The newly released National Heart, Lung, and Blood Institute Expert Panel Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents1 and the American Academy of Pediatrics Bright Futures: Guideline for Health Supervision of Infants, Children, and Adolescents (Bright Futures Guidelines)2 are both based on the best available scientific evidence. They are designed to be implemented in accordance with the American Academy of Pediatrics (AAP) Periodicity Schedule, as part of standard preventive health supervision visits.2 They focus on developmentally appropriate health promotion and preventive strategies, including age-specific selective and universal screening to identify youth with specific risk factors and/or conditions.
The Integrated Cardiovascular Health and Risk Factor Screening Schedule reflects a stronger and more focused emphasis on promoting CV health and in identifying children at increased risk for CV disease because of the presence of specific CV risk factors.
Both sets of guidelines recommend that family history of CV disease and its treatment be ascertained, since premature CV disease in a parent or grandparent is a risk factor for dyslipidemia and CV disease in the child. Bright Futures defines premature CV disease as onset before age 55 years in a sibling, parent, or grandparent; the CV Guidelines extend this definition to before 55 years in men and 65 years in women, and expand the pedigree for consideration to include aunts and uncles. Both guidelines recommend a detailed family history for CV disease and CV risk factors at the initial (prenatal) visit, with an update of the family history at intervening preventive visits. The Integrated CV Health Schedule also calls for a detailed CV family history assessment at the 3-year, 9- to 11-year, and 18-year visits. Both guidelines recommend that youth identified with a positive family history of premature CV disease and/or parental hypercholesterolemia be screened for dyslipidemia.
Both guidelines recognize that tobacco use is the leading preventable cause of death. Parental smoking is a risk factor for youth smoking and exposes the fetus and child to secondhand smoke. Ascertainment of the smoking status of parents, other household members, and primary care providers should begin prenatally and continue annually. Counseling regarding a smoke-free home should also begin during the prenatal/newborn period and continue as long as needed. Smoking cessation assistance and referral to community-based cessation programs, telephone quit lines, and other interventions should be provided to parents or other care givers.
Screening and active antismoking counseling of children should begin early — age 5 years (CV Guidelines) or 7 years (Bright Futures Guidelines) — and continue annually. School, community and peer-based programs to prevent initiation are to be supported. For youth who smoke or use tobacco products, tobacco cessation assistance (counseling and nicotine replacement therapy and other pharmacotherapy, as indicated) should be provided. Public health strategies, such as taxation of tobacco products, clean indoor air legislation, and counter advertising, have been very effective in preventing initiation (especially among youth) and increasing cessation.
Diet and Nutrition
The obesity epidemic, the result of multiple factors leading to a chronic imbalance between caloric intake and energy expenditure, affects children of all ages. It highlights the critical role that pediatric care providers have in educating children, parents, and other caregivers about what constitutes a healthful diet.
Both guidelines recommend that nutrition be discussed at every preventive care visit. The focus changes as children age, but should include discussions of: nutrition for appropriate growth; prevention of overweight/obesity; supporting the development of feeding and eating skills; a positive, nurturing environment and healthy patterns of feeding and eating, promotion of eating habits based on variety, balance, and moderation; a healthy parent/adult-child feeding relationship to support social and emotional development; and recognition of specific health conditions with special nutrient demands and/or dietary restrictions.2
0 to 24 Months
During the first 6 months of life, the Bright Futures and the CV Guidelines concur that exclusive breast-feeding is the best way to ensure optimal nutrition, growth, development, and health. At 6 months, complementary foods should be added, and breast-feeding continued until at least 12 months of age.3 For children aged 12 to 23 months, the CV Guidelines describe a diet designed to transition from the infant diet to that recommended for children 2 years and older with introduction of reduced-fat milk, guided by the pediatric care provider and based on the child’s growth, dietary intake of other foods, and family history of obesity and CV disease.
2 Years and Older
For healthy children older than 2 years of age, the Dietary Guidelines for Americans4 are the nutrition framework used in both guidelines, emphasizing a diet that includes a variety of fruits, vegetables, whole grains, fat-free or low-fat milk and milk products, and lean protein sources (meat, poultry, fish, beans, eggs, and nuts).4 The recommended Dietary Guidelines Eating Plans are low in saturated fats, trans fats, cholesterol, sodium, and added sugars. Sugar-sweetened beverages are limited and high dietary fiber foods are encouraged. Recommended total daily calorie intakes estimate caloric needs (for growth, metabolism, and physical activity) based on age, sex, and physical activity level (see Table, page 32).
Table. Estimated Calorie Requirements (in Kilocalories [kcal]) for Gender and Age Groups at Three Levels of Physical Activity
Reduced Fat Intake
The CV Guidelines provide more detail than Bright Futures on a diet to promote CV health and reduce CV risk factors. The CV Guidelines were based on an updated evidence review of dietary studies that promote CV health and reduce CV risk. This review provided strong evidence that diets reduced in saturated fat (< 10% daily calories), trans fat (as low as possible), total fat (25% to 30% of daily calories) and dietary cholesterol (< 300 mg/day) introduced in infancy and sustained into adolescence, reduce LDL cholesterol and overall CV risk with no measurable harmful effects on growth, sexual maturation, or neurologic development. To decrease saturated fat intake, choosing non-fat milk is essential, especially for children who tend to drink more milk than adults. For those older than 2 years of age, fat-free milk and dairy products are specifically recommended in the CV Guidelines.
Support from Dietitians
Almost all of the studies in the evidence review for the CV Guidelines used registered dietitians to guide families in implementation of the recommended diets. Because many pediatric health care providers may not have the training to assess dietary intake and/or guide behavior change, they and/or their staff may need to increase their knowledge, skills, and competency to provide age- and developmentally appropriate dietary and behavioral counseling to parents and families.
The Toolkit for Health Professionals provides online guidance for translating the Dietary Guidelines into practical food-based recommendations for parents, families, and children.5 Personalized eating plans, based on the child’s age, sex, and physical activity level can also be prepared online and printed as a teaching tool for parents and families of children 2 years and older.
Age-specific activities are also available to teach preschool (aged 2 to 5 years) or early elementary children (aged 6 to 11 years) and their parents about using the food pyramid to plan meals and guide food selection.6 The plan is based on low-fat, unsweetened versions of all foods. For most US children who are not very physically active, very few “extra” calories from higher fat or sweetened foods can be consumed before they will exceed their daily calorie allowance, which can lead to excess weight gain, and ultimately, overweight and obesity. For children at increased CV risk, with nutritional concerns and/or specific diet-influenced conditions such as overweight, obesity, diabetes, hyperlipidemia, or hypertension, referral to a registered dietitian experienced in assessing children’s dietary intakes and counseling children with special nutritional needs and their families is recommended.
Public health nutrition programs, such as the US Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants and Children (WIC), have expanded their mission from preventing nutritional deficiencies and under-nutrition to include preventing childhood obesity by changing their counseling messages, promoting breastfeeding, and revising their food packages. Local community and national efforts to improve nutrition standards for foods served in schools, childcare, and after-school settings are promising environmental and policy strategies to improve children’s nutrition.
Physical Activity and Sedentary Behaviors
The CV Guidelines identified strong evidence that routine moderate to vigorous physical activity is associated with reduced CV risk, including lower blood pressure, decreased body fatness, improved fitness, better lipid profiles, and reduced insulin resistance.
Additionally, the evidence review identified multiple studies in children and young adults, strongly linking increased time spent in sedentary activities with reduced overall physical activity levels; disadvantageous lipid profile changes; higher systolic blood pressure; increased levels of obesity; and the obesity-related CV risk factors, including hypertension, insulin resistance, and type 2 diabetes.1 In diverse populations, tracking of both sedentary and active behaviors is moderately strong from childhood into young adulthood.
Both sets of guidelines recommend that beginning in infancy, parents and other caregivers provide both planned and spontaneous opportunities for active play and physical activity, and limit the amount of time children’s movement is restricted by infant seats, swings, strollers, and play pens. At each visit, health care providers should provide parents with appropriate guidance about the child’s next developmental steps to help them plan safe, educational, and appropriate physical activities. During early childhood (ages 1 to 4 years), the most prevalent form of physical activity is active play. Children tend to be more physically active when playing outdoors. Interactive developmentally appropriate structured play allows a caregiver to help a child develop specific motor skills in a safe and supervised manner.
While information about the specific type and amount of exercise required for optimal CV health in youth is limited, recommendations for youth, aged 5 through 17 years in the CV guidelines and in the 2008 Physical Activity Guidelines for Americans from the US Department of Health and Human Services, call for at least 1 hour per day of moderate to vigorous physical activity, with vigorous activity on at least three of those days.7 Older teens and adults, 18 years and older, should be physically active at least 3 days per week and accumulate a minimum of 75 minutes of vigorous or 2.5 hours of moderate physical activity per week. In working with children and families, the CV Guidelines suggest that moderate to vigorous activity is comparable to jogging or playing baseball and that vigorous physical activity can be compared with running, playing singles tennis, or soccer.
The CDC provides online resources — their Youth Physical Activity Guidelines Toolkit and Fact Sheets — that outline the roles of schools, families, and communities and how they can provide opportunities, space, time, facilities, and support for youth to be active every day.8 Increasing the total time and the percent of time spent in moderate to vigorous physical activity during school-based physical education classes has been shown to increase the amount of daily physical activity. Community and environmental changes that make it easier for children to walk or bike to school have been associated with increases in physical activity.8
Limited Screen Time
There has been a dramatic increase in sedentary behaviors, especially television viewing and recreational media use by youth. Increased television viewing is associated with poor diets, reflecting the response to advertised foods, and increased rates of obesity. Both the CV and Bright Futures Guidelines recommend that parents set limits to their children’s television and media use consistent with the AAP’s guidelines: children younger than 2 years should be discouraged from watching any television/screen media; children aged 2 to 17 years should limit recreational screen time to no more than 1 to 2 hours per day, and television sets should not be placed in a child’s bedroom.9 Children’s viewing habits tend to mirror the habits of their parents; this needs to be addressed since it can impede implementation of these guidelines. School-based curricula and interventions specifically targeting reduction in television viewing or media use have been associated with reduced viewing, reduced violent ideation, and reduced obesity measures.
Blood Pressure and Hypertension
At a prevalence as high as 5%, hypertension is one of the most common chronic diseases of childhood. Detection of hypertension in childhood identifies an individual at defined risk for hypertension as an adult and at increased risk for accelerated atherosclerosis and future premature CVD. By contrast, information from epidemiologic studies and randomized trials indicates that healthy lifestyle choices in childhood are consistently associated with lower blood pressures later in life. The approach to detection, evaluation, and treatment of elevated blood pressure in children and adolescents in both guidelines is based on the Fourth Report of the NHLBI Task Force.10 For children younger than 3 years, selective blood pressure measurement using an oscillometric device is recommended for those with a history of neonatal complications, congenital heart disease, urinary tract or renal pathology, solid organ transplant, malignancy, or any drug, or other condition associated with blood pressure elevation or increased intracranial pressure. Treatment of high blood pressure in young children is often directed at the underlying cause since primary hypertension is uncommon.
For children 3 years and older, routine universal blood pressure measurement using auscultation during annual preventive health visits and acute/illness visits is recommended. For children, aged 3 to 12 years, the blood pressure percentiles from the Fourth Report, based on age, sex, and height percentile, should be used to categorize the blood pressure as prehypertensive, stage 1 or stage 2 hypertension. Blood pressure elevation must be persistent to be considered hypertensive as outlined in the algorithms in the CV Guidelines.
12 to 18 Years
For adolescents aged 12 to 18 years, the percentiles from the Fourth Report are used to evaluate blood pressure, except for pre-hypertension, which is defined as blood pressure greater than 120/80 mm/Hg (the adult cutpoint). For the young adult group, aged 18 to 21 years, the adult cutpoints from JNC VII are used.11
Obesity is increasingly being recognized as a cause of hypertension in children and adolescents. The presence of stage 1 or stage 2 hypertension with BMI at the 95th percentile or greater represents obesity with a defined comorbidity. In this situation, the CV Guidelines strongly recommend referral to a comprehensive multidisciplinary weight-loss program for intensive management. The first treatment step is dietary intervention with a Dietary Approaches to Stop Hypertension (DASH)-style diet that focuses on increased fruits, vegetables, low-fat dairy, and whole grains, with reduced salt and fat, combined with increased physical activity.12 A diet similar to this is outlined in the CV Guidelines.
With BMI above the 95th percentile and a comorbidity such as hypertension, the AMA/CDC/Maternal and Child Health Bureau Expert Committee and the AAP recommendation is gradual weight loss not to exceed 1 lb per month in children aged 2 to 11 years or 2 lb per week in adolescents. Management, further evaluation, pharmacotherapy, and follow-up of hypertension are described in the CV Guidelines and in the forthcoming Pediatric Annals section on blood pressure management (coming in Spring 2012). Infants, young children, and youth with very elevated blood pressure should be referred directly to a pediatric hypertension expert. A series of randomized trials summarized in the CV Guidelines have demonstrated the safety and efficacy of blood pressure lowering drugs in those rare children and adolescents who require pharmacologic therapy.1
Lipids, Lipoproteins, and Dyslipidemia
The evidence review for the CV Guidelines includes a series of critical observational studies, which demonstrate a clear correlation between lipoprotein disorders and the onset and severity of atherosclerosis in children, adolescents, and young adults. Both the CV and Bright Futures guidelines call for selective screening beginning at age 2 years to identify children and adolescents with hypercholesterolemia (especially elevated LDL cholesterol) or dyslipidemia (including elevated LDL, elevated triglycerides and/or low levels of HDL cholesterol) based on family history of premature CV disease and/or parent with hyperlipidemia. Because of the increased prevalence of obesity, the prevalence of dyslipidemia in children has increased, and combined hyperlipidemia — moderate to severe elevation in triglycerides, normal to mild elevation in LDL cholesterol, and reduced HDL cholesterol — the pattern associated with obesity, is now the predominant dyslipidemic pattern seen in childhood. In pathology and imaging studies, both familial hypercholesterolemia with elevated LDL cholesterol and combined dyslipidemia have been associated with initiation and progression of atherosclerotic lesions in children and adolescents.
One difference in the Integrated CV Health Schedule is the recommendation for universal screening of children for hypercholesterolemia between the ages of 9 and 11 years. Depending on the pediatric provider and/or parental preferences and the child’s fasting state, either a nonfasting lipid profile (to calculate non-HDL cholesterol) or a fasting lipid profile should be measured, with confirmation and follow-up determined by the results according to recommended protocols shown in the algorithms in the CV Guidelines. Both sets of guidelines call for assessment of lipids in young adults (age 17 to 21 years).
Overweight and Obesity
To improve early recognition of excess weight gain, overweight, and obesity, universal screening is recommended at every preventive visit beginning at 2 years of age.13 For children younger than 2 years, review of weight-for-age and weight-for-height growth charts may help identify infants with disproportionately rapid weight gain. For children 2 years of age and older, assessment of body mass index (BMI)–for-age percentile is recommended as a more sensitive indicator of obesity at every well-child visit. Children aged 2 to 18 years with a BMI at or above the 85th percentile and below the 95th percentile are classified as “overweight;” while those with a BMI at or above 95th percentile are classified as “obese.”
Family-based behavioral modification counseling to improve diet and energy balance, increase physical activity, and reduce television/screen time is recommended for overweight and obese youth. For younger children, aged 2 to 11 years, the CV Guidelines evidence review showed that counseling with parents as the focus for behavioral change is more effective, while after the age of 12 years, counseling with the adolescent as the agent of change is recommended. Age and BMI-specific recommendations are outlined in the algorithms in the CV Guidelines. If BMI percentiles do not improve, referral to a dietitian is recommended. For youth with BMI at or above the 95th percentile, a more detailed family history of obesity, type 2 diabetes, CV disease and hypercholesterolemia, and assessment/screening for comorbidities (dyslipidemia, hypertension, and diabetes) is recommended. Youth with BMI at or above the 95th percentile and any comorbidity should be referred to a comprehensive, medium- to high-intensity behavioral management program, defined as a program with at least 25 hours of meetings over 6 months).
Diabetes, Atherosclerosis, and Early CV Disease
A difference between the two guidelines is that the “Integrated CV Health Schedule” in the CV Guidelines includes the recommendation of the American Diabetes Association that children be selectively assessed for risk of type 2 diabetes, beginning at age 10 years.14 Children who are overweight or obese (BMI-for-age at or above the 85th percentile) and have at least two of the following risk factors: family history of type 2 diabetes in first or second degree relative; selected race/ethnicity (African American, American Indian, Asian/South Pacific Islander, or Hispanic); and/or signs of insulin resistance, are considered at high risk for diabetes and should be screened every 2 years with a fasting plasma glucose measurement.
In addition, children with conditions predisposing to accelerated atherosclerosis and early CVD, such as chronic kidney disease, diabetes (type 1 or type 2), Kawasaki disease with coronary aneurysms, post-heart transplant, chronic inflammatory disease, HIV, nephrotic syndrome, etc, should be risk stratified by disease process, CV risk factors and comorbidities, screened for lipid abnormalities, and treated by dietary treatment, physical activity and lifestyle counseling, and pharmacotherapy, as indicated in the CV Guidelines.
The new NHLBI guidelines can be integrated readily into the recommended pediatric health supervision visits in the Bright Futures Guidelines. The current obesity epidemic is driving up the prevalence of CV risk factors — dyslipidemia, hypertension, and type 2 diabetes — in childhood and adolescence. Because of the evidence that these risk factors are associated with increased extent and severity of atherosclerosis in children and adolescents, and the availability of improved management and treatment, early detection and targeted screening is warranted. The combined effect of the CV Guidelines and the Bright Futures Guidelines has the potential to address the root causes of the childhood obesity epidemic — poor nutrition, excessive caloric intake, and physical inactivity.
- Expert Panel on Integrated Pediatric Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart, Lung and Blood Institute, NIH, Bethesda, MD. Pediatrics (Supplement 5) 2011;128:S213–S309. Available at: www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm. Accessed Dec. 19, 2011.
- Hagan JF, Shaw JS, Duncan PM eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Third Edition, Elk Grove Village, IL: American Academy of Pediatrics, 2008.
- American Academy of Pediatrics (AAP), Section on Breastfeeding: Breastfeeding and the use of human milk. Pediatrics. 2005;115:496–506. Available at: aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496. Accessed Nov. 30, 2011.
- U.S. Health and Human Services, U.S. Department of Agriculture. Dietary Guidelines for Americans 2005. Available at: www.cnpp.usda.gov/Publications/DietaryGuidelines/2005/2005DGPolicyDocument.pdf. Accessed Nov. 30, 2011.
- US Department of Health and Human Services. Dietary Guidelines for Americans: Toolkit for Health Professionals. Available at: www.health.gov/dietaryguidelines/dga2005/toolkit. Accessed Nov. 30, 2011.
- US Department of Agriculture. MyPyramid.gov: Steps to a Healthier You. Available at: www.mypyramid.gov. Accessed Nov. 30, 2011.
- US Department of Health and Human Services. 2008Physical Activity Guidelines for Americans. Available at: www.health.gov/paguidelines. Accessed Nov. 30, 2011.
- Centers for Disease Control and Prevention (CDC). National Center for Chronic Disease Prevention and Health Promotion. Physical Activities Guidelines for Americans: Children and Adolescents. Available at: www.cdc.gov/Healthyyouth/physicalactivity/guidelines.htm#1. Accessed Nov. 30, 2011.
- American Academy of Pediatrics (AAP), Committee on Public Education: Children, adolescents and television. Pediatrics2001; 107:423–426. Available at: aappolicy.aappublications.org/cgi/content/full/pediatrics;107/2/423. Accessed Nov. 30, 2011.
- US Department of Health and Human Services, NIH, National Heart, Lung and Blood Institute. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents. May2005. NIH Pub. No. 05-5267. Available at: www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf. Accessed Nov. 30, 2011.
- Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;21;289(19):2560–2572. doi:10.1001/jama.289.19.2560 [CrossRef]
- US Department of Health and Human Services, NIH, National Heart, Lung and Blood Institute. Your Guide to Lowering your Blood Pressure with DASH. 1988, Revised April 2006. NIH Pub. No. 06-4082. Available at: www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf. Accessed Nov. 30, 2011.
- Barlow SEExpert Committee. Expert committee recommendations regarding the prevention, assessment and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120:S164–S192. Available at: pediatrics.aappublications.org/cgi/reprint/120/Supplement_4/S164. Accessed Nov. 30, 2011. doi:10.1542/peds.2007-2329C [CrossRef]
- American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care2000;23:381–389. Available at: care.diabetesjournals.org/content/23/3/381.full.pdf. Accessed Nov. 30, 2011.
Estimated Calorie Requirements (in Kilocalories [kcal]) for Gender and Age Groups at Three Levels of Physical Activitya
|Gender||Age (years)||Sedentaryb||Moderately Activec||Actived|
|Child||2 to 3||1,000||1,000 to 1,400e||1,000 to 1,400e|
|Female||4 to 8||1,200||1,400 to 1,600||1,400 to 1,800|
|9 to 13||1,600||1,600 to 2,000||1,800 to 2,200|
|14 to 18||1,800||2,000||2,400|
|19 to 30||2,000||2,000 to 2,200||2,400|
|31 to 50||1,800||2,000||2,200|
|51+||1,600||1,800||2,000 to 2,200|
|Male||4 to 8||1,400||1,400 to 1,600||1,600 to 2,000|
|9 to 13||1,800||1,800 to 2,200||2,000 to 2,600|
|14 to 18||2,200||2,400 to 2,800||2,800 to 3,200|
|19 to 30||2,400||2,600 to 2,800||3,000|
|31 to 50||2,200||2,400 to 2,600||2,800 to 3,000|
|51+||2,000||2,200 to 2,400||2,400 to 2,800|