Maternal calcium intake during pregnancy and blood pressure in the offspring at age 3 years: a follow-up analysis of the Project Viva cohort

Maternal calcium intake during pregnancy and childhood blood pressure: the Kyushu Okinawa Maternal and Child Health Study

PURPOSE

Evidence regarding the relationship between maternal calcium intake during pregnancy and childhood blood pressure is limited and inconsistent. The present prebirth cohort study examined this issue in Japanese children aged 6 years.

METHODS

Subjects were 854 mother-child pairs. Maternal intake during pregnancy was assessed with a validated diet history questionnaire. A research technician measured systolic and diastolic blood pressures at home in children aged 6 years using an electronic sphygmomanometer. Analysis of covariance was used to calculate adjusted means of systolic and diastolic blood pressures according to maternal calcium intake during pregnancy.

RESULTS

Maternal calcium intake during pregnancy was not related to systolic blood pressure in children. On the other hand, compared with children of mothers whose calcium intake during pregnancy was in the lowest quartile, those of mothers whose calcium intake during pregnancy was in the highest quartile had 2.8 mmHg lower adjusted mean diastolic blood pressure (95% confidence interval: 0.3-5.3 mmHg, P for trend = .009).

CONCLUSIONS

Higher maternal calcium intake during pregnancy may be associated with a decrease in diastolic, but not systolic, blood pressure in Japanese children aged 6 years.

Calcium supplementation during pregnancy and long‐term offspring outcome: a systematic literature review and meta‐analysis

The World Health Organization currently recommends calcium supplementation for pregnant women, especially those with low calcium intakes, to reduce the risk of hypertension and preeclampsia. We aimed to evaluate the effect of this intervention on selected offspring outcomes. A systematic search was conducted in 11 databases for published randomized controlled trials (RCTs) on the effect of maternal calcium supplementation with or without vitamin D during pregnancy on selected offspring cardiovascular, growth, and metabolic and neurodevelopmental outcomes. Screening of titles and abstracts of 3555 records and full texts of 31 records yielded six RCTs (nine reports, n = 1616). Forest plot analyses were performed if at least two studies presented comparable data on the same outcome. In one study (n = 591), high‐dose calcium supplementation during pregnancy was associated with a decreased risk of offspring high systolic blood pressure at 5–7 years of age (risk ratio = 0.59; 95% confidence interval: 0.39–0.90). The effects of the intervention on offspring growth, metabolic, and neurodevelopmental outcomes remain unknown because of conflicting or insufficient data. High risk of attrition bias decreased the quality of the evidence. Limited available data from RCTs do not provide sufficient evidence to conclude that prenatal calcium supplementation influences offspring health outcomes beyond the newborn period.

Early nutritional influences of cardiovascular health

INTRODUCTION

Increasing evidence shows that nutritional choices during children's formative years, including prenatally, impacts the development of adult onset cardiovascular diseases (CVDs), such as hypertension, myocardial infarction, or stroke.

AREAS COVERED

This literature review aims to synthesize the current body of evidence on nutritional factors, from conception through adolescence, which may influence a person's risk factors for future development of CVD.

EXPERT OPINION

Given the escalating healthcare costs associated with CVD, it is imperative that medical professionals and scientists remain steadfast in prioritizing and promoting early CVD prevention, even within the first few years of life. Though not the only contributing risk factor, diet is a modifiable risk factor and has been shown to have a profound impact on the reduction of cardiovascular morbidity and mortality in adult literature. Nutritional choices should be targeted on multiple levels: prenatally with the mother, individually with the patient, in conjunction with their family unit, and also within the broader community wherein they reside. Healthcare providers can play a key advocacy role for local and national food environment policy changes.

Factors Associated with Primary Hypertension in Pediatric Patients: An Up-to-Date

BACKGROUND

Arterial hypertension in children is considered a common alteration nowadays, mainly because obesity is a growing worldwide problem closely related to increased blood pressure. Childhood hypertension can be classified as primary or secondary, depending on the etiology. Primary or essential hypertension still has its pathophysiology not fully elucidated, and there is no consensus in the literature on most underlying mechanisms. In this review, genetic and environmental factors, including sodium and potassium intake, socioeconomic status, ethnicity, family structure, obesity, sedentary lifestyle, prematurity and low birth weight, prenatal and postnatal exposures are highlighted.

OBJECTIVE

The present study aimed to perform an update on primary hypertension in childhood, providing clinicians and researchers an overview of the current state of the literature regarding the influence of genetic and environmental factors.

METHODS

This integrative review searched for articles on genetic and environmental factors related to primary hypertension in pediatric patients. The databases evaluated were PubMed and Scopus.

RESULTS

The studies have provided insights regarding many genetic and environmental factors, in addition to their association with the pathophysiology of primary hypertension in childhood. Findings corroborated the idea that primary hypertension is a multifactorial disease. Further studies in the pediatric population are needed to elucidate the underlying mechanisms.

CONCLUSION

The study of primary hypertension in pediatrics has utmost importance for the adoption of preventive measures and the development of more efficient treatments, therefore reducing childhood morbidity and the incidence of cardiovascular diseases and other health consequences later in life.

Maternal Macronutrient Intake and Offspring Blood Pressure 20 Years Later

BACKGROUND

Results from 2 cohort studies in Scotland established in the 1940s and 1950s (Aberdeen and Motherwell) suggested that a high protein diet during pregnancy might adversely influence offspring blood pressure at adult age. Our objective was to examine this association in the Danish Fetal Origins Cohort (DaFO88).

METHODS AND RESULTS

This was a prospective birth cohort of 965 women who gave birth in 1988-1989 in Aarhus, Denmark, and whose offspring (n=434) participated in a clinical examination ≈20 years later. Macronutrient intake was assessed in gestational week 30. Multivariable adjusted linear regression was used to examine the relation between higher maternal protein intake, at the expense of carbohydrates, and offspring blood pressure (isocaloric substitution). Main analyses were adjusted for mother's age during pregnancy, prepregnancy body mass index, parity, smoking during pregnancy, educational level, and offspring's sex. The mean total energy intake was 8.7 MJ/day (SD 2.3 MJ/day). The mean energy from carbohydrate, fat, and protein intake was 51, 31, and 16 of total energy, respectively. The results showed that after adjustment, higher maternal protein intake was associated with slightly higher offspring diastolic blood pressure (highest compared with the lowest quintile of protein intake: ∆=2.4 mm Hg; 95% CI 0.4-4.4; P=0.03 for trend). Similar differences, although not significant, were found for systolic blood pressure (∆=2.6 mm Hg; 95% CI -0.0 to 5.3; P=0.08 for trend).

CONCLUSIONS

Higher maternal dietary protein intake at the expense of carbohydrates was associated with a modest increase in offspring blood pressure in young adulthood.

A Calcium-Deficient Diet in Rat Dams during Gestation Decreases HOMA-β% in 3 Generations of Offspring

BACKGROUND

Prenatal malnutrition can affect the phenotype of offspring by altering epigenetic regulation. Calcium (Ca) plays an important role in the pathogenesis of insulin resistance syndrome.

AIMS

We hypothesized that a Ca-deficient diet during pregnancy would alter insulin resistance and secretion in more than 1 generation of offspring.

METHODS

Female Wistar rats consumed either a Ca-deficient or a control diet ad libitum from 3 weeks before conception to 21 days after parturition and were mated with control males. Randomly selected F1 and F2 females were mated with males of each generation on postnatal day 70. The F1 and F2 dams were fed a control diet ad libitum during pregnancy and lactation. All offspring were fed a control diet starting at the time of weaning and were sacrificed on day 180.

RESULTS

HOMA-β% decreased in F1 through F3, and levels in F2 and F3 males and females were significantly lower than in controls. The mean levels of insulin and HOMA-IR were higher in F1 males but lower in F3 males than in control males. The HOMA-IR did not differ between any of the female offspring and controls.

CONCLUSIONS

Maternal Ca restriction during pregnancy and/or lactation influences insulin secretion in 3 generations of offspring.

Calcium revisited: part II calcium supplements and their effects

Calcium supplements were tested in pregnancy and lactation, in childhood and adolescence, in pre- and postmenopausal women and in elderly persons with various effects on bone density and fracture incidence. They must be properly chosen and adequately used. In this case, the reported minor negative side-effects do not restrict their use. All these aspects are reviewed here.

Components of height and blood pressure in childhood

BACKGROUND

In children being taller is associated with higher blood pressure (BP), but few studies have divided height into its components: trunk and leg length. We examined the associations of total height, trunk length and leg length with systolic BP (SBP), diastolic BP (DBP) and pulse pressure (PP) at early childhood and mid-childhood visits, as well as change between the two visits.

METHODS

We obtained five measures of SBP and DBP at the early childhood visit (N = 1153, follow-up rate = 54%) and at the mid-childhood visit (N = 1086, follow-up rate = 51%) respectively, in Project Viva, a US cohort study. We measured total height and sitting height (a measure of trunk length that includes head and neck) and calculated leg length as the difference between the two. Using mixed models, we adjusted the cross-sectional analyses for leg length when trunk length was the exposure of interest, and vice versa. We also adjusted for maternal race/ethnicity, child age, sex, overall adiposity and BP measurement conditions.

RESULTS

At the mid-childhood visit, total height was positively associated with SBP [0.34 (0.24; 0.45) mmHg/cm] but not with DBP [0.07 (-0.003; 0.15)]. In models examining trunk and leg length separately, each was positively associated with SBP [0.72 (0.52; 0.92) and 0.33 (0.16; 0.49) respectively]. In a fully adjusted model with both leg and trunk length, only trunk length remained associated with BP. For a given leg length, a 1-cm increment in trunk length was associated with a 0.63-mmHg (0.42; 0.83) higher SBP and a 0.17-mmHg (0.02; 0.31) higher DBP. For a given trunk length, however, the associations of leg length with SBP [0.13 (-0.03; 0.30)] and with DBP [0.002 (-0.11; 0.12)] were null. These patterns were similar at the early childhood visit.

CONCLUSIONS

Children with greater trunk lengths have higher BPs, perhaps because of the additional pressure needed to overcome gravity to perfuse the brain.

A calcium-deficient diet in rat dams during gestation and nursing affects hepatic 11β-hydroxysteroid dehydrogenase-1 expression in the offspring

BACKGROUND

Prenatal malnutrition can affect the phenotype of offspring by changing epigenetic regulation of specific genes. Several lines of evidence demonstrate that calcium (Ca) plays an important role in the pathogenesis of insulin resistance syndrome. We hypothesized that pregnant female rats fed a Ca-deficient diet would have offspring with altered hepatic glucocorticoid-related gene expression and that lactation would modify these alterations.

METHODOLOGY

We determined the effects of Ca deficiency during pregnancy and/or lactation on hepatic 11β-hydroxysteroid dehydrogenase-1 (Hsd11b1) expression in offspring. Female Wistar rats consumed either a Ca-deficient (D: 0.008% Ca) or control (C: 0.90% Ca) diet ad libitum from 3 weeks preconception to 21 days postparturition. On postnatal day 1, pups were cross-fostered to the same or opposite dams and divided into the following four groups: CC, DD, CD, and DC (first letter: original mother's diet; second letter: nursing mother's diet). All offspring were fed a control diet beginning at weaning (day 21) and were killed on day 200 ± 7. Serum insulin and adipokines in offspring were measured using ELISA kits.

PRINCIPAL FINDINGS

In males, mean levels of insulin, glucose, and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) were higher in the DD and DC groups than in the CC group. We found no difference in HOMA-IR between the CC and CD groups in either males or females. Expression of Hsd11b1 was lower in male DD rats than in CC rats. Hsd11b1 expression in male offspring nursed by cross-fostered dams was higher than that in those nursed by dams fed the same diet; CC vs. CD and DD vs. DC. In females, Hsd11b1 expression in DC rats was higher than that in CC rats.

CONCLUSIONS

These findings indicated that maternal Ca restriction during pregnancy and/or lactation alters postnatal growth, Hsd11b1 expression, and insulin resistance in a sex-specific manner.

Infant macronutrient composition is associated with differences in cardiovascular structures and function in childhood

Early-life nutrition may influence cardiovascular development. Not much is known about the associations between dietary composition and cardiovascular risk factors in childhood. We examined the associations of infant macronutrient intake with cardiovascular structures and function in 2882 children participating in a prospective, population-based cohort study. Information on macronutrient intake at the age of 14 mo was obtained from food-frequency questionnaires completed by a parent. Systolic and diastolic blood pressure, carotid-femoral pulse wave velocity (PWV), fractional shortening, and left cardiac structures (left atrial diameter, aortic root diameter, and left ventricular mass) were measured at the age of 6 y. Linear regression analyses were performed by using energy-adjusted macronutrient intakes, adjusted for maternal, child, and other dietary factors. Higher total fat intake was associated with higher carotid-femoral PWV (P-trend = 0.03), whereas higher intakes of total carbohydrate and mono- and disaccharides were associated with lower carotid-femoral PWV. No consistent associations were observed for macronutrient intake with systolic blood pressure, diastolic blood pressure, fractional shortening, and aortic root diameter. Higher intakes of total, saturated, monounsaturated, and polyunsaturated fat were associated with lower left atrial diameter (all P-trend ≤ 0.01), and higher total carbohydrate and mono- and disaccharide intakes were associated with higher left atrial diameter (P-trend < 0.01 and 0.02, respectively). Furthermore, the third tertile of mono- and disaccharide intake was associated with a higher left ventricular mass (difference: 1.01 g; 95% CI: 0.18, 1.85 g; P = 0.02). Dietary macronutrient composition in infancy may lead to developmental differences in cardiovascular structures and function in childhood. Further studies are needed to investigate whether these differences have consequences for the risk of future cardiovascular disease.

Metabolic syndrome: role of maternal undernutrition and fetal programming

Development of metabolic syndrome is attributed to genes, dietary intake, physical activity and environmental factors. Fetal programming due to maternal nutrition is also an important factor especially in developing countries where intrauterine growth retardation followed by excess nutrition postnatally is causing mismatch predisposing individuals to development of metabolic syndrome and its components. Several epidemiological and animal studies have provided evidence for the link between intrauterine growth retardation and adult metabolic diseases. Deficiency of macronutrients, protein and carbohydrates, during pregnancy and gestation results in lower infant birth weight, a surrogate marker of fetal growth and subsequently insulin resistance, glucose intolerance, hypertension and adiposity in adulthood. The role of micronutrients is less extensively studied but however gaining attention with several recent studies focusing on this aspect. Several mechanisms have been proposed to explain the developmental origin of adult diseases important among them being alteration of hypothalamic pituitary axis, epigenetic regulation of gene expression and oxidative stress. All of these mechanisms may be acting at different time during gestation and contributing to development of metabolic syndrome in adulthood.

A calcium-deficient diet in pregnant, nursing rats induces hypomethylation of specific cytosines in the 11β-hydroxysteroid dehydrogenase-1 promoter in pup liver

Prenatal undernutrition affects offspring phenotype via changes in the epigenetic regulation of specific genes. We hypothesized that pregnant females that were fed a calcium (Ca)-deficient diet would have offspring with altered hepatic glucocorticoid-related gene expression and altered epigenetic gene regulation. Female Wistar rats ate either a Ca-deficient or control diet from 3 weeks before conception to 21 days after parturition. Pups were allowed to nurse from their original mothers and then euthanized on day 21. Methylation of individual cytosine-guanine dinucleotides in the phosphoenolpyruvate carboxykinase (Pck1), peroxisome proliferator-activated receptor α (Ppara), glucocorticoid receptor (Nr3c1), 11β-hydroxysteroid dehydrogenase-1 (Hsd11b1), and 11β-hydroxysteroid dehydrogenase-2 (Hsd11b2) promoters was measured in liver tissue using pyrosequencing. For each gene, quantitative real-time polymerase chain reaction was used to assess mRNA levels in liver tissue. Overall Hsd11b1 methylation was lower in the Ca-deficient group than in the control group; however, overall methylation of each other gene did not differ between groups. Serum corticosterone levels in male pups from Ca-deficient dams were higher than those in control pups. Expression of Pck1 and Nr3c1 was lower in the Ca-deficient group than in the control group. A Ca-deficient diet for a dam during gestation and early nursing may alter glucocorticoid metabolism and lead to higher intracellular glucocorticoid concentrations in the hepatic cells of her offspring; moreover, this abnormal glucocorticoid metabolism may induce the metabolic complications that are associated with Ca deficiency. These findings indicated that prenatal nutrition affected glucocorticoid metabolism in offspring in part by affecting the epigenome of offspring.

Parental psychological distress during pregnancy and childhood cardiovascular development. The Generation R Study

BACKGROUND

Maternal psychological distress during pregnancy might lead to higher fetal cortisol exposure, which subsequently leads to fetal cardiovascular developmental adaptations and cardiovascular dysfunction in later life.

AIMS

We examined whether maternal and paternal psychological distress was associated with the cardiovascular outcome measurements in school age children.

STUDY DESIGN AND SUBJECTS

In a population-based prospective cohort study among 4831 children, we assessed maternal and paternal psychological distress during pregnancy by questionnaire, using the Brief Symptom Inventory (see Fig. 1).

OUTCOME MEASURES

At the child age of six years, we performed blood pressure and carotid-femoral pulse wave velocity measurements, and M-mode measurements of left cardiac structures and fractional shortening.

RESULTS

We did not observe associations of high maternal and paternal psychological symptom scores with childhood blood pressure and carotid-femoral pulse wave velocity after adjustment for potential confounders. Maternal overall psychological symptoms were associated with a lower childhood left ventricular mass (difference -1.10 g (95% confidence interval -2.13 to -0.07) between mothers with high scores and normal scores), but not with other cardiac structures and fractional shortening. Paternal overall psychological symptoms showed a similar association with childhood left ventricular mass (difference -1.34 grams (95% confidence interval -3.69 to 1.02) between fathers with high scores and normal scores).

CONCLUSIONS

Our results do not support the hypothesis that maternal psychological distress affects cardiovascular development in early life. Similar associations of maternal and paternal psychological distress with left ventricular mass suggest that these associations could be due to unmeasured social and environmental factors, rather than direct intra-uterine effects.

Maternal first-trimester dietary intake and childhood blood pressure: the Generation R Study

Suboptimal maternal dietary intake during pregnancy might lead to fetal cardiovascular adaptations and higher blood pressure in the offspring. The aim of the present study was to investigate the associations of maternal first-trimester dietary intake with blood pressure in children at the age of 6 years. We assessed first-trimester maternal daily dietary intake by a FFQ and measured folate, homocysteine and vitamin B₁₂ concentrations in the blood, in a population-based prospective cohort study among 2863 mothers and children. Childhood systolic and diastolic blood pressure was measured using a validated automatic sphygmomanometer. First-trimester maternal daily intake of energy, fat, protein and carbohydrate was not associated with childhood blood pressure. Furthermore, maternal intake of micronutrients was not associated with childhood blood pressure. Also, higher maternal vitamin B₁₂ concentrations were associated with a higher diastolic blood pressure (0·31 mmHg per standard deviation increase in vitamin B₁₂ (95% CI 0·06, 0·56)). After taking into account multiple testing, none of the associations was statistically significant. Maternal first-trimester folate and homocysteine concentrations were not associated with childhood blood pressure. The results from the present study suggest that maternal Fe intake and vitamin B₁₂ concentrations during the first trimester of pregnancy might affect childhood blood pressure, although the effect estimates were small and were not significant after correction for multiple testing. Further studies are needed to replicate these findings, to elucidate the underlying mechanisms and to assess whether these differences in blood pressure persist in later life.

Effect of maternal calcium supplementation on offspring blood pressure in 5- to 10-y-old rural Gambian children

BACKGROUND

Evidence suggests that increased maternal calcium intake during pregnancy may result in lower offspring blood pressure, prompting calls for more robust data in this field, particularly in settings of habitually low calcium intake.

OBJECTIVE

The objective was to investigate the effect of maternal calcium supplementation on blood pressure in offspring by recruiting children born after a randomized, double-blind, placebo-controlled trial of calcium supplementation during pregnancy.

DESIGN

Children (n = 389) from a rural area of The Gambia (mean age: 7.4 ± 1.2 y; range: 5-10 y), whose mothers received a calcium supplement (1500 mg Ca/d from 20 wk of gestation until delivery) or placebo, were followed up in West Africa. Blood pressure was assessed under standardized conditions with use of the Omron 705IT automated oscillometric device (Morton Medical Ltd, London, United Kingdom), and anthropometric and body composition (bioelectrical impedance) measurements were also made.

RESULTS

The analysis was restricted to 350 children born at term, which represented 64% of original trial births. There was no difference in systolic (adjusted mean difference: -0.04 mm Hg; 95% CI: -1.78, 1.69 mm Hg) or diastolic (adjusted mean difference: 0.25 mm Hg; 95% CI: -1.27, 1.77 mm Hg) blood pressure between children whose mothers had received calcium and those who received placebo. No interaction between childhood body mass index (in kg/m(2); mean: 14.0) and maternal calcium supplementation was observed in this study.

CONCLUSION

Calcium supplementation in the second half of pregnancy in Gambian women with very low habitual calcium intakes may not result in lower offspring blood pressure at 5-10 y of age.

Early influences on cardiovascular and renal development

The hypothesis that a developmental component plays a role in subsequent disease initially arose from epidemiological studies relating birth size to both risk factors for cardiovascular disease and actual cardiovascular disease prevalence in later life. The findings that small size at birth is associated with an increased risk of cardiovascular disease have led to concerns about the effect size and the causality of the associations. However, recent studies have overcome most methodological flaws and suggested small effect sizes for these associations for the individual, but an potential important effect size on a population level. Various mechanisms underlying these associations have been hypothesized, including fetal undernutrition, genetic susceptibility and postnatal accelerated growth. The specific adverse exposures in fetal and early postnatal life leading to cardiovascular disease in adult life are not yet fully understood. Current studies suggest that both environmental and genetic factors in various periods of life may underlie the complex associations of fetal growth retardation and low birth weight with cardiovascular disease in later life. To estimate the population effect size and to identify the underlying mechanisms, well-designed epidemiological studies are needed. This review is focused on specific adverse fetal exposures, cardiovascular adaptations and perspectives for new studies.

Nutraceuticals in the early infancy

Atherosclerosis disease and its extent in childhood correlate positively with established risk factors, namely obesity, hypercholesterolemia, diabetes mellitus, and hypertension. The safety and efficacy of some dietary interventions to modulate risk factors in childhood are documented by an increasing body of evidence. The present review analyzes nutritional and nutraceutical current strategies addressed to modify some risk factors of atherosclerosis in childhood. In particular, studies concerning nutrients such as fibers, omega-3-fatty acids, vitamin D, antioxidants, and calcium have been evaluated. An overall analysis suggests that some nutraceuticals might represent an attractive tool to lower the development of atherosclerotic-related cardiovascular complication in children. Nevertheless, at this moment, due to the methodological weakness that characterizes the majority of the analyzed studies, nutrients or supplements should not be considered as a therapeutic tool potentially usable for clinical purpose in children at risk for cardiovascular disease.

Maternal micronutrient deficiency, fetal development, and the risk of chronic disease

Early life nutritional exposures, combined with changes in lifestyle in adult life, can result in increased risk of chronic diseases. Although much of the focus on the developmental origins of disease has been on birth size and growth in postnatal life and the availability of energy and protein during these critical developmental periods, micronutrient deficiencies may also play an important role in fetal growth and development. Micronutrient status in fetal and early life may alter metabolism, vasculature, and organ growth and function, leading to increased risk of cardiometabolic disorders, adiposity, altered kidney function, and, ultimately, to type 2 diabetes and cardiovascular diseases. This review elucidates pathways through which micronutrient deficiencies lead to developmental impairment and describes the research to date on the evidence that micronutrient deficiencies in utero influence the development of chronic disease risk. Animal studies, observational human studies examining maternal diet or micronutrient status, and limited data from intervention studies are reviewed. Where data are lacking, plausible mechanisms and pathways of action have been derived from the existing animal and in vitro models. This review fills a critical gap in the literature related to the seminal role of micronutrients in early life and extends the discussion on the developmental origins of health and disease beyond birth size and energy and protein deficiency.

Clinical research directions in pediatric cardiology

PURPOSE OF REVIEW

Clinical research in pediatric cardiology is under-appreciated and under-funded, yet it has enormous implications for cardiovascular health and healthcare over the entire life-course. Renewed interest in federally funded clinical research makes it timely to propose a comprehensive research agenda that, with its associated rationale, will attract public funds for research into child cardiovascular health and disease.

RECENT FINDINGS

We propose here a comprehensive pediatric cardiology research agenda consisting of 22 topics and associated research questions. We describe the following five topics in more detail: the need for life-course studies of pediatric cardiac disease and epigenetic factors for later onset of cardiovascular effects; the need to study cardiometabolic disease risk in children; recent pediatric cardiology clinical trials and observational studies; the need to explore the role of physical activity in preventing and treating pediatric cardiology patients; and the need to develop and implement evidence-based interventions to manage pediatric cardiovascular problems.

SUMMARY

If the field of pediatric cardiology can adopt a comprehensive research agenda that identifies the most-needed studies, then research could be better coordinated, long-term and collaborative studies would be more readily organized and funded, and the overall financial and scientific efficiency of research in pediatric cardiology would be improved. Targeted research efforts are more likely to realize potential breakthroughs in areas such as genetic and epigenetic screening, biomarkers, cardioprotective strategies, life-course studies, long-term monitoring technologies, environmental influences on disease, evidence-based practice guidelines, and more rapid and safer development of drugs.