Cover of the guidelines report
Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents
Published Oct 2012
DownloadPDF 4 MB


In 2005, based on recommendations from experts convened in a national Thought Leaders Meeting, the National Heart, Lung, and Blood Institute (NHLBI), under the leadership of the Director Elizabeth G. Nabel, M.D., endorsed a new approach for guideline development. This new approach is characterized by a formal evidence review and an integrated format with the major cardiovascular (CV) risk factors addressed simultaneously in a single guideline document.

Atherosclerotic cardiovascular disease (CVD) remains the leading cause of death among North Americans. Although manifest disease in childhood and adolescence is rare, risk factors and risk behaviors that accelerate the development of atherosclerosis begin in childhood, and there is increasing evidence that risk reduction delays progression toward clinical disease. To address this health issue, the NHLBI appointed an Expert Panel to develop cardiovascular (CV) health and risk reduction guidelines for pediatric care providers based on the new approach, using a formal evidence review of this science with an integrated format addressing all the major CV risk factors simultaneously. This publication, Full Report of the Expert Panel on Integrated Guidelines for Pediatric Cardiovascular Health and Risk Reduction, is the result of the Expert Panel's work

Chaired by Dr. Stephen R. Daniels, the Expert Panel's goal was development of evidence-based guidelines addressing all of the major risk factors to assist pediatric care providers—pediatricians, family practitioners, nurses and nurse practitioners, physician assistants, and registered dietitians—in both the promotion of CV health and the identification and management of specific risk factors from infancy to young adulthood. The Expert Panel determined that a focus on CV risk reduction in children and adolescents addresses a disease process—atherosclerosis—in which the clinical endpoint of manifest CVD is much later in life. Therefore, the recommendations would need to address both the prevention of risk factor development—primordial prevention—and the prevention of future CVD by effective management of identified risk factors—primary prevention.

There have been no previous NHLBI-appointed expert panels that addressed multiple risk factors in children. Previous CV pediatric guidelines have addressed cholesterol (National Cholesterol Education Program: Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents (1992)) and blood pressure (The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (2004)). The Expert Panel used these reports as a framework for development of the integrated format. A systematic review of the evidence was conducted to address a broad array of questions concerning the development, progression, and management of multiple CV risk factors extending from before birth to 21 years of age. This review required assessing all the evidence pertaining to the role of risk factors in childhood on the development and progression of atherosclerosis from childhood and adolescence to adulthood, as well as the body of evidence that addresses the impact of managing risk factors in childhood on the development and progression of atherosclerosis. Based on the assembled evidence, the Expert Panel developed graded, age-specific recommendations that are integrated across risk factors and across age groups.

In developing these comprehensive evidence-based Guidelines addressing all of the major risk factors, the panel has provided a practical approach to both the optimization of CV health and the management of identified risk factors throughout childhood and adolescence, a time when many health-behavior patterns develop and when risk reduction should have the greatest impact. These Guidelines should be of use to all those who provide health care to children to help them reduce future CV morbidity and mortality. By addressing the major population-based risk factors for CVD in children and adolescents, these guidelines will support pediatric care providers in optimizing CV health in infancy, early childhood, and adolescence-developmental periods when many health behavior patterns develop, risk factors may become evident, and risk reduction should have the greatest impact.

Review/Financial and Other Disclosures

Expert panel members disclosed relevant financial interests to each other prior to discussions. The following financial interests are reported in the publication in the Journal of Pediatrics:

Dr. Benuck, Dr. Christakis, Dr. Dennison, Dr. O'Donnell , Dr. Rocchini, and Dr. Washington have declared no relevant relationships.

Dr. Daniels has served as a consultant for Abbott Laboratories and Merck, Schering-Plough. He has received funding/grant support for research from the NIH.

Dr. Gidding has served as a consultant for Merck, Schering-Plough. He has received funding/grant support for research from GlaxoSmithKline.

Dr. Gillman has given invited talks for Nestle Nutrition Institute and Danone. He has received funding /grant support for research from Mead Johnson, Sanofi-aventis and the NIH.

Dr. Gottesman has served on the Health Advisory Board, Child Development Council of Franklin County. She was a consultant to Early Head Start for Region 5B. She has written for iVillage and taught classes through Garrison Associates for the State of Ohio, Bureau of Early Intervention Services and Help Me Grow program. She has received funding /grant support for research from NIH.

Dr. Kwiterovich has served as a consultant or advisory board member for Merck, Schering-Plough, Pfizer, Sankyo, LipoScience and Astra Zeneca. He has served on speaker bureaus for Merck, Schering-Plough, Pfizer, Sankyo, Kos and Astra Zeneca. He has received funding/grant support for research from Pfizer, Merck, GlaxoSmithKline, Sankyo and Schering-Plough.

Dr. McBride has served as a consultant or advisory board member for Bristol-Myers Squibb, and Merck. He has served on speakers bureaus for Kos, Merck and Pfizer. He declared no relevant relationships since July 2007.

Dr. McCrindle has been a consultant for Abbott, Bristol-Myers Squibb, Daichii Sankyo and Roche. He owns stock in CellAegis. He reports funding/grant support for research from Astra Zeneca, Sankyo, Merck, Schering-Plough and the NIH.

Dr. Urbina reports funding/grant support for research from Merck, Schering-Plough, Sankyo and the NIH.

Dr. Van Horn has provided advice to Chartwells School Food Service. She has received funding/grant support for research from General Mills and the NIH.

Evidence Tables

State of the Science: Cardiovascular Risk Factors and the Development of Atherosclerosis in Childhood

Multiple Risk Factors

Family History of Early Atherosclerotic Cardiovascular Disease

Nutrition and Diet

Physical Activity

Tobacco Exposure

High Blood Pressure

Lipids and Lipoproteins

Overweight and Obesity

Diabetes Mellitus

Risk Factor Clustering and the Metabolic Syndrome

Perinatal Factors

Inflammatory Markers

Other Conditions Predisposing to the Development of Accelerated Atherosclerosis

Expert Panel Members

Expert Panel Chair

Stephen R. Daniels, M.D., Ph.D., Panel Chair
Professor and Chairman, Department of Pediatrics
University of Colorado School of Medicine
Pediatrician in Chief and L. Joseph Butterfield Chair of Pediatrics
The Children's Hospital

Expert Panel Members

Irwin Benuck, M.D., Ph.D.
Northwestern University Feinberg School of Medicine
Chicago, IL

Dimitri A. Christakis, M.D., M.P.H.
Director, Child Health Institute
Associate Professor of Pediatrics
University of Washington

Barbara A. Dennison, M.D.
Director, Policy and Research Translation Unit
Division of Chronic Disease and Injury Prevention
New York State Department of Health

Samuel S. Gidding, M.D.
Chief, Division of Pediatric Cardiology
Department of Pediatrics
Nemours/Alfred I. duPont Hospital for Children

Matthew W. Gillman, M.D., M.S.
Department of Ambulatory Care and Prevention
Harvard Pilgrim Health Care

Mary Margaret Gottesman, Ph.D., R.N., CPNP
Cochairperson, Bright Futures Pediatric Implementation Project
Ohio State University College of Nursing

Peter O. Kwiterovich, M.D.
Professor of Pediatrics and Medicine
Lipid Research Unit

Patrick E. McBride, M.D., M.P.H.
Professor of Medicine and Family Medicine
Codirector, Preventive Cardiology Program
University of Wisconsin School of Medicine and Public Health
Health Sciences Learning Center, Room 2150

Brian W. McCrindle, M.D., M.P.H.
Division of Cardiology
Department of Pediatrics
Section Head, Clinical Epidemiology
The Hospital for Sick Children

Albert P. Rocchini, M.D.
Professor of Pediatrics
Division Chief, Cardiology
C.S. Mott Children?s Hospital

Elaine M. Urbina, M.D.
Preventive Cardiology Program
Cincinnati Children?s Hospital Medical Center

Linda V. Van Horn, Ph.D., R.D.
Professor of Preventive Medicine
Feinberg School of Medicine
Northwestern University

Reginald L. Washington, M.D.
Chief Medical Officer
Rocky Mountain Hospital for Children

NHLBI Staff Members

Karen Donato, S.M.
Acting Deputy Director
Division for the Application of Research Discoveries

Robinson Fulwood, Ph.D., M.S.P.H.
Scientific Program Manager
Division for the Application of Research Discoveries

Janet de Jesus, M.S., R.D.
Nutrition Education Specialist
Division for the Application of Research Discoveries

Rae-Ellen W. Kavey, M.D., M.P.H.
Former Coordinator, Pediatric Cardiovascular Risk Reduction Program
Division for the Application of Research Discoveries

Christopher J. O?Donnell, M.D., M.P.H.
Associate Director, Framingham Heart Study
Division of Intramural Research

Denise Simons-Morton, M.D., Ph.D.
Division for the Application of Research Discoveries

Contractor Support

The Lewin Group
Clifford Goodman, M.S., Ph.D.
Christel M. Villarivera, M.S.
Charlene Chen, M.H.S.
Erin Karnes, M.H.S.
Ayodola Anise, M.H.S.