1. PEDIATRICSOFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF
PEDIATRICSDECEMBER 2011 VOLUME 128 SUPPLEMENT 5A SUPPLEMENT TO
PEDIATRICSExpert Panel on Integrated Guidelines for
CardiovascularHealth and Risk Reduction in Children and
Adolescents:Summary ReportRae-Ellen W. Kavey, MD, MPH, Denise G.
Simons-Morton, MD, MH, PhD,and Janet M. de Jesus, MS, RD,
Supplement EditorsSponsored by the National Heart, Lung, and Blood
Institute,National Institutes of HealthThese guidelines have been
endorsed by the American Academy ofPediatrics. Statements and
opinions expressed in this supplementare those of the authors and
not necessarily those of Pediatricsor the Editor or Editorial Board
of Pediatrics.PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275). Copyright 2011 by theAmerican Academy of
Pediatrics
2. SUPPLEMENT TO PEDIATRICSCONTENTS 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.2009-2107Awww.pediatrics.org
A3
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 Childrens Hospital Ann
Arbor, MI Elaine M. Urbina, MD Cincinnati Childrens 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,
MDA4
4. Christopher J. ODonnell, MD, MPHNational Heart, Lung, and
Blood InstituteFramingham, MAKaren A. Donato, SMNational Heart,
Lung, and Blood InstituteBethesda, MDRobinson Fulwood, PhD,
MSPHNational Heart, Lung, and Blood InstituteBethesda, MDJanet M.
de Jesus, MS, RDNational Heart, Lung, and Blood InstituteBethesda,
MDDenise G. Simons-Morton, MD, MPH, PhDNational Heart, Lung, and
Blood InstituteBethesda, MDContract StaffThe Lewin Group, Falls
Church, VAClifford Goodman, MS, PhDChristel M. Villarivera,
MSCharlene Chen, MHSErin Karnes, MHSAyodola Anise,
MHSdoi:10.1542/peds.2009-2107B A5
5. SUPPLEMENT ARTICLESExpert Panel on Integrated Guidelines
forCardiovascular Health and Risk Reduction in Childrenand
Adolescents: Summary ReportEXPERT PANEL ON INTEGRATED GUIDELINES
FOR Atherosclerotic cardiovascular disease (CVD) remains the
leadingCARDIOVASCULAR HEALTH AND RISK REDUCTION IN cause of death
in North Americans, but manifest disease in childhoodCHILDREN AND
ADOLESCENTS and adolescence is rare. By contrast, risk factors and
risk behaviorsABBREVIATIONS that accelerate the development of
atherosclerosis begin in childhood,CVDcardiovascular
diseaseNHLBINational Heart, Lung, and Blood Institute and there is
increasing evidence that risk reduction delays
progres-RCTrandomized controlled trial sion toward clinical
disease. In response, the former director of thePDAYPathobiological
Determinants of Atherosclerosis in National Heart, Lung, and Blood
Institute (NHLBI), Dr Elizabeth Nabel,YouthBPblood pressure
initiated development of cardiovascular health guidelines for
pediatricHDLhigh-density lipoprotein care providers based on a
formal evidence review of the science withDMdiabetes mellitus an
integrated format addressing all the major cardiovascular
riskCIMTcarotid intima-media thicknessLDLlow-density lipoprotein
factors simultaneously. An expert panel was appointed to develop
theT1DMtype 1 diabetes mellitus guidelines in the fall of
2006.T2DMtype 2 diabetes mellitusTCtotal cholesterol The goal of
the expert panel was to develop comprehensive evidence-AAPAmerican
Academy of Pediatrics based guidelines that address the known risk
factors for CVD (TableDGADietary Guidelines for Americans 1-1) to
assist all primary pediatric care providers in both the
promo-NCEPNational Cholesterol Education ProgramDASHDietary
Approaches to Stop Hypertension tion of cardiovascular health and
the identication and management ofCHILDCardiovascular Health
Integrated Lifestyle Die specic risk factors from infancy into
young adult life. An innovativeFLPfasting lipid prole approach was
needed, because a focus on cardiovascular risk reduc-CDCCenters for
Disease Control and Prevention tion in children and adolescents
addresses a disease process (athero-AMAAmerican Medical
AssociationMCHBMaternal and Child Health Bureau sclerosis) in which
the clinical end point of manifest CVD is remote. TheFDAFood and
Drug Administration recommendations, therefore, need to address 2
different goals:AHAAmerican Heart Association the prevention of
risk-factor development (primordial prevention)
andwww.pediatrics.org/cgi/doi/10.1542/peds.2009-2107C the
prevention of future CVD by effective management of identied
riskdoi: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, 31Center Dr, Building
31, Room 4A17, MSC 2480, Bethesda, MD tematic evidence reviews
include 1 or, at most, a small number of nite20892. E-mail:
[email protected] questions that address the impact of specic
interventions on specicPEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). health outcomes, and a rigorous literature
review often results in onlyCopyright 2011 by the American Academy
of Pediatrics a handful of in-scope articles for inclusion.
Typically, evidence is limitedFINANCIAL 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 dened time
period. There is a dened for-received funding/grant support for
research from the National mat for abstracting studies, grading the
evidence, and presenting ofInstitutes of Health (NIH); Dr Gidding
has served as a consultantfor Merck and Schering-Plough and has
received funding/grant results. The results of the review lead to
the conclusions, independentsupport for research from
GlaxoSmithKline; Dr Gillman has of interpretation.given invited
talks for Nestle Nutrition Institute and Danone andhas received
funding/grant support for research from Mead By contrast, given the
scope of the charge to the expert panel, thisJohnson, Sano-Aventis,
and the NIH; Dr Gottesman has servedon 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 multiple5B, 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, 5 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 GradesFamily history Grade EvidenceAge A
Well-designed RCTs or diagnostic studies performed on a population
similar to the guidelinesGender target populationNutrition/diet B
RCTs or diagnostic studies with minor limitations; genetic natural
history studies;Physical inactivity overwhelmingly consistent
evidence from observational studiesTobacco exposure C Observational
studies (case-control and cohort design)BP D Expert opinion, case
reports, or reasoning from rst principles (bench research or
animalLipid 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 conditionsMetabolic syndromeInammatory
markersPerinatal 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 evidencemust 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
expertdresses the impact of managing risk views according to risk
factor, discus- panel that these recommendations will befactors in
childhood on the develop- sion of the expert panels rationale for
useful for all those who provide cardiovas-ment and progression of
atherosclero- recommendations, and 1000 cita- cular health care to
children.sis. Because of known gaps in the evi- tions from the
published literature anddence 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 FACTORSevents in adult life, the review
must in- complete evidence tables will be avail- AND THE
DEVELOPMENT OFclude the available evidence that justi- able as a
direct link from that site. This ATHEROSCLEROSIS IN CHILDHOODes
evaluation and treatment of risk summary report presents the
expertfactors in childhood. The process of Atherosclerosis begins
in youth, and this panels recommendations for patientidentifying,
assembling, and organiz- process, from its earliest phases, is re-
care relative to cardiovascular healthing the evidence was
extensive, the re- and risk-factor detection and manage- lated to
the presence and intensity of theview process was complex, and the
ment with only the references cited in known cardiovascular risk
factorsconclusions could only be developed the text provided. It
begins with a state- shown in Table 1-1. Clinical events suchby
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
processthe evidence was inadequate. When rectly to the presence and
intensity of of atherosclerosis. Pathologically, thethis occurred,
recommendations were known risk factors. This is followed by
process begins with the accumulationmade 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 tograding the evidence appears in Ta- panels age-based
recommendations an advanced stage in which a core ofbles 1-2 and
1-3; expert consensus according to risk factor in a 1-page pe-
extracellular lipid is covered by a bro-opinions are identied as
grade D. riodic table. Risk factor specic sec- muscular cap, and
culminates inThe NHLBI expert panel integrated tions follow, with
the graded conclu- thrombosis, vascular rupture, or acuteguidelines
for cardiovascular health sions of the evidence review, normative
ischemic syndromes.and risk reduction in children and ad- tables,
and age-specic recommenda-olescents contain recommendations tions.
These recommendations are often Evidence Linking Risk Factors
inbased on the evidence review and are accompanied by supportive
actions, Childhood to Atherosclerosis atdirected toward all primary
pediatric which represent expert consensus sug- Autopsycare
providers: pediatricians, family gestions from the panel provided
to sup- Atherosclerosis at a young age waspractitioners, nurses and
nurse prac- port implementation of the recommen- rst identied in
Korean and VietnamS2 EXPERT PANEL
7. SUPPLEMENT ARTICLESTABLE 1-3 Evidence Grading System:
Strength of Recommendations Statement Type Denition
ImplicationStrong recommendation The expert panel believes that the
benets 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 dened
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
benets clearly outweigh the harms.Recommendation The expert panel
feels that the benets 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 dened 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 benets clearly outweigh the harms.Optional Either
the quality of the evidence that exists is suspect (grade D) or
well- Clinicians should be exible 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 inuencing 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 benets and harms. decision-making and be alert to
new published evidence that claries the balance of benet versus
harm; patient and family preference should have a substantial
inuencing 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 familialtent
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 coronaryaccidentally. 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 havestudy 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,
andsis 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) haveshown between the presence and in- Over the last
decade, measures of sub- signicantly abnormal endothelialtensity 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 agate 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,
highercauses. 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
beenhigh-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
specic to racial or ethnic with severe obesity. vascular disease in
adults. Consonant groups or socioeconomic status. with this
evidence, in 15- to 19-yearFour longitudinal studies have found The
Impact of Risk-Factor olds in the PDAY study, the presence
ofrelationships of risk factors measured Clustering in Childhood on
the hyperglycemia was associated within youth (specically 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 mostbacco
use, and DM) with measures of also a strong relationship between
ab- common association with prematuresubclinical 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
showedfactors 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 mostthe time of the
subclinical atheroscle- prevalent multiple-risk combinationsrosis
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 insulinChildhood 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 knownserved 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 bothcardiovascular
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 ofthe biological model for risk-factor im-
lence of cardiovascular risk factors; obesity in childhood is
associated withpact on the atherosclerotic process. these
differences are often partially the same obesity-related
risk-factorWith homozygous hypercholesterol- explained by
differences in socioeco- clustering seen in adults and that itemia,
in which LDL cholesterol levels nomic status. No group within the
continues into adult life. This high-riskexceed 800 mg/dL beginning
in infancy, United States is without a signicant combination is
among the reasonscoronary events begin in the rst de- prevalence of
risk. Several longitudi- that the current obesity epidemic withcade
of life and life span is severely nal cohort studies referenced
exten- its relationship to future CVD and DM isshortened. With
heterozygous hyper- sively in this report (Bogalusa Heart
considered one of the most importantcholesterolemia, 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
prevalentand typically 200 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 t-mg/dL beginning in infancy, 50%
of studies have been conducted outside ness (identied in 33.6% of
adoles-men and 25% of women experience the United States. However,
longitudi- cents in the National Health andclinical 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
overweightated 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 cholesterolPDAY study,2
every 30 mg/dL increase race and gender, particularly with re-
level.S4 EXPERT PANEL
9. SUPPLEMENT ARTICLESRisk-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. ThisTracking studies from childhood
to childhood is not known. concept is supported by research
thatadulthood have been performed for all As already discussed,
risk-factor has found that (1) societies with lowthe 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 2000 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 identied 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 99th 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 dened risks to treatment
of cardio- correlation coefcients 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 identied
risk factors. sufcient time to determine if cardio- ing these
measures in children 5 to The evidence for the rst 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 identied risk factors is ad-
is intellectually attractive, because the upper portion of the
pediatric dressed in the risk-factorspecic 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 benet. 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
tness 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 50% 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 identied 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 sufciently 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 rst-degree relative (heartginning in childhood:
atherosclerosis vascular health, beginning in infancy, attack,
treated angina, percutaneousbegins 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 identied in childhood; and the ers (pediatricians,
family practitio- gery, stroke, or sudden cardiac deathpresence of
these risk factors in a ners, nurses, nurse practitioners, in a
male parent or sibling before thegiven child predicts an adult with
risk physician assistants, registered dieti- age of 55 years or a
female parent orif no intervention occurs. The remain- tians) are
ideally positioned to rein- sibling before the age of 65 years) is
aning evidence links pertain to the dem- force cardiovascular
health behaviors important independent risk factor foronstration
that interventions to lower as part of routine care. The guideline
future CVD. The process of atheroscle-risk will have a health benet
and that also offers specic guidance on pri- rosis is complex and
involves many ge-the risk and cost of interventions to mary
prevention with age-specic, netic loci and multiple
environmentalimprove 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 foundevidence reviews of each risk factor. care
recommendations for risk reduc- to signicantly increase baseline
riskThe recommendations reect a com- tion within the pediatric care
setting for CVD. The risk for CVD in offspring isplex decision
process that integrates and identify risk-factor levels that re-
strongly inversely related to the age ofthe strength of the
evidence with quire specialist referral. The guide- the parent at
the time of the indexknowledge of the natural history of lines also
identify specic medical con- event. The association of a
positiveatherosclerotic 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 conrmed forsicians 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 identied all RCTs, sys-for those caring for
children will be agement for children and adolescents tematic
reviews, meta-analyses, andmost effective when complemented by with
these diagnoses are provided. observational studies that addresseda
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 developmentThe
Childhood Medical Ofce Visit health care system, physicians and and
progression of atherosclerosisas 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
theOne cornerstone of pediatric care is provides an ideal context
for effective Evidence Review for the Role ofplacing clinical
recommendations in a delivery of the cardiovascular health Family
History in Cardiovasculardevelopmental context. Those who message.
Pediatric care providers Healthmake pediatric recommendationsmust
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 aity 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
identifyingFor each risk factor, recommenda- from infancy into
young adult life. children at risk for accelerated ath-tions must
be specic to age and devel- erosclerosis and for the presence
ofopmental stage. The Bright Futures 4. FAMILY HISTORY OF EARLY an
abnormal risk prole (grade B).concept of the American Academy of
ATHEROSCLEROTIC CVD For adults, a positive family
historyPediatrics8 (AAP) is used to provide a A family history of
CVD represents the is dened as a parent and/or siblingframework 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 specic 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 ed 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 erals Ofce, 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 efcacy of specic di- dation is insufcient to
date (grade sive breastfeeding is recommended etary changes in
reducing cardiovas- D). for the rst 6 months of life. Contin- cular
risk from the current evidence Identication 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 specically 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
benets, 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 specic 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
benets and the po- based requirements for growth and tential to
decrease future risk for CVD. nutrition, in normal children and
in5. NUTRITION AND DIET The expert panel accepts the 2010 DGA8
children with hypercholesterolemiaThe 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 cholesterolCholesterol Education Program
(NCEP) intended for pediatric care providers limited to 300 mg/day.
Under thePediatric Panel report1 provided di- to use with their
patients to address guidance of qualied nutritionists,etary
recommendations for all chil- cardiovascular risk reduction. The
this dietary composition has beendren as part of a population-based
ap- conclusions of the expert panels re- shown to result in lower
TC and LDLproach 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 specic childs 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 specically 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 5%
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 specied 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 ber 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 ber 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 ber 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 benets 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 benecial for dren
transition from breast milk or B). Specic 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 childs 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 14 y 59 y 911 y 1217 y 1821 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 55 y
old, 55 y old, women 65 y old; women 65 y old review with parents
and refer as needed; positive family history identies 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 1224 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 cows 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 4 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 review
with parent and child; with child and parent; BMI 85th health with
patient; BMI 85th obesity for-height tracking, age 2 y; review with
parent 85th percentile, crossing BMI 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 95th per obesity algorithms
manage per obesity BMI 95th percentile, manage percentile, manage
per obesity BMI 95th percentile, manage algorithms; BMI 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 nonHDL or FLP in for CVD is positive,
parent has for CVD is positive, parent nonfasting non-HDL TC
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 1 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 2 limit screen/sedentary time
recommend MVPA of 1 h/d to reinforce MVPA of 1 h/d and limits with
patient no screen time before h/d; no TV in bedroom to 2 h/d and
screen/sedentary time of leisure screen time of 2 h/d the age of 2
y 2 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 neededPEDIATRICS 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 ARTICLESS9 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, becauseBirth to 18 y
Take detailed family history of CVD at initial encounter and/or at
3, Grade B physical inactivity has been identied 911, and 18 ya
Recommend as an independent risk factor for cor- If positive family
history identied, 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 identied, 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 identied many studies in youth ranging in age from
4 to 21 years Use family history to stratify risk for CVD risk as
risk prole 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 proles, 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 reect the ndings of
the evidence review; recommendation levels reect 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 theof the recommendations
(they are not graded). Evidence Review for Physicala Family
includes parent, grandparent, aunt, uncle, or sibling with heart
attack, treated angina, coronary artery
bypassgraft/stent/angioplasty, stroke, or sudden cardiac death at
55 y in males and 65 y in females. Activity The expert panel felt
that the evidence strongly supports the role of physicalGraded,
age-specic recommenda- bles. This diet has been modied for activity
in optimizing cardiovasculartions 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 evidencehealth 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 carriedHealth Integrated Lifestyle Diet healthy
eating plan using CHILD-1 forward into adulthood (grade(CHILD-1) is
the rst stage in dietary recommendations. C).change for children
with identied 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-vigorousmedical conditions that might ulti- ment
produced by contraction of skel- physical activity are associated
withmately 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
tness mea-tive family history of early cardiovas- ing muscles,
bones, and joints, but be- sures, lower TC level, lower LDLcular
disease, dyslipidemia, obesity, cause these guidelines address car-
cholesterol level, lower triglycerideprimary 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
inetary modication must provide nutri- ity and on the opposite of
activity: sed- childhood and adolescence (gradeents and calories
needed for optimal entary behavior. There is strong evi- A).growth
and development (Table 5-2). dence for benecial 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 atherosclerosisincreased intake of
fruits and vegeta- across a broad array of domains. Our (grade
B).S10 EXPERT PANEL
15. SUPPLEMENT ARTICLESTABLE 5-1 Evidence-Based Recommendations
for Diet and Nutrition: CHILD-1Birth to 6 mo Infants should be
exclusively breastfed (no supplemental formula or other foods)
until the age of 6 moa Grade B Strongly recommend6 to 12 mo
Continue breastfeeding until at least 12 mo of age while gradually
adding solids; transition to iron- Grade B fortied formula until 12
mo if reducing breastfeedinga Strongly recommend Fat intake in
infants 12 mo of age should not be restricted without medical
indication Grade D Recommend Limit other drinks to 100% fruit juice
(4 oz/d); no sweetened beverages; encourage water Grade D
recommend12 to 24 mo Transition to reduced-fatb (2% to fat-free)
unavored cows 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 300 mg/d
Grade B Strongly recommend Supportive actions The fat content of
cows milk to introduce at 1224 mo of age should be decided together
by parents and health care providers on the basis of the childs
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