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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1875] [Impact Index Per Article: 267.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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2
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An update on the assessment and management of metabolic syndrome, a growing medical emergency in paediatric populations. Pharmacol Res 2017; 119:99-117. [PMID: 28111263 DOI: 10.1016/j.phrs.2017.01.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 01/19/2023]
Abstract
In the last decades the increasing rate of obesity in children and adolescents worldwide has led to the onset in paediatric age of metabolic syndrome, a disease commonly associated to adulthood. Central obesity, dyslipidaemia, hyperglycaemia, and hypertension are typical features of metabolic syndrome that seem to hesitate often in type 2 diabetes, cardiovascular disease, non-alcoholic fatty liver disease, and many other clinical conditions. Thus preventing and curing metabolic syndrome in paediatric patients is becoming an urgent need for public health. While diagnostic criteria and therapy of metabolic syndrome in adults are very well defined, there is no consensus on the definition of metabolic syndrome in children and adolescents as well as on healing approaches. The aim of this review is to describe the recent advances on the pathogenesis and clinical outcomes of paediatric metabolic syndrome. We then detail the therapeutic strategies (i.e. dietary regimens, physical exercise, nutraceuticals, and medications) employed to manage the disease. Finally, we analyse the safety profile of the drugs used in children and adolescents by performing a retrospective review of paediatric adverse reactions reported in the FDA's Adverse Event Reporting System database.
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Strambi M, Giussani M, Ambruzzi MA, Brambilla P, Corrado C, Giordano U, Maffeis C, Maringhin S, Matteucci MC, Menghetti E, Salice P, Schena F, Strisciuglio P, Valerio G, Viazzi F, Virdis R, Genovesi S. Novelty in hypertension in children and adolescents: focus on hypertension during the first year of life, use and interpretation of ambulatory blood pressure monitoring, role of physical activity in prevention and treatment, simple carbohydrates and uric acid as risk factors. Ital J Pediatr 2016; 42:69. [PMID: 27423331 PMCID: PMC4947361 DOI: 10.1186/s13052-016-0277-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 07/05/2016] [Indexed: 02/07/2023] Open
Abstract
The present article intends to provide an update of the article "Focus on prevention, diagnosis and treatment of hypertension in children and adolescents" published in 2013 (Spagnolo et al., Ital J Pediatr 39:20, 2013) in this journal. This revision is justified by the fact that during the last years there have been several new scientific contributions to the problem of hypertension in pediatric age and during adolescence. Nevertheless, for what regards some aspects of the previous article, the newly acquired information did not require substantial changes to what was already published, both from a cultural and from a clinical point of view. We felt, however, the necessity to rewrite and/or to extend other parts in the light of the most recent scientific publications. More specifically, we updated and extended the chapters on the diagnosis and management of hypertension in newborns and unweaned babies, on the use and interpretation of ambulatory blood pressure monitoring, and on the usefulness of and indications for physical activity. Furthermore, we added an entirely new section on the role that simple carbohydrates (fructose in particular) and uric acid may play in the pathogenesis of hypertension in pediatric age.
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Affiliation(s)
- Mirella Strambi
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,Dipartimento di Biologia Molecolare e dello Sviluppo, Università di Siena, Siena, Italy
| | - Marco Giussani
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy. .,ASL Milano 1, Novate Milanese Ollearo 2, 20155, Milan, Italy.
| | | | | | - Ciro Corrado
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,UOC Nefrologia Pediatrica A.R.N.A.S. Civico, Di Cristina e Benfratelli, Palermo, Italy
| | - Ugo Giordano
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,Alta Specializzazione Ipertensione Arteriosa, UOS Medicina dello Sport, Dipartimento Medico-Chirurgico di Cardiologia Pediatrica, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Claudio Maffeis
- UOC Pediatria ad Indirizzo Dietologico e Malattie del Metabolismo Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Silvio Maringhin
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,UOC Nefrologia Pediatrica A.R.N.A.S. Civico, Di Cristina e Benfratelli, Palermo, Italy.,Società Italiana Nefrologia Pediatrica, Milan, Italy
| | - Maria Chiara Matteucci
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,Ospedale Pediatrico Bambino Gesù IRCCS, Rome, Italy
| | - Ettore Menghetti
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy
| | - Patrizia Salice
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,Cardiologia Perinatale e Pediatrica, UOC Malattie Cardiovascolari, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Società Italiana Cardiologia Pediatrica, Florence, Italy
| | - Federico Schena
- Neonatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Strisciuglio
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,Dipartimento di Scienze Mediche Translazionali, Università Federico II Napoli, Naples, Italy
| | - Giuliana Valerio
- Dipartimento di Scienze Motorie e del Benessere, Università degli Studi di Napoli Parthenope, Naples, Italy
| | - Francesca Viazzi
- Dipartimento di Medicina Interna, Università di Genova e IRCCS AOU San Martino-IST, Genoa, Italy
| | - Raffaele Virdis
- Gruppo di Studio Ipertensione Arteriosa Società Italiana di Pediatria, Rome, Italy.,Dipartimento Scienze Biomediche, Biotecnologiche e Traslazionali - S.Bi.Bi.T. Università di Parma, Parma, Italy
| | - Simonetta Genovesi
- Dipartimento di Medicina e Chirurgia, Università di Milano Bicocca, Monza, Italy.,Dipartimento di Scienze Cardiovascolari, Neurologiche e Metaboliche, Ospedale S. Luca, IRCCS, Istituto Auxologico Italiano, Milan, Italy.,Società Italiana Ipertensione Arteriosa, Milan, Italy
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Batisky DL. Blood pressure variability, prehypertension, and hypertension in adolescents. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2012; 3:43-50. [PMID: 24600286 PMCID: PMC3915787 DOI: 10.2147/ahmt.s15942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Medical conditions diagnosed during adolescence may have long term impacts on the health of an individual. As a result, identifying cardiovascular risk factors earlier in life such as prehypertension (pre-HTN) and hypertension (HTN) can have significant benefits across an individual’s lifespan. Diagnosing elevated blood pressure (BP) during adolescence can be difficult, partially due to the natural variability that occurs during this period of life. Levels of BP that define adolescent prehypertension/hypertension are provided as well as an abridged review of BP variability across research groups. Strategies for BP management of adolescents are considered, with the primary focus on nonpharmacologic interventions.
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Affiliation(s)
- Donald L Batisky
- Emory Children's Center, Emory University School of Medicine, Atlanta, GA, USA
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5
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Pacifico L, Anania C, Osborn JF, Ferraro F, Bonci E, Olivero E, Chiesa C. Low 25(OH)D3 levels are associated with total adiposity, metabolic syndrome, and hypertension in Caucasian children and adolescents. Eur J Endocrinol 2011; 165:603-11. [PMID: 21753070 DOI: 10.1530/eje-11-0545] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Evidence of the association between vitamin D and cardiovascular risk factors in the young is limited. We therefore assessed the relationships between circulating 25-hydroxyvitamin D(3) (25(OH)D(3)) and metabolic syndrome (MetS), its components, and early atherosclerotic changes in 452 (304 overweight/obese and 148 healthy, normal weight) Caucasian children. METHODS We determined serum 25(OH)D(3) concentrations in relation to MetS, its components (central obesity, hypertension, low high-density lipoprotein (HDL)-cholesterol, hypertriglyceridemia, glucose impairment, and/or insulin resistance (IR)), and impairment of flow-mediated vasodilatation (FMD) and increased carotid intima-media thickness (cIMT) - two markers of subclinical atherosclerosis. RESULTS Higher 25(OH)D(3) was significantly associated with a reduced presence of MetS. Obesity, central obesity, hypertension, hypertriglyceridemia, low HDL-cholesterol, IR, and MetS were all associated with increased odds of having low 25(OH)D(3) levels, after adjustment for age, sex, and Tanner stage. After additional adjustment for SDS-body mass index, elevated blood pressure (BP) and MetS remained significantly associated with low vitamin D status. The adjusted odds ratio (95% confidence interval) for those in the lowest (<17 ng/ml) compared with the highest tertile (>27 ng/ml) of 25(OH)D(3) for hypertension was 1.72 (1.02-2.92), and for MetS, it was 2.30 (1.20-4.40). A similar pattern of association between 25(OH)D(3), high BP, and MetS was observed when models were adjusted for waist circumference. No correlation was found between 25(OH)D(3) concentrations and either FMD or cIMT. CONCLUSIONS Low 25(OH)D(3) levels in Caucasian children are inversely related to total adiposity, MetS, and hypertension.
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Affiliation(s)
- L Pacifico
- Department of Pediatrics, Sapienza University of Rome, Viale Regina Elena, 324 00161 Rome, Italy.
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6
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Pacifico L, Anania C, Martino F, Poggiogalle E, Chiarelli F, Arca M, Chiesa C. Management of metabolic syndrome in children and adolescents. Nutr Metab Cardiovasc Dis 2011; 21:455-466. [PMID: 21565479 DOI: 10.1016/j.numecd.2011.01.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 01/17/2011] [Accepted: 01/19/2011] [Indexed: 02/06/2023]
Abstract
Concomitantly with the increasing prevalence of childhood obesity, the prevalence of metabolic syndrome (MS) is rising among children and adolescents, leading to fears for future epidemics of type 2 diabetes mellitus and cardiovascular disease in the young. This makes the accurate identification and the appropriate treatment of children and adolescents with MS an important priority for health care systems. This review will focus on the management of each component of MS, including the nonalcoholic fatty liver disease (NAFLD), which is currently considered as the hepatic component of the syndrome. The most relevant target of treatment of MS in children and adolescents is the abdominal obesity. To this end, we will discuss the efficacy of dietary approaches, possibly coupled with regular physical activity, on eliciting visceral fat reduction. We will also highlight several aspects of the treatment of the high triglyceride/low high-density lipoprotein cholesterol phenotype, including the use of non-pharmacological measures, and indications for instituting drug therapies. Part of this review will address treatment of glucose abnormalities, including the benefits of lifestyle modification alone, and the potential adjunctive role of hypoglycemic drugs. The treatment of hypertension in children with MS also requires a multifaceted approach and the available data of this topic will be examined. The remainder of this review will address treatment to reverse NAFLD and prevent progression to end-stage disease.
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Affiliation(s)
- L Pacifico
- Department of Pediatrics, La Sapienza University of Rome, 00161 Rome, Italy
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7
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Flynn JT, Falkner BE. Obesity hypertension in adolescents: epidemiology, evaluation, and management. J Clin Hypertens (Greenwich) 2011; 13:323-31. [PMID: 21545393 DOI: 10.1111/j.1751-7176.2011.00452.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The prevalence of hypertension among all adolescents is approximately 3.5%, with somewhat higher rates of prehypertension. Obesity affects approximately 20% of adolescents in the United States, and the prevalence of hypertension is much higher among obese adolescents compared with nonobese adolescents. As in other populations, the evaluation of elevated blood pressure in obese adolescents should begin with a confirmation of the blood pressure elevation, followed by a focused diagnostic work-up to detect possible secondary causes of hypertension. Primary therapy for obesity-related hypertension in adolescents begins with weight loss, and may include antihypertensive medications if target-organ damage or other indications for drug therapy are present. The emphasis of management should be reduction of future cardiovascular risk.
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Affiliation(s)
- Joseph T Flynn
- Pediatric Hypertension Program, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
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8
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Lindbäck SM, Gabbert C, Johnson BL, Smorodinsky E, Sirlin CB, Garcia N, Pardee PE, Kistler KD, Schwimmer JB. Pediatric nonalcoholic fatty liver disease: a comprehensive review. Adv Pediatr 2010; 57:85-140. [PMID: 21056736 DOI: 10.1016/j.yapd.2010.08.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Sarah M Lindbäck
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, 200 West Arbor Drive, San Diego, CA 92103-8450, USA
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9
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Lande MB, Flynn JT. Treatment of hypertension in children and adolescents. Pediatr Nephrol 2009; 24:1939-49. [PMID: 17690916 PMCID: PMC2756388 DOI: 10.1007/s00467-007-0573-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 06/29/2007] [Accepted: 07/05/2007] [Indexed: 01/10/2023]
Abstract
The treatment of hypertension in children and adolescents has been markedly changed in recent years by several factors, including the publication of new consensus recommendations, the obesity epidemic, and the increased availability of information on efficacy and safety of antihypertensive medications in the young. In this review we present an updated approach to the outpatient management of hypertension in the child or adolescent, utilizing representative cases to illustrate important principles as well as possible controversies.
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Affiliation(s)
- Marc B. Lande
- Pediatric Nephrology, University of Rochester, Rochester, NY USA
| | - Joseph T. Flynn
- Division of Nephrology, A-7931, Children’s Hospital & Regional Medical Center, 4800 Sand Point Way NE, Seattle, WA 98105 USA
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Varda NM, Gregoric A. Metabolic syndrome in the pediatric population: a short overview. Pediatr Rep 2009; 1:e1. [PMID: 21589817 PMCID: PMC3096028 DOI: 10.4081/pr.2009.e1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 05/05/2009] [Accepted: 05/15/2009] [Indexed: 02/06/2023] Open
Abstract
The metabolic syndrome (MS) in adults is defined as a concurrence of obesity, disturbed glucose and insulin metabolism, hypertension and dyslipidemia, and is associated with increased morbidity and mortality from cardiovascular diseases and type 2 diabetes. Studies now indicate that many of its components are also present in children and adolescents. Moreover, the clustering of these risk factors has been documented in some children, who are at increased cardiovascular risk in adulthood. The MS is highly prevalent among overweight children and adolescents. Identifying these children is important for early prevention and treatment of different components of the syndrome. The first-line treatment comprises lifestyle modification consisting of diet and exercise. The most effective tool for prevention of the MS is to stop the development of childhood obesity. The first attempt at consensus-based pediatric diagnostic criteria was published in 2007 by the International Diabetes Federation. Nevertheless, national prevalence data, based on uniform pediatric definition, protocols for prevention, early recognition and effective treatment of pediatric MS are still needed.The aim of this article is to provide a short overview of the diagnosis and treatment options of childhood MS, as well as to present the relationships between MS and its individual components.
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