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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, FAAPProfessor of Pediatrics, Division of Pediatric CardiologyFormer NHLBI Coordinator for Cardiovascular Risk Reduction in ChildhoodGolisano Children’s HospitalUniversity of Rochester Medical Center

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Prepared for your next patient.

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• 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.

Disclaimers

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• 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.

Learning Objectives

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• 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 diet2) Lipid screening and management

Webinar Format

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I. Formal evidence review Graded recommendations by an expert panel.

II. Integrated—multiple RFs addressed in a single guideline

III. Formal United States Department of Health and Human Services (HHS) review and approval process

IV. Routinely updated

NHLBI Guidelines: New Approach

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• 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

Pediatric Guideline Considerations

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• (+) 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

Risk Factors/Behaviors for CVD

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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.

Modified Evidence Review: Defined Process/Scope

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I. Define critical questions + evidence grading system. II. Electronic search: >1,000,000 titles serial review

400 RCTs/systematic reviews/meta-analyses + 248 epidemiologic studies abstracted into evidence tables

III. Define decision making process for recommendations.IV. Review and grade evidence.V. Develop age-specific recommendations integrated

across RFs and within regular pediatric care.

Guideline Development Process

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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 practiceguidelines. Pediatrics. 2004;114(3):874–877

Evidence Grading System

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Statement Definition Implication

Strong recommendation

Evidence grade A or BBenefit clearly exceeds harm

Should follow

RecommendationEvidence grade B or CBenefit exceeds harm but evidence is not as clear

Should generally follow

OptionalWell-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

Strength of Recommendation

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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

Expert Panel Decision-making Process

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STATE OF THE SCIENCE

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NormalNormal FattyFattyStreakStreak

FibrousFibrousPlaquePlaque

Occlusive Occlusive AtheroscleroticAtherosclerotic

PlaquePlaque

PlaquePlaqueRupture/Rupture/Fissure &Fissure &

ThrombosisThrombosis

Increasing ageIncreasing age

EffortEffortAngina orAngina or

ClaudicationClaudication

Atherosclerosis: A Progressive Process

Plaque Plaque progression/progression/extensionextension

Birth 20 30 40 50+ 50Clinically silent

10Clinical events

60 +

Angina, MI,Coronary death, Stroke, Peripheralischemia

Development of Risk Factors (RF)

EndothelialDysfunction,Plaqueinitiation

ONGOING RF EXPOSURE

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Review of the evidence linking RFs in childhood todevelopment 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.

State of the Science Evidence Review

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• 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.

Individual Risk Factor Sections

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INDIVIDUAL RISK FACTOR SECTIONS:NUTRITION AND DIET

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Abbreviation: STRIP, Special Turku Coronary Risk Factor Intervention ProjectSimell 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

Evidence for Controlling Fat Intake in Childhood: Safety and EfficacySTRIP Study: Prospective randomized trial of a low saturated fat, low cholesterol diet beginning in infancy.

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• 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

STRIP Study

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% of energy 7 m*(B/L) 13 m*INT CON p INT CON p

Total fat 29 + 5 28 + 3 ns 26 + 6 28 + 5 nsSat fat 13 + 2 12 + 2 ns 9 + 3 13 + 3 <.001Chol (mg/d) 70 + 26 73 + 20 ns 84 + 37 113 + 44 <.001Protein 11 + 2 13 + 2 ns 18 + 2 17 + 3 nsCarb 60 + 5 59 + 4 ns 56 + 5 55 + 5 ns

* Formula fed infants only

STRIP Study: Initial Diet Results

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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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• 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.

STRIP Study Conclusions

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• STRIP Study findings and multiple other RCTs in healthy, normo- and hyper-cholesterolemic 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)

Evidence Review Summary for Dietary Fat Intake

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• 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).

Sugar-Sweetened Beverages: Background

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Sugar-Sweetened BeverageConsumption

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• 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

Evidence for Role of Sugar-SweetenedBeverages in Obesity: Epidemiologic Data

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• 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+0.153) 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

RCT Evidence Regarding Sugar-Sweetened Beverage Intake: 2 Trials

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• 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

Preventing Childhood Obesity by Reducing Consumption of Carbonated Drinks: Cluster-Randomized Controlled Trial

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• 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 sugar-sweetened

beverages. (Grade B)

Conclusions of the Evidence Review on Sugar-Sweetened Beverage Consumption

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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. DLimit 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.

Cardiovascular Health Integrated Lifestyle Diet (CHILD 1)

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Age Recommendation Grade12–24 months Transition to reduced-fat (2% to fat free)

unflavored cow’s milk. B Limit/avoid sugar-sweetened beverage intake; encourage water. BTransition to table food with: - 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

Supportive 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.

Cardiovascular Health Integrated Lifestyle Diet (CHILD 1) cont.

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Age Recommendation Grade

2–10 years Primary beverage: fat-free, unflavored milk A Limit/avoid sugar-sweetened beverage intake; encourage water. BEncourage high dietary fiber intake from food. BFat 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.

Cardiovascular Health Integrated Lifestyle Diet (CHILD 1) cont.

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Age Recommendation Grade

11−21 years Primary beverage: fat-free, unflavored milk A Limit/avoid sugar-sweetened beverage intake; encourage water. BEncourage high dietary fiber intake from food. BFat 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.

Cardiovascular Health Integrated Lifestyle Diet (CHILD 1) cont.

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Gender Age (Years) SedentaryModerately

Active ActiveChild 2–3 1,000–1,200 1,000–1,400 1,000–1,400

Female

4–89–13

14–1819–30

1,200–1,4001,400–1,600

1,8001,800–2,000

1,400–1,6001,600–2,000

2,0002,000–2,200

1,400–1,8001,800–2,200

2,4002,400

Male

4–89–13

14–1819–30

1,200–1,4001,600–2,0002,000–2,4002,400–2,600

1,400–1,6001,800–2,2002,400–2,8002,600–2,800

1,600–2,0002,000–2,6002,800–3,200

3,000

Estimated Energy Requirements by Age, Gender, and Activity Level

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DASH Eating Plan: Servings per Day by Food Group and EER

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DASH Eating Plan: Servings per Day by Food Group and EER cont.

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RISK FACTOR: LIPIDS AND LIPOPROTEINSSCREENING AND MANAGEMENT

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• 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.

Criteria for Screening Recommendation

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• 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.

Evidence Rationale for Lipid Screening

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• 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)

Evidence Rationale for Lipid Screening cont.

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• 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.

Evidence Limited/Lacking

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• 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.

Results of Targeted Cholesterol Screening Using Family History and BMI

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• 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.

Non-HDL-C = New Screening Measure

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ACCEPTABLE BORDERLINE ABNORMAL

TC <170 170−199 >200

LDL-C <110 110−129 >130

Non-HDL-C <120 120−144 >145

TG0−9y: <75

10−19y: <90 75−99

90−129>100>130

HDL >45 40−45 <40

Plasma Lipid Distribution (mg/dL) for Children and Adolescents

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• 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

Guideline Lipid Management Recommendations

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• No screening below 2 years of age (Grade C/Recommend)• 2−10 years: Selective screening if:

1)Family history (+) for early CVD2)Parent with known dyslipidemia3)Child with established RF4)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

(Grade B/Strongly recommend)

Overview of Lipid Screening Recommendations

TMEvidence-Based Lipid Assessment Recommendations by Age

TMEvidence-Based Lipid Assessment Recommendations by Age cont.

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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

Special Risk Conditions

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FLP x 2, average results

LDL-C >130, <250 mg/dL* → Target LDL-CTG >100, <500 mg/dL, <10y → Target TG >130, <500 mg/dL, 10−19y (TG algorithm)

Exclude secondary causes.Evaluate for other RFs.Start CHILD 2-LDL diet + lifestyle modification for 6 months.

FLP

LDL-C >190 mg/dL

→ Initiate statin therapy

LDL-C >160–189 mg/dLFHx (+) or1 high-level RF or >2 moderate-level RFs

→ Initiate statin therapy

TG >500 mg/dL,→ Consult lipid specialist

LDL-C <130 mg/dL (=GOAL)

→ Continue CHILD 2-LDL diet.

→ Repeat fasting lipid profile q 12m.

LDL-C >250 mg/dL→ Consult lipid specialist

LDL-C >130–189 mg/dLFHx (-) No other RFs

→ Continue CHILD 2-LDL diet. Follow q 6m with lipid profile, FHx/RF update.

LDL-C >130–159 mg/dL +2 high-level RFs or 1 high-level + >2 moderate-level RFs or clinical CVD

→ Initiate statin therapy

Follow with FLPs, related chemistries.

Dyslipidemia Algorithm: TARGET LDL-C

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→ 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.

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.

Abbreviation: FHx, family history

Dyslipidemia Algorithm: TARGET LDL-C cont.

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– Saturated fat <7% of calories Grade A Highly recommend

– Dietary cholesterol <200 mg/d Grade A Highly recommend

+ With high TGs: Eliminate sugar- Grade B sweetened beverages, reduce simple Recommend carbohydrates, increase dietary omega 3 content + weight management as needed.

CHILD 2-LDL and CHILD 2-TG

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• 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

How Many Adolescents Would Be Candidates for Medication?

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INTEGRATED CARDIOVASCULAR HEALTH SCHEDULE

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Birth–12m 1–4y 5–9y 9–11y 12–17y 18–21y

FHx of EARLY CVD

AT 3Y, EVALUATE FHx FOR EARLY CVD: Parents, grandparents, aunts/uncles,M <55y, F <65y. Review with parents. Refer prn.

Update at each non-urgent 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 anti-smoking 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.

NUTRITION/ DIET

Support breastfeeding as optimal to 12m if possible. Add formula if breastfeeding decreases before 12m.

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.

Integrated Cardiovascular Health Schedule

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GROWTH

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 perobesity 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 obesityalgorithms.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 referralManage 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.

Birth–12m 1–4y 5–9y 9–11y 12–17y 18–21y

Integrated Cardiovascular Health Schedule cont.

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• “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

For more information

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• 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

Implementation Process

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For more information… On this topic and a host of other topics, visit www.pediatriccareonline.org.

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