Authors: Sarah D de Ferranti, MD, MPH; Jane W Newburger, MD, MPH
Editors: David R Fulton, MD; Leah K Moynihan, RNC, MSN; Melanie S Kim, MD

CHILDREN AND HEART DISEASE OVERVIEW — Atherosclerosis is the medical term used to describe the build up of fat and cholesterol-filled plaques inside the arteries of the body. Atherosclerosis increases the risk of cardiovascular disease, such as heart attack and stroke, when it affects arteries that supply blood to the heart and brain.

It is unusual for children or teenagers to have a heart attack or stroke as a result of atherosclerosis. This is because vessel narrowing, caused by atherosclerosis, takes many years to develop. However, the process of atherosclerosis begins in childhood. For most children, atherosclerosis is mild and progresses slowly. In some children, atherosclerosis worsens rapidly, increasing the risk of heart disease, and less commonly, stroke in early adult life.

It is often possible to identify which children are at risk for atherosclerosis and to begin making improvements in lifestyle (like eating a healthy diet and exercising). In addition, medications may be prescribed for children with the greatest likelihood of developing early atherosclerosis. In the sections that follow, we will discuss childhood risk factors for early atherosclerosis and cardiovascular disease.

IS MY CHILD AT RISK FOR ATHEROSCLEROSIS?

Risk factors — Certain factors increase a child's risk of developing early atherosclerosis, including the following:

* Overweight — Children and teenagers who are overweight or obese have an increased risk of developing high blood pressure, diabetes, and high cholesterol and lipids. In adults, these factors increase the risk for early atherosclerotic disease. Children who are overweight/obese are more likely to be overweight/obese as adults. In addition, there is increasing evidence that childhood obesity raises the risk of other risk factors that are associated with heart disease in early adulthood, such as high blood pressure or diabetes mellitus. The definitions of obesity and overweight for children and teenagers are described below. (See 'Obesity' below.)

* High blood pressure — Children and adolescents with high blood pressure are more likely to have high blood pressure as adults. High blood pressure in adulthood increases the risk of cardiovascular disease. (See "Patient information: High blood pressure in children".)

* Family history of cardiovascular disease — Children whose parents or grandparents had a heart attack or stroke at an early age have twice the risk of developing cardiovascular disease. A family history of early-age cardiovascular disease is defined as a parent or grandparent who had a heart attack, a stroke, or peripheral vascular disease (blockages in the large blood vessels of the arms or legs) before the age of 56 years for men or 66 years for women.
* Exposure to cigarette smoke — Smoking and exposure to smoking increases the risk of developing early cardiovascular disease. Children/teenagers who smoke themselves are likely to continue smoking into adulthood, thus increasing their risk of early cardiovascular disease.
* Underlying medical problems — Certain underlying medical problems increase the risk of early cardiovascular disease. These include diabetes, chronic kidney disease, heart transplantation, Kawasaki disease, and treatment for cancer during childhood (table 1). Children with these problems are treated especially vigorously with lifestyle changes and sometimes medications to lower their risk. (See "Diseases associated with atherosclerosis in childhood".)

Is testing for risk factors recommended? — Screening every child with tests to look for atherosclerosis risk factors is not currently recommended. However, expert groups do recommend screening tests for children older than two years who have one or more of the following risks (table 2):

* Family history of high cholesterol or lipids, early cardiovascular disease, or diabetes. Family history is defined as a parent, sibling, or grandparent with a heart attack, a stroke, or peripheral vascular disease (blockages in the large blood vessels of the arms or legs) before 55 years of age for men and ≤65 years of age for women.
* Medical diseases associated with cardiovascular disease (table 1).
* Overweight/obesity, high blood pressure, or high cholesterol or lipids (see below).

Screening tests — The following screening tests are recommended for children who have one or more of the above risk factors:

* Fasting cholesterol and lipid blood testing (drawn before the first meal or drink of the day)
* Fasting blood sugar testing

All children, especially those with a risk factor for atherosclerosis, should have yearly measurement of:

* Blood pressure
* Height and weight and calculation of body mass index (BMI), which is a way to measure for overweight or obesity (see 'Obesity' below)
* Review of lifestyle issues, such as tobacco smoke exposure, exercise, diet, and sleep

TREATMENT OF AT RISK CHILDREN — The management of children with an increased risk of cardiovascular disease includes the following:

* Lifestyle changes, including increased exercise, changes in diet, avoiding exposure to cigarette smoke, or weight loss
* If necessary, one or more medications to treat high cholesterol and/or high blood pressure

Is treatment necessary? — Treatment of atherosclerosis risk factors may prevent or delay the development of cardiovascular disease later in life. The decision about when to start treatment depends upon:

* The severity of risk for future heart disease
* The risk of side effects of the treatment
* The effectiveness of the treatment

Making healthy lifestyle changes (diet, exercise, weight control, avoiding smoking) is effective and has few risks. The use of a medication(s) requires more careful consideration. For each child or teenager, the caregiver will work to individualize a treatment plan that has the greatest potential benefits and fewest risks.

HIGH CHOLESTEROL AND LIPIDS — Cholesterol and lipids are measured by testing the blood level of several components, including total cholesterol, LDL (bad cholesterol), HDL (good cholesterol), and triglycerides. The most accurate time to measure these levels is before the first meal or drink of the day, 8 to 12 hours after the last meal (called fasting).

The following levels are considered abnormal and may indicate a need for treatment:

* Total cholesterol >200 mg/dL (5.18 mmol/L)
* Low-density lipoprotein (LDL) cholesterol >130 mg/dL (3.36 mmol/L)

Initial treatment — The initial treatment for high cholesterol includes a combination of changes in diet and increased activity. These treatments are usually recommended for at least 6 to 12 months before considering the use of medication.

Diet — Parents of children with elevated low-density lipoprotein levels should offer their child a low-saturated fat, low-cholesterol diet. Increasing fruits and vegetables, whole grains, low-fat or nonfat dairy products, beans, fish, and lean proteins can help to meet this goal.

Children with high triglycerides should eat a diet without excessive carbohydrates, particularly "refined" carbohydrates (white rice, pasta, bread, desserts), which raise blood sugar and are low in fiber.

Meeting with a dietitian or nutritionist can help families to set realistic, individual goals and make long-lasting changes. In most cases, the entire family should change their diet together to maximize the child's chances of success. More than one visit with a nutritionist is often necessary.

Activity — Increasing daily activity can help to decrease the risk of cardiovascular disease and improve cholesterol levels. Most expert groups recommend that children get 30 to 60 minutes of exercise four to six days per week.

For children who are not already active, the increase in activity should be gradual. For example, the initial goal may be to ride a bicycle outside for 10 minutes 3 times per week. Other options include joining a gym or YMCA, riding an exercise bike, or running on a treadmill; activity should be tailored to the child's age and interests.

Dietary supplements — Dietary supplements, such as fiber and omega-3 fatty acids, are sometimes recommended to decrease LDL cholesterol and triglyceride levels. However, the best source of fiber is from dietary sources, such as fruits, vegetables, and whole grains. The best source of omega-3 fatty acids is fish. (See "Patient information: High fiber diet".)

Medications — If changes in diet and activity do not decrease cholesterol levels enough after 6 to 12 months, or if a child's cholesterol or triglyceride levels are very high, one or more medications may be recommended. Medications do not permanently cure the problem but work to lower the child's risk factors. A table describing when medication is recommended is available here (table 3).

Statins — The most commonly used medication to treat high cholesterol belongs to a class of drugs called statins. Several statins are approved for use in children (table 3). These medications are usually taken in pill form, once per day. More detailed information about use of statins in children is available separately. (See "Management of the child at-risk for atherosclerosis".)

American Academy of Pediatrics recommendations on high cholesterol treatment in children

When to perform screening tests*?

If family history of high cholesterol or early cardiovascular disease

If family history unknown

If child has risk factors (obesity, high blood pressure, medical illness that increases risk)

Perform testing every 3 to 5 years beginning at age 2 years

When to begin lifestyle changes (diet, exercise)?

At 1 year of age, begin reduced-fat (2 percent) milk for children at risk due to obesity or family history of cardiovascular disease

In children with elevated serum LDL-C, the recommended diet should have saturated fat <7 percent, trans fat <1 percent, dietary cholesterol <200 mg/day, and fiber intake equal to child's age plus 5 g/day (up to 20 g/day at 15 years of age)

Encourage physical activity to manage weight and treat high triglyceride levels and low HDL cholesterol levels

When to consider medication for high cholesterol?

Consider medication in children at least 8 years of age or older, if LDL 190 mg/dL or 160 mg/dL with positive family history or two additional risk factors or 130 mg/dL with type 1 diabetes mellitus

* Screening tests usually include blood tests for total cholesterol, HDL (high density lipoprotein), LDL (low density lipoprotein), and triglycerides, drawn before the first meal of the day.
Data from: Daniels, SR, Greer, FR. Lipid screening and cardiovascular health in childhood. Pediatrics 2008; 122:198.