Article Figures & Data
Figures
- 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
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
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
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
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.
Tables
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 Grade Evidence A Well-designed RCTs or diagnostic studies performed on a population similar to the guideline's target population B RCTs or diagnostic studies with minor limitations; genetic natural history studies; overwhelmingly consistent evidence from observational studies C Observational studies (case-control and cohort design) D Expert 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.
Statement Type Definition Implication Strong recommendation The 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. Recommendation The 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. Optional Either 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 recommendation There 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.
3. INTEGRATED CARDIOVASCULAR HEALTH SCHEDULE
Risk Factor Age Birth to 12 mo 1–4 y 5–9 y 9–11 y 12–17 y 18–21 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 attention Update at each nonurgent health encounter Reevaluate family history for early CVD in parents, grandparents, aunts/uncles, men ≤55 y old, women ≤65 y old Update at each nonurgent health encounter Repeat family-history evaluation with patient Tobacco exposure Advise smoke-free home; offer smoking-cessation assistance or referral to parents Continue active antismoking advice with parents; offer smoking-cessation assistance and referral as needed Obtain smoke exposure history from child Begin active antismoking advice with child Assess smoking status of child; active antismoking counseling or referral as needed Continue active antismoking counseling with patient; offer smoking-cessation assistance or referral as needed Reinforce strong antismoking message; offer smoking-cessation assistance or referral as needed Nutrition/diet Support breastfeeding as optimal to 12 mo of age if possible; add formula if breastfeeding decreases or stops before 12 mo of age At 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 y Reinforce CHILD-1 diet messages Reinforce CHILD-1 diet messages as needed Obtain diet information from child and use to reinforce healthy diet and limitations and provide counseling as needed Review healthy diet with patient Growth, overweight/obesity Review family history for obesity; discuss weight-for-height tracking, growth chart, and healthy diet Chart height/weight/BMI; classify weight-by BMI from age 2 y; review with parent Chart 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 algorithms Chart 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 algorithms Chart 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 algorithms Review 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 Lipids No routine lipid screening Obtain FLP only if family history for CVD is positive, parent has dyslipidemia, child has any other RFs or high-risk condition Obtain FLP only if family history for CVD is positive, parent has dyslipidemia, child has any other RFs or high-risk condition Obtain universal lipid screen with nonfasting non-HDL = TC − HDL, or FLP: manage per lipid algorithms as needed Obtain FLP if family history newly positive, parent has dyslipidemia, child has any other RFs or high-risk condition; manage per lipid algorithms as needed Measure 1 nonfasting non–HDL or FLP in all: review with patient; manage with lipid algorithms per ATP as needed BP Measure BP in infants with renal/urologic/cardiac diagnosis or history of neonatal ICU Measure BP annually in all from the age of 3 y; chart for age/gender/height percentile and review with parent Check BP annually and chart for age/gender/height: review with parent; workup and/or management per BP algorithm as needed Check BP annually and chart for age/gender/height: review with parent, workup and/or management per BP algorithm as needed Check BP annually and chart for age/gender/height: review with adolescent and parent, workup and/or management per BP algorithm as needed Measure BP: review with patient; evaluate and treat per JNC guidelines Physical activity Encourage parents to model routine activity; no screen time before the age of 2 y Encourage active play; limit sedentary/screen time to ≤2 h/d; no TV in bedroom Recommend MVPA of ≥1 h/d; limit screen/sedentary time to ≤2 h/d Obtain activity history from child: recommend MVPA of ≥1 h/d and screen/sedentary time of ≤2 h/d Use activity history with adolescent to reinforce MVPA of ≥1 h/d and leisure screen time of ≤2 h/d Discuss lifelong activity, sedentary time limits with patient Diabetes — — — Measure fasting glucose level per ADA guidelines; refer to endocrinologist as needed Measure fasting glucose level per ADA guidelines; refer to endocrinologist as needed Obtain 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).
- TABLE 4-1
Evidence-Based Recommendations for Use of Family History in Cardiovascular Health Promotion
Birth to 18 y Take detailed family history of CVD at initial encounter and/or at 3, 9–11, and 18 ya Grade 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 factors Grade B Recommend Update family history at each nonurgent health encounter Grade D Recommend Use family history to stratify risk for CVD risk as risk profile evolves Grade D Recommend Supportive action: educate parents about the importance of family history in estimating future health risks for all family members 18 to 21 y Review family history of heart disease with young adult patient Grade 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.
Birth to 6 mo Infants should be exclusively breastfed (no supplemental formula or other foods) until the age of 6 moa Grade B Strongly recommend 6 to 12 mo Continue breastfeeding until at least 12 mo of age while gradually adding solids; transition to iron-fortified formula until 12 mo if reducing breastfeedinga Grade B Strongly recommend Fat intake in infants <12 mo of age should not be restricted without medical indication Grade D Recommend Limit other drinks to 100% fruit juice (≤4 oz/d); no sweetened beverages; encourage water Grade D recommend 12 to 24 mo Transition to reduced-fatb (2% to fat-free) unflavored cow's milkc (see supportive actions) Grade B Recommend Limit/avoid sugar-sweetened beverage intake; encourage water Grade B Strongly recommend Transition to table food with: Total fat 30% of daily kcal/EERd Grade B Recommend Saturated fat 8%–10% of daily kcal/EER Grade B Recommend Avoid trans fat as much as possible Grade D Strongly recommend Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER Grade D recommend Cholesterol < 300 mg/d Grade 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 y Primary beverage: fat-free unflavored milk Grade A Strongly recommend Limit/avoid sugar-sweetened beverages; encourage water Grade B Recommend Fat content: Total fat 25%–30% of daily kcal/EER Grade A Strongly recommend Saturated fat 8%–10% of daily kcal/EER Grade A Strongly recommend Avoid trans fats as much as possible Grade D, recommend Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER Grade D Recommend Cholesterol < 300 mg/d Grade A Strongly Recommend Encourage high dietary fiber intake from foodse Grade 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 y Primary beverage: fat-free unflavored milk Grade A Strongly recommend Limit/avoid sugar-sweetened beverages; encourage water Grade B Recommend Fat content: Total fat 25%–30% of daily kcal/EERd Grade A Strongly recommend Saturated fat 8%–10% of daily kcal/EER Grade A Strongly recommend Avoid trans fat as much as possible Grade D Recommend Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER Grade D Recommend Cholesterol < 300 mg/d Grade A Strongly recommend Encourage high dietary fiber intake from foodse Grade 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).
Gender Age (Years) Calorie Requirements (kcals) by Activity Levelb Sedentary Moderately Active Active Child 2–3 1000–1200 1000–1400c 1000–1400c Femaled 4–8 1200–1400 1400–1600 1400–1800 9–13 1400–1600 1600–2000 1800–2200 14–18 1800 2000 2400 19–30 1800–2000 2000–2200 2400 Male 4–8 1200–1400 1400–1600 1600–2000 9–13 1600–2000 1800–2200 2000–2600 14–18 2000–2400 2400–2800 2800–3200 19–30 2400–2600 2600–2800 3000 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.
- TABLE 5-3
DASH Eating Plan: Servings per Day According to Food Group and Total Energy Intake
Food Group No. of Servings Serving Size Examples and Notes Significance of Each Food Group to the DASH Eating Plan 1200 cal 1400 cal 1600 cal 1800 cal 2000 cal 2600 cal Grainsa 4–5/d 5–6/d 6/d 6/d 6–8/d 10–11/d 1 slice bread; 1 oz dry cerealb; ½ cup cooked rice, pasta, or cerealb Whole-wheat bread and rolls, whole-wheat pasta, English muffin, pita bread, bagel, cereals, grits, oatmeal, brown rice, unsalted pretzels and popcorn Major sources of energy and fiber Vegetables 3–4/d 3–4/d 3–4/d 4–5/d 4–5/d 5–6/d 1 cup raw leafy vegetable; ½ cup cut-up raw or cooked vegetable; ½ cup vegetable juice Broccoli, carrots, collards, green beans, green peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes Rich sources of potassium, magnesium, and fiber Fruits 3–4/d 4/d 4/d 4–5/d 4–5/d 5–6/d 1 medium fruit; ¼ cup dried fruit; ½ cup fresh, frozen, or canned fruit; ½ cup fruit juice Apples, apricots, bananas, dates, grapes, oranges, grapefruit, grapefruit juice, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines Important sources of potassium, magnesium, and fiber Fat-free or low-fat milk and milk products 2–3/d 2–3/d 2–3/d 2–3/d 2–3/d 3/d 1 cup milk or yogurt; 1½ oz cheese Fat-free milk or buttermilk, fat-free, low-fat, or reduced-fat cheese, fat-free/low-fat regular or frozen yogurt Major sources of calcium and protein Lean meats, poultry, and fish ≤3/d ≤3–4/d ≤3–4/d ≤6/d ≤6/d ≤6/d 1 oz cooked meats, poultry, or fish; 1 eggc Select only lean; trim away visible fats; broil, roast, or poach; remove skin from poultry Rich sources of protein and magnesium Nuts, seeds, and legumes 3/wk 3/wk 3–4/wk 4/wk 4–5/wk 1/d ⅓ 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 peas Rich sources of energy, magnesium, protein, and fiber Fats and oilsd 1/d 1/d 2/d 2–3/d 2–3/d 3/d 1 tsp soft margarine; 1 tsp vegetable oil; 1 tbsp mayonnaise; 2 tbsp salad dressing Soft margarine, vegetable oil (such as canola, corn, olive, or safflower), low-fat mayonnaise, light salad dressing The 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/d 1 tbsp sugar; 1 tbsp jelly or jam; ½ cup sorbet, gelatin; 1 cup lemonade Fruit-flavored gelatin, fruit punch, hard candy, jelly, maple syrup, sorbet and ices, sugar Sweets 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.
Newborn to 12 mo Parents should create an environment that promotes and models physical activity and limits sedentary time Grade D Recommend Supportive actions: Discourage TV viewing altogether 1 to 4 y Allow unlimited active playtime in safe, supportive environments Grade D Recommend Limit sedentary time, especially TV/video Grade 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 y Moderate-to-vigorous physical activity every daya Grade 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 y Moderate-to-vigorous physical activity every daya Grade A Strongly recommend Limit leisure time TV/video/computer use Grade 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 y Moderate-to-vigorous physical activity every daya Grade A Strongly recommend Limit leisure time TV/video/computer Grade 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.
Prenatal Obtain smoking history from mothers; provide explicit smoking-cessation message before and during pregnancy Grade 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 y Smoke-free home environment Grade B Strongly recommend Reinforce this message at every encounter, including urgent visits for respiratory problems Grade 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 y Obtain smoke-exposure history from child, including personal history of tobacco use Grade C Recommend Counsel patients strongly about not smoking, including providing explicit information about the addictive and adverse health effects of smoking Grade C Recommend 11 to 21 y Obtain personal smoking history at every nonurgent health encounter Grade B Strongly recommend Explicitly recommend against smoking Grade B Strongly recommend Provide specific smoking-cessation guidance Grade 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).
Birth to 3 y No 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 y Annual 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 y Annual 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 y Measure 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.
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.
Age, y BP %ile SBP, mm Hg DBP, mm Hg Percentile of Height Percentile of Height 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th 1 50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39 90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54 95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58 99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66 2 50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44 90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59 95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63 99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71 3 50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48 90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63 95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67 99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75 4 50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52 90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67 95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71 99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79 5 50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55 90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70 95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74 99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82 6 50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57 90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72 95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76 99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84 7 50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59 90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74 95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78 99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86 8 50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61 90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76 95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80 99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88 9 50th 95 96 98 100 102 103 104 57 58 59 60 61 61 62 90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77 95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81 99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89 10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63 90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78 95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82 99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90 11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63 90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78 95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82 99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90 12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64 90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79 95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83 99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91 13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64 90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79 95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83 99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91 14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65 90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80 95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84 99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92 15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66 90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81 95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85 99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93 16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67 90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82 95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87 99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94 17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70 90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84 95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89 99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97 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.
Age, y BP %ile SBP, mm Hg DBP, mm Hg Percentile of Height Percentile of Height 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th 1 50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42 90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56 95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60 99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67 2 50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47 90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61 95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65 99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72 3 50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51 90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65 95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69 99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76 4 50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54 90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68 95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72 99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79 5 50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56 90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70 95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74 99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81 6 50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58 90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72 95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76 99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83 7 50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59 90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73 95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77 99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84 8 50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60 90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74 95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78 99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86 9 50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61 90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75 95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79 99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87 10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62 90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76 95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80 99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88 11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63 90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77 95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81 99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89 12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64 90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78 95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82 99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90 13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65 90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79 95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83 99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91 14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66 90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80 95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84 99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92 15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67 90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81 95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85 99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93 16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68 90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82 95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86 99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93 17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68 90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82 95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86 99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93 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.
Class Drug Initial Dosea Maximal Dose Dosing Interval Evidenceb FDAc Commentsd ACE inhibitors Benazepril 0.2 mg/kg per d up to 10 mg/d 0.6 mg/kg per d up to 40 mg/d QD RCT Yes 1. All ACE inhibitors are contraindicated in pregnancy; women of childbearing age should use reliable contraception Captopril 0.3–0.5 mg/kg per dose (>12 mo) 6 mg/kg per d TID RCT, CS No 2. 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 Fosinoprile Children >50 kg: 5–10 mg/d 40 mg/d QD RCT Yes 4. Benazepril, enalapril, and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension Lisinoprile 0.07 mg/kg per d up to 5 mg/d 0.6 mg/kg per d up to 40 mg/d QD RCT Yes 5. 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 Quinapril 5–10 mg/d 80 mg/d QD RCT, EO No 6. Initial dose of fosinopril of 0.1 mg/kg per d may be effective, although black patients might require a higher dose ARBs Irbesartan 6–12 y: 75–150 mg/d; ≥13 y: 150–300 mg/d 300 mg/d QD CS Yes 1. All ARBs are contraindicated in pregnancy; women of childbearing age should use reliable contraception Losartane 0.7 mg/kg per d up to 50 mg/d 1.4 mg/kg per d up to 100 mg/d QD–BID RCT Yes 2. Check serum potassium and creatinine levels periodically to monitor for hyperkalemia and azotemia Valsartane 5–10 mg/d; 0.4 mg/kg per d 40–80 mg/d; 3.4 mg/kg per d QD RCT No 3. 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-antagonist Labetalol 1–3 mg/kg per d 10–12 mg/kg per d up to 1200 mg/d BID CS, EO No 1. 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-antagonists Atenolol 0.5–1 mg/kg per d 2 mg/kg per d up to 100 mg/d QD–BID CS No 1. Noncardioselective agents (propranolol) are contraindicated in asthma and heart failure Bisoprolol/hydrochlorothiazide 2.5–6.25 mg/d 10/6.25 mg/d QD RCT No 2. Heart rate is dose-limiting Metoprolole Children >6 y: 1 mg/kg per d (12.5–50 mg/d) 2 mg/kg per d up to 200 mg/d BID CS Yesf 3. May impair athletic performance in athletes Propranolol 1–2 mg/kg per d 4 mg/kg per d up to 640 mg/d BID–TID RCT, EO Yes 4. Should not be used in insulin-dependent diabetic patients 5. A sustained-release, once-daily formulation of propranolol is available Calcium-channel blockers Amlodipinee Children 6–17 y: 2.5 mg/d 5 mg/d QD RCT Yes 1. Amlodipine and isradipine can be compounded into stable extemporaneous suspensions Felodipine 2.5 mg/d 10 mg/d QD RCT, EO No 2. Felodipine and extended-release nifedipine tablets must be swallowed whole Isradipine 0.15–0.2 mg/kg per d 0.8 mg/kg per d up to 20 mg/d TID–QID CS, EO No 3. Isradipine is available in both immediate- and sustained-release formulations; sustained release form is dosed QD or BID Extended-release nifedipine 0.25–0.5 mg/kg per d 3 mg/kg per d up to 120 mg/d QD–BID CS, EO No 4. 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-agonist Clonidine Children ≥12 y: 0.2 mg/d 2.4 mg/d BID EO Yes 1. May cause dry mouth and/or sedation 2. Transdermal preparation is available 3. Sudden cessation of therapy can lead to severe rebound hypertension Diuretics Hydrochlorothiazide 1 mg/kg per d 3 mg/kg per d up to 50 mg/d QD EO Yes 1. All patients treated with diuretics should have their electrolytes monitored shortly after initiating therapy and periodically thereafter Chlorthalidone 0.3 mg/kg per d 2 mg/kg per d up to 50 mg/d QD EO No 2. Useful as add-on therapy in patients being treated with drugs from other drug classes Furosemide 0.5–2.0 mg/kg per dose 6 mg/kg per d QD–BID EO No 3. Potassium-sparing diuretics (spironolactone, triamterene, amiloride) may cause severe hyperkalemia, especially if given with an ACE inhibitor or ARB Spironolactone 1 mg/kg per d 3.3 mg/kg per d up to 100 mg/d QD–BID EO No 4. 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 Triamterene 1–2 mg/kg per d 3–4 mg/kg per d up to 300 mg/d BID EO No 5. Chlorthalidone may precipitate azotemia in patients with renal diseases and should be used with caution in those with severe renal impairment Amiloride 0.4–0.625 mg/kg per d 20 mg/d QD EO No Peripheral α-antagonists Doxazosin 1 mg/d 4 mg/d QD EO No 1. May cause first-dose hypotension Prazosin 0.05–0.1 mg/kg per day 0.5 mg/kg per d TID EO No Terazosin 1 mg/d 20 mg/d QD EO No Vasodilators Hydralazine 0.75 mg/kg per d 7.5 mg/kg per d up to 200 mg/d QID EO Yes 1. Tachycardia and fluid retention are common adverse effects Minoxidil Children <12 y: 0.2 mg/kg per d; Children <12 y: 50 mg/d; children QD–TID CS, EO Yes 2. Hydralazine can cause a lupus-like syndrome in slow acetylators children >12 y: 5 mg/d ≥12 y: 100 mg/d 3. 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.
- TABLE 9-1
Acceptable, Borderline-High, and High Plasma Lipid, Lipoprotein, and Apolipoprotein Concentrations for Children and Adolescents
Category Low, mg/dLa Acceptable, mg/dL Borderline-High, mg/dL High, mg/dLa TC — <170 170–199 ≥200 LDL cholesterol — <110 110–129 ≥130 Non-HDL cholesterol — <120 120–144 ≥145 Apolipoprotein B — <90 90–109 ≥110 Triglycerides 0–9 y — <75 75–99 ≥100 10–19 y — <90 90–129 ≥130 HDL cholesterol <40 >45 40–45 — Apolipoprotein A-1 <115 >120 115–120 — 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.
Category Low, mg/dL Borderline-Low, mg/dL Acceptable, mg/dL Borderline-High, mg/dL High, mg/dL TC — — <190 190–224 ≥225 LDL cholesterol — — <120 120–159 ≥160 Non-HDL cholesterol — — <150 150–189 ≥190 Triglycerides — — <115 115–149 ≥150 HDL cholesterol <40 40–44 >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.
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.
Primary Lipid Disorders Lipid/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.
Birth to 2 y No lipid screening Grade C Recommend 2 to 8 y No routine lipid screening Grade B Recommend Measure fasting lipid profile twice,a average results if: Parent, grandparent, aunt/uncle, or sibling with Grade B MI, angina, stroke, CABG/stent/angioplasty at <55 y in males, <65 y in females Strongly recommend Parent with TC ≥ 240 mg/dL or known dyslipidemia Grade B Parent with TC ≥ 240 mg/dL or known dyslipidemia Strongly recommend Child has diabetes, hypertension, BMI ≥ 95th percentile or smokes cigarettes Grade 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 y Universal screening Grade 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 y No routine screeningc Grade 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 female Grade B Strongly recommend Parent with TC ≥ 240 mg/dL or known dyslipidemia Grade B Strongly recommend Patient has diabetes, hypertension, BMI ≥ 85th percentile or smokes cigarettes Grade 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 y Universal 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.
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.
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 - TABLE 9-8
Evidence-Based Recommendations for Dietary Management of Elevated LDL Cholesterol, Non-HDL Cholesterol, and Triglyceride Levels
2 to 21 y Elevated LDL cholesterol: CHILD-2–LDL Refer to a registered dietitian for family medical nutrition therapy Grade 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 possible Grade 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 therapyb Grade 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 possible Grade A Recommend Decrease sugar intake Grade B Recommend Replace simple with complex carbohydrates No sugar-sweetened beverages Increase dietary fish to increase ω-3 fatty acidsc Grade 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.
Birth to 10 y Pharmacologic 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 specialist Grade C Recommend ≥10 to 21 y Detailed 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 specialist Grade 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 FLP Grade A Strongly recommend Repeat FLP LDL cholesterol < 130 mg/dL, continue CHILD-2–LDL, reevaluate in 12 mo Grade A Strongly recommend LDL cholesterol ≥ 190 mg/dL,b consider initiation of statin therapy per Tables 9-11 and 9-12 Grade A Strongly recommend LDL cholesterol ≥ 130–189 mg/dL, negative family history, no other RF or RC, continue CHILD-2–LDL, reevaluate every 6 mo Grade 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 9-12 Grade 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 9-12 Grade B Recommend Children on statin therapy should be counseled and carefully monitored per Table 9-12 Grade A Strongly recommend ≥10 to 21 y Detailed 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 specialist Grade 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 mo Grade B Strongly recommend Repeat FLP Triglycerides < 100 (130) mg/dL, continue CHILD-2–TG, monitor every 6–12 mo Grade B Strongly recommend Triglycerides > 100 (130) mg/dL, reconsult dietitian for intensified CHILD-2–TG diet counseling Grade C Recommend Triglycerides ≥ 200–499 mg/dL, non-HDL ≥ 145 mg/dL, consider fish oil ± consult lipid specialist Grade 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 consultation Grade 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.
Type of Medication Mechanism of Action Major Effects Examples Adverse Reactions FDA 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 receptors Mainly lowers LDL cholesterol; some decrease in triglycerides and modest increase in HDL cholesterol Atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin Raised hepatic enzymes, raised creatine kinase, myopathy possibly progressing to rhabdomyolysis All 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 sequestrants Binds intestinal bile acids, interrupting enterohepatic recirculation; more cholesterol converted into bile acids; decreases hepatic cholesterol pool; upregulates LDL receptors Lowers LDL cholesterol; small increase in HDL cholesterol; raises triglycerides Cholestyramine, colestipol, colesevelam Limited to gastrointestinal tract: gas, bloating, constipation, cramps No 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 inhibitors Inhibits intestinal absorption of cholesterol and plant sterols; decreases hepatic cholesterol pool; upregulates LDL receptors Mainly lowers LDL cholesterol; some decrease in triglycerides and small increase in HDL cholesterol Ezetimibe Myopathy, gastrointestinal upset, headache Not approved Fibric acid derivatives Agonist 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 decreased Mainly lowers triglycerides and raises HDL cholesterol; little effect on LDL cholesterol Fenofibrate, gemfibrozil Dyspepsia, constipation, myositis, anemia Not approved Nicotinic acid (extended release) Inhibits release of FFA from adipose tissue; decreases VLDL and LDL cholesterol production and HDL cholesterol degradation Lowers triglycerides and LDL cholesterol and raises HDL cholesterol; can decrease lipoprotein(a) Niacin, extended release Flushing, hepatic toxicity, can increase fasting blood glucose, uric acid; can cause hyperacidity Use not recommended in children <2 y old ω-3 fish oil Decreases hepatic FA and triglycerides synthesis while enhancing FA degradation/oxidation, with subsequent reduced VLDL cholesterol release Lowers triglycerides; raises HDL cholesterol; increases LDL cholesterol and LDL cholesterol particle size ω-3 acid ethyl esters Occasional adverse gastrointestinal effects but no adverse effect on glucose levels or muscle or liver enzymes or bleeding Only 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.
- TABLE 9-11
Clinical Trials of Lipid-Lowering Medication Therapy in Children and Adolescents
Study Authors, Type, and Duration Medication No. of Subjects, Gender, Condition Daily Dose Effect on Lipid Profile, % TC LDL Cholesterol HDL Cholesterol Triglycerides Bile acid–binding resins Tonstad et al, RCT, 1 y Cholestyramine 72, 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 −17 8 NA McCrindle et al, RCT crossover, 2 × 8 wk Cholestyramine 40, 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 −15 2 to 4 6 to 9 Tonstad et al, RCT, 8 wk; open label, 44–52 wk Colestipol 66, 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 wk Colestipol 36, male and female, FH/FCHL (LDL ≥ 160 mg/dL after 6 mo of diet counseling; ages 8–18 y) 10 g −7 −10 2 12 Stein et al, RCT, 8 wk; open label, 18 wk Colesevelam 191, male and female, FH (LDL ≥ 190 mg/dL or LDL ≥ plus 2 additional risk factors after 6 mo of diet counseling; ages 10–17 y 1.87 g −3 −6 5 6 3.75 g −7 −13 8 5 HMG-CoA reductase inhibitors (statins) McCrindle et al, RCT; open label, 26 wk Atorvastatin 187, 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 −40 6 −13 Van der Graaf et al, open label, 2 y Fluvastatin 85, 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 −34 5 −5 Lambert et al, RCT, 8 wk Lovastatin 69, male, FH (LDL cholesterol > 95th percentile, family history of atherosclerosis and hyperlipidemia; on diet; mean age: 13 y) 10 mg −17 −21 9 −18 20 mg −19 −24 2 9 30 mg −21 −27 11 3 40 mg −29 −36 3 −9 Stein et al, RCT, 48 wk Lovastatin 132, 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 −17 4 4 20 mg −19 −24 4 8 40 mg −21 −27 5 6 Clauss et al, RCT, 24 wk Lovastatin 54, 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 −27 3 −23 Knipscheer et al, RCT, 12 wk Pravastatin 72, male and female, FH (family history hypercholesterolemia or premature atherosclerosis; LDL > 95th percentile; diet for 8 wk; ages 8–16 y) 5 mg −18 −23 4 2 10 mg −17 −24 6 7 20 mg −25 −33 11 3 Wiegman et al, RCT, 2 y Pravastatin 214, 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 −24 6 −17 Rodenburg et al, open-label, 2-y RCT; 4.5-y open-label follow-up Pravastatin 186, 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 −29 3 −2 de Jongh et al, RCT, 48 wk Simvastatin 173, male and female, FH (LDL cholesterol = 158–397 mg/dL; ages 10–17 y) 10–40 mg −31 −41 3 −9 de Jongh et al, RCT, 28 wk Simvastatin 50, male and female, FH (LDL cholesterol > 95th percentile, family history of hyperlipidemia, or LDL receptor mutation; ages 9–18 y) 40 mg −30 −40 5 −17 Avis et al, RCT, 12 wk; then, 40-wk open-label follow-up Rosuvastatin 177, 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 −38 4 −13 10 mg −34 −45 10 −15 20 mg −39 −50 9 −16 Other agents Wheeler et al, RCT, 26 wk Bezafibrate 14, male and female, FH (TC > 269 mg/dL, normal triglycerides + family history of FH or premature CAD; ages 4–15 y) 10–20 mg −22 NC 15 −23 Colletti et al, open label, 1–19 mo Niacin 21, 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 −17 4 13 McCrindle et al, RCT crossover, 2 × 18 wk Pravastatin and colestipol 36, 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 −17 4 8 van der Graaf et al, RCT, 6 and 27 wk; open label to 53 wk Simvastatin and ezetimibe 248, 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 −49 7 −17 Addendum Goldberg et al, ω-3 fatty acid review in adults; no RCTs in children ω-3 fish oils (1 g per capsule)a — 1–4 g/d NC 17 to 31 6 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.
- TABLE 9-12
Recommendations for Use of 3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Inhibitors (Statins) in Children and Adolescents
Patient selection Use algorithm (Fig 9-1) and risk-factor categories (Tables 9-6 and 9-7) to select statin therapy for patients.
Include preferences of patient and family in decision-making.
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).
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.
Conduct baseline hepatic panel and CK before initiating treatment.
Initiation and titration 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.
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.
Measure baseline CK, ALT, and AST.
Instruct the patient to report all potential adverse effects, especially muscle cramps, weakness, asthenia, and more diffuse symptoms suggestive of myopathy.
Advise female patients about concerns with pregnancy and the need for appropriate contraception.
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. 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.
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.
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.
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.
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 Monitor growth (height, weight, and BMI relative to normal growth charts), sexual maturation, and development.
Whenever potential myopathy symptoms present, stop medication and assess CK.
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.
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.
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.
Birth to 24 mo No 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 y Identify children at high risk for obesity because of parental obesity and excessive BMI increase Grade 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 mo Grade 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 comorbiditiesa Grade 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-up Grade B Recommend 6 to 11 y Identify 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 education Grade 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-up Grade 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 comorbiditiesa Grade 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 mo Grade 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 therapy Grade 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 y Identify 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 mo Grade 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 mo Grade 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 comorbiditiesa Grade 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 mo Grade 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 mo Grade 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.
- 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.
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.
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.
- TABLE 12-1
Metabolic Syndrome Component Levels for Evaluation of Children With Multiple Cardiovascular Risk Factors
Risk Factor Cut Point Reference Obesity, percentile BMI ≥85th to <95th CDC growth charts Waist circumference ≥90th to <95th NHANES BP, percentile ≥90th to <95th “The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents” Dyslipidemia, mg/dL See “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/dL ADA screening recommendations Fasting glucose ≥100 to <126 Fasting insulin Elevated 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.
Smoking-cessation guidance during pregnancy is strongly advised Grade 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).
In this issue
Jump to section
- 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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