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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 Childrens 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 presenters 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 sectionsOverview 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.
Integratedmultiple 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 studiesnot 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
Include rationale for evaluation/intervention in childhood.
Include selected observational/epidemiologic studies:
Process/Scope
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 Childrens Blood Pressure Study
Fels Longitudinal Study
National Growth and Health Study (NGHS)
Cardiovascular Risk in Young Finns Study

Time frame: 19812008; 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

Well-designed RCTs in a population similar to the

guidelines target population

RCTs with minor limitations; genetic natural history

studies; overwhelmingly consistent evidence from
observational studies

Observational studies (case-control and cohort design)

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
guidelines. Pediatrics. 2004;114(3):874877

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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) show no clear
advantage, or evidence is
suspect (Grade D)

Flexible response
including patient
preference

No
recommendation

Evidence lacking, or balance

between benefit and harm is
unclear

Independent
decision; need
new evidence

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Expert Panel Decisionmaking 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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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 panels view of the most important
evidence.
Conclusions: Evidence is summarized and graded agespecific 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
TM

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, Rnnemaa 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

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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

13 m*
CON

INT

CON

28 + 5

ns

29 + 5

28 +
26 +
ns
3
6

13 + 2

12 +
ns 9 + 3 13 + 3
2

<.0
01

Chol
* Formula fed infants only 70 + 26
(mg/d)

73 +
84 +
ns
20
37

113 +
44

<.0
01

Protein

13 +
18 +
ns
2
2

17 + 3

ns

Sat fat

Carb

11 + 2

59 +

56 +

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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 neuro-cognitive 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 SugarSweetened

Beverages
in Obesity:
From NHANES 20032004,
nearly 40% of total calories
Epidemiologic
Data in the US were empty
consumed by 2- to 18-year-olds

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 sugarsweetened beverages is significantly associated with both
weight RH,
gain
andD,obesity.
Striegel-Moore
Thompson
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):152154; Malik
VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J
Clin Nutr. 2006;84(2):274288

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RCT Evidence Regarding

Sugar-Sweetened 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
Ebbeling
CB, Feldman HA, Osganian SK, et al. Effects of decreasing sugar-sweetened beverage
adolescents.
consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics.
2006;117(3):673680

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Preventing Childhood Obesity

by Reducing Consumption of
Carbonated Drinks: ClusterRandomized 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

sugar-sweetened 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 sugarsweetened beverages. (Grade B)

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Cardiovascular Health
Integrated Lifestyle Diet
(CHILD 1)
Age

Birth6 months
612 months

Recommendation

Infants should be exclusively breastfed (no

supplemental formula or other foods) until 6
months of age.*
Continue breastfeeding** until at least 12
months of age while gradually adding solids;
transition to iron-fortified formula until 12
months if reducing breastfeeding.
Fat intake in infants <12 months of age should
not be restricted without medical indication.
Limit other drinks to 100% fruit juice 4 oz/day;
no sweetened beverages. Encourage water.

Grad
e
B
B
D
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.
Recommendatio Gra Supportive
Age

1224
months

n
Transition to reduced-fat (2% to
fat free) unflavored cows milk.
Limit/avoid sugar-sweetened
beverage intake; encourage
water.
Transition to table food with:
- Total fat <30% of daily kcal/
estimated energy
requirements
(EER)
- Saturated fat 8%10% of daily
kcal/EER
- Avoid trans fat as much as
possible
- Monounsaturated and
polyunsaturated fat up to 20%
of
daily kcal/EER
- Cholesterol <300 mg/d

de
B
B
B
B
D
D
B

Actions:

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.

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Cardiovascular Health
Integrated Lifestyle Diet (CHILD
Supportive
Recommendati
1) cont.
Age
Grade
Actions:

on

210 years

Primary beverage: fat-free,

unflavored milk
Limit/avoid sugar-sweetened
beverage intake; encourage
water.
Encourage high dietary fiber
intake from food.
Fat content:
- Total fat 25%30% of daily
kcal/EER
- Saturated fat 8%10% of
daily
kcal/EER
- Avoid trans fat as much as
possible
- Monounsaturated and
polyunsaturated fat up to
20% of
daily kcal/EER
- Cholesterol <300 mg/d

A
B
B
A
A
D
D
A

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
1121
years

Recommendati Grad
on
e

Supportive
Actions:

Primary beverage: fat-free,

unflavored milk

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 46
oz/day.
Limit sodium intake.
Encourage healthy
eating habits:

Limit/avoid sugar-sweetened
beverage intake; encourage
water.
Encourage high dietary fiber
intake from food.
Fat content:
- Total fat <30% of daily
kcal/EER
- Saturated fat 8%10% of
daily
kcal/EER
- Avoid trans fat as much as
possible
- Monounsaturated and
polyunsaturated fat up to
20%
of daily kcal/EER
- Cholesterol <300 mg/d

A
B
B
A
A
D
D

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
Moderatel
Age
Gender (Years) Sedentary y Active

Active

Child

23

1,0001,200

1,0001,400

1,0001,400

Female

48
913
1418
1930

1,2001,400
1,4001,600
1,800
1,8002,000

1,4001,600
1,6002,000
2,000
2,0002,200

1,4001,800
1,8002,200
2,400
2,400

Male

48
913
1418
1930

1,2001,400
1,6002,000
2,0002,400
2,4002,600

1,4001,600
1,8002,200
2,4002,800
2,6002,800

1,6002,000
2,0002,600
2,8003,200
3,000

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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 3342 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 LDLC significantly reduces clinical CV events. (Grade A)
Medication for severely hypercholesterolemic
children is proven safe and effective in lowering LDLC 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)

TM

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.

TM

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
ACCEPTABL BORDERLI
E

NE

ABNORMA
L

TC

<170

170199

>200

LDL-C

<110

110129

>130

NonHDL-C

<120

120144

>145

09y: <75
1019y:
<90

7599
90129

>100
>130

>45

4045

<40

TG
HDL

TM

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

TM

Overview of Lipid
Screening
No Recommendations
screening below 2 years of age (Grade

C/Recommend)
210 years: Selective screening if:
1)Family history (+) for early CVD (Grade B/Strongly
recommend)
2)Parent with known dyslipidemia
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
1118 years: Selective screening (as above)
18 years: Universal screening

Evidence-Based Lipid Assessment

Recommendations by Age
TM

Evidence-Based Lipid Assessment

Recommendations by Age cont.
TM

TM

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

TM

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, 1019y

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 >130189 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 >160189 mg/dL

FHx (+) or
1 high-level RF or
>2 moderate-level RFs
Initiate statin therapy

Follow with FLPs, related chemistries.

LDL-C >130159 mg/dL +

2 high-level RFs or
1 high-level + >2 moderate-level
RFs or clinical CVD
Initiate statin therapy

Dyslipidemia Algorithm: TARGET LDL-C

cont.
TM

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.

TM

CHILD 2-LDL and CHILD 2TG

Saturated fat <7% of calories
A

Grade
Highly

recommend
Dietary cholesterol <200 mg/d

Grade A
Highly

recommend
+

With high TGs: Eliminate sugarB

sweetened beverages, reduce simple
carbohydrates, increase dietary
omega 3 content + weight
management as needed.

Grade
Recommend

TM

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):11081115

TM

INTEGRATED CARDIOVASCULAR HEALTH

SCHEDULE

Integrated Cardiovascular Health

Schedule
TM

Birth
12m

59y

911y

1217y

1821y

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.

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 antismoking
counseling
with child.

Assess
smoking
status of
child.
Offer active
anti-smoking
counseling or
referral as
needed.

Continue active
anti-smoking
counseling with
patient.
Offer smoking
cessation
assistance as
needed.

Reinforce
strong antismoking
message.
Offer
smoking
cessation
assistance or
referral as
needed.

Support
breastfeedin
g as optimal
to 12m if
possible.
Add formula

At 1224m,
may change to
cows milk with
% fat (per
family and
pediatric care

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.

Review
healthy diet
with patient.

FHx of
EARLY
CVD

TOBACCO
EXPOSUR
E

NUTRITIO
N/ DIET

14y

Integrated Cardiovascular Health

Schedule cont.
TM

Birth
12mFHx
Review
GROWTH

for obesity
discuss
weight (wt)
for height
(ht)
tracking,
growth
chart, and
healthy diet.

14y

59y

911y

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.

1217y
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.

1821y
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.

TM

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:S213S256),
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

TM

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
field-testing.
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

TM

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