1. PEDIATRICS
OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
DECEMBER 2011 • VOLUME 128 • SUPPLEMENT 5
A SUPPLEMENT TO PEDIATRICS
Expert Panel on Integrated Guidelines for Cardiovascular
Health and Risk Reduction in Children and Adolescents:
Summary Report
Rae-Ellen W. Kavey, MD, MPH, Denise G. Simons-Morton, MD, MH, PhD,
and Janet M. de Jesus, MS, RD, Supplement Editors
Sponsored by the National Heart, Lung, and Blood Institute,
National Institutes of Health
These guidelines have been endorsed by the American Academy of
Pediatrics. Statements and opinions expressed in this supplement
are those of the authors and not necessarily those of Pediatrics
or the Editor or Editorial Board of Pediatrics.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2011 by the
American Academy of Pediatrics

2. SUPPLEMENT TO PEDIATRICS
CONTENTS S•••• 1. Introduction
S•••• 2. State of the Science: Cardiovascular Risk Factors and the Development of
Atherosclerosis in Childhood
S••••• 3. Integrated Cardiovascular Health Schedule
S•••• 4. Family History of Early Atherosclerotic CVD
S•••• 5. Nutrition and Diet
S•••• 6. Physical Activity
S•••• 7. Tobacco Exposure
S•••• 8. High BP
S•••• 9. Lipids and Lipoproteins
S•••• 10. Overweight and Obesity
S•••• 11. DM and Other Conditions Predisposing to the Development of Accelerated
Atherosclerosis
S•••• 12. Risk-Factor Clustering and the Metabolic Syndrome
S•••• 13. Perinatal Factors
doi:10.1542/peds.2009-2107A
www.pediatrics.org
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3. Expert Panel Members
Stephen R. Daniels, MD, PhD, Panel Chair
University of Colorado School of Medicine
Denver, CO
Irwin Benuck, MD, PhD
Northwestern University Feinberg School of Medicine
Chicago, IL
Dimitri A. Christakis, MD, MPH
University of Washington
Seattle, WA
Barbara A. Dennison, MD
New York State Department of Health
Albany, NY
Samuel S. Gidding, MD
Alfred I du Pont Hospital for Children
Wilmington, DE
Matthew W. Gillman, MD, MS
Harvard Pilgrim Health Care
Boston, MA
Mary Margaret Gottesman, PhD, RN, CPNP
Ohio State University-College of Nursing
Columbus, OH
Peter O. Kwiterovich, MD
Johns Hopkins University School of Medicine
Baltimore, MD
Patrick E. McBride, MD, MPH
University of Wisconsin School of Medicine and Public Health
Madison, WI
Brian W. McCrindle, MD, MPH
Hospital for Sick Children
Toronto, Ontario, Canada
Albert P. Rocchini, MD
C. S. Mott Children’s Hospital
Ann Arbor, MI
Elaine M. Urbina, MD
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH
Linda V. Van Horn, PhD, RD
Northwestern University-Feinberg School of Medicine
Chicago, IL
Reginald L. Washington, MD
Rocky Mountain Hospital for Children
Denver, CO
NHLBI Staff
Rae-Ellen W. Kavey, MD, MPH
Panel Coordinator
National Heart, Lung, and Blood Institute
Bethesda, MD
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4. Christopher J. O’Donnell, MD, MPH
National Heart, Lung, and Blood Institute
Framingham, MA
Karen A. Donato, SM
National Heart, Lung, and Blood Institute
Bethesda, MD
Robinson Fulwood, PhD, MSPH
National Heart, Lung, and Blood Institute
Bethesda, MD
Janet M. de Jesus, MS, RD
National Heart, Lung, and Blood Institute
Bethesda, MD
Denise G. Simons-Morton, MD, MPH, PhD
National Heart, Lung, and Blood Institute
Bethesda, MD
Contract Staff
The Lewin Group, Falls Church, VA
Clifford Goodman, MS, PhD
Christel M. Villarivera, MS
Charlene Chen, MHS
Erin Karnes, MHS
Ayodola Anise, MHS
doi:10.1542/peds.2009-2107B
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5. SUPPLEMENT ARTICLES
Expert Panel on Integrated Guidelines for
Cardiovascular Health and Risk Reduction in Children
and Adolescents: Summary Report
EXPERT PANEL ON INTEGRATED GUIDELINES FOR Atherosclerotic cardiovascular disease (CVD) remains the leading
CARDIOVASCULAR HEALTH AND RISK REDUCTION IN cause of death in North Americans, but manifest disease in childhood
CHILDREN AND ADOLESCENTS
and adolescence is rare. By contrast, risk factors and risk behaviors
ABBREVIATIONS
that accelerate the development of atherosclerosis begin in childhood,
CVD—cardiovascular disease
NHLBI—National Heart, Lung, and Blood Institute and there is increasing evidence that risk reduction delays progres-
RCT—randomized controlled trial sion toward clinical disease. In response, the former director of the
PDAY—Pathobiological Determinants of Atherosclerosis in National Heart, Lung, and Blood Institute (NHLBI), Dr Elizabeth Nabel,
Youth
BP—blood pressure initiated development of cardiovascular health guidelines for pediatric
HDL—high-density lipoprotein care providers based on a formal evidence review of the science with
DM—diabetes mellitus an integrated format addressing all the major cardiovascular risk
CIMT—carotid intima-media thickness
LDL—low-density lipoprotein
factors simultaneously. An expert panel was appointed to develop the
T1DM—type 1 diabetes mellitus guidelines in the fall of 2006.
T2DM—type 2 diabetes mellitus
TC—total cholesterol The goal of the expert panel was to develop comprehensive evidence-
AAP—American Academy of Pediatrics based guidelines that address the known risk factors for CVD (Table
DGA—Dietary Guidelines for Americans 1-1) to assist all primary pediatric care providers in both the promo-
NCEP—National Cholesterol Education Program
DASH—Dietary Approaches to Stop Hypertension
tion of cardiovascular health and the identification and management of
CHILD—Cardiovascular Health Integrated Lifestyle Die specific risk factors from infancy into young adult life. An innovative
FLP—fasting lipid profile approach was needed, because a focus on cardiovascular risk reduc-
CDC—Centers for Disease Control and Prevention
tion in children and adolescents addresses a disease process (athero-
AMA—American Medical Association
MCHB—Maternal and Child Health Bureau sclerosis) in which the clinical end point of manifest CVD is remote. The
FDA—Food and Drug Administration recommendations, therefore, need to address 2 different goals:
AHA—American Heart Association the prevention of risk-factor development (primordial prevention) and
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2107C the prevention of future CVD by effective management of identified risk
doi:10.1542/peds.2009-2107C factors (primary prevention).
Accepted for publication Aug 4, 2009
The evidence review also required an innovative approach. Most sys-
Address correspondence to Janet M. de Jesus, MS, RD, 31
Center Dr, Building 31, Room 4A17, MSC 2480, Bethesda, MD
tematic evidence reviews include 1 or, at most, a small number of finite
20892. E-mail: dejesusjm@nhlbi.nih.gov questions that address the impact of specific interventions on specific
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). health outcomes, and a rigorous literature review often results in only
Copyright © 2011 by the American Academy of Pediatrics a handful of in-scope articles for inclusion. Typically, evidence is limited
FINANCIAL DISCLOSURE: Dr Daniels has served as a consultant
to randomized controlled trials (RCTs), systematic reviews, and meta-
for Abbott Laboratories, Merck, and Schering-Plough and has analyses published over a defined time period. There is a defined for-
received funding/grant support for research from the National mat for abstracting studies, grading the evidence, and presenting of
Institutes of Health (NIH); Dr Gidding has served as a consultant
for Merck and Schering-Plough and has received funding/grant results. The results of the review lead to the conclusions, independent
support for research from GlaxoSmithKline; Dr Gillman has of interpretation.
given invited talks for Nestle Nutrition Institute and Danone and
has received funding/grant support for research from Mead By contrast, given the scope of the charge to the expert panel, this
Johnson, Sanofi-Aventis, and the NIH; Dr Gottesman has served
on the Health Advisory Board, Child Development Council of evidence review needed to address a broad array of questions con-
Franklin County, was a consultant to Early Head Start for Region cerning the development, progression, and management of multiple
5B, has written for iVillage and taught classes through Garrison
risk factors extending from birth through 21 years of age, including
(Continued on last page)
studies with follow-up into later adult life. The time frame extended
back to 1985, ϳ5 years before the review for the last NHLBI guideline
addressing lipids in children published in 1992.1 This evidence is
largely available in the form of epidemiologic observational studies
PEDIATRICS Volume 128, Supplement 6, December 2011 S1

6. TABLE 1-1 Evaluated Risk Factors TABLE 1-2 Evidence Grading System: Quality Grades
Family history Grade Evidence
Age A Well-designed RCTs or diagnostic studies performed on a population similar to the guideline’s
Gender target population
Nutrition/diet B RCTs or diagnostic studies with minor limitations; genetic natural history studies;
Physical inactivity overwhelmingly consistent evidence from observational studies
Tobacco exposure C Observational studies (case-control and cohort design)
BP D Expert opinion, case reports, or reasoning from first principles (bench research or animal
Lipid levels studies)
Overweight/obesity
Adapted from American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Pediatrics.
Diabetes mellitus 2004;114(3):874 – 877.
Predisposing conditions
Metabolic syndrome
Inflammatory markers
Perinatal factors titioners, physician assistants, and dations. The summary report will be
registered dietitians. The full report released simultaneously with online
contains complete background infor- availability of the full report with refer-
(rather than RCTs) that, therefore, mation on the state of the science, ences for each section and the evidence
must be included in the review. In ad- methodology of the evidence review tables at www.nhlbi.nih.gov/guidelines/
dition, the review required critical ap- and the guideline-development pro- cvd_ped/index.htm.
praisal of the body of evidence that ad- cess, summaries of the evidence re- It is the hope of the NHLBI and the expert
dresses the impact of managing risk views according to risk factor, discus- panel that these recommendations will be
factors in childhood on the develop- sion of the expert panel’s rationale for useful for all those who provide cardiovas-
ment and progression of atherosclero- recommendations, and Ͼ1000 cita- cular health care to children.
sis. Because of known gaps in the evi- tions from the published literature and
dence base relating risk factors and is available at www.nhlbi.nih.gov/ 2. STATE OF THE SCIENCE:
risk reduction in childhood to clinical guidelines/cvd_ped/index.htm. The CARDIOVASCULAR RISK FACTORS
events in adult life, the review must in- complete evidence tables will be avail- AND THE DEVELOPMENT OF
clude the available evidence that justi- able as a direct link from that site. This ATHEROSCLEROSIS IN CHILDHOOD
fies evaluation and treatment of risk summary report presents the expert
factors in childhood. The process of Atherosclerosis begins in youth, and this
panel’s recommendations for patient
identifying, assembling, and organiz- process, from its earliest phases, is re-
care relative to cardiovascular health
ing the evidence was extensive, the re- and risk-factor detection and manage- lated to the presence and intensity of the
view process was complex, and the ment with only the references cited in known cardiovascular risk factors
conclusions could only be developed the text provided. It begins with a state- shown in Table 1-1. Clinical events such
by interpretation of the body of evi- of-the-science synopsis of the evi- as myocardial infarction, stroke, pe-
dence. Even with inclusion of every rel- dence, which indicates that athero- ripheral arterial disease, and rup-
evant study from the evidence review, sclerosis begins in childhood, and the tured aortic aneurysm are the culmi-
there were important areas in which extent of atherosclerosis is linked di- nation of the lifelong vascular process
the evidence was inadequate. When rectly to the presence and intensity of of atherosclerosis. Pathologically, the
this occurred, recommendations were known risk factors. This is followed by process begins with the accumulation
made on the basis of a consensus of a cardiovascular health schedule (Sec- of abnormal lipids in the vascular in-
the expert panel. The schema used in tion 3), which summarizes the expert tima, a reversible stage, progresses to
grading the evidence appears in Ta- panel’s age-based recommendations an advanced stage in which a core of
bles 1-2 and 1-3; expert consensus according to risk factor in a 1-page pe- extracellular lipid is covered by a fibro-
opinions are identified as grade D. riodic table. Risk factor specific sec- muscular cap, and culminates in
The NHLBI expert panel integrated tions follow, with the graded conclu- thrombosis, vascular rupture, or acute
guidelines for cardiovascular health sions of the evidence review, normative ischemic syndromes.
and risk reduction in children and ad- tables, and age-specific recommenda-
olescents contain recommendations tions. These recommendations are often Evidence Linking Risk Factors in
based on the evidence review and are accompanied by supportive actions, Childhood to Atherosclerosis at
directed toward all primary pediatric which represent expert consensus sug- Autopsy
care providers: pediatricians, family gestions from the panel provided to sup- Atherosclerosis at a young age was
practitioners, nurses and nurse prac- port implementation of the recommen- first identified in Korean and Vietnam
S2 EXPERT PANEL

7. SUPPLEMENT ARTICLES
TABLE 1-3 Evidence Grading System: Strength of Recommendations
Statement Type Definition Implication
Strong recommendation The expert panel believes that the benefits of the recommended approach Clinicians should follow a strong recommendation
clearly exceed the harms and that the quality of the supporting unless a clear and compelling rationale for an
evidence is excellent (grade A or B). In some clearly defined alternative approach is present.
circumstances, strong recommendations may be made on the basis of
lesser evidence when high-quality evidence is impossible to obtain and
the anticipated benefits clearly outweigh the harms.
Recommendation The expert panel feels that the benefits exceed the harms but that the Clinicians should generally follow a
quality of the evidence is not as strong (grade B or C). In some clearly recommendation but remain alert to new
defined circumstances, recommendations may be made on the basis of information and sensitive to patient
lesser evidence when high-quality evidence is impossible to obtain and preferences.
when the anticipated benefits clearly outweigh the harms.
Optional Either the quality of the evidence that exists is suspect (grade D) or well- Clinicians should be flexible in their decision-
performed studies (grade A, B, or C) have found little clear advantage making regarding appropriate practice,
to one approach versus another. although they may set boundaries on
alternatives; patient and family preference
should have a substantial influencing role.
No recommendation There is both a lack of pertinent evidence (grade D) and an unclear Clinicians should not be constrained in their
balance between benefits and harms. decision-making and be alert to new published
evidence that clarifies the balance of benefit
versus harm; patient and family preference
should have a substantial influencing role.
Adapted from American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Pediatrics. 2004;114(3):874 – 877.
War casualties. Two major contempo- (determined by renal artery thick- young people with severe abnormali-
rary studies, the Pathobiological De- ness), tobacco use (thiocyanate con- ties of individual risk factors:
terminants of Atherosclerosis in Youth centration), diabetes mellitus (DM) ● In adolescents with a marked eleva-
(PDAY) study2 and the Bogalusa Heart (glycohemoglobin), and (in men) obe- tion of low-density lipoprotein (LDL)
Study,3 subsequently evaluated the ex- sity. There was a striking increase in cholesterol level caused by familial
tent of atherosclerosis in children, ad- both severity and extent as age and the heterozygous hypercholesterol-
olescents, and young adults who died number of risk factors increased. By
emia, abnormal levels of coronary
accidentally. The Bogalusa study3 mea- contrast, the absence of risk factors
calcium, increased CIMT, and im-
sured cardiovascular risk factors was shown to be associated with a vir-
paired endothelial function have
(lipid levels, blood pressure [BP], BMI, tual absence of advanced atheroscle-
been found.
and tobacco use) as part of a compre- rotic lesions, even in the oldest sub-
hensive school-based epidemiologic jects in the study. ● Children with hypertension have
study in a biracial community. These been shown to have increased CIMT,
results were related to atherosclero- Evidence Linking Risk Factors in increased left ventricular mass, and
sis measured at autopsy after acciden- Childhood to Atherosclerosis eccentric left ventricular geometry.
tal death. Strong correlations were Assessed Noninvasively
● Children with type 1 DM (T1DM) have
shown between the presence and in- Over the last decade, measures of sub- significantly abnormal endothelial
tensity of risk factors and the extent clinical atherosclerosis have devel- function and, in some studies, in-
and severity of atherosclerosis. In the oped, including the demonstration of creased CIMT.
PDAY study,2 risk factors and surro- coronary calcium on electron beam
● Children and young adults with a
gate measures of risk factors were computed tomography imaging, in-
family history of myocardial infarc-
measured after death in 15- to 34-year creased carotid intima-media thick-
olds who died accidentally of external ness (CIMT) assessed with ultrasound, tion have increased CIMT, higher
causes. Strong relationships were endothelial dysfunction (reduced arte- prevalence of coronary calcium,
found between atherosclerotic sever- rial dilation) with brachial ultrasound and endothelial dysfunction.
ity and extent, and age, non– imaging, and increased left ventricular ● Endothelial dysfunction has been
high-density lipoprotein (HDL) choles- mass with cardiac ultrasound. These shown by ultrasound and plethys-
terol, HDL cholesterol, hypertension measures have been assessed in mography in association with ciga-
PEDIATRICS Volume 128, Supplement 6, December 2011 S3

8. rette smoking (passive and active) in non-HDL cholesterol level was asso- gard to tobacco-use rates, obesity
and obesity. In obese children, im- ciated with a visible incremental in- prevalence, hypertension, and dyslipi-
provement in endothelial function crease in the extent and severity of demia. Low socioeconomic status in
occurs with regular exercise. atherosclerosis. In natural-history and of itself confers substantial risk.
● Left ventricular hypertrophy at lev- studies of DM, early CVD mortality is so However, evidence is not adequate for
els associated with excess mortality consistently observed that the pres- the recommendations provided in this
in adults has been found in children ence of DM is considered evidence of report to be specific to racial or ethnic
with severe obesity. vascular disease in adults. Consonant groups or socioeconomic status.
with this evidence, in 15- to 19-year
Four longitudinal studies have found The Impact of Risk-Factor
olds in the PDAY study, the presence of
relationships of risk factors measured Clustering in Childhood on the
hyperglycemia was associated with
in youth (specifically LDL cholesterol, Development of Atherosclerosis
the demonstration of advanced ath-
non-HDL cholesterol and serum apoli- erosclerotic lesions of the coronary From a population standpoint, cluster-
poproteins, obesity, hypertension, to- arteries. In the PDAY study, there was ing of multiple risk factors is the most
bacco use, and DM) with measures of also a strong relationship between ab- common association with premature
subclinical atherosclerosis in adult- dominal aortic atherosclerosis and to- atherosclerosis. The pathologic stud-
hood. In many of these studies, risk bacco use. Finally, in a 25-year follow- ies reviewed above clearly showed
factors measured in childhood and ad- up, the presence of the metabolic that the presence of multiple risk fac-
olescence were better predictors of syndrome risk-factor cluster in child- tors is associated with striking evi-
the severity of adult atherosclerosis hood predicted clinical CVD in adult dence of an accelerated atheroscle-
than were risk factors measured at subjects at 30 to 48 years of age.4 rotic process. Among the most
the time of the subclinical atheroscle- prevalent multiple-risk combinations
rosis study. The Impact of Racial/Ethnic are the use of tobacco with 1 other risk
Background and Socioeconomic factor and the development of obesity,
Evidence Linking Risk Factors in Status in Childhood on the which is often associated with insulin
Childhood to Clinical CVD Development of Atherosclerosis resistance, elevated triglyceride lev-
The most important evidence relating CVD has been observed in diverse geo- els, reduced HDL cholesterol levels,
risk in youth to clinical CVD is the ob- graphic areas and all racial and ethnic and elevated BP, a combination known
served association of risk factors for backgrounds. Cross-sectional re- in adults as the metabolic syndrome.
atherosclerosis to clinically manifest search in children has found differ- There is ample evidence from both
cardiovascular conditions. Genetic dis- ences according to race and ethnicity cross-sectional and longitudinal stud-
orders related to high cholesterol are and according to geography for preva- ies that the increasing prevalence of
the biological model for risk-factor im- lence of cardiovascular risk factors; obesity in childhood is associated with
pact on the atherosclerotic process. these differences are often partially the same obesity-related risk-factor
With homozygous hypercholesterol- explained by differences in socioeco- clustering seen in adults and that it
emia, in which LDL cholesterol levels nomic status. No group within the continues into adult life. This high-risk
exceed 800 mg/dL beginning in infancy, United States is without a significant combination is among the reasons
coronary events begin in the first de- prevalence of risk. Several longitudi- that the current obesity epidemic with
cade of life and life span is severely nal cohort studies referenced exten- its relationship to future CVD and DM is
shortened. With heterozygous hyper- sively in this report (Bogalusa Heart considered one of the most important
cholesterolemia, in which LDL choles- Study,3 the PDAY study,2 and the Coro- public health challenges in contempo-
terol levels are minimally 160 mg/dL nary Artery Risk Development in Young rary society. One other prevalent
and typically Ͼ200 mg/dL and total Adults [CARDIA] study5) have included multiple-risk combination is the asso-
cholesterol (TC) levels exceed 250 racially diverse populations, and other ciation of low cardiorespiratory fit-
mg/dL beginning in infancy, 50% of studies have been conducted outside ness (identified in 33.6% of adoles-
men and 25% of women experience the United States. However, longitudi- cents in the National Health and
clinical coronary events by the age of nal data on Hispanic, Native American, Nutrition Examination Surveys [NHANES]
50. By contrast, genetic traits associ- and Asian children are lacking. Clini- from 1999 to 20026) with overweight
ated with low cholesterol are associ- cally important differences in preva- and obesity, elevated TC level and sys-
ated with longer life expectancy. In the lence of risk factors exist according to tolic BP, and a reduced HDL cholesterol
PDAY study,2 every 30 mg/dL increase race and gender, particularly with re- level.
S4 EXPERT PANEL

9. SUPPLEMENT ARTICLES
Risk-Factor Tracking From bariatric surgery, but the long-term out- have less atherosclerosis and will col-
Childhood Into Adult Life come of those with T2DM diagnosed in lectively have lower CVD rates. This
Tracking studies from childhood to childhood is not known. concept is supported by research that
adulthood have been performed for all ● As already discussed, risk-factor has found that (1) societies with low
the major risk factors. clusters such as those seen with levels of cardiovascular risk factors
obesity and the metabolic syndrome have low CVD rates and that changes
● Obesity tracks more strongly than
have been shown to track from in risk in those societies are associ-
any other risk factor; among many
childhood into adulthood. ated with a change in CVD rates, (2)
reports from studies that have dem-
in adults, control of risk factors
onstrated this fact, one of the most
CVD Prevention Beginning in Youth leads to a decline in morbidity and
recent is from the Bogalusa study,7
The rationale for these guidelines mortality from CVD, and (3) those
in which Ͼ2000 children were fol-
comes from the following evidence. without childhood risk have minimal
lowed from initial evaluation at 5 to
atherosclerosis at 30 to 34 years of
14 years of age to adult follow-up at ● Atherosclerosis, the pathologic ba-
age, absence of subclinical athero-
a mean age of 27 years. On the basis sis for clinical CVD, originates in
childhood. sclerosis as young adults, extended
of BMI percentiles derived from the
life expectancy, and a better quality
study population, 84% of those with ● Risk factors for the development of
of life free from CVD.
a BMI in the 95th to 99th percentile atherosclerosis can be identified in
as children were obese as adults, childhood. The Pathway to Recommending
and all of those with a BMI at the ● Development and progression of Clinical Practice-Based Prevention
Ͼ99th percentile were obese in atherosclerosis clearly relates to
adulthood. Increased correlation is The most direct means of establishing
the number and intensity of cardio-
seen with increasing age at which evidence for active CVD prevention be-
vascular risk factors, which begin in
the elevated BMI occurs. ginning at a young age would be to ran-
childhood.
domly assign young people with
● For cholesterol and BP, tracking ● Risk factors track from childhood defined risks to treatment of cardio-
correlation coefficients in the range into adult life. vascular risk factors or to no treat-
of 0.4 have been reported consis-
● Interventions exist for the manage- ment and follow both groups over
tently from many studies, correlat-
ment of identified risk factors. sufficient time to determine if cardio-
ing these measures in children 5 to
The evidence for the first 4 bullet vascular events are prevented without
10 years of age with results 20 to 30
points is reviewed in this section, and undue increase in morbidity arising
years later. These data suggest that
the evidence surrounding interven- from treatment. This direct approach
having cholesterol or BP levels in
tions for identified risk factors is ad- is intellectually attractive, because
the upper portion of the pediatric
dressed in the risk-factor–specific atherosclerosis prevention would be-
distribution makes having them as
sections of the guideline to follow. gin at the earliest stage of the disease
adult risk factors likely but not cer-
process and thereby maximize the
tain. Those who develop obesity It is important to distinguish between
benefit. However, this approach is as
have been shown to be more likely the goals of prevention at a young age
unachievable as it is attractive, pri-
to develop hypertension or dyslipi- and those at older ages in which ath-
marily because such studies would be
demia as adults. erosclerosis is well established, mor-
extremely expensive and would be sev-
● Tracking data on physical fitness bidity may already exist, and the pro-
cess is only minimally reversible. At a eral decades in duration, a time period
are more limited. Physical activity in which changes in environment and
levels do track but not as strongly young age, there have historically been
2 goals of prevention: (1) prevent the medical practice would diminish the
as other risk factors. relevance of the results.
development of risk factors (primor-
● By its addictive nature, tobacco use
dial prevention); and (2) recognize and The recognition that evidence from
persists into adulthood, although
manage those children and adoles- this direct pathway is unlikely to be
ϳ50% of those who have ever
cents who are at increased risk as a achieved requires an alternative step-
smoked eventually quit.
result of the presence of identified risk wise approach in which segments of
● T1DM is a lifelong condition. factors (primary prevention). It is well an evidence chain are linked in a man-
● The insulin resistance of T2DM can be established that a population that en- ner that serves as a sufficiently rigor-
alleviated by exercise, weight loss, and ters adulthood with lower risk will ous proxy for the causal inference of a
PEDIATRICS Volume 128, Supplement 6, December 2011 S5

10. clinical trial. The evidence reviewed in This document provides recommenda- studies have found that a family his-
this section provides the critical ratio- tions for preventing the development tory of premature coronary heart dis-
nale for cardiovascular prevention be- of risk factors and optimizing cardio- ease in a first-degree relative (heart
ginning in childhood: atherosclerosis vascular health, beginning in infancy, attack, treated angina, percutaneous
begins in youth; the atherosclerotic that are based on the results of the coronary catheter interventional pro-
process relates to risk factors that can evidence review. Pediatric care provid- cedure, coronary artery bypass sur-
be identified in childhood; and the ers (pediatricians, family practitio- gery, stroke, or sudden cardiac death
presence of these risk factors in a ners, nurses, nurse practitioners, in a male parent or sibling before the
given child predicts an adult with risk physician assistants, registered dieti- age of 55 years or a female parent or
if no intervention occurs. The remain- tians) are ideally positioned to rein- sibling before the age of 65 years) is an
ing evidence links pertain to the dem- force cardiovascular health behaviors important independent risk factor for
onstration that interventions to lower as part of routine care. The guideline future CVD. The process of atheroscle-
risk will have a health benefit and that also offers specific guidance on pri- rosis is complex and involves many ge-
the risk and cost of interventions to mary prevention with age-specific, netic loci and multiple environmental
improve risk are outweighed by the re- evidence-based recommendations for and personal risk factors. Nonethe-
duction in CVD morbidity and mortal- individual risk-factor detection. Man- less, the presence of a positive paren-
ity. These issues are captured in the agement algorithms provide staged tal history has been consistently found
evidence reviews of each risk factor. care recommendations for risk reduc- to significantly increase baseline risk
The recommendations reflect a com- tion within the pediatric care setting for CVD. The risk for CVD in offspring is
plex decision process that integrates and identify risk-factor levels that re- strongly inversely related to the age of
the strength of the evidence with quire specialist referral. The guide- the parent at the time of the index
knowledge of the natural history of lines also identify specific medical con- event. The association of a positive
atherosclerotic vascular disease, esti- ditions such as DM and chronic kidney family history with increased cardio-
mates of intervention risk, and the phy- disease that are associated with in- vascular risk has been confirmed for
sician’s responsibility to provide both creased risk for accelerated athero- men, women, and siblings and in dif-
health education and effective disease sclerosis. Recommendations for ferent racial and ethnic groups. The ev-
treatment. These recommendations ongoing cardiovascular health man- idence review identified all RCTs, sys-
for those caring for children will be agement for children and adolescents tematic reviews, meta-analyses, and
most effective when complemented by with these diagnoses are provided. observational studies that addressed
a broader public health strategy. A cornerstone of pediatric care is the family history of premature athero-
provision of health education. In the US sclerotic disease and the development
The Childhood Medical Office Visit health care system, physicians and and progression of atherosclerosis
as the Setting for Cardiovascular nurses are perceived as credible mes- from childhood into young adult life.
Health Management sengers for health information. The
childhood health maintenance visit Conclusions and Grading of the
One cornerstone of pediatric care is
provides an ideal context for effective Evidence Review for the Role of
placing clinical recommendations in a
delivery of the cardiovascular health Family History in Cardiovascular
developmental context. Those who
message. Pediatric care providers Health
make pediatric recommendations
must consider not only the relation of provide an effective team educated to ● Evidence from observational stud-
age to disease expression but the abil- initiate behavior change to diminish ies strongly supports inclusion of a
ity of the patient and family to under- risk of CVD and promote lifelong car- positive family history of early coro-
stand and implement medical advice. diovascular health in their patients nary heart disease in identifying
For each risk factor, recommenda- from infancy into young adult life. children at risk for accelerated ath-
tions must be specific to age and devel- erosclerosis and for the presence of
opmental stage. The Bright Futures 4. FAMILY HISTORY OF EARLY an abnormal risk profile (grade B).
concept of the American Academy of ATHEROSCLEROTIC CVD ● For adults, a positive family history
Pediatrics8 (AAP) is used to provide a A family history of CVD represents the is defined as a parent and/or sibling
framework for these guidelines with net effect of shared genetic, biochemi- with a history of treated angina,
cardiovascular risk-reduction recom- cal, behavioral, and environmental myocardial infarction, percutane-
mendations for each age group. components. In adults, epidemiologic ous coronary catheter interven-
S6 EXPERT PANEL

11. SUPPLEMENT ARTICLES
tional procedure, coronary artery risk. Evidence relative to diet and the specific nutrition area with grades are
bypass grafting, stroke, or sudden development of atherosclerosis in summarized. Where the evidence is in-
cardiac death before 55 years in childhood and adolescence was identi- adequate yet nutrition guidance is
men or 65 years in women. Because fied by the evidence review for this needed, recommendations for pediat-
the parents and siblings of children guideline and, collectively, provides ric care providers are based on a con-
and adolescents are usually young the rationale for new dietary preven- sensus of the expert panel (grade D).
themselves, it was the panel con- tion efforts initiated early in life. The age- and evidence-based recom-
sensus that when evaluating family This new pediatric cardiovascular mendations of the expert panel follow.
history of a child, history should guideline not only builds on the recom-
also be ascertained for the occur- mendations for achieving nutrient ad- In accordance with the Surgeon Gen-
rence of CVD in grandparents, equacy in growing children as stated eral’s Office, the World Health Organi-
aunts, and uncles, although the evi- zation, the AAP, and the American
in the 2010 DGA but also adds evidence
dence supporting this recommen- Academy of Family Physicians, exclu-
regarding the efficacy of specific di-
dation is insufficient to date (grade sive breastfeeding is recommended
etary changes in reducing cardiovas-
D). for the first 6 months of life. Contin-
cular risk from the current evidence
● Identification of a positive family ued breastfeeding is recommended
review for use by pediatric care pro-
history for cardiovascular disease to at least 12 months of age with the
viders in the care of their patients. Be-
and/or cardiovascular risk fac- addition of complementary foods. If
cause the focus of these guidelines is
tors should lead to evaluation of breastfeeding per se is not possible,
on cardiovascular risk reduction, the
all family members, especially feeding human milk by bottle is sec-
evidence review specifically evaluated
parents, for cardiovascular risk ond best, and formula-feeding is the
dietary fatty acid and energy compo-
factors (grade B). third choice.
nents as major contributors to hyper-
● Family history evolves as a child ma- cholesterolemia and obesity, as well
tures, so regular updates are a nec- as dietary composition and micronu- ● Long-term follow-up studies have
essary part of routine pediatric trients as they affect hypertension. found that subjects who were
care (grade D). New evidence from multiple dietary tri- breastfed have sustained cardio-
als that addressed cardiovascular risk vascular health benefits, including
● Education about the importance of
reduction in children has provided lower cholesterol levels, lower
accurate and complete family
important information for these BMI, reduced prevalence of type 2
health information should be part of
recommendations. DM, and lower CIMT in adulthood
routine care for children and ado-
(grade B).
lescents. As genetic sophistication
increases, linking family history to Conclusions and Grading of the ● Ongoing nutrition counseling has
specific genetic abnormalities will Evidence Review for Diet and been effective in assisting children
provide important new knowledge Nutrition in Cardiovascular Risk and families to adopt and sustain
about the atherosclerotic process Reduction recommended diets for both nutri-
(grade D). The expert panel concluded that there ent adequacy and reducing cardio-
Recommendations for the use of fam- is strong and consistent evidence that vascular risk (grade A).
ily history in cardiovascular health good nutrition beginning at birth has ● Within appropriate age- and gender-
promotion are listed in Table 4-1. profound health benefits and the po- based requirements for growth and
tential to decrease future risk for CVD. nutrition, in normal children and in
5. NUTRITION AND DIET The expert panel accepts the 2010 DGA8 children with hypercholesterolemia
The 2010 Dietary Guidelines for Ameri- as containing appropriate recommen- intake of total fat can be safely lim-
cans (DGA)8 include important recom- dations for diet and nutrition in chil- ited to 30% of total calories, satu-
mendations for the population aged 2 dren aged 2 years and older. The rec- rated fat intake limited to 7% to 10%
years and older. In 1992, the National ommendations in these guidelines are of calories, and dietary cholesterol
Cholesterol Education Program (NCEP) intended for pediatric care providers limited to 300 mg/day. Under the
Pediatric Panel report1 provided di- to use with their patients to address guidance of qualified nutritionists,
etary recommendations for all chil- cardiovascular risk reduction. The this dietary composition has been
dren as part of a population-based ap- conclusions of the expert panel’s re- shown to result in lower TC and LDL
proach to reducing cardiovascular view of the entire body of evidence in a cholesterol levels, less obesity, and
PEDIATRICS Volume 128, Supplement 6, December 2011 S7

12. less insulin resistance (grade A). tervention should be tailored to activity. Calorie intake needs to
Under similar conditions and with each specific child’s needs. match growth demands and physi-
ongoing follow-up, these levels of fat ● Optimal intakes of total protein and cal activity needs (grade A). Esti-
intake might have similar effects total carbohydrate in children were mated calorie requirements ac-
starting in infancy (grade B). Fats not specifically addressed, but with cording to gender and age group at
are important to infant diets be- a recommended total fat intake of 3 levels of physical activity from the
cause of their role in brain and cog- 30% of energy, the expert panel rec- dietary guidelines are shown in Ta-
nitive development. Fat intake for in- ommends that the remaining 70% of ble 5-2. For children of normal
fants younger than 12 months calories include 15% to 20% from weight whose activity is minimal,
should not be restricted without protein and 50% to 55% from carbo- most calories are needed to meet
medical indication. hydrate sources (no grade). These nutritional requirements, which
● The remaining 20% of fat intake leaves only ϳ5% to 15% of calorie
recommended ranges fall within
should comprise a combination of intake from extra calories. These
the acceptable macronutrient dis-
monosaturated and polyunsatu- calories can be derived from fat or
tribution range specified by the
rated fats (grade D). Intake of trans sugar added to nutrient-dense
2010 DGA: 10% to 30% of calories
fats should be limited as much as foods to allow their consumption as
from protein and 45% to 65% of cal-
possible (grade D). sweets, desserts, or snack foods
ories from carbohydrate for chil-
(grade D).
● For adults, the current NCEP guide- dren aged 4 to 18 years.
● Dietary fiber intake is inversely as-
lines9 recommend that adults con- ● Sodium intake was not addressed
sociated with energy density and in-
sume 25% to 35% of calories from by the evidence review for this sec-
creased levels of body fat and is pos-
fat. The 2010 DGA supports the Insti- tion on nutrition and diet. From the
itively associated with nutrient
tute of Medicine recommendations evidence review for the “High BP”
density (grade B); a daily total di-
for 30% to 40% of calories from fat section, lower sodium intake is as-
etary fiber intake from food sources
for ages 1 to 3 years, 25% to 35% of sociated with lower systolic and di- of at least age plus 5 g for young
calories from fat for ages 4 to 18 astolic BP in infants, children, and children up to 14 g/1000 kcal for
years, and 20% to 35% of calories adolescents. older children and adolescents is
from fat for adults. For growing chil- ● Plant-based foods are important recommended (grade D).
dren, milk provides essential nutri- low-calorie sources of nutrients in-
ents, including protein, calcium, ● The expert panel supports the 2008
cluding vitamins and fiber in the di- AAP recommendation for vitamin D
magnesium, and vitamin D, that are
ets of children; increasing access to supplementation with 400 IU/day for
not readily available elsewhere in
fruits and vegetables has been all infants and children.10 No other
the diet. Consumption of fat-free
shown to increase their intake vitamin, mineral, or dietary supple-
milk in childhood after 2 years of
(grade A). However, increasing fruit ments are recommended (grade D).
age and through adolescence opti-
and vegetable intake is an ongoing The new recommended daily allow-
mizes these benefits without com-
challenge. ance for vitamin D for those aged 1
promising nutrient quality while
avoiding excess saturated fat and ● Reduced intake of sugar-sweetened to 70 years is 600 IU/day.
calorie intake (grade A). Between beverages is associated with de- ● Use of dietary patterns modeled on
the ages of 1 and 2 years, as chil- creased obesity measures (grade those shown to be beneficial for
dren transition from breast milk or B). Specific information about fruit adults (eg, Dietary Approaches to
formula, reduced-fat milk (ranging juice intake is too limited for an Stop Hypertension [DASH] pattern)
from 2% milk to fat-free milk) can be evidence-based recommendation. is a promising approach to improv-
used on the basis of the child’s Recommendations for intake of ing nutrition and decreasing cardio-
growth, appetite, intake of other 100% fruit juice by infants was vascular risk (grade B).
nutrient-dense foods, intake of made by a consensus of the expert ● All diet recommendations must be
other sources of fat, and risk for panel (grade D) and are in agree- interpreted for each child and fam-
obesity and CVD. Milk with reduced ment with those of the AAP. ily to address individual diet pat-
fat should be used only in the con- ● Per the 2010 DGA, energy intake terns and patient sensitivities such
text of an overall diet that supplies should not exceed energy needed as lactose intolerance and food al-
30% of calories from fat. Dietary in- for adequate growth and physical lergies (grade D).
S8 EXPERT PANEL

13. 3. INTEGRATED CARDIOVASCULAR HEALTH SCHEDULE
Risk Factor Age
Birth to 12 mo 1–4 y 5–9 y 9–11 y 12–17 y 18–21 y
Family — At 3 y, evaluate family history for Update at each nonurgent health Reevaluate family history for early Update at each nonurgent health Repeat family-history evaluation with
history of early CVD: parents, grand- encounter CVD in parents, grandparents, encounter patient
early CVD parents, aunts/uncles, men aunts/uncles, men Յ55 y old,
Յ55 y old, women Յ65 y old; women Յ65 y old
review with parents and refer
as needed; positive family
history identifies children for
intensive CVD RF attention
Tobacco Advise smoke-free home; Continue active antismoking Obtain smoke exposure history Assess smoking status of child; Continue active antismoking Reinforce strong antismoking message;
exposure offer smoking-cessation advice with parents; offer from child Begin active active antismoking counseling counseling with patient; offer offer smoking-cessation assistance or
assistance or referral smoking-cessation assistance antismoking advice with child or referral as needed smoking-cessation assistance or referral as needed
to parents and referral as needed referral as needed
Nutrition/diet Support breastfeeding as At age 12–24 mo, may change to Reinforce CHILD-1 diet messages Reinforce CHILD-1 diet messages Obtain diet information from child Review healthy diet with patient
optimal to 12 mo of age cow’s milk with 2% as needed and use to reinforce healthy diet
if possible; add formula percentage of fat decided by and limitations and provide
if breastfeeding family and pediatric care counseling as needed
decreases or stops provider; after 2 y of age,
before 12 mo of age fat-free milk for all; juice Յ4
oz/d; transition to CHILD-1
diet by the age of 2 y
Growth, Review family history for Chart height/weight/BMI; Chart height/weight/BMI and Chart height/weight/BMI and Chart height/weight/BMI and review Review height/weight/BMI and norms for
overweight/ obesity; discuss weight- classify weight-by BMI from review with parent; BMI Ն review with parent and child; with child and parent; BMI Ն85th health with patient; BMI Ն 85th
obesity for-height tracking, age 2 y; review with parent 85th percentile, crossing BMI Ն 85th percentile, percentile, crossing percentiles: percentile, crossing percentiles:
growth chart, and percentiles: Intensify diet/ crossing percentiles: Intensify intensify diet/activity focus for 6 intensify diet/activity focus for 6 mo;
healthy diet activity focus for 6 mo; if no diet/activity focus for 6 mo; if mo; if no change: RD referral, if no change: RD referral, manage per
change: RD referral, manage no change: RD referral, manage per obesity algorithms; obesity algorithms; BMI Ն 95th
per obesity algorithms manage per obesity BMI Ն 95th percentile, manage percentile, manage per obesity
BMI Ն 95th percentile, manage algorithms; BMI Ն 95th per obesity algorithms algorithms
per obesity algorithms percentile: manage per obesity
algorithms
Lipids No routine lipid screening Obtain FLP only if family history Obtain FLP only if family history Obtain universal lipid screen with Obtain FLP if family history newly Measure 1 nonfasting non–HDL or FLP in
for CVD is positive, parent has for CVD is positive, parent nonfasting non-HDL ϭ TC Ϫ positive, parent has all: review with patient; manage with
dyslipidemia, child has any has dyslipidemia, child has HDL, or FLP: manage per lipid dyslipidemia, child has any other lipid algorithms per ATP as needed
other RFs or high-risk any other RFs or high-risk algorithms as needed RFs or high-risk condition;
condition condition manage per lipid algorithms as
needed
BP Measure BP in infants with Measure BP annually in all from Check BP annually and chart for Check BP annually and chart for Check BP annually and chart for Measure BP: review with patient;
renal/urologic/cardiac the age of 3 y; chart for age/ age/gender/height: review age/gender/height: review with age/gender/height: review with evaluate and treat per JNC guidelines
diagnosis or history of gender/height percentile and with parent; workup and/or parent, workup and/or adolescent and parent, workup
neonatal ICU review with parent management per BP management per BP algorithm and/or management per BP
algorithm as needed as needed algorithm as needed
Physical Encourage parents to Encourage active play; limit Recommend MVPA of Ն1 h/d; Obtain activity history from child: Use activity history with adolescent Discuss lifelong activity, sedentary time
activity model routine activity; sedentary/screen time to Յ2 limit screen/sedentary time recommend MVPA of Ն1 h/d to reinforce MVPA of Ն1 h/d and limits with patient
no screen time before h/d; no TV in bedroom to Յ2 h/d and screen/sedentary time of leisure screen time of Յ2 h/d
the age of 2 y Յ2 h/d
Diabetes — — — Measure fasting glucose level per Measure fasting glucose level per Obtain fasting glucose level if indicated;
ADA guidelines; refer to ADA guidelines; refer to refer to endocrinologist as needed
endocrinologist as needed endocrinologist as needed
PEDIATRICS Volume 128, Supplement 6, December 2011
All algorithms and guidelines in this schedule are included in this summary report. RF indicates risk factor; RD, registered dietitian; ATP, Adult Treatment Panel III (“Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults”); JNC, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; MVPA, moderate-to-vigorous physical activity; ADA, American Diabetes Association.
SUPPLEMENT ARTICLES
S9
The full and summary reports of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents can also be found on the NHLBI Web site (www.nhlbi.nih.gov).

14. TABLE 4-1 Evidence-Based Recommendations for Use of Family History in Cardiovascular review focused on the effects of activ-
Health Promotion
ity on cardiovascular health, because
Birth to 18 y Take detailed family history of CVD at initial encounter and/or at 3, Grade B
physical inactivity has been identified
9–11, and 18 ya Recommend
as an independent risk factor for cor-
If positive family history identified, evaluate patient for other onary heart disease in adults. Over the
cardiovascular risk factors, including dyslipidemia, hypertension, last several decades, there has been a
DM, obesity, history of smoking, and sedentary lifestyle
steady decrease in the amount of time
If positive family history and/or cardiovascular risk factors identified, Grade B that children spend being physically
evaluate family, especially parents, for cardiovascular risk factors Recommend active and an accompanying increase
Update family history at each nonurgent health encounter Grade D
in time spent in sedentary activities. The
Recommend evidence review identified many studies
in youth ranging in age from 4 to 21 years
Use family history to stratify risk for CVD risk as risk profile evolves Grade D
that strongly linked increased time
Recommend
spent in sedentary activities with re-
Supportive action: educate parents about the importance of family duced overall activity levels, disadvanta-
history in estimating future health risks for all family members geous lipid profiles, higher systolic BP,
18 to 21 y Review family history of heart disease with young adult patient Grade B higher levels of obesity, and higher levels
Strongly recommend of all the obesity-related cardiovascular
Supportive action: educate patient about family/personal risk for risk factors including hypertension, in-
early heart disease, including the need for evaluation for all
cardiovascular risk factors
sulin resistance, and type 2 DM.
Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel;
and supportive actions represent expert consensus suggestions from the expert panel provided to support implementation Conclusions and Grading of the
of the recommendations (they are not graded). Evidence Review for Physical
a “Family” includes parent, grandparent, aunt, uncle, or sibling with heart attack, treated angina, coronary artery bypass
graft/stent/angioplasty, stroke, or sudden cardiac death at Ͻ55 y in males and Ͻ65 y in females. Activity
The expert panel felt that the evidence
strongly supports the role of physical
Graded, age-specific recommenda- bles. This diet has been modified for activity in optimizing cardiovascular
tions for pediatric care providers to use in children aged 4 years and older health in children and adolescents.
use in optimizing cardiovascular on the basis of daily energy needs ac-
● There is reasonably good evidence
health in their patients are summa- cording to food group and is shown in
that physical activity patterns es-
rized in Table 5-1. The Cardiovascular Table 5-3 as an example of a heart-
tablished in childhood are carried
Health Integrated Lifestyle Diet healthy eating plan using CHILD-1
forward into adulthood (grade
(CHILD-1) is the first stage in dietary recommendations.
C).
change for children with identified dys-
lipidemia, overweight and obesity, 6. PHYSICAL ACTIVITY ● There is strong evidence that in-
risk-factor clustering, and high-risk Physical activity is any bodily move- creases in moderate-to-vigorous
medical conditions that might ulti- ment produced by contraction of skel- physical activity are associated with
mately require more intensive dietary etal muscle that increases energy ex- lower systolic and diastolic BP, de-
change. CHILD-1 is also the recom- penditure above a basal level. Physical creased measures of body fat, de-
mended diet for children with a posi- activity can be focused on strengthen- creased BMI, improved fitness mea-
tive family history of early cardiovas- ing muscles, bones, and joints, but be- sures, lower TC level, lower LDL
cular disease, dyslipidemia, obesity, cause these guidelines address car- cholesterol level, lower triglyceride
primary hypertension, DM, or expo- diovascular health, the evidence level, higher HDL cholesterol level,
sure to smoking in the home. Any di- review concentrated on aerobic activ- and decreased insulin resistance in
etary modification must provide nutri- ity and on the opposite of activity: sed- childhood and adolescence (grade
ents and calories needed for optimal entary behavior. There is strong evi- A).
growth and development (Table 5-2). dence for beneficial effects of physical ● There is limited but strong and con-
Recommended intakes are adequately activity and disadvantageous effects of sistent evidence that physical exer-
met by a DASH-style eating plan, which a sedentary lifestyle on the overall cise interventions improve subclini-
emphasizes fat-free/low-fat dairy and health of children and adolescents cal measures of atherosclerosis
increased intake of fruits and vegeta- across a broad array of domains. Our (grade B).
S10 EXPERT PANEL

15. SUPPLEMENT ARTICLES
TABLE 5-1 Evidence-Based Recommendations for Diet and Nutrition: CHILD-1
Birth to 6 mo Infants should be exclusively breastfed (no supplemental formula or other foods) until the age of 6 moa Grade B
Strongly recommend
6 to 12 mo Continue breastfeeding until at least 12 mo of age while gradually adding solids; transition to iron- Grade B
fortified formula until 12 mo if reducing breastfeedinga Strongly recommend
Fat intake in infants Ͻ12 mo of age should not be restricted without medical indication Grade D
Recommend
Limit other drinks to 100% fruit juice (Յ4 oz/d); no sweetened beverages; encourage water Grade D
recommend
12 to 24 mo Transition to reduced-fatb (2% to fat-free) unflavored cow’s milkc (see supportive actions) Grade B
Recommend
Limit/avoid sugar-sweetened beverage intake; encourage water Grade B
Strongly recommend
Transition to table food with:
Total fat 30% of daily kcal/EERd Grade B
Recommend
Saturated fat 8%–10% of daily kcal/EER Grade B
Recommend
Avoid trans fat as much as possible Grade D
Strongly recommend
Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER Grade D
recommend
Cholesterol Ͻ 300 mg/d Grade B
Strongly recommend
Supportive actions
The fat content of cow’s milk to introduce at 12–24 mo of age should be decided together by parents
and health care providers on the basis of the child’s growth, appetite, intake of other nutrient-dense
foods, intake of other sources of fat, and potential risk for obesity and CVD
100% fruit juice (from a cup), no more than 4 oz/d
Limit sodium intake
Consider DASH-type diet rich in fruits, vegetables, whole grains, and low-fat/fat-free milk and milk
products and lower in sugar (Table 5-3)
2 to 10 y Primary beverage: fat-free unflavored milk Grade A
Strongly recommend
Limit/avoid sugar-sweetened beverages; encourage water Grade B
Recommend
Fat content:
Total fat 25%–30% of daily kcal/EER Grade A
Strongly recommend
Saturated fat 8%–10% of daily kcal/EER Grade A
Strongly recommend
Avoid trans fats as much as possible Grade D, recommend
Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER Grade D
Recommend
Cholesterol Ͻ 300 mg/d Grade A
Strongly Recommend
Encourage high dietary fiber intake from foodse Grade B
recommend
Supportive actions:
Teach portions based on EER for age/gender/age (Table 5-2)
Encourage moderately increased energy intake during periods of rapid growth and/or regular
moderate-to-vigorous physical activity
Encourage dietary fiber from foods: age ϩ 5 g/de
Limit naturally sweetened juice (no added sugar) to 4 oz/d
Limit sodium intake
Support DASH-style eating plan (Table 5-3)
11 to 21 y Primary beverage: fat-free unflavored milk Grade A
Strongly recommend
Limit/avoid sugar-sweetened beverages; encourage water Grade B
Recommend
PEDIATRICS Volume 128, Supplement 6, December 2011 S11