5-y open-label follow-upPravastatin186, male and female, FH (LDL cholesterol ≥ 154 mg/dL and triglycerides < 154 mg/dL; diet for 3 mo; ages 8–18 y)20 mg (ages <14 y) or 40 mg (ages ≥ 14 y)−23−293−2
        de Jongh et al, RCT, 48 wkSimvastatin173, male and female, FH (LDL cholesterol = 158–397 mg/dL; ages 10–17 y)10–40 mg−31−413−9
        de Jongh et al, RCT, 28 wkSimvastatin50, male and female, FH (LDL cholesterol > 95th percentile, family history of hyperlipidemia, or LDL receptor mutation; ages 9–18 y)40 mg−30−405−17
        Avis et al, RCT, 12 wk; then, 40-wk open-label follow-upRosuvastatin177, male and female, FH (LDL cholesterol ≥ 190 mg/dL or LDL cholesterol > 160 mg/dL plus positive family history of early CVD or ≥2 other risk factors for CVD)5 mg−30−384−13
    10 mg−34−4510−15
    20 mg−39−509−16
    Other agents
        Wheeler et al, RCT, 26 wkBezafibrate14, male and female, FH (TC > 269 mg/dL, normal triglycerides + family history of FH or premature CAD; ages 4–15 y)10–20 mg−22NC15−23
        Colletti et al, open label, 1–19 moNiacin21, male and female, FH (mean LDL = 243 ± 45 mg/dL on low-fat diet; mean triglycerides = 87 ± 39 mg/dL; ages 4–14 y)500–2200 mg−13−17413
        McCrindle et al, RCT crossover, 2 × 18 wkPravastatin and colestipol36, male and female, FH/FCHL (LDL > 160 mg/dL + family history of FH or premature CAD; triglycerides > 177 mg/dL in 10 of the 36; ages 10–18 y)Pravastatin, 10 mg (with colestipol, 5g)−13−1748
        van der Graaf et al, RCT, 6 and 27 wk; open label to 53 wkSimvastatin and ezetimibe248, male and female, FH (LDL > 159 mg/dL + genotype-confirmed FH or + parental genotype-confirmed FH or + parental LDL > 210 mg/dL or + tendinous xanthomas or LDL > 189 mg/dL + family history of hypercholesterolemia; ages 10–17 y)Simvastatin 10–40 mg (with ezetimibe, 10 mg)−38−497−17
    Addendum
        Goldberg et al, ω-3 fatty acid review in adults; no RCTs in childrenω-3 fish oils (1 g per capsule)a—1–4 g/dNC17 to 316 to 17−30 to −40
    • FH indicates heterozygous familial hypercholesterolemia; NA, not available; FCHL, familial combined hyperlipidemia; HMG-CoA, hydroxymethylglutaryl coenzyme A; CAD, coronary artery disease; NC, not calculated.

    • ↵a There is only one FDA-approved fish-oil preparation, but there are many generic forms of fish-oil capsules that are commercially available. The University of Wisconsin maintains a preventive cardiology patient education Web site (www.heartdecision.org). The fish-oil section includes information about the content of various preparations. The Web site is updated every 6 months (www.heartdecision.org/chdrisk/v_hd/patient_edu_docs/Fish_Oil_11-2007.pdf).

    • Adapted from McCrindle BW, Urbina EM, Dennison BA, et al; American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee; American Heart Association, Council of Cardiovascular Disease in the Young; American Heart Association, Council on Cardiovascular Nursing. Circulation. 2007;115(14):1948–1967.

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    TABLE 9-12

    Recommendations for Use of 3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Inhibitors (Statins) in Children and Adolescents

    Patient selection
    1. Use algorithm (Fig 9-1) and risk-factor categories (Tables 9-6 and 9-7) to select statin therapy for patients.

    2. Include preferences of patient and family in decision-making.

    3. In general, do not start treatment with statins before the age of 10 y (patients with high-risk family history, high-risk conditions, or multiple risk factors [Tables 9-6 and 9-7] might be considered for medication initiation at age ≤10 y).

    4. Precaution/contraindication with potentially interactive medications (cyclosporine, niacin, fibric acid derivatives, erythromycin, azole antifungal agents, nefazodone, many HIV protease inhibitors); check for potential interaction with all current medications at baseline.

    5. Conduct baseline hepatic panel and CK before initiating treatment.

    Initiation and titration
    1. Choice of particular statin is a matter of preference. Clinicians are encouraged to develop familiarity and experience with one of the statins, including dosage regimen and potential drug-drug interactions.

    2. Start with the lowest dose once daily, usually at bedtime. Atorvastatin and rosuvastatin can be taken in the morning or evening because of their long half-lives.

    3. Measure baseline CK, ALT, and AST.

    4. Instruct the patient to report all potential adverse effects, especially muscle cramps, weakness, asthenia, and more diffuse symptoms suggestive of myopathy.

    5. Advise female patients about concerns with pregnancy and the need for appropriate contraception.

    6. Advise about potential future medication interactions, especially cyclosporine, niacin, fibric acid derivatives, erythromycin, azole antifungal agents, nefazodone, and HIV protease inhibitors.

        Check for potential interaction whenever any new medication is initiated.
    1. Whenever potential myopathy symptoms are present, stop medication and assess CK; determine relation to recent physical activity. The threshold for worrisome level of CK is 10 times above the upper limit of reported normal, considering the impact of physical activity. Monitor the patient for resolution of myopathy symptoms and any associated increase in CK level. Consideration can be given to restarting the medication once symptoms and laboratory abnormalities have resolved.

    2. After 4 wk, measure FLP, ALT, and AST and compare with laboratory-specific reported normal values.

      • The threshold for worrisome levels of ALT or AST is ≥3 times the upper limit of reported normal.

      • Target levels for LDL cholesterol: minimal, <130 mg/dL; ideal, <110 mg/dL.

    3. If target LDL cholesterol levels are achieved and there are no potential myopathy symptoms or laboratory abnormalities, continue therapy and recheck FLP, ALT, and AST in 8 wk and then in 3 mo.

    4. If laboratory abnormalities are noted or symptoms are reported, temporarily withhold the medication and repeat the blood work in 2 wk. When abnormalities resolve, the medication may be restarted with close monitoring.

    5. If target LDL cholesterol levels are not achieved, increase the dose by 1 increment (usually 10 mg) and repeat the blood work in 4 wk. If target LDL cholesterol levels are still not achieved, dose may be further increased by 1 increment, or another agent (bile acid sequestrant or cholesterol absorption inhibitor) may be added under the direction of a lipid specialist.

    Maintenance monitoring
    1. Monitor growth (height, weight, and BMI relative to normal growth charts), sexual maturation, and development.

    2. Whenever potential myopathy symptoms present, stop medication and assess CK.

    3. Monitor FLP, ALT, and AST every 3–4 mo in the first year, every 6 mo in the second year and beyond, and whenever clinically indicated.

    4. Monitor and encourage compliance with lipid-lowering dietary and medication therapy. Serially assess and counsel for other risk factors such as weight gain, smoking, and inactivity.

    5. Counsel adolescent girls about statin contraindications in pregnancy and the need for abstinence or use of appropriate contraceptive measures. Use of oral contraceptives is not contraindicated if medically appropriate. Seek referral to an adolescent medicine or gynecologic specialist as appropriate.

    • CK indicates creatine kinase; ALT, alanine aminotransferase; AST, aspartate aminotransferase.

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    TABLE 10-1

    Evidence-Based Recommendations for Management of Overweight and Obesity

    Birth to 24 moNo weight-for-height–specific recommendations
    CHILD-1 diet is recommended for pediatric care providers to use with their child and adolescent patients to reduce cardiovascular risk
    2 to 5 yIdentify children at high risk for obesity because of parental obesity and excessive BMI increaseGrade B Recommend
        Focused CHILD-1 diet and physical activity education
            BMI percentile stable: reinforce current program, follow-up in 6 mo
            Increasing BMI percentile: RD counseling for energy-balanced diet, intensify physical activity change; 6-mo follow-up
        BMI = 85th–95th percentile
            Excess weight-gain prevention with parents as focus for energy-balanced diet; reinforce physical activity recommendations for 6 moGrade D Recommend
            Improvement in BMI percentile: continue current program
            Increasing BMI percentile: RD counseling for energy-balanced diet; intensify physical activity recommendations; 6-mo follow-up
        BMI ≥ 95th percentile
            Specific assessment for comorbiditiesaGrade B Strongly recommend
            Family-based weight-gain prevention with parents as focus; RD counseling and follow-up for energy-balanced diet; MVPA prescription; limit sedentary screen time; 3-mo follow-upGrade B Recommend
    6 to 11 yIdentify children at increased risk for obesity because of parental obesity, change in physical activity ± excessive gain in BMI for focused CHILD-1 diet/physical activity educationGrade B Recommend
        BMI percentile stable: reinforce current program, 6-mo follow-up
        Increasing BMI percentile: RD counseling for energy-balanced CHILD-1 diet, intensified physical activity, 3 mo follow-up
        BMI = 85th–95th percentile
            Excessive weight-gain prevention with parents as focus for energy-balanced diet; reinforce physical activity recommendations, 6-mo follow-upGrade D Recommend
            Stable/improving BMI percentile: reinforce current program, 6-mo follow-up
            Increasing BMI percentile: RD counseling for energy-balanced CHILD-1 diet, intensified physical activity recommendations, 3-mo follow-up
        BMI ≥ 95th percentile
            Specific assessment for comorbiditiesaGrade B Strongly recommend
        BMI ≥ 95th percentile with no comorbidities
            Office-based weight-loss plan: family-centered program with parents as focus for behavior modification, (−) energy-balanced diet, counseling by RD, prescription for increased MVPA, decreased sedentary time for 6 moGrade A Strongly recommend
            Improvement in BMI percentile/comorbidities: continue current plan
            No improvement in BMI percentile: refer to comprehensive multidisciplinary lifestyle weight-loss program
        BMI ≥ 95th percentile with comorbidities, BMI > 97th percentile, or progressive rise in BMI despite therapyGrade A Strongly recommend
            Refer to comprehensive multidisciplinary weight-loss program for intensive management for 6 mo
            Improvement in BMI percentile: continue current program
            No improvement in BMI percentile: consider referral to another comprehensive multidisciplinary weight-loss program
    12 to 21 yIdentify adolescents at increased risk for obesity because of parental obesity, change in physical activity ± excess gain in BMI for focused diet/physical activity education for 6 moGrade B Recommend
        BMI/BMI percentile stable: reinforce current program, 6-mo follow-up
        Increasing BMI/BMI percentile: RD counseling for energy-balanced CHILD-1 diet, intensified physical activity for 3 mo
    BMI = 85th–95th percentile
        Excess weight-gain prevention with adolescent as change agent for energy-balanced CHILD-1 diet, reinforced physical activity recommendations for 6 moGrade B Recommend
        Improvement in BMI percentile: continue current program
        Increasing BMI percentile: RD counseling for energy-balanced weight-control diet, intensified physical activity, 3-mo follow-up
    BMI ≥ 95th percentile
        Specific assessment for comorbiditiesaGrade B Strongly recommend
            BMI ≥ 95th percentile with no comorbidities
                Office-based weight-loss plan: family-centered with adolescent as change agent for behavior-modification counseling, RD counseling for (−) energy-balanced diet, prescription for increased MVPA, decreased sedentary time for 6 moGrade B Strongly recommend
                Improvement in BMI/BMI percentile: continue current program
                No improvement in BMI/BMI percentile: refer to comprehensive multidisciplinary weight-loss program with peers
                No improvement in BMI/BMI percentile: consider initiation of medication (orlistat) under care of experienced clinician for 6–12 mo
            BMI ≥ 95th percentile with comorbidities or BMI > 35
                Refer to comprehensive lifestyle weight-loss program for intensive management for 6–12 moGrade A Strongly recommend
                Improvement in BMI/BMI percentile: continue current program
                No improvement in BMI/BMI percentile: consider initiation of orlistat under care of experienced clinician for 6–12 mo
            If BMI is far above 35 and comorbidities unresponsive to lifestyle therapy for >1 y, consider bariatric surgery/referral to center with experience/expertise in procedures
    • Grades reflect the findings of the evidence review, and recommendation levels reflect the consensus opinion of the expert panel. RD indicates registered dietitian; MVPA, moderate-to-vigorous physical activity.

    • ↵a Comorbidities: hypertension, dyslipidemia, and T2DM.

    • View popup
    TABLE 11-1

    American Diabetes Association (ADA) Screening Recommendations for Type 2 DM in Childhood

    Criteria:
    • Overweight, defined by:

      • –BMI ≥ 85th percentile for age and gender, or

      • –Weight for height ≥ 85th percentile, or

      • –Weight > 120% of ideal for height

    Plus any two of the following risk factors:
    • Family history of type 2 DM in first- or second-degree relative

    • Race/ethnicity (Native American, African-American, Latino, Asian-American, Pacific Islander)

    • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome)

    Screening procedure:
    Age of initiation:
    ≥10 y, or at onset of puberty, if puberty occurs at a younger age
    Frequency:
    Every 2 y
    Test:
    Fasting plasma glucose
    • Reproduced with permission from American Diabetes Association. Diabetes Care. 2000;23(3):386.

    • View popup
    TABLE 11-2

    Special Risk Pediatric Conditions: Stratification by Risk Category

    High risk
        Manifest coronary artery disease at ≤30 y of age: clinical evidence
            T1DM or T2DM
            Chronic kidney disease/end-stage renal disease/post–renal transplant
            Post–orthotopic heart transplantation
            Kawasaki disease with current coronary aneurysms
    Moderate risk
        Accelerated atherosclerosis: pathophysiologic evidence
            Kawasaki disease with regressed coronary aneurysms
            Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
            HIV infection
            Nephrotic syndrome
    • Adapted from Kavey RE, Allada V, Daniels SR, et al; American Heart Association, Expert Panel on Population and Prevention Science; American Heart Association, Council on Cardiovascular Disease in the Young; American Heart Association, Council on Epidemiology and Prevention; American Heart Association, Council on Nutrition, Physical Activity and Metabolism; American Heart Association, Council on High Blood Pressure Research; American Heart Association, Council on Cardiovascular Nursing; American Heart Association, Council on the Kidney in Heart Disease; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2006;114(24):2710–2738.

    • View popup
    TABLE 11-3

    Condition-Specific Treatment Recommendations for High-Risk Conditions

    Rigorous age-appropriate education in diet, activity, smoking cessation for all
    Specific therapy as needed to achieve BP, LDL cholesterol, glucose, and HbA1c goals indicated for each tier, as outlined in algorithm; timing individualized for each patient and diagnosis
    DM regardless of type:
        For T1DM, intensive glucose management per endocrinologist with frequent glucose monitoring/insulin titration to maintain optimal plasma glucose and HbA1c levels for age
        For T2DM, intensive weight management and glucose control in consultation with an endocrinologist as needed to maintain optimal plasma glucose and HbA1c levels for age
        Assess BMI and fasting lipid levels: step 4 lifestyle management of weight and lipid levels for 6 mo
        If LDL goals are not achieved, consider statin therapy if age is ≥10 y to achieve tier 1 treatment goals for LDL cholesterol
        Initial BP ≥ 90th percentile: step 4 lifestyle management plus no added salt, increased activity for 6 mo
        If BP is consistently at the ≥95th percentile for age/gender/height, initiate angiotensin-converting enzyme inhibitor therapy with a BP goal of <90th percentile for gender/height or <120/80 mm Hg, whichever is lower
    Chronic kidney disease/end-stage renal disease/post–renal transplant:
        Optimization of renal-failure management with dialysis/transplantation per nephrology
        Assess BMI, BP, and lipid and FG levels: step 4 lifestyle management for 6 mo
        If LDL goals are not achieved, consider statin therapy if age is ≥10 y to achieve tier 1 treatment goals for LDL cholesterol
        If BP is consistently at the ≥95th percentile for age/gender/height, initiate angiotensin-converting enzyme inhibitor therapy with a BP goal of <90th percentile for gender/height or <120/80 mm Hg, whichever is lower
    After heart transplantation:
        Optimization of antirejection therapy, treatment for cytomegalovirus infection, routine evaluation by angiography/perfusion imaging per transplant physician
        Assess BMI, BP, and lipid and FG levels: initiate step 5 therapy, including statins, immediately for all patients aged ≥1 y to achieve tier 1 treatment goals
    Kawasaki disease with current coronary aneurysms:
        Antithrombotic therapy, activity restriction, ongoing myocardial perfusion evaluation per cardiologist
        Assess BMI, BP, and lipid and FG levels: step 4 lifestyle management for 6 mo
        If goals are not achieved, consider pharmacologic therapy for LDL cholesterol and BP if age is ≥10 y to achieve tier 1 treatment goals
    • FG indicates fasting glucose.

    • Adapted from Kavey RE, Allada V, Daniels SR, et al; American Heart Association, Expert Panel on Population and Prevention Science; American Heart Association, Council on Cardiovascular Disease in the Young; American Heart Association, Council on Epidemiology and Prevention; American Heart Association, Council on Nutrition, Physical Activity and Metabolism; American Heart Association, Council on High Blood Pressure Research; American Heart Association, Council on Cardiovascular Nursing; American Heart Association, Council on the Kidney in Heart Disease; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2006;114(24):2710–2738.

    • View popup
    TABLE 12-1

    Metabolic Syndrome Component Levels for Evaluation of Children With Multiple Cardiovascular Risk Factors

    Risk FactorCut PointReference
    Obesity, percentile
        BMI≥85th to <95thCDC growth charts
        Waist circumference≥90th to <95thNHANES
    BP, percentile≥90th to <95th“The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents”
    Dyslipidemia, mg/dLSee “Lipids and Lipoproteins” for normative values
        HDL cholesterol≥40 to ≤45
        Triglycerides
            0–9 y≥75 to <100
            ≥10 y≥90 to <130
        Non-HDL cholesterol≥120 to <144
    Glycemia, mg/dLADA screening recommendations
        Fasting glucose≥100 to <126
        Fasting insulinElevated fasting insulin level, above normal for gender, race, and pubertal status, is considered evidence of insulin resistance
    • NHANES indicates National Health and Nutrition Examination Survey; ADA, American Diabetes Association.

    • View popup
    TABLE 13-1

    Evidence-Based Recommendations for Maternal Smoking Cessation

    Smoking-cessation guidance during pregnancy is strongly advisedGrade A, strongly recommend
    Supportive action:
        Pediatric care providers should be provided with appropriate training and materials to deliver, or refer to, a smoking-cessation program in the postpartum period for all smoking women of childbearing age
        This intervention should be directly linked to ongoing smoke-free home recommendations directed at all young mothers and fathers as described in the “Tobacco Exposure” section
    • Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support implementation of the recommendations (they are not graded).

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Pediatrics
Vol. 128, Issue Supplement 5
1 Dec 2011
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Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report
EXPERT PANEL ON INTEGRATED GUIDELINES FOR CARDIOVASCULAR HEALTH AND RISK REDUCTION IN CHILDREN AND ADOLESCENTS
Pediatrics Dec 2011, 128 (Supplement 5) S213-S256; DOI: 10.1542/peds.2009-2107C

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Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report
EXPERT PANEL ON INTEGRATED GUIDELINES FOR CARDIOVASCULAR HEALTH AND RISK REDUCTION IN CHILDREN AND ADOLESCENTS
Pediatrics Dec 2011, 128 (Supplement 5) S213-S256; DOI: 10.1542/peds.2009-2107C
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  • Table of Contents

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  • Article
    • 1. INTRODUCTION
    • 2. STATE OF THE SCIENCE: CARDIOVASCULAR RISK FACTORS AND THE DEVELOPMENT OF ATHEROSCLEROSIS IN CHILDHOOD
    • 4. FAMILY HISTORY OF EARLY ATHEROSCLEROTIC CVD
    • 5. NUTRITION AND DIET
    • 6. PHYSICAL ACTIVITY
    • 7. TOBACCO EXPOSURE
    • 8. HIGH BP
    • 9. LIPIDS AND LIPOPROTEINS
    • 10. OVERWEIGHT AND OBESITY
    • 11. DM AND OTHER CONDITIONS PREDISPOSING TO THE DEVELOPMENT OF ACCELERATED ATHEROSCLEROSIS
    • 12. RISK-FACTOR CLUSTERING AND THE METABOLIC SYNDROME
    • RECOMMENDATIONS FOR MANAGEMENT OF RISK-FACTOR CLUSTERING AND THE METABOLIC SYNDROME
    • 13. PERINATAL FACTORS
    • Footnotes
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • Comments

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