Version July 2025
INTRODUCTION —
Although atherosclerotic cardiovascular disease (ASCVD) generally manifests in adulthood, the atherosclerotic process begins in childhood. For most children, atherosclerotic vascular changes are minor and can be minimized or even prevented with adherence to a healthy lifestyle. However, in some children, the atherosclerotic process is accelerated because of the presence of identifiable risk factors (eg, obesity and hypertension) and/or specific diseases that are associated with premature ASCVD (eg, familial hypercholesterolemia and diabetes mellitus) (table 1).
Primary prevention measures to minimize the risk of developing atherosclerosis in childhood will be reviewed here. In addition, the primary care assessment to identify the child at risk for premature atherosclerosis and, by extension, ASCVD will also be discussed. Related topics include:
●(See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)".)
●(See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis".)
●(See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis".)
●(See "Familial hypercholesterolemia in children".)
●(See "Overview of the health consequences of obesity in children and adolescents".)
●(See "Chronic complications and screening in children and adolescents with type 2 diabetes mellitus".)
●(See "Hypertension in children and adolescents: Epidemiology, risk factors, and etiology".)
CARDIOVASCULAR HEALTH PROMOTION —
The two primary goals of cardiovascular health promotion in children are [1-3]:
●To prevent the development of risk factors associated with accelerated atherosclerosis. This is referred to as "primordial prevention." It focuses on adherence to a healthy lifestyle. (See 'Promoting a heart-healthy lifestyle' below.)
●To identify and manage conditions that are well recognized as risk factors for developing early ASCVD. These include obesity, hypertension, dyslipidemia, and diabetes. (See 'Identifying children at risk for early ASCVD' below.)
Ideal cardiovascular health — The construct of ideal cardiovascular health, well developed in the adult literature, has been adapted for children and adolescents. It includes the following health factors and behaviors, which the American Heart Association (AHA) refers to as "Life's Essential 8" [2,4,5]:
●Avoiding or quitting tobacco use or exposure (see 'Avoid tobacco and nicotine exposure' below)
●Maintaining a healthy weight, as measured with body mass index (BMI) (calculator 1 and calculator 2)
●Engaging in regular physical activity (see 'Physical activity' below)
●Eating a healthy diet (see 'Heart-healthy diet' below)
●Establishing healthy sleep habits (see 'Healthy sleep habits' below)
●Managing health factors such as high cholesterol, elevated fasting blood sugar, and/or high blood pressure (see 'Risk factors and special conditions' below)
Establishing healthy behaviors in each of these areas during childhood sets the stage for continued healthy lifestyle choices in adulthood. Ideal cardiovascular health in childhood and early adulthood has been associated with a lower prevalence of ASCVD risk factors in later adulthood in several large longitudinal pediatric and young adult cohorts [6-9]. Increasing numbers of ideal cardiovascular health measures in youth were associated with a reduced risk of hypertension, metabolic syndrome, and dyslipidemia (ie, elevated low-density lipoprotein cholesterol) and decreased carotid artery and aortic intima-media thickness (which are markers of preclinical atherosclerosis) in adulthood [7].
The cardiovascular health (CVH) score is a metric that assesses each of the domains of Life's Essential 8, with an overall score of 100 representing ideal cardiovascular health [5]. In a study that analyzed data from the United States National Health and Nutrition Examination Survey (NHANES; 2013 through 2018), which included 4455 adolescents ages 12 to 19 years, the mean CVH score (based on all domains except for sleep) was 74 points [10].
Promoting a heart-healthy lifestyle — Routine pediatric health care supervision should promote and reinforce positive health behaviors to reduce the risk of developing ASCVD, focusing on the areas discussed in the sections below [1-3,11]. On a population level, advocacy should focus on the same areas (eg, improving school lunch programs, encouraging smaller portion sizes, increasing public awareness regarding healthy dietary choices, and promoting tobacco smoke and nicotine avoidance).
The guidance in the sections below is generally consistent with published guidelines and position statements from the AHA, American Academy of Pediatrics (AAP), European Society of Cardiology (ESC), United States National Heart, Lung, and Blood Institute (NHLBI), and the United States Departments of Agriculture (USDA) and Health and Human Services (HHS) [1-3,11-14]. Links to these and other society guidelines are provided separately. (See 'Society guideline links' below.)
Heart-healthy diet — Good nutrition, beginning at birth, has profound health benefits, including a potential to decrease the risk of ASCVD by preventing or ameliorating obesity, dyslipidemia, hypertension, and insulin resistance/diabetes mellitus. Dietary guidelines for children and adolescents are summarized in the table (table 2) and discussed in greater detail separately. (See "Dietary recommendations for toddlers and preschool and school-age children", section on 'General guidance'.)
Important aspects of a heart-healthy diet for infants, children, and adolescents include the following [1]:
●Breastfeeding – Exclusive breastfeeding for the first six months after birth and continued breastfeeding to at least 12 months of age is strongly supported by many governmental and medical professional organizations. Breastfeeding is linked to a decrease in the prevalence of future obesity and dyslipidemia, two important CVD risk factors. These issues and other benefits of breastfeeding are discussed separately. (See "Infant benefits of breastfeeding", section on 'Limited evidence for benefit'.)
●Fat intake – A specific limit for total fat intake to reduce ASCVD risk has not been established. Rather, we emphasize that dietary fat should be primarily plant-based and consist of monosaturated and polyunsaturated fat. In the absence of a medical indication, fat intake should not be restricted during infancy.
•Monosaturated and polyunsaturated fat – The majority of fat intake should be composed of a combination of monosaturated and polyunsaturated fat (table 3).
•Saturated fat – In clinical practice, we generally find that focusing on specific targets for fat intake is neither productive nor necessary. Instead, we emphasize the intake of "healthier" fats (mono- and polyunsaturated fats) as a substitute for saturated fats. Nevertheless, when specific guidance is solicited, we suggest limiting saturated fat to 7 to 10 percent of total calories and dietary cholesterol to <300 mg/day (table 3). Support for this recommendation is based on the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) trial that demonstrated modest improvements in fasting lipid profiles in infants whose parents/caregivers received counseling regarding a low-saturated fat, low-cholesterol diet compared with those whose parents/caregivers did not receive any dietary counseling [8,15-18]. At 14 and 19 years of age, the group that received repeated dietary counseling for a low-saturated fat diet had lower saturated fat intakes and serum low-density lipoprotein cholesterol than the control group [19,20]. As noted above, the intervention group was more likely to have ideal cardiovascular health metrics as compared with the control group, which correlated with a decreased aortic IMT and improved elasticity [7]. Importantly, there was no difference in neurodevelopmental outcomes, which effectively addressed an initial concern that a low-fat diet may adversely affect neurodevelopment. This diet primarily relied on fruit and vegetables, whole grains, low-fat and nonfat dairy products, beans, fish, and lean meat [21].
•Trans fats – Trans fats should be eliminated from the diet.
●Protein and carbohydrate intake – Approximately 15 to 20 percent of caloric intake should be derived from protein and 50 to 55 percent from carbohydrates, primarily in the form of whole grains.
●Other dietary measures – Other heart-healthy dietary advice for pediatric patients includes:
•Encourage the intake of dietary fiber in the form of naturally fiber-rich foods such as fruits, vegetables, and whole grains, as supported by longitudinal data following children into adolescence and young adults into middle adulthood [22,23].
•Reduce the intake of sugar-sweetened beverages and foods – In infants between 6 and 12 months of age, only 100 percent juice should be allowed and the intake should not exceed 4 ounces per day.
•In children ≥1 year old, if cow's milk is introduced, decisions regarding the milk's fat content should be based upon the child's growth, appetite, BMI, ASCVD risk factors, and intake of other sources of fat- and calorie-dense foods. The medical provider may decide that low-fat dairy is appropriate as early as 12 months. By two years of age, saturated fat should be limited to 8 to 10 percent of the daily caloric intake and milk should be provided as 1 percent fat or skim.
•A daily minimum intake of vitamin D supplementation (600 international units/day) is recommended for all children. (See "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Recommended vitamin D intake'.)
For families with children with identified ASCVD risk factors, ongoing nutritional counseling by a registered dietitian can help children adopt and sustain a diet that provides adequate nutrition and reduces ASCVD risk. A behavioral approach that engages the child and family has been shown to be the most effective method for achieving dietary change [1]. Dietary counseling should be tailored to each child and family based on diet patterns, social setting, and patient sensitivities, such as lactose intolerance and food allergy.
Physical activity — Routine physical activity should be encouraged throughout childhood. Regular physical activity is associated with decreased risk of atherosclerosis and ASCVD. However, the optimal type and level of physical activity are uncertain.
Based on the available data and in accordance with the physical activity guidelines for Americans published by the HHS, we suggest the following age-based goals (table 4) [1,24] (see "Prevention and management of childhood obesity in the primary care setting", section on 'Physical activity goals'):
●Preschool-aged children – For preschool-aged children, parents/caregivers should allow for ≥2 hours of unstructured active playtime in a safe and supportive environment. Children <2 years should ideally have little to no screen time. For those ≥2 years, screen time should be limited to no more than one hour per day.
●School-aged and older – Children >5 years of age should participate in moderate to vigorous structured physical activity for at least 60 minutes per day, which can consist of several shorter periods of activity. Recreational screen time (eg, television, videos, video games) should ideally be limited to no more and one hour per day [25].
Evidence supporting the role of regular physical activity in ASCVD prevention comes from studies in adults demonstrating that daily vigorous activity decreases the risk of ASCVD and type 2 diabetes mellitus, reduces blood pressure, and improves fasting lipid profiles. These data are discussed in detail separately. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)
Although data of similar quality are limited in children, there are several reports demonstrating beneficial effects of physical activity on reducing the risk of atherosclerosis in children and adolescents.
●In the STRIP study, lower amounts of physical activity among adolescents (as determined by questionnaire) correlated with more subclinical atherosclerosis (ie, increased mean aortic IMT and decreased endothelial function as measured by flow-mediated dilation) [26,27]. Sedentary adolescents who increased their level of physical activity decreased the progression of IMT compared with adolescents who remained sedentary. In persistently active adolescents, the progression of IMT was attenuated compared with those who became sedentary. (See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", section on 'Evidence of subclinical atherosclerosis'.)
●In another report from the STRIP study, sedentary adolescents were at an increased risk for clustered metabolic risk factors compared with more physically active peers [28]. Physical activity was based on self-report, and the cluster risk factors were BMI, lipid profile, and blood pressure.
●In a report from the longitudinal Cardiovascular Risk in Young Finns study that recruited children from ages 3 to 18 years, low physical activity was associated with accelerated IMT progression over 27 years of follow-up [29].
●Data from the International Children's Accelerometry Database demonstrated that increasing time for moderate to vigorous activity was associated with better cardiometabolic risk factors regardless of the amount of sedentary time [30]. Higher mean time spent in moderate to vigorous activity correlated with reductions in mean waist circumference, systolic blood pressure, fasting insulin, and fasting triglycerides and increases in high-density lipoprotein cholesterol.
●In the Dietary Intervention Study in Childhood, higher self-reported levels of physical activity were associated with lower systolic blood pressure [31].
●Several small studies have shown that exercise programs that improve physical fitness resulted in a reduction of CVD risk factors including lowering BMI, blood pressure, and arterial stiffness and improving lipid profiles [32-35].
In addition, there is evidence that physical activity patterns established in childhood continue into adulthood [1].
Other benefits of physical activity in children are discussed separately. (See "Physical activity and strength training in children and adolescents: An overview", section on 'Benefits of regular physical activity'.)
Healthy sleep habits — In adults, abnormal sleep duration (both too little and too much) and sleep disordered breathing (eg, obstructive sleep apnea) have been linked to increased risk of ASCVD. These associations are discussed elsewhere. (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Cardiovascular morbidity' and "Obstructive sleep apnea and cardiovascular disease in adults".)
There are fewer data establishing a link between sleep problems in childhood and risk of premature ASCVD. Nevertheless, we emphasize the importance of establishing healthy sleep habits (table 5A-B), including appropriate duration of sleep (figure 1), as part of a heart-healthy lifestyle. (See "Assessment of sleep disorders in children".)
Avoid tobacco and nicotine exposure — Pediatric health care clinicians should provide ongoing counseling on the benefits of a tobacco-free environment for the child and family. Patients and parents/caregivers should be informed about the addictive and adverse health effects of smoking cigarettes and other nicotine exposures. The adverse effects include increased risk of ASCVD for themselves and for their children. (See "Secondhand smoke exposure: Effects in children" and "Prevention of smoking and vaping initiation in children and adolescents" and "Overview of smoking cessation management in adults" and "Cardiovascular effects of nicotine".)
Identifying children at risk for early ASCVD
Rationale — Screening is a routine part of pediatric care and aims to identify conditions that, if untreated, increase risk of disease sequelae and for which there is an available cost-effective intervention. When deciding whether screening should be performed, the test's sensitivity and specificity, prevalence of the screened condition, cost of the screening test, and potential benefits and harms of screening and intervention must be considered. (See "Screening tests in children and adolescents", section on 'Overview'.)
Data are not available regarding the optimal approach to assessing individual risk for ASCVD in pediatric practice. It is generally not feasible to conduct randomized trials assessing the effectiveness of different pediatric screening practices for ASCVD because ASCVD occurs decades after childhood exposures and early atherosclerosis is generally asymptomatic. Because randomized trials are lacking, the United States Preventive Services Task Force concluded that there are insufficient data to recommend for or against screening children for lipid or blood pressure abnormalities [36-41]. (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis", section on 'Approach to screening' and "Hypertension in children and adolescents: Definition and diagnosis", section on 'Societal and governmental recommendations'.)
By contrast, multiple large prospective population-based studies involving adults have assessed individual risk for cardiovascular events and risk calculators based on these data are used to guide risk reduction strategies in adult patients (eg, PREVENT or ASCVD Risk Estimator Plus). This approach directly links risk factors to cardiovascular events and is discussed in greater detail separately. (See "Atherosclerotic cardiovascular disease risk assessment for primary prevention in adults" and "Cardiovascular disease risk assessment for primary prevention: Risk calculators".)
Despite the lack of evidence from randomized trials in children, pediatric risk factors for accelerated atherosclerosis (and, by extension, ASCVD) have been identified through longitudinal studies showing associations between traditional ASCVD risk factors (table 1) in childhood/adolescence and development of clinical ASCVD in adulthood; studies using noninvasive imaging demonstrating preclinical atherosclerotic vascular changes in children, adolescents, and young adults; and autopsy studies showing atherosclerotic changes in the young. These data are described separately. (See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", section on 'Association between pediatric risk factors and adult ASCVD'.)
Long-term prospective data are not available to conclusively demonstrate that identifying and treating risk factors in childhood will reduce the prevalence of clinical disease in adulthood. Nevertheless, many experts (including the authors of this review) believe it is reasonable to assume, based on the limited pediatric data and the evidence from adult studies, that timely intervention to prevent (primordial prevention), decrease, and possibly eliminate ASCVD risk factor(s) in children will decelerate the atherosclerotic process and prevent or delay the onset of clinical ASCVD [1,3]. (See "Overview of the management of the child or adolescent at risk for premature atherosclerotic cardiovascular disease (ASCVD)".)
Risk factors and special conditions — In children, traditional ASCVD risk factors and certain conditions are associated with accelerated development and/or progression of atherosclerosis and early ASCVD. These factors are summarized in the table (table 1) and are discussed in greater detail separately [1,3]. (See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)".)
Routine screening — During routine health supervision visits, we suggest screening for ASCVD risk factors as recommended by the AAP, AHA, and NHLBI expert panel [1-3,12]:
●Assess tobacco smoke and nicotine exposure – Obtain a history of smoke and inhaled nicotine exposure, including both personal and secondhand smoke. Smoking prevention in children and adolescents is discussed in detail separately. (See "Prevention of smoking and vaping initiation in children and adolescents" and "Secondhand smoke exposure: Effects in children".)
●Review diet. (See 'Heart-healthy diet' above and "Dietary recommendations for toddlers and preschool and school-age children".)
●Review frequency and intensity of physical activity. (See 'Physical activity' above and "Prevention and management of childhood obesity in the primary care setting", section on 'Physical activity goals'.)
●Review sleep history – Sleep duration and quality is an emerging cardiovascular risk factor. Specifically, obstructive sleep apnea is a risk factor for CVD and is discussed separately. (See "Assessment of sleep disorders in children" and "Cardiovascular consequences of obstructive sleep apnea in children".)
●Review the family history for premature ASCVD – Premature ASCVD is defined as a heart attack, treated angina, interventions for coronary artery disease, sudden cardiac death, or stroke in a parent or sibling before age 55 (males) or 65 (females).
●Measure blood pressure – Age- and height-specific blood pressure percentiles should be determined using the tables for girls (table 6) or boys (table 7). Blood pressure screening in children is discussed in detail separately. (See "Hypertension in children and adolescents: Definition and diagnosis", section on 'Screening of blood pressure'.)
●Measure weight and height and calculate body mass index (BMI) – BMI and BMI percentiles may be determined using linked calculators for girls (calculator 1) or boys (calculator 2). For children under two years of age, we suggest using weight-for-height percentiles. (See "Measurement of growth in children".)
●Perform lipid screening at least twice during childhood and adolescence – For children without risk factors, the first screening is performed at 9 to 11 years of age, with a second screening between 17 and 21 years of age. Earlier screening (starting as young as two years of age) and more frequent monitoring may be warranted if the child has identified risk factor(s) for early ASCVD. The approach to pediatric lipid screening is summarized in the algorithms (algorithm 1A-B) and is discussed in detail separately. (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis", section on 'Approach to screening'.)
●Perform screening for type 2 diabetes mellitus in at-risk children and adolescents, as summarized in the table (table 8) and discussed in detail separately. (See "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Screening'.)
●Identify other conditions associated with accelerated atherosclerosis (table 1 and algorithm 2). (See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", section on 'Other conditions'.)
The severity of childhood atherosclerosis (and, by extension, the risk of ASCVD) increases as the number of ASCVD risk factors increases. Thus, it is important to consider all cardiovascular risk factors together in making management decisions (algorithm 2).
Management of children who are at an increased risk for atherosclerosis includes nonpharmacologic and pharmacologic interventions, which are discussed in detail separately. (See "Overview of the management of the child or adolescent at risk for premature atherosclerotic cardiovascular disease (ASCVD)" and "Dyslipidemia in children and adolescents: Management" and "Hypertension in children and adolescents: Nonemergency treatment".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately:
●(See "Society guideline links: Lipid disorders and atherosclerosis in children".)
●(See "Society guideline links: Healthy diet in children and adolescents".)
●(See "Society guideline links: Obesity in children".)
●(See "Society guideline links: Smoking cessation, e-cigarettes, and tobacco control".)
●(See "Society guideline links: Hypertension in children".)
SUMMARY AND RECOMMENDATIONS
●Goals – The two primary goals of cardiovascular health promotion in children are:
•To prevent the development of risk factors associated with accelerated atherosclerosis. This is referred to as "primordial prevention." It focuses on adherence to a healthy lifestyle. (See 'Promoting a heart-healthy lifestyle' above.)
•To identify and manage conditions that are well recognized as risk factors for developing early ASCVD. These include obesity, hypertension, dyslipidemia, and diabetes (algorithm 2 and table 1). (See 'Identifying children at risk for early ASCVD' above.)
●Promoting a heart-healthy lifestyle – Routine pediatric health care supervision should promote and reinforce positive health behaviors to reduce the risk of developing ASCVD. (See 'Promoting a heart-healthy lifestyle' above.)
Pediatric care providers should provide age-appropriate information and support to children and their families/caregivers regarding the following:
•Heart-healthy diet (table 2) (see 'Heart-healthy diet' above and "Dietary recommendations for toddlers and preschool and school-age children")
•Physical activity (table 4) (see 'Physical activity' above and "Prevention and management of childhood obesity in the primary care setting", section on 'Physical activity goals')
•Healthy sleep habits (table 5A-B and figure 1) (see 'Healthy sleep habits' above and "Assessment of sleep disorders in children")
•Avoidance of tobacco and nicotine exposure (see 'Avoid tobacco and nicotine exposure' above and "Prevention of smoking and vaping initiation in children and adolescents")
●Routine screening – Screening for ASCVD risk factors during childhood includes the following, each of which is discussed in greater detail separately (see 'Routine screening' above):
•Reviewing the child's diet (see "Dietary recommendations for toddlers and preschool and school-age children")
•Assessing the child's physical activity level (table 4) (see 'Physical activity' above and "Prevention and management of childhood obesity in the primary care setting", section on 'Physical activity goals')
•Assessing tobacco and nicotine use/exposure (see "Prevention of smoking and vaping initiation in children and adolescents" and "Secondhand smoke exposure: Effects in children")
•Reviewing the family history for premature ASCVD (see "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", section on 'Family history of premature ASCVD')
•Measuring blood pressure (see "Hypertension in children and adolescents: Definition and diagnosis", section on 'Screening of blood pressure')
•Measuring weight and height and calculate body mass index (BMI) (see "Measurement of growth in children")
•Lipid screening (algorithm 1A-B) (see "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis", section on 'Rationale for lipid screening')
•Screening for type 2 diabetes mellitus in at-risk children (table 8) (see "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Screening')
•Identifying other conditions associated with accelerated atherosclerosis (table 1 and algorithm 2) (see "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", section on 'Other conditions')
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges Jane Newburger, MD, MPH, and Michael Mendelson, MD, ScM, who contributed to an earlier version of this topic review.
