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Prepared for your next patient.
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New National Heart Lung and Blood
Institute (NHLBI) Expert Panel
Guidelines for Cardiovascular Health
and Risk Reduction in Childhood
Rae-Ellen W. Kavey, MD, MPH, FAAP
Professor of Pediatrics, Division of Pediatric Cardiology
Former NHLBI Coordinator for Cardiovascular Risk
Reduction in Childhood
Golisano Children’s Hospital
University of Rochester Medical Center
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Disclaimers
• Statements and opinions expressed are those of the authors and not
necessarily those of the American Academy of Pediatrics.
• Mead Johnson sponsors programs such as this to give healthcare professionals
access to scientific and educational information provided by experts. The
presenter has complete and independent control over the planning and
content of the presentation, and is not receiving any compensation from
Mead Johnson for this presentation. The presenter’s comments and opinions
are not necessarily those of Mead Johnson. In the event that the presentation
contains statements about uses of drugs that are not within the drugs'
approved indications, Mead Johnson does not promote the use of any drug
for indications outside the FDA-approved product label.
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Learning Objectives
• Understand the complex and diverse evidence base and the
review process that led to the 2011 recommendations.
• Be aware of the new evidence-based dietary
recommendations for cardiovascular health.
• Recognize the guideline recommendations for lipid
screening and management in childhood.
• Be familiar with the format of the guidelines and how to
access risk factor (RF)-specific information to use in
managing children and adolescents.
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Webinar Format
• Introduction to the guidelines and evidence review
process/grading system
• Overview of the report format:
− State of the science
− Individual RF sections—Overview of the evidence and
graded recommendations for each major risk factor
− Age- and RF-specific integrated cardiovascular (CV) health
schedule
• Examples:
1) CV health diet
2) Lipid screening and management
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NHLBI Guidelines: New Approach
I.
II.
III.
IV.
Formal evidence review  Graded
recommendations by an expert panel.
Integrated—multiple RFs addressed in a single
guideline
Formal United States Department of Health and
Human Services (HHS) review and approval
process
Routinely updated
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Pediatric Guideline Considerations
• Endpoint of clinical cardiovascular disease (CVD)
remote
• Wide age range of subjects: Birth to 21 years of age
• Multiple RFs to be addressed
• Epidemiologic studies—not just randomized
controlled trials (RCTs) = Important evidence
• Goal: Prevention of risk factors
+ Prevention of future disease:
Primordial and primary prevention
• Acknowledged gaps in the evidence base but
recommendations needed to guide patient care
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Risk Factors/Behaviors for CVD
•
•
•
•
(+) family history for CVD
Increasing age
Male sex
Blood pressure (BP)/
hypertension
• Lipids/dyslipidemia
• Diabetes mellitus
• Metabolic syndrome
• Inflammation
• Physical inactivity/
sedentary lifestyle
• Diet/food preferences
• Obesity
• Cigarette smoking
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Modified Evidence Review:
Defined Process/Scope
 Include rationale for evaluation/intervention in childhood.
 Include selected observational/epidemiologic studies:
−
−
−
−
−
−
−
−
−
−
National Health and Nutrition Examination Survey (NHANES)
Bogalusa Heart Study
Muscatine Study
Beaver County Lipid Study
Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Study
Princeton Study
Minnesota Children’s Blood Pressure Study
Fels Longitudinal Study
National Growth and Health Study (NGHS)
Cardiovascular Risk in Young Finns Study
 Time frame: 1981–2008; English language
 PubMed/MEDLINE/Cochrane Databases
 Expert panel intrinsic throughout guideline development process, including
development of consensus-based recommendations when evidence is insufficient.
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Guideline Development Process
I.
II.
III.
IV.
V.
Define critical questions + evidence grading system.
Electronic search: >1,000,000 titles  serial review
 400 RCTs/systematic reviews/meta-analyses + 248
epidemiologic studies abstracted into evidence tables
Define decision making process for recommendations.
Review and grade evidence.
Develop age-specific recommendations integrated
across RFs and within regular pediatric care.
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Evidence Grading System
Grade
Evidence
A
Well-designed RCTs in a population similar to the guideline’s target
population
B
RCTs 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)
American Academy of Pediatrics Steering Committee on Quality Improvement. Classifying recommendations for clinical practice
guidelines. Pediatrics. 2004;114(3):874–877
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Strength of Recommendation
Statement
Definition
Implication
Strong
recommendation
Evidence grade A or B
Benefit clearly exceeds harm
Should follow
Recommendation
Evidence grade B or C
Benefit exceeds harm but evidence is
not as clear
Should generally
follow
Optional
Well-performed studies (Grade A, B, C) Flexible response
show no clear advantage, or evidence including patient
is suspect (Grade D)
preference
No recommendation
Evidence lacking, or balance between
benefit and harm is unclear
Independent decision;
need new evidence
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Expert Panel Decision-making Process
Voting to be "in support of" or "opposed to" a recommendation:
• Agreement by ≥80%  Strong consensus, presented as such
in the guidelines
• Agreement by ≤60%  Recommendation not included in the
guidelines; however, review of the subject could be included
in the discussion for that RF area
• Agreement by 60%–80%  Moderate consensus in support of
the recommendation; this level of agreement to be presented
with that language in the guidelines and accompanied by
discussion of the conflicting issues
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STATE OF THE SCIENCE
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Atherosclerosis: A Progressive Process
Fatty
Streak
Normal
Development
of Risk
Factors (RF)
Occlusive
Atherosclerotic
Plaque
Fibrous
Plaque
Endothelial
Dysfunction,
Plaque
initiation
Plaque
progression/
extension
Effort
Angina or
Claudication
Plaque
Rupture/
Fissure &
Thrombosis
Angina, MI,
Coronary death,
Stroke, Peripheral
ischemia
ONGOING RF EXPOSURE
Clinically silent
Birth
10
Clinical events
20
Increasing age
30
40 50+
50
60 +
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State of the Science Evidence Review
Review of the evidence linking RFs in childhood to
development and progression of atherosclerosis to manifest
clinical CVD:
 From autopsy and vascular imaging studies:
 Atherosclerosis begins in childhood.
 Atherosclerotic extent and progression correlate directly with the
number/severity of known RFs.
 From epidemiologic studies:
 RFs are present from infancy and track into adult life.
 Risk behaviors are acquired in childhood and persist into adult life.
 Low risk entering young adult life is associated with sustained low
risk for CVD events.
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Individual Risk Factor Sections
• Background: Summary of the epidemiologic evidence linking the RF
in childhood to development of CVD
• Evidence Review Process: All RCTs addressing RF change relative to
measured outcomes included and graded with pre-identified
criteria.
• Evidence tables are available at
http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm
• Overview: Due to the large volume/diverse nature of included
studies, critical overview is provided in each RF section, highlighting
the panel’s view of the most important evidence.
• Conclusions: Evidence is summarized and graded  age-specific
recommendations. Where evidence is inadequate,
recommendations are a consensus of the expert panel.
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INDIVIDUAL RISK FACTOR SECTIONS:
NUTRITION AND DIET
Evidence for Controlling Fat Intake in Childhood: Safety and Efficacy
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STRIP Study: Prospective randomized trial of a low saturated fat, low cholesterol diet beginning in infancy.
Abbreviation: STRIP, Special Turku Coronary Risk Factor Intervention Project
Simell O, Niinikoski H, Rönnemaa T, et al. STRIP Study Group. Cohort Profile: The STRIP Study (Special Turku Coronary Risk Factor
Intervention Project), an Infancy-onset Dietary and Life-style Intervention Trial. Int J Epidemiol. 2009;38(3):650–655
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STRIP Study
• Intervention (INT) group counseled by dietitians to limit
saturated fat intake to <10%, total fat to 30%−35% of total
calories beginning at 7 months of age
• Breastfeeding encouraged as long as possible
• Transitioned from breastfeeding to skim milk
• Control (CON) group received no special dietary guidance
• Lipids checked at 8 and 13 months of age, then
annually/biannually to 19 years of age
• Food records/BP/growth at every evaluation
• Glucose/insulin, bone density at 7 to 8, and 12 and 15 years of
age
• Neuro-cognitive testing at 5, 10, and 15 years of age
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STRIP Study: Initial Diet Results
% of energy 7 m*(B/L)
INT
Total fat
29 + 5
CON
Sat fat
Chol (mg/d)
Protein
Carb
* Formula fed infants only
13 + 2
70 + 26
11 + 2
60 + 5
p
13 m*
INT
CON
p
28 + 3
ns
26 + 6
28 + 5
ns
12 + 2
73 + 20
13 + 2
59 + 4
ns 9 + 3
13 + 3 <.001
ns 84 + 37 113 + 44 <.001
ns 18 + 2
17 + 3
ns
ns 56 + 5
55 + 5
ns
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STRIP Study Results: Intervention vs Control
 DIET: Significantly lower saturated fat/cholesterol intake from 13 months to
19 years of age.
 LIPIDS: Significantly lower low-density lipoprotein cholesterol (LDL-C) levels
from 13 months to 19 years of age.
 BP: Systolic blood pressure (SBP) and diastolic blood pressure (DBP) are
significantly lower at 15 years of age.
 OBESITY: Prevalence of obesity is significantly lower in INT girls at 10 years of
age (10% vs 18%); no difference in boys.
 Insulin Resistance: In a random subgroup of 78 INT and 89 CON children at 9
years of age, homeostasis model assessment of insulin resistance index is
significantly lower.
 Metabolic Syndrome (MetS): (MetS = high body mass index [BMI] + ≥2 other
RFs); significantly lower prevalence of MetS cluster at 15 years of age, 13% of
INT girls/10.8% of INT boys vs 17.5% of CON girls/18.8% of CON boys
 Vascular Function: Vascular endothelial function is better in boys at 11 years
of age.
 SAFETY: No difference in growth, pubertal change, bone density, or neurocognitive function at any time.
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STRIP Study Conclusions
• Dietary counseling begun in infancy is effective with
results sustained into young adult life.
• Lower saturated fat and cholesterol intake from
infancy is associated with multiple measures of CV
health: sustained lower LDL-C, lower SBP and DBP,
less obesity, and less insulin resistance.
• No adverse effects identified.
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Evidence Review Summary for Dietary
Fat Intake
• STRIP Study findings and multiple other RCTs in healthy, normo- and hypercholesterolemic children (7 months to 18 years of age) achieved an average total
fat intake of 28%−30%, and saturated fat intake of 8%−10% of calories.
• Lower total cholesterol (TC) and LDL-C levels, lower BP, and less insulin resistance
on follow-up
• No harmful, adverse effects demonstrated on follow-up from 4 months to 19 years
of age.
 Grade A evidence
Evidence-based recommendations for routine pediatric care:
1) After 2 years of age, fat free milk is the primary recommended beverage for all
children. (Grade A)
2) Low fat milk (fat free  2% [based on judgment of the pediatrician]) can be safely
introduced in infants 1 to 2 years of age with weight for height disproportion or
with a family history of lipid abnormalities, high BP, morbid obesity, Type 2
diabetes mellitus, or early coronary artery disease (CAD). (Grade B)
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Sugar-Sweetened Beverages:
Background
• Among children 2 to 18 years of age in the US, the
average daily intake of energy from added sugars is
365 kcal.
• Sugar-sweetened beverages (soda, energy/sports
drinks, fruit drinks) are the top 2 sources of calories
from added sugars in all age and demographic
groups.
• Across beverage categories, children 2 to 18 years of
age consumed 171 kcal/day from sugar-sweetened
beverages (soda and fruit drinks combined).
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Sugar-Sweetened Beverage
Consumption
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Evidence for Role of Sugar-Sweetened
Beverages in Obesity: Epidemiologic Data
• From NHANES 2003–2004, nearly 40% of total calories consumed
by 2- to 18-year-olds in the US were empty calories.
• Half of all empty calories come from 6 specific foods: soda, fruit
drinks, dairy, grain desserts, and pizza.
• In the NGHS, sugar-sweetened beverage consumption was
significantly associated with higher daily calorie intake. The average
daily calorie intake increased by approximately 82 calories for every
100 grams of soda.
• A 2006 systematic review of sugar-sweetened beverage intake and
weight gain with 21 studies in children and adolescents concluded
that greater consumption of sugar-sweetened beverages is
significantly associated with both weight gain and obesity.
Striegel-Moore RH, Thompson D, Affenito SG, et al. Correlates of beverage intake in adolescent girls: the National Heart, Lung, and
Blood Institute Growth and Health Study. J Pediatr. 2006;148(2):152–154; Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened
beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2):274–288
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RCT Evidence Regarding SugarSweetened Beverage Intake: 2 Trials
•
•
•
•
103 adolescents (BMI >25th percentile) randomized
INT: Free home delivery of non-caloric beverages for 25 weeks
CON: Usual beverage consumption
Results:
1) Consumption of sugar-sweetened beverages decreased by 82% in
INT vs no change in CON.
2) Change in BMI: INT: +0.07+0.14; CON: +0.21+0.15
3) Among BMI top tertile, change was significantly greater for INT
(-0.63+0.23 vs +0.12+0.26)
• Conclusion: Limitation of sugar-sweetened beverage consumption
may significantly decrease BMI in obese adolescents.
Ebbeling CB, Feldman HA, Osganian SK, et al. Effects of decreasing sugar-sweetened beverage consumption on body weight in
adolescents: a randomized, controlled pilot study. Pediatrics. 2006;117(3):673–680
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Preventing Childhood Obesity by Reducing
Consumption of Carbonated Drinks:
Cluster-Randomized Controlled Trial
• 6 primary schools in southwest England: 644 children, 7 to 11 years
of age
• Educational program on nutrition focused on carbonated drink
consumption for 1 school year.
Results:
1) 3-day consumption of carbonated drinks decreased by 0.6 glasses
in INT vs an increase of 0.2 glasses in CON.
2) At 12 months of age, the percentage of overweight and obese
children decreased by a mean of 0.2% in INT vs an increase of 7.5%
in CON.
James J, Thomas P, Cavan D, et al. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised
controlled trial. BMJ. 2004;328(7450):1237
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Conclusions of the Evidence Review on
Sugar-Sweetened Beverage Consumption
• Epidemiologic Data: Strong evidence that a higher consumption of sugarsweetened beverages is associated with higher caloric intake and development
of obesity.
• RCTs: In small, select populations, RCTs that limit sugar-sweetened beverage
consumption reduce development and/or progression of obesity.
 Evidence review led to recommendation: Limit naturally sweetened juice
consumption to <4 oz/day from a cup in infancy and <6 oz/day in childhood.
Recommend no other sugar-sweetened beverage consumption. (Grade B)
Evidence-based implications for routine pediatric care:
1) Proactive counseling limiting naturally sweetened juice consumption beginning
in early infancy. (Grade B)
2) Clear recommendation advising no consumption of other sugar-sweetened
beverages. (Grade B)
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Cardiovascular Health Integrated
Lifestyle Diet (CHILD 1)
Age
Recommendation
Grade
Birth–6 months
Infants should be exclusively breastfed (no supplemental
formula or other foods) until 6 months of age.*
B
6–12 months
Continue breastfeeding** until at least 12 months of age
while gradually adding solids; transition to iron-fortified
formula until 12 months if reducing breastfeeding.
B
Fat intake in infants <12 months of age should not be
restricted without medical indication.
D
Limit other drinks to 100% fruit juice ≤4 oz/day; no
sweetened beverages. Encourage water.
B
* Infants who cannot be breastfed should be fed expressed milk. Infants for whom expressed milk is not available should be fed
iron-fortified infant formula.
** Recommended first step diet, etc.
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Cardiovascular Health Integrated Lifestyle
Diet (CHILD 1) cont.
Age
12–24 months
Recommendation
Grade
Supportive Actions:
Transition to reduced-fat (2% to fat free)
unflavored cow’s milk.
B
Limit/avoid sugar-sweetened beverage
intake; encourage water.
Transition to table food with:
B
 Milk fat content is to be
determined by parents
and providers based on
growth, appetite, nutrient
quality, and risk of
obesity/CVD.
 100% fruit juice (from a
cup); <4 oz/day
 Limit sodium intake.
 Consider Dietary
Approaches to Stop
Hypertension (DASH)-type
diet rich in fruits,
vegetables, whole grains,
low-fat/fat-free milk and
milk products; lower in
sugar.
- Total fat <30% of daily kcal/
estimated energy requirements
(EER)
B
- Saturated fat 8%–10% of daily
kcal/EER
B
- Avoid trans fat as much as
possible
D
- Monounsaturated and
polyunsaturated fat up to 20% of
daily kcal/EER
D
- Cholesterol <300 mg/d
B
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Cardiovascular Health Integrated Lifestyle
Diet (CHILD 1) cont.
Age
2–10 years
Recommendation
Grade
Primary beverage: fat-free,
unflavored milk
A
Limit/avoid sugar-sweetened
beverage intake; encourage water.
B
Encourage high dietary fiber intake
from food.
B
Fat content:
- Total fat 25%–30% of daily
kcal/EER
A
- Saturated fat 8%–10% of daily
kcal/EER
A
- Avoid trans fat as much as
possible
D
- Monounsaturated and
polyunsaturated fat up to 20% of
daily kcal/EER
D
- Cholesterol <300 mg/d
A
Supportive Actions:
 Teach portions based on
EER.
 Encourage moderately
increased energy intake
during periods of rapid
growth and/or regular
moderate-to-vigorous
physical activity (MVPA).
 Encourage dietary fiber
from foods: Goal = Age + 5
g/day
 Limit naturally sweetened
juice to 4 oz/day.
 Limit sodium intake.
 Encourage healthy eating
habits:
− Breakfast every day
− Eating meals as a family
− Limiting fast food meals
 Support DASH-style eating
plan.
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Cardiovascular Health Integrated Lifestyle
Diet (CHILD 1) cont.
Age
11−21 years
Recommendation
Grade
Primary beverage: fat-free,
unflavored milk
A
Limit/avoid sugar-sweetened
beverage intake; encourage water.
B
Encourage high dietary fiber intake
from food.
B
Fat content:
- Total fat <30% of daily kcal/EER
A
- Saturated fat 8%−10% of daily
kcal/EER
A
- Avoid trans fat as much as
possible
D
- Monounsaturated and
polyunsaturated fat up to 20%
of daily kcal/EER
D
- Cholesterol <300 mg/d
A
Supportive Actions:
 Teach portions based on
EER.
 Encourage moderately
increased energy intake
during periods of rapid
growth and/or regular
MVPA.
 Advocate dietary fiber:
Goal of 14 g/1,000 kcal.
 Limit naturally sweetened
juice to 4–6 oz/day.
 Limit sodium intake.
 Encourage healthy eating
habits:
− Breakfast every day
− Eating meals as a family
− Limiting fast food meals
 Support DASH-style eating
plan.
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Estimated Energy Requirements by Age,
Gender, and Activity Level
Gender
Age (Years)
Sedentary
Moderately
Active
Child
2–3
1,000–1,200
1,000–1,400
1,000–1,400
Female
4–8
9–13
14–18
19–30
1,200–1,400
1,400–1,600
1,800
1,800–2,000
1,400–1,600
1,600–2,000
2,000
2,000–2,200
1,400–1,800
1,800–2,200
2,400
2,400
Male
4–8
9–13
14–18
19–30
1,200–1,400
1,600–2,000
2,000–2,400
2,400–2,600
1,400–1,600
1,800–2,200
2,400–2,800
2,600–2,800
1,600–2,000
2,000–2,600
2,800–3,200
3,000
Active
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DASH Eating Plan: Servings per Day by Food Group and EER
DASH Eating Plan: Servings per Day by Food Group and EER cont.
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RISK FACTOR: LIPIDS AND LIPOPROTEINS
SCREENING AND MANAGEMENT
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Criteria for Screening Recommendation
•
•
•
•
•
•
•
•
Condition is an important health problem.
Natural history of the condition is well understood.
Detectable RF or disease marker with established norms.
Latent period or early asymptomatic stage of disease
Acceptable test
Benefits of testing exceed risks/harm.
Effective treatment exists.
Early stage treatment is more effective than later stage.
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Evidence Rationale for Lipid Screening
• Epidemiologic studies provide normative distributions for lipid levels in
children and adolescents. (Grade B)
• Analysis of fasting lipid profile (FLP) identifies 2 major dyslipidemic patterns in
childhood (familial hypercholesterolemia, combined dyslipidemia).
• Dyslipidemia in childhood is directly linked to atherosclerosis at autopsy.
(Grade B)
 In PDAY, 30 mg/dL increment of non-high-density lipoprotein cholesterol
(HDL-C) = 2 years of vascular aging.
• Dyslipidemia in childhood strongly correlates with evidence of atherosclerosis:
(Grade B)
 In the Hopkins medical student study, TC >207 mg/dL at age 21  5x
greater risk of CAD 40 years later (vs TC <172 mg/dL)
 In Muscatine study, elevated TC in youth correlated directly with increased
vascular change (carotid intima-media thickness [CIMT]) at 33–42 years of
age.
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Evidence Rationale for Lipid Screening cont.
• Selective screening protocols identify less than half of
children with extreme hypercholesterolemia. (Grade B)
• In hypercholesterolemic adults, normalization of LDL-C
significantly reduces clinical CV events. (Grade A)
• Medication for severely hypercholesterolemic children is
proven safe and effective in lowering LDL-C in 10 separate
RCTs in children for up to 4.5 years. (Grade A)
• Vascular imaging in children shows decreased
atherosclerosis progression with reduction in LDL.
(Grade B)
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Evidence Limited/Lacking
• No RCT of screening in childhood  treatment
vs no treatment with follow-up to clinical
disease proving that early stage treatment is
more effective than treatment at a later stage.
• Treatment trials in children are relatively short
in duration.
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Results of Targeted Cholesterol Screening
Using Family History and BMI
• Prior guidelines recommend targeted screening based on (+)
family history of premature CVD (M <55 years of age; F <65 years
of age in expanded 1st degree pedigree) or dyslipidemia, +/obesity.
• In multiple studies, 35%–45% of children have been found to
have (+) family history and up to 35% will have a BMI >85th
percentile.
• In trials of universal screening, 30%–60% of children/
adolescents with high cholesterol were not identified with
targeted screen based on family hx +/- obesity.
• In addition, family history is not reliable and is often unavailable.
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Non-HDL-C = New Screening Measure
• Non-HDL-C = TC – HDL-C; age-specific norms available
• Combined measure of all the atherogenic LDL-containing
lipoproteins in plasma
• Accurate in non-fasting state
• In adults, non-HDL-C = better predictor of CV events than LDL-C
• In children, non-HDL-C and LDL-C are equally good predictors of
adult lipid levels.
• In epidemiologic studies, non-HDL-C correlated highly with raised
lesions in coronary arteries and aorta at autopsy, and with subclinical
atherosclerosis on vascular imaging in childhood.
 Non-HDL-C is an accurate screen for dyslipidemia in childhood.
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Plasma Lipid Distribution (mg/dL) for
Children and Adolescents
ACCEPTABLE
BORDERLINE
ABNORMAL
TC
<170
170−199
>200
LDL-C
<110
110−129
>130
Non-HDL-C
<120
120−144
>145
TG
0−9y: <75
10−19y: <90
75−99
90−129
>100
>130
HDL
>45
40−45
<40
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Guideline Lipid Management
Recommendations
• Age-specific screening recommendations
• Graded treatment algorithms for diet and drug
treatment
• Evidence-based diet recommendations for children
with elevated LDL-C and elevated triglycerides (TG)
• Drug tables, including age-appropriate dose regimens,
side effect profiles, and monitoring schedules
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 Overview of Lipid Screening
Recommendations
• No screening below 2 years of age (Grade C/Recommend)
• 2−10 years: Selective screening if:
1) Family history (+) for early CVD
(Grade B/Strongly
2) Parent with known dyslipidemia
recommend)
3) Child with established RF
4) Child with special risk condition
• 10 years: Universal screening (Grade B/Strongly recommend)
with non-fasting non-HDL-C
• 11−18 years: Selective screening (as above)
• 18 years: Universal screening
Evidence-Based Lipid Assessment Recommendations by Age
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Evidence-Based Lipid Assessment Recommendations by Age cont.
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Special Risk Conditions
High Risk:
• Diabetes mellitus, Type 1 and Type 2
• Chronic renal disease/end-stage renal disease/postrenal
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)
• Human immunodeficiency virus infection
• Nephrotic syndrome
Dyslipidemia Algorithm: TARGET LDL-C
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FLP x 2, average results
TG >500 mg/dL,
→ Consult lipid
specialist
LDL-C >250 mg/dL
→ Consult lipid
specialist
LDL-C >130, <250 mg/dL*
TG >100, <500 mg/dL, <10y
>130, <500 mg/dL, 10−19y
→ Target LDL-C
→ Target TG
(TG algorithm)
Exclude secondary causes.
Evaluate for other RFs.
Start CHILD 2-LDL diet
+ lifestyle modification for 6 months.
FLP
LDL-C <130 mg/dL (=GOAL)
→ Continue CHILD 2-LDL diet.
→ Repeat fasting lipid profile q 12m.
LDL-C >130–189 mg/dL
FHx (-)
No other RFs
→ Continue CHILD 2-LDL diet.
Follow q 6m with lipid
profile, FHx/RF update.
LDL-C >190 mg/dL
→ Initiate statin therapy
LDL-C >160–189 mg/dL
FHx (+) or
1 high-level RF or
>2 moderate-level RFs
→ Initiate statin therapy
Follow with FLPs, related chemistries.
LDL-C >130–159 mg/dL +
2 high-level RFs or
1 high-level + >2 moderate-level
RFs or clinical CVD
→ Initiate statin therapy
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Dyslipidemia Algorithm: TARGET LDL-C cont.
→ LDL-C still >130 mg/dL, TG <200 mg/dL, may consider bile acid
sequestrant or ezetimibe.***
→ In high LDL-C patients, if non-HDL-C >145 mg/dL with LDL-C
<130 mg/dL, → Target TG.
Abbreviation: FHx, family history
NOTE:
* Use of drug therapy limited to children >10 years of age with defined risk profiles.
** In a child with LDL-C >190 mg/dL and other RFs, trial of CHILD 2-LDL-C diet
may be abbreviated.
*** In consultation with a lipid specialist.
 Guidelines contain complete drug tables with RCT results, dosages, side effects,
and schedules.
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CHILD 2-LDL and CHILD 2-TG
– Saturated fat <7% of calories
Grade A
Highly recommend
– Dietary cholesterol <200 mg/d
Grade A
Highly recommend
+ With high TGs: Eliminate sugarsweetened beverages, reduce simple
carbohydrates, increase dietary
omega 3 content + weight
management as needed.
Grade B
Recommend
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How Many Adolescents Would Be
Candidates for Medication?
• 2700 adolescents 12 to 17 years of age who had LDL
screened in NHANES
• Total cholesterol elevated in 10%; LDL >130 mg/dL in
5%−7%
• Based on NHLBI recommendations, <1% would be
candidates for medication.
• With 25 million children in these age groups, an
estimated total of approximately 200,000 would be
considered for statin treatment.
Ford ES, Li C, Zhao G, et al. Concentrations of low-density lipoprotein cholesterol and total cholesterol among children and adolescents
in the United States. Circulation. 2009;119(8):1108–1115
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INTEGRATED CARDIOVASCULAR HEALTH SCHEDULE
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Integrated Cardiovascular Health Schedule
Birth–12m
1–4y
5–9y
9–11y
12–17y
18–21y
AT 3Y, EVALUATE
FHx FOR EARLY
CVD: Parents,
grandparents,
aunts/uncles,
M <55y, F <65y.
Review with
parents. Refer prn.
Update at
each nonurgent health
encounter.
Reevaluate FHx
for early CVD in
grandparents,
parents, aunts,
uncles, M <55y,
F <65y. Review
with parents.
Update at each
non-urgent health
encounter.
Repeat FHx
evaluation with
patient.
TOBACCO
EXPOSURE
ADVISE SMOKE
FREE HOME.
Offer smoking
cessation
assistance to
parents.
Continue active
anti-smoking
counseling with
parents.
Offer smoking
cessation assistance
as needed.
Begin active
anti-smoking
counseling
with child.
Assess smoking
status of child.
Offer active antismoking
counseling or
referral as
needed.
Continue active
anti-smoking
counseling with
patient.
Offer smoking
cessation
assistance as
needed.
Reinforce strong
anti-smoking
message.
Offer smoking
cessation
assistance or
referral as
needed.
At 12−24m, may
change to cow’s
milk with % fat (per
family and pediatric
care provider).
After 2y, fat free
milk for all;
juice <4 oz/day;
transition to CHILD
1 diet by 2y.
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.
Offer counseling as
needed.
Review healthy
diet with
patient.
NUTRITION/
DIET
Support
breastfeeding
as optimal to
12m if possible.
Add formula if
breastfeeding
decreases
before 12m.
FHx of EARLY
CVD
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Integrated Cardiovascular Health Schedule cont.
GROWTH
Birth–12m
1–4y
5–9y
9–11y
12–17y
18–21y
Review FHx for
obesity 
discuss weight
(wt) for height
(ht) tracking,
growth chart,
and healthy
diet.
CHART
HT/WT/BMI 
CLASSIFY
WEIGHT BY
BMI, FROM AGE
2 and review
with parent.
Chart
HT/WT/BMI and
review
with parent.
BMI >85th
percentile
crossing
percentiles,
intensify diet/
activity focus for
6 months. If no
change 
registered
dietician (RD)
referral.
Manage per
obesity
algorithms.
BMI >95th
percentile,
manage per
obesity
algorithms.
Chart
HT/WT/BMI 
Review with
parent and child.
BMI >85th
percentile
crossing
percentiles,
intensify diet/
activity focus for
6 months. If no
change  RD
referral.
Manage per
obesity
algorithms.
BMI >95th
percentile,
manage per
obesity
algorithms.
Chart HT/WT/BMI
 Review with
child and parent.
BMI >85th
percentile
crossing
percentiles,
intensify diet/
activity focus for
6 months. If no
change  RD
referral
Manage per
obesity
algorithms.
BMI >95th
percentile,
manage per
obesity
algorithms.
Review
HT/WT/BMI and
norms for health
with patient.
BMI >85th
percentile
crossing
percentiles,
intensify diet/
activity focus for
6 months. If no
change  RD
referral.
Manage per
obesity
algorithms.
BMI >95th
percentile,
manage per
obesity
algorithms.
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For more information
• “Expert Panel on Integrated Guidelines for
Cardiovascular Health and Risk Reduction in Children
and Adolescents: Summary Report” published as a
Supplement in the December issue of Pediatrics
(2011;128:S213–S256), available at:
http://pediatrics.aappublications.org/content/128/Supplement_5.toc
• Full Report, Summary Report, and Evidence Tables
available on the NHLBI website at:
http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm
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Implementation Process
• The guidelines were extensively reviewed by HHS,
professional groups, and the public before release.
• Endorsed by the American Academy of Pediatrics.
• Support materials developed by NHLBI to facilitate
implementation of the recommendations are now in fieldtesting.
• Include toolkit and virtual applications plus a mobile app.
• Potential direct link between CV health schedule and risk
factor-specific information in the guidelines.
• Release date: January, 2013
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