Screening children to identify families at increased risk for cardiovascular disease

Tracking of serum lipid levels from childhood to adulthood: Systematic review and meta-analysis

BACKGROUND AND AIMS

The utility of lipid screening in pediatric settings for preventing adult atherosclerotic cardiovascular diseases partly depends on the lifelong tracking of lipid levels. This systematic review aimed to quantify the tracking of lipid levels from childhood and adolescence to adulthood.

METHODS

We systematically searched MEDLINE, Embase, Web of Science, and Google Scholar in March 2022. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42020208859). We included cohort studies that measured tracking of lipids from childhood or adolescence (<18 years) to adulthood (≥18) with correlation or tracking coefficients. We estimated pooled correlation and tracking coefficients using random-effects meta-analysis. Risk of bias was assessed with a review-specific tool.

RESULTS

Thirty-three studies of 19 cohorts (11,020 participants) were included. The degree of tracking from childhood and adolescence to adulthood differed among lipids. Tracking was observed for low-density lipoprotein cholesterol (pooled r = 0.55-0.65), total cholesterol (pooled r = 0.51-0.65), high-density lipoprotein cholesterol (pooled r = 0.46-0.57), and triglycerides (pooled r = 0.32-0.40). Only one study included tracking of non-high-density lipoprotein cholesterol (r = 0.42-0.59). Substantial heterogeneity was observed. Study risk of bias was moderate, mostly due to insufficient reporting and singular measurements at baseline and follow-up.

CONCLUSIONS

Early-life lipid measurements are important for predicting adult levels. However, further research is needed to understand the tracking of non-high-density lipoprotein cholesterol and the stability of risk classification over time, which may further inform pediatric lipid screening and assessment strategies.

Association between parenthood and cardiovascular disease risk: Analysis from NHANES 2011-2016

The objective of this study was to examine the association between parenthood and cardiovascular disease (CVD) risk factors among a nationally representative sample of United States adults. A cross sectional analysis was conducted with adults aged 20-59 years from the National Health and Nutrition Examination Survey 2011-2016. Adults were classified as parents and non-parents based on the presence of children birth-17 years in the home. CVD risk factors assessed included: physical inactivity, obesity, blood pressure, HDL cholesterol, glycohemoglobin, and smoking status. Multivariable logistic regression models stratified by sex were used to examine the association between parenthood and each risk factor. 10,908 adults (5,329 [49%] male, weighted mean age 39.6 years) were included. In adjusted analyses, fathers had greater odds of obesity (OR: 1.22; 95% CI: 1.04-1.42) and lower odds of being a current smoker (OR: 0.82; 95% CI: 0.68-0.98) compared to non-fathers. Mothers had greater odds of physical inactivity (OR: 1.27; 95% CI: 1.03-1.56) and low HDL cholesterol (OR: 1.24; 95% CI: 1.06-1.45), and lower odds of being a current smoker (OR: 0.78; 95% CI: 0.63-0.96) compared to non-mothers. Parents with younger children in the household tended to have greater odds of CVD risk factors compared to non-parents. No clear patterns emerged in CVD factor risk based on the number of children in the household. Parents are at greater risk for several modifiable CVD risk factors. This illustrates the importance of including parental health promotion in settings that serve children and implementing policies that support parental health and wellbeing.

Blood pressure profile, prevalence of hypertension and associated familial factors in school children in Accra, Ghana

Background

Essential hypertension, which is hypertension without a known cause, runs in families. Children from families with hypertension are likely to have a higher blood pressure than children from normotensive families.

Aim

The aim of this study was to find the prevalence of hypertension and the associated family risk factors for hypertension in the school children.

Patients and Methods

This prevalence study was conducted in six first-cycle schools in Accra, Ghana. School children between the ages of five to fourteen years were recruited into the study. A questionnaire, which gathered information on demographic data, family history, and risk factors associated with childhood hypertension and the child's clinical data, was used. An average of three blood pressure readings with an automated sphygmomanometer and height measurement was taken for each child. Blood pressure was categorized as normal, pre-hypertension, and hypertension using the Centers for Disease Control and Prevention (CDC) reference charts.

Results

A total of 600 school children comprising 358 (59.7%) females and 242 (40.3%) males were studied. Fifty-one (8.5%) school children had elevated blood pressure. Of these, 15 (2.5%) had hypertension, while 36 (6.0%) had pre-hypertension. Two hundred and thirty-eight participants had a family history of risk factors for hypertension. Twenty-five (10.5%) children with risk factors (family history of hypertension, diabetes mellitus, obesity, stroke) had elevated blood pressure (BP) compared to 7.2% of those without risk factors.

Conclusion

Urgent positive lifestyle transformations, which should start from school to reduce the incidence of hypertension in children.

Association between Parent's Metabolic Syndrome and 12- to18-Year-Old Offspring's Overweight: Results from the Korea National Health and Nutrition Examination Survey (K-NHANES) 2009-2016

BACKGROUND

Little information is available on the association between parents' metabolic syndrome (MetS) and adolescent offspring's obesity in Korea. The aim of our study is to determine the association between parent's metabolic syndrome and offspring's obesity.

METHODS

The study data were obtained from the Korean National Health and Nutrition Examination Survey conducted during 2009-2016. In the present study, 3140 adolescents aged 12 to 18 years, their paternal pairs (PP, fathers = 2244), and maternal pairs (MP, mothers = 3022) were analyzed. Of these 3140 adolescents, 2637 had normal weight {age- and sex-specific body mass index (BMI) under the 85^th percentile}, whereas 467 were overweight (age- and sex-specific BMI over the 85^th percentile).

RESULTS

Offspring's overweight and central obesity were associated with all components of the PP's metabolic risk factors, including central obesity (p < 0.001), systolic (p < 0.001) and diastolic blood pressure (p < 0.001), glucose intolerance (p < 0.001), and triglyceride (p < 0.002) and high-density lipoprotein levels (p=0.049). In addition, offspring's overweight and central obesity were also associated with the metabolic risk factors of MP, including central obesity (p < 0.001), systolic (p < 0.001) and diastolic blood pressure (p < 0.001), glucose intolerance (p < 0.001), and triglyceride levels (p < 0.001). In multivariate logistic regression analysis, offspring's overweight was significantly and positively associated with parental central obesity (PP, adjusted odds ratio (OR) = 1.593; 95% confidence interval (CI): 1.192-2.128; MP, adjusted OR = 2.221, 95% CI: 1.755-2.812) and parental metabolic syndrome (PP, adjusted OR = 2.032; 95% CI: 1.451-2.846; MP, adjusted OR = 2.972, 95% CI: 2.239-3.964). As the number of parental metabolic risk factors increased, offspring's risk for overweight and central obesity increased (p for trends < 0.001).

CONCLUSION

Parental metabolic syndrome was associated with obesity in 12- to 18-year-old offspring in Korea.

Family Based Prevention of Cardiovascular Disease Risk Factors in Children by Lifestyle Change: The PEP Family Heart Study

AIM

The 14 years' Prevention Education Program PEP was started 1994 among first graders, their siblings and parents living in the half million city Nuremberg (Germany). The aim of prospective family-based observational study was early detection and lifestyle intervention of traditional cardiovascular risk factors.

SUBJECTS AND METHODS

Out of 3370 families 24,927 adults and 23,740 children participated in the PEP Family Heart study. Anthropometric parameters including blood pressure and fasting lipids were measured. Because these variables change specifically because of natural growth and development in 3-18 years old children we had to calculate age-and gender-specific growth curves using the LMS method. Non-overweight (normal weight) is defined as BMI < 85th percentile (pctl), overweight as BMI 85th to <95th percentile, obesity as BMI ≥ 95th percentile and severe obesity as ≥ 120% of the 95th pctl. Prehypertension is categorized as the ≥90th to <95th pctl or ≥120/80 mm Hg and hypertension as ≥95th pctl on ≥3 occasions.

MAIN RESULTS

1. Cardiovascular risk (CVD) factor screening in school children predicted CVD risk in parents. 2. The growths curves for auscultatory systolic (SBP) and diastolic (DBP) blood pressure of non-overweight 8713 boys and 8138 girls nearly identical with the percentile curves of all 11,328 boys and 10,723 girls. 3. The shapes of the 10 lipid percentile curves between the 3rd and 97th pctl differ considerably by age and gender. 4. The wais-to-height ratio (WHtR) percentiles as a measure for abdominal adiposity vary substantially by age and gender 5. Among overweight and obese ≥85th pctl the percentile curves of body fat increase steeply until age 10 years and then decrease slowly in boys whereas the BF% percentile curves in girls increase continuously until age 18 years 6. The prevalence of hypertension increased strongly in severe obesity at the 99th pctl, more steeply beyond 120% of the 95th pctl to 59.1% in boys and 56% in girls. 7. The association between hypertension and normal weight, overweight and obesity increased in boys from 0,5, via 2,7 to 4,3 and in girls from 0,4 via 2,1 to 5,9. 8. Between 2000 and 2007 mean blood pressure decreased from 138.3 ± 18.5 mm Hg to 124.0 ± 13.8 mm Hg in fathers and from 119.1 ± 2.8 mm Hg to 110.4 ± 11.2 mm Hg in mothers. 9. After 1 year weighed dietary protocols demonstrate in 166 fathers a decrease of all six nutrional components like daily energy consumption from 2423 to 2307 Kcal, from 98 g to 91 g fat, from 260 g to 252 g carbohydrates, from 88 g to 84 g protein, cholesterol from 362 mg to 339 mg and alcohol from 19 g to 17 g per day and in 237 mothers from 1915 Kcal to 1830 Kcal, from 79 g to 73 g total fat, from 216 g to 212 g carbohydrates, from 66 g to 64 g protein, from 299 g to 244 mg cholesterol. 10. Sustained intensive individual and family-based lifestyle counseling in daily life in terms of healthy diet, less sedentary behavior and more leisure time physical activity slightly improved the CVD risk factor profiles in parents and their children already after 1 year.

What do we Learn from the Prevention Education Program Family Heart Study about Lifestyle change, Blood Pressure, and Lipids in Children and Parents?

Objectives

The PEP Family Heart Study is a perspective community-based long-term project for the whole family to improve cardiovascular health aiming to assess and to amend risk factors in children and their parents by lifestyle change.

Methods

A total of 48,667 subjects (24,927 adults and 23,740 children) from 3,370 families living in 94% of the elementary school districts of Nuremberg (Germany) participated in this observational study from 1993/1994 -2007/2008. The yearly surveys consisting of personal and family histories, structured interviews on leisure time physical activity and tobacco smoke exposition, physical examinations and nutritional intake as documented by seven days weighed dietary protocols and sustained healthy lifestyle counselling were mainly performed at home. Fasting blood collections for biochemical analyses in the study laboratories, cooking courses and seminars on healthy lifestyle were performed on weekends in central school buildings.

Results

Here we report some of the main results demonstrating e.g., that at least one CVD risk factor in a child conferred a 2-4 fold higher risk among their parents, that obese children and adolescents had a nearly five times higher prevalence of hypertension than non-overweight youths.

Conclusions

Sustained healthy lifestyle behavior can be implemented in daily life of family members which results in amended nutritional intake and improved cardiometabolic risk factors.

Socioeconomic differences in prevalence of biochemical, physiological, and metabolic risk factors for non-communicable diseases among urban youth in Delhi, India

This study examined whether the distribution of biochemical, physiological, and metabolic risk factors for non-communicable diseases (NCDs) among children and youth in urban India vary by socioeconomic status (SES). Data were derived from a cross-sectional survey of students enrolled in the 2nd and 11th grades in 19 randomly selected schools in Delhi (N = 1329) in 2014-15. Mixed-effect regression models were used to determine the prevalence of risk factors for NCDs among private (higher SES) and government (lower SES) school students. After adjusting for age, gender, and grade we found the percentage of overweight (13.16% vs. 3.1%, p value < 0.01) and obese (8.7% vs. 0.3%, p value < 0.01) students was significantly higher among private relative to government school students. Similarly, significantly higher percentage of private school students had higher waist circumference values (7.72% vs. 0.58%, p value < 0.01) than government school students. Furthermore, similar trend was observed across schools in the distribution of other NCD risk factors: raised blood pressure, raised total cholesterol, and low-density lipoprotein. Surprisingly, despite a higher prevalence of all risk factors, significantly higher percentage of private school students had adequate/ideal levels of high-density lipoprotein. Overall, the risk profile of private school students suggests they are more vulnerable to future NCDs.

Impact of Obesity on Pediatric Acute Recurrent and Chronic Pancreatitis

OBJECTIVE

The aim of this study was to assess the impact of obesity on pediatric acute recurrent pancreatitis or chronic pancreatitis (CP).

METHODS

We determined body mass index (BMI) status at enrollment in INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) cohort using CDC criteria for pediatric-specific BMI percentiles. We used the Cochran-Armitage test to assess trends and the Jonckheere-Terpstra test to determine associations.

RESULTS

Of 446 subjects (acute recurrent pancreatitis, n = 241; CP, n = 205), 22 were underweight, 258 normal weight, 75 overweight, and 91 were obese. The BMI groups were similar in sex, race, and age at presentation. Hypertriglyceridemia was more common in overweight or obese. Obese children were less likely to have CP and more likely to have acute inflammation on imaging. Compared with children with normal weight, obese or overweight children were older at first acute pancreatitis episode and diagnosed with CP at an older age. Obese or overweight children were less likely to undergo medical or endoscopic treatment, develop exocrine pancreatic insufficiency, and require total pancreatectomy with islet autotransplantation. Diabetes was similar among all groups.

CONCLUSIONS

Obesity or overweight seems to delay the initial acute pancreatitis episode and diagnosis of CP compared with normal weight or underweight. The impact of obesity on pediatric CP progression and severity deserves further study.

Association of cardiovascular risk factors between Hispanic/Latino parents and youth: the Hispanic Community Health Study/Study of Latino Youth

PURPOSE

Hispanic/Latinos have a high burden of cardiovascular disease (CVD) risk factors which may begin at young ages. We tested the association of CVD risk factors between Hispanic/Latino parents and their children.

METHODS

We conducted a cross-sectional study in the Hispanic Community Health Study/Study of Latinos Youth study. Girls (n = 674) and boys (n = 667) aged 8 to 16 years (mean age 12.1 years) and their parents (n = 942) had their CVD risk factors measured.

RESULTS

CVD risk factors in parents were significantly positively associated with those same risk factors among youth. After adjustment for demographic characteristics, diet and physical activity, obese parents were significantly more likely to have youth who were overweight (odds ratios [ORs], 2.39; 95% confidence interval [CI], 1.20-4.76) or obese (OR, 6.16; 95% CI, 3.23-11.77) versus normal weight. Dyslipidemia among parents was associated with 1.98 higher odds of dyslipidemia among youth (95% CI, 1.37-2.87). Neither hypertension nor diabetes was associated with higher odds of high blood pressure or hyperglycemia (prediabetes or diabetes) in youth. Findings were consistent by sex and in younger (age <12 years) versus older (≥12 years) youth.

CONCLUSIONS

Hispanic/Latino youth share patterns of obesity and CVD risk factors with their parents, which portends high risk for adult CVD.

Factors associated with overweight among elementary schoolchildren in Campinas, São Paulo, Brazil

ABSTRACT Objective To assess overweight/obesity of elementary schoolchildren in Campinas , São Paulo , Brazil, and its association with parental nutritional status, children's food consumption, food preferences, and level of physical activity, and familial socioeconomic status. Methods This case-control study included 509 schoolchildren aged 7 to 10 years. Body mass index Z-score was used to determine nutritional status, defining cases (>+1 Z-score) and controls (³-2 ?+1 Z-score). To address association with overweight/obesity, a conceptual model was established and used for multiple analysis, performed by logistic regression. Results The children had an overweight/obesity frequency of 39.5%. Multiple analysis adjusted for socioeconomic level showed that overweight/obese children were more likely to eat at the mall (1.55; 95%CI=1.00-2.40), have overweight and obese parents (OR=1.71; 95%CI=1.08-2.71 and OR=3.55; 95%CI=2.18-5.80 respectively), report use of passive school transport (OR=1.57; 95%CI=1.04-2.36), and consume chicken nuggets on 3 or more days per week (OR=3.03; 95%CI=1.32-6.95). Conclusion These results support the urgent need of strategies to reduce overweight/obesity and promote its prevention in schoolchildren. Moreover, intervention studies involving parents and addressing environmental factors are important for the development of effective programs.

Universal screening for cardiovascular disease risk factors in adolescents to identify high-risk families: a population-based cross-sectional study

Background

Universal screening of children for dyslipidemia and other cardiovascular risk factors has been recommended. Given the clustering of cardiovascular risk factors within families, one benefit of screening adolescents may be to identify “at-risk” families in which adult members might also be at elevated risk and potentially benefit from medical evaluation.

Methods

Cross-sectional study of grade 9 students evaluating adiposity, lipids and blood pressure. Data collected by Heart Niagara Inc. through the Healthy Heart Schools’ Program. Parents completed questionnaires, evaluating family history of dyslipidemia, hypertension, diabetes and early cardiovascular disease events in parents and siblings (first-degree relatives), and grandparents (second-degree relatives). Associations between positive risk factor findings in adolescents and presence of a positive family history were assessed in logistic regression models.

Results

N = 4014 adolescents ages 14–15 years were screened; 3467 (86 %) provided family medical history. Amongst adolescents, 4.7 % had dyslipidemia, 9.5 % had obesity, and 3.5 % had elevated blood pressure. Central adiposity (waist-to-height ratio ≥0.5) in the adolescent was associated with increased odds of diabetes in first- (OR:2.0 (1.6–2.6), p < 0.001) and second-degree relatives (OR:1.3 (1.1–1.6), p = 0.002). Dyslipidemia was associated with increased odds of diabetes (OR:1.6 (1.1–2.3), p < 0.001), hypertension (OR:2.2 (1.5–3.2), p < 0.001) and dyslipidemia (OR:2.2 (1.5–3.2),p < 0.001) in first degree relatives. Elevated blood pressure did not identify increased odds of a positive family history.

Conclusions

Presence of obesity and/or dyslipidemia in adolescents identified through a universal school-based screening program is associated with risk factor clustering within families. Universal pediatric cardiometabolic screening may be an effective entry into reverse cascade screening.

Relation of Cardiometabolic Risk Factors between Parents and Children

OBJECTIVES

To explore the relations of parent-child cardiometabolic risk factors and assess the influence of adiposity on these associations.

STUDY DESIGN

Associations of adiposity, blood pressure (BP), lipids, fasting insulin and glucose, and a risk factor cluster score (CS) were evaluated in a cross-sectional study of 179 parents and their children (6-18 years, N = 255). Insulin resistance was assessed by euglycemic clamp in parents and children aged 10 years or older. Metabolic syndrome in parents was defined by National Cholesterol Education Program's Adult Treatment Panel III criteria. CSs of the risk factors were created based on age-specific z-scores. Analyses included Pearson correlation and linear regression, adjusted for parent and child age, sex, race, and body mass index (BMI), accounting for within-family correlation.

RESULTS

We found positive parent-child correlations for measures of adiposity (BMI, BMI percentile, waist, subcutaneous fat, and visceral fat; r = 0.22-0.34, all P ≤ .003), systolic BP (r = 0.20, P = .002), total cholesterol (r = 0.39, P < .001), low-density lipoprotein cholesterol (r = 0.34, P < .001), high density lipoprotein cholesterol (r = 0.26, P < .001), triglycerides (r = 0.19, P = .01), and insulin sensitivity (r = 0.22, P = .02) as well as CSs (r = 0.15, P = .02). After adjustment for BMI all parent-child correlations, except systolic BP, remained significant.

CONCLUSIONS

Although adiposity is strongly correlated between parents and children, many cardiometabolic risk factors correlate independent of parent and child BMI. Adverse parental cardiometabolic profiles may identify at-risk children independent of the child's adiposity status.

Prevalence of metabolic syndrome and associated cardiovascular risk factors in Guatemalan school children

Guatemala is experiencing a nutritional and lifestyle transition. While chronic malnutrition is prevalent, overweight, obesity and chronic diseases have increased substantially in the country. This study was conducted to investigate the prevalence of metabolic syndrome and the associated cardiovascular risk factors in the pre-adolescent Guatemalan population. A cross-sectional study was conducted among 302 Guatemalan children (8-13 years old) attending public and private schools in the Municipality of Chimaltenango. Demographic data and anthropometric and blood pressure measurements were collected. A blood sample was taken after an 8 h overnight fast and analyzed for glucose, triglyceride and high-density lipoprotein cholesterol levels. The data were analyzed to identify factors associated with metabolic syndrome and with its components. The prevalence of metabolic syndrome in the study population was 2.0 %. However, approximately 54 % of the children had at least one component of metabolic syndrome, while none had four or five of the components. The three most prevalent risk factors were high triglycerides (43.4 %), low HDL cholesterol (17.2 %) and obesity (12.3 %). Boys were more likely to be obese than girls and rural children were more likely to have higher triglyceride levels than urban children. Although the prevalence of metabolic syndrome is low, the fact that majority of the children already have at least one component of metabolic syndrome is cause for concern since components of metabolic syndrome can continue into adulthood and increase the risk for chronic diseases later in life. Therefore, immediate action should be taken to address the problem.

The Impact of Familial Predisposition to Obesity and Cardiovascular Disease on Childhood Obesity

The prevalence of childhood obesity has reached alarming rates world-wide. The aetiology seems to be an interplay between genetic and environmental factors, and a surrogate measure of this complex interaction is suggested as familial predisposition. Familial predisposition to obesity and related cardiovascular disease (CVD) complications constitute the presence of obesity and/or obesity-related complications in primarily blood-related family members. The approaches of its measurement and applicability vary, and the evidence especially of its influence on obesity and obesity treatment in childhood is limited. Studies have linked a familial predisposition of obesity, CVD (hypertension, dyslipidaemia and thromboembolic events), and type 2 diabetes mellitus to BMI as well as other adiposity measures in children, suggesting degrees of familial aggregation of metabolic derangements. A pattern of predispositions arising from mothers, parents or grandparents as being most influential have been found, but further comprehensive studies are needed in order to specify the exact implications of familial predisposition. In the scope of childhood obesity this article reviews the current literature regarding familial predisposition to obesity and obesity-related complications, and how these familial predispositions may impact obesity in the offspring.

Hypercholesterolemia--a disease with expression from childhood

INTRODUCTION

Hypercholesterolemia results from an alteration, genetic or acquired, in lipoprotein metabolism. Evidence that hypercholesterolemia is associated with the atherosclerotic process from childhood justifies the screening of high-risk children and initiation of therapy at preschool ages.

OBJECTIVE

To assess children referred for pediatric consultations due to hypercholesterolemia.

METHODS

Children and adolescents referred for pediatric consultations with a diagnosis of hypercholesterolemia were enrolled. Information on family history and clinical, anthropometric and biochemical parameters was recorded and, when appropriate, molecular study was performed.

RESULTS

A total of 168 children were assessed. Forty-six presented a familial hypercholesterolemia phenotype and in 22 of these, a mutation in the low-density lipoprotein (LDL) receptor gene was identified. The lipid profile of the group with mutations showed significantly higher values of total and non-high-density lipoprotein (HDL) cholesterol compared to the group without mutations (total cholesterol 316.5±75.9 mg/dl vs. 260.9±42,0 mg/dl; non-HDL cholesterol 268.3±72.6 mg/dl vs. 203.5±43.9 mg/dl; p<0.05). Of the total, 55 were prescribed pharmacological therapy and the others underwent diet and exercise interventions only. A greater reduction in LDL cholesterol was observed in individuals under pharmacological therapy compared to those prescribed diet and exercise only (30.3% vs. 18.1%). Drug side effects were insignificant.

CONCLUSION

It is possible to maintain a normal lipid profile in most individuals with familial hypercholesterolemia in order to reduce the risk of early onset of atherosclerosis, which is associated with serious cardiovascular complications from childhood.

[A cross-sectional study to assess cardiovascular risk in the children of parents with diabetes mellitus or arterial hypertension]

INTRODUCTION

Cardiovascular disease in adults is the first cause of death, and in adolescents under 15 years old, it is the third cause of death. The purpose of this study was to investigate which risk factors for cardiovascular disease have the children of parents with diabetes or hypertension.

MATERIAL AND METHODS

In a cross-sectional study conducted in the Family Medicine Unit No. 80 in Morelia, Michoacán, Mexico, were included 156 patients with diabetes mellitus, hypertension and without diabetes or hypertension (10 years of disease progression), and a biological child (age 7-15 years) to form pairs. Three groups were formed: child-parent with Diabetes; child-parent with Hypertension and child-parent without Diabetes or Hypertension. Medical history, body mass index, blood glucose, cholesterol, triglycerides, c-LDL, c-HDL and signs of metabolic syndrome were recorded.

RESULTS

The frequency of signs of metabolic syndrome was higher in parents with Diabetes (28.8%), and in children of parents without either diabetes or hypertension (11.5%). In binomial children-parents with Diabetes, serum glucose (OR=4.50: 95% CI; 2.32-8.73, P<.0001) was the most important risk factor to develop cardiovascular disease; in binomial children-parents with Hypertension it was total cholesterol (OR=4.143: 95% CI; 1.996-8.60, P<.0001); and, in binomial children-parents without either Diabetes or Hypertension, the abdominal circumference (OR=3.429: 95% CI; 1.621-7.251, P<.0001) was the most important risk factor.

CONCLUSIONS

We conclude that children of parents with or without diabetes mellitus or hypertension are at increased risk for developing cardiovascular disease. Longitudinal studies are required using non-pharmacological and pharmacological strategies that will have an impact on the most important risk factors for preventing cardiovascular disease.

Mothers' perceptions of family health history and an online, parent-generated family health history tool

Family health history (FHH) can identify families at increased risk for disease. Purpose. To learn mothers' (1) perceptions of the benefits of FHH and (2) willingness to complete a FHH tool, My Family Health Portrait (MFHP). Methods. Qualitative in-depth interviews were conducted with mothers recruited through Cincinnati Children's Hospital. Deductive and inductive codes were developed. Results. A total of 25 mothers were interviewed. Perceived benefits included keeping the pediatrician informed (n = 12; 48%) and preventive screenings recommended based on FHH (n = 10; 40%). Participants had positive impressions of MFHP and felt that it was user-friendly (n = 17; 68%). Lack of FHH knowledge was the most common challenge to completing MFHP, but most respondents stated that they would be able to complete MFHP prior to their child's medical appointment (n = 23; 92%). Conclusion. Mothers are interested in and may be motivated to complete a parent-generated FHH prior to a pediatric appointment. Future research should focus on FHH implementation in practice.

Metabolic risk factors and arterial stiffness in Indian children of parents with metabolic syndrome

OBJECTIVE

To investigate the possible association between metabolic syndrome (MS) and arterial stiffness in Indian children with parental MS status.

METHODS

A cross-sectional study was conducted in 140 overweight/obese and 60 normal-weight Indian children (mean age, 11.4 ± 2.8 years) along with one of their parents during 2008-2009. Data on weight, height, blood pressure, serum lipids, zinc, insulin, and glucose were collected. Intima media thickness (CIMT) and stiffness parameters were assessed in the right carotid artery. Physical activity and diet were assessed using structured questionnaires. Body composition was measured using dual-energy x-ray absorptiometry.

RESULTS

A gradual increase in the percentage of MS children with an increasing number of MS components in parents was observed. Mean values for arterial stiffness, pulse wave velocity, and elastic modulus were significantly higher in MS children of MS parents than in MS children of normal parents (p < 0.05). A significant correlation was observed for lifestyle, metabolic, and arterial parameters among child-parent pairs (p < 0.05). Multiple logistic regression revealed that children's CIMT and arterial stiffness were significantly associated (p < 0.01) with their serum levels of triglycerides, high-density lipoprotein, and zinc, as well as with parental MS-CIMT.

CONCLUSION

Parental MS status and lifestyle factors increase the risk of MS and arterial abnormalities in children.

[Overweight and obesity in prepubertal schoolchildren: the association with low birth weight and family antecedents of cardiovascular disease. Embu - metropolitan region of São Paulo, 2006]

The aim was to determine the prevalence of overweight and obesity in schoolchildren and the association with birth weight and family antecedents of cardiovascular disease. This cross-sectional study used a probabilistic sample of 929 schoolchildren aged 6 to 10 years. The variables were: body mass index (BMI), birth weight and family antecedents of cardiovascular disease. The statistical analysis consisted of the chi-square test (Pearson) and odds ratio, as association measurements. Of the schoolchildren (54.6% of which were female), 14.4% and 13.3% were overweight and obese, respectively. Low birth weight was reported among 9.4% and family antecedents of cardiovascular disease among 35.2%. Overweight or obesity (BMI e" P85) was associated with the presence of family antecedents of cardiovascular disease (OR = 1.66; 95% CI 1.23-2.23) and male sex (OR = 1.37; 95%CI 1.02-1.83); there was no association with birth weight. The results indicate the need for preventive actions for children with family antecedents of cardiovascular disease.

The child as proband for future parental cardiometabolic disease: the 26-year prospective Princeton Lipid Research Clinics Follow-up Study

OBJECTIVE

To evaluate children's cardiovascular disease (CVD) risk factors as predictors of parents' subsequent CVD, type 2 diabetes mellitus (T2DM), and high blood pressure (HBP).

STUDY DESIGN

We conducted a 26-year prospective follow-up of 852 5- to 19-year-old black and white schoolchildren (mean age, 12 years; Lipid Research Clinics, 1973-8), and parents (mean age, 40 years) from 519 families in Princeton Schools, Cincinnati, Ohio. Schoolchildren were reassessed in the Princeton Follow-up study 1999-2003 at mean age 39 years; CVD, T2DM, and HBP history of their 1038 parents were reassessed by mean age 66 years. We assessed relationships of childhood risk factors with parental CVD, T2DM, and HBP. Child-probands identified with triglyceride (TG) levels, blood pressure, low-density lipoprotein cholesterol levels, body mass index (BMI), and glucose level greater than and high-density lipoprotein cholesterol levels less than established cutoff points.

RESULTS

Pediatric HBP (P=.006) and low high-density lipoprotein cholesterol (P=.018) were predictive of parental CVD at age ≤50 years. Pediatric HBP (P=.02) and high TG (P=.03) were predictive of parental CVD at age ≤60 years. Pediatric high TG (P=.009) and high low-density lipoprotein cholesterol (P=.04) were predictive of parental CVD by age 66 years. Pediatric high BMI (P=.0006) were predictive of parental T2DM. Pediatric high BMI (P=.003) and black race (P=.004) were predictive of parental HBP.

CONCLUSIONS

Pediatric risk factors identify families with parents at increased risk for CVD, T2DM, and HBP, emphasizing the usefulness of the child as proband.

Prevalência de pressão arterial elevada em crianças e adolescentes do ensino fundamental

OBJETIVO: Verificar a prevalência de pressão arterial elevada em crianças e adolescentes e sua associação com indicadores antropométricos. MÉTODOS: Estudo transversal de estudantes de três instituições de ensino em Botucatu (SP). As variáveis avaliadas foram: pressão arterial (PA) (obtida em três ocasiões diferentes), peso, estatura, índice de massa corporal (IMC), circunferência braquial, circunferência abdominal (CA), dobras cutâneas tricipital e subescapular. A PA foi aferida por método auscultatório e classificada em pré-hipertensão (PH) e hipertensão arterial (HAS), para os valores entre os percentis 90 e 95 e maior que o percentil 95, respectivamente. Os dados antropométricos foram comparados, segundo o sexo, pelo teste t de Student. A correlação de Pearson foi utilizada para verificar a variação das PA sistólica (PAS) e diastólica (PAD) segundo dados antropométricos. A variação do escore Z da PA segundo percentil de IMC foi avaliada pela análise de variância seguida do teste de Tukey. RESULTADOS: Foram avaliadas 903 crianças (51,7% meninos), com idade de 9,3±2,5 anos para ambos os sexos. A prevalência de PH foi de 9,1% e de HAS foi de 2,9%. Houve correlação positiva significativa entre os níveis de PAS e PAD elevados e as variáveis antropométricas, com valores maiores para peso (r=0,53 e r=0,45, p<0,05, respectivamente) e CA (r=0,50 e r=0,38, p<0,05, respectivamente). CONCLUSÕES: A prevalência de níveis pressóricos elevados nesta casuística foi compatível com outros estudos brasileiros e internacionais, correlacionando-se positivamente com indicadores antropométricos elevados, o que sinaliza a influência do excesso de peso na PA já na infância.

Gender differences in cardiovascular risk factors among adolescents in Aseer Region, southwestern Saudi Arabia

OBJECTIVE

The objective of this study was to explore gender differences in the prevalence of silent and clinical apparent cardiovascular risk factors among adolescents in Aseer Region, southwestern Saudi Arabia.

MATERIALS AND METHODS

A cross-sectional study on a stratified sample of 1869 adolescents was carried out. They were interviewed and examined for weight and height, systolic and diastolic blood pressure using standardized techniques.

RESULTS

The study revealed high prevalence of some potential behavioral and biological cardiovascular diseases (CVD) risk factors among adolescent males and females in the study area. Behavioral risk factors included inadequate low consumption of fruits and vegetables, physical inactivity, and smoking. Physical inactivity was significantly more prevalent among females than males (42.9% and 25.7%, respectively). Smoking was significantly more among females than males (11.8% and 1.3%, respectively). Biological risk factors found were family history of CVD, obesity and high blood pressure. Obesity was significantly prevalent among females (29.4%) compared to males (20.6%). Males had significantly more high blood pressure than females. In logistic regression analysis, being male (aOR = 2.992, 95% CI = 1.933-4.742) and obesity (aOR = 2.995, 95% CI = 2.342-3.991) were found to be significant risk factors in developing high blood pressure among adolescents in the region.

CONCLUSIONS

Presence of cardiovascular risk factors among adolescents is a public health problem in the region. There is a need for a national program in the country to prevent and control cardiovascular risk factors among adolescents.

Waist circumference and risk of elevated blood pressure in children: a cross-sectional study

Background

Increasing childhood obesity has become a major health threat. This cross-sectional study reports associations between schoolchildren's waist circumference (WC) and risk of elevated blood pressure.

Methods

We measured height, weight, neck and waist circumference, and blood pressure in regular health examinations among children in grade 1 (ages 6-7 years) at six elementary schools in Taipei County, Taiwan. Elevated blood pressure was defined in children found to have mean systolic or diastolic blood pressure greater than or equal to the gender-, age-, and height-percentile-specific 95th-percentile blood pressure value.

Results

All 2,334 schoolchildren were examined (response rate was 100% in the six schools). The mean of systolic and diastolic blood pressure increased as WC quartiles increased (p < 0.0001). The prevalence of elevated blood pressure for boys and girls within the fourth quartile of waist circumference was 38.9% and 26.8%, respectively. In the multivariate logistic regression analyses, the adjusted odds ratios of elevated blood pressure were 1.78 (95% confidence interval [CI] = 1.13-2.80), 2.45 (95% CI = 1.56-3.85), and 6.03 (95% CI = 3.59-10.1) for children in the second, third, and fourth waist circumference quartiles compared with the first quartile. The odds ratios for per-unit increase and per increase of standard deviation associated with elevated blood pressure were 1.14 (95% CI = 1.10-1.18) and 2.22 (95% CI = 1.76-2.78), respectively.

Conclusions

Elevated blood pressure in children was associated with waist circumference. Not only is waist circumference easier to measure than blood pressure, but it also provides important information on metabolic risk. Further research is needed on effective interventions to identify and monitor children with increased waist circumference to reduce metabolic and blood pressure risks.

Perceived utility of parent-generated family health history as a health promotion tool in pediatric practice

OBJECTIVES

The purpose of this study was to describe how pediatric providers collect and use family health history (FHH) and their perceptions about My Family Health Portrait (MFHP) as a pediatric health promotion and disease prevention tool. STUDY DESIGNL: A random sample of 148 pediatric providers was invited to participate in a semistructured qualitative interview. Transcripts were reviewed by 2 coders, and interrater reliability was determined.

RESULTS

In all, 21 providers were interviewed. All participants collected FHH at new visits and when patients presented with a symptom or complaint. Most providers believed that collecting FHH of chronic disease benefits the pediatric population. Time was the most commonly cited barrier to FHH collection; collecting FHH prior to the office visit was the most frequently cited facilitator. Providers believed that the use of MFHP would improve FHH collection and allow targeted education and preventive recommendations. Respondents also identified logistical and other issues that must be resolved to integrate MFHP into clinical practice.

CONCLUSION

This research suggests that pediatric primary care presents many opportunities to collect and discuss FHH and that providers are optimistic about the clinical use of a parent-generated FHH collection tool. Future research should assess parent perspectives about the use of MFHP.

Hypertriglyceridemia in a pediatric referral practice: experience with 300 patients

BACKGROUND

Pediatric hypertriglyceridemia is an emerging comorbidity of childhood obesity.

METHODS

This study reviewed medical records retrospectively to describe the characteristics and clinical course of 300 at-risk children followed in a pediatric preventive cardiology clinic.

RESULTS

Average baseline triglyceride (TG) level was 269 mg/dL (SD 342 mg/dL); 91% had TG levels between 150 and 399 mg/dL. A total of 77% were overweight/obese, 23% had elevated blood pressure, 23% had a family history of high triglycerides, and 11% reported a psychiatric diagnosis (33.3% of those with severe TG elevations). Diet and activity change were the first-line therapies; few were taking lipid-lowering medications (baseline, 5.1%; follow-up, 11.4%). TG levels declined by 23% (average, 88 mg/dL; SD 231), often with a decline or plateau in TG risk category. Children with a lower body mass index (<85% gender- and age-matched percentile) were more likely to improve in TG category than heavier children (70% vs 40%; P ≤ .05).

Overweight and waist circumference among Norwegian 11-year-olds and associations with reported parental overweight and waist circumference: The HEIA study

Aims: The aim of this paper is to investigate anthropometric characteristics in 11-year-old Norwegian by gender and parental education, and to study associations between adolescents’ overweight and waist circumference (WC) and maternal and paternal overweight and WC. Methods: A total of 1483 adolescents, 1156 mothers, and 1016 fathers participated in the baseline survey of the HEalth In Adolescents (HEIA) study (September 2007). Anthropometric measures of the adolescents were assessed by project staff according to standard procedures. Self-reported data about pubertal status were collected through questionnaires. Parental education and anthropometric measures of parents were collected by self-report. Results: The prevalence of overweight (including obesity) determined by the cut-offs for body mass index (BMI) suggested by the International Obesity Task Force was 14.6% among girls and 13.6% among boys. The highest prevalence of overweight was observed among adolescents with parents who had less than 12 years of education (18.8%). Overweight and WC in girls was strongly associated with maternal overweight and WC. For boys, overweight and WC was strongly associated with both maternal and paternal overweight and WC. Conclusions: There was a social gradient in anthropometric characteristics and overweight rates among Norwegian 11-year-old adolescents. Maternal overweight and WC was associated with overweight and WC in girls and boys, while paternal overweight and WC were associated with overweight and WC in boys. The results indicate that mothers are key persons in prevention of overweight among adolescents, despite gender. Fathers are important as role models for their sons. Targeting parental overweight/ obesity could be a strategy in future interventions.

Lifestyle and cardiovascular risk factors in 2001 child-parent pairs: the PEP Family Heart Study

OBJECTIVE

Genes and environment are the main determinants of cardiovascular disease (CVD) risk factor clustering in families. Since individual risk factor profiles are easily predicted within families, we examined whether CVD risk factors are affected by lifestyle factors in these families.

METHODS

Nutrition, physical activity, and smoking habits were assessed in 2001 biological child-parent pairs from 852 families participating in the Prevention Education Program (PEP). Height, weight, body mass index, waist circumference, blood pressure, and fasting lipid levels were measured. Within-family associations were calculated using generalized estimating equations (GEE).

RESULTS

Fathers possessed the most adverse risk profile. Daily energy consumption above the recommended levels was higher in children (daughters +35.4%, sons +26.7%) than in parents (fathers +15.7%, mothers +10.6%). Higher energy consumption was significantly associated with hypertension in mothers (OR 2.5) and in fathers (OR 1.7). Hyper-caloric nutrition of the parents predicted the energy intake of the children in: mother-daughter (OR 7.5), mother-son (OR 3.0), and father-son (OR 2.8) pairs. Low mono-unsaturated fatty acid intake was significantly associated with a high LDL/HDL-C ratio (OR 3.4) and hypertriglyceridemia (OR 2.2) in fathers. Approximately 25% of parents and children reported at least two physical activities twice a week. The 23% of children who were passive smokers presented a far more adverse risk profile than children without exposure to second-hand smoke.

CONCLUSION

Intergenerational lifestyle habits affect cardiovascular risk factors within biological families. As lifestyle habits are predictable, they may be used for implementation of family-based CVD prevention strategies.

Insulin resistance among Brazilian schoolchildren: association with risk factors for cardiovascular diseases

AIM

Our purpose was to evaluate Insulin Resistance (IR) and its association with risk factors for cardiovascular diseases (CVDs) among 161 (6- to 10-year-old) schoolchildren.

METHODS

This two-stage cross-sectional study evaluated: BMI, blood pressure, personal history (birth weight) and family history of CVDs. Children with at least one of the following criteria participated in the second stage: obesity, personal or family history. Insulin resistance was determined using Homeostasis Model Assessment (HOMA).

RESULTS

The HOMA distribution in terciles showed mean values for the first, second and third tercile of 0.41, 0.79 and 2.11 respectively. The HOMA distribution in the third tercile demonstrated statistically significant associations with overweight/obesity (p = 0.007), hypertension (p = 0.008) and low HDL (p = 0.02). Analysis of mean birth weight in each tercile and between terciles did not present any positive correlation (p = 0.213).

CONCLUSION

Higher levels of HOMA (IR) were positively associated with risk factors for CVD among schoolchildren.

Circulating triglycerides after a high-fat meal: predictor of increased caloric intake, orexigenic peptide expression, and dietary obesity

Recent studies in normal-weight rats have linked circulating triglycerides (TG), when elevated by a high-fat (HF) compared to equicaloric low-fat (LF) meal, to an increase in subsequent food intake and hypothalamic expression of orexigenic peptides. The present study tested whether natural variations between rats in their TG levels after a small HF meal can also be related to their individual patterns of eating and peptide expression. In tail vein blood collected on three separate days 60 min after a HF meal, levels of TG were found to be strongly, positively correlated within rats from day to day but were highly variable between rats (75-365 mg/dl), allowing distinct subgroups (33% lowest or highest) to be formed. Compared to "Low-TG responders" with post-meal levels averaging 109 mg/dl, "High-TG responders" with 240 mg/dl showed in two separate experiments a significant increase in caloric intake in a subsequent laboratory chow meal. Before this larger meal, these rats with elevated TG consistently exhibited higher expression levels and synthesis of the orexigenic peptides, enkephalin, orexin and melanin-concentrating hormone, as revealed using real-time quantitative PCR, radiolabeled in situ hybridization, and immunofluorescence histochemistry. Over the long-term, the High-TG responders also showed an increased propensity to overeat, gain weight and accumulate excess body fat on a chronic HF diet. This simple measure of TG levels after a HF meal may offer a useful tool for identifying subpopulations with increased risk for overeating and dietary obesity and detecting early signs of brain disturbances that may contribute to this high-risk phenotype.

Community-based participatory research from the margin to the mainstream: are researchers prepared?

Despite an increasing arsenal of effective treatments, there are mounting challenges in developing strategies that prevent and control cardiovascular diseases, and that can be sustained and scaled to meet the needs of those most vulnerable to their impact. Community-based participatory research (CBPR) is an approach to conducting research by equitably partnering researchers and those directly affected by and knowledgeable of the local circumstances that impact health. To inform research design, implementation and dissemination, this approach challenges academic and community partners to invest in team building, share resources, and mutually exchange ideas and expertise. CBPR has led to a deeper understanding of the myriad factors influencing health and illness, a stream of ideas and innovations, and there are expanding opportunities for funding and academic advancement. To maximize the chance that CBPR will lead to tangible, lasting health benefits for communities, researchers will need to balance rigorous research with routine adoption of its conduct in ways that respectfully, productively and equally involve local partners. If successful, lessons learned should inform policy and inspire structural changes in healthcare systems and in communities.

Metabolic syndrome among prepubertal Brazilian schoolchildren

This was a two-stage cross-sectional study that assessed metabolic syndrome and associated factors among prepubertal schoolchildren. In the first stage, nutritional status, blood pressure, personal (low birth weight) and family antecedents for cardiovascular disease (CVD) were collected. In the second stage, schoolchildren with at least one of these criteria participated: obesity, personal or family history. Metabolic syndrome (MS) was defined by ATP III and WHO definitions. Among 929 (6-10 year old) schoolchildren, 27.7% presented with overweight/obesity, 12.2% hypertension, and personal (9.4%) and family (35.3%) antecedents. 205 children finished the second stage. The frequencies of MS-ATP and MS-WHO were 9.3% and 1.9%. Among the obese, MS was present in 25.8% (ATP) and 5.2% (WHO). Children with normal weight presented: low HDL (23.6%), hyperglycaemia (3.6%), HOMA-IR (0.9%) and MS-ATP (0.9%). In conclusion, overweight/obesity was associated with metabolic syndrome in schoolchildren. It was found that children with normal weight with personal and/or family antecedents presented with HOMA-IR and MS-ATP.

C-reactive protein and metabolic syndrome in youth: a strong relationship?

OBJECTIVE

Metabolic syndrome (MS) is on the rise in youth. As high-sensitivity C-reactive protein (hs-CRP) is associated with cardiovascular/metabolic disorders, we evaluated the association between MS and its components and hs-CRP in a sample of Brazilian overweight and obese youth.

METHODS AND PROCEDURES

A total of 407 students (229 girls, 273 with excessive weight, 11.3+/-3.2 years) were evaluated. Measurement included BMI, waist circumference (WC), blood pressure, lipids, insulin, and hs-CRP. Excessive weight was defined using BMI z -score; MS by the modified National Cholesterol Education Program-Adult Treatment Panel III.

RESULTS

Subjects were classified into two groups: with MS (n=72) and without (n=335). hs-CRP means and medians were higher in MS group (1.41 mg/l vs. 1.06 mg/l, P<0.001; 2.21 mg/l vs. 1.23 mg/l, P<0.001). Associations between hs-CRP quartiles and insulin resistance (IR) (P<0.001), MS (P<0.001), WC (P<0.000), BMI z-score (P<0.001), hypertension (P<0.001), hypertriglyceridemia (P<0.001), and low HDL-c (P=0.023) were significant; adjustment of hs-CRP for BMI z-score eliminated the previous association, except for the number of MS components (nMSc) (P<0.001). Adjusting for homeostasis model assessment method of IR (HOMA-IR) did not eliminate the relation between hs-CRP and MS components. Furthermore, increases in BMI z-score and nMSc were associated with an increased hs-CRP. Excessive weight (odds ratio (OR), 7.9; confidence interval (CI), 4.7-13.4; P=0.000), hypertension (OR, 2.3; CI, 1.3-4.2; P=0.003), and hypertriglyceridemia (OR, 2.3; CI, 1.5-3.7; P<0.001) were independently associated with hs-CRP.

DISCUSSION

In youth, hs-CRP is strongly related with MS and its components, and is also determined by the body composition. This association indicates a precocious proinflammatory state.

Metabolic syndrome rates in United States adolescents, from the National Health and Nutrition Examination Survey, 1999-2002

OBJECTIVE

To report the prevalence rates of the metabolic syndrome in a nationally representative sample of adolescents in the United States using 4 previously reported definitions of the syndrome.

STUDY DESIGN

Data from 12- to 19-year-old adolescents included in the National Health and Nutrition Examination Survey from 1999 to 2002 (NHANES 99-02) were analyzed by cross-sectional methods, by using 4 definitions of the metabolic syndrome previously applied to adolescents.

RESULTS

In NHANES 99-02, the prevalence of the metabolic syndrome in all teens varied from 2.0% to 9.4% of teens in the United States, depending on the definition used. In obese teens, these prevalence rates varied from 12.4% to 44.2%. In the group of obese teens, application of the definition by Cruz produced a metabolic syndrome prevalence rate of 12.4%; that of Caprio produced a rate of 14.1%. However, none of the normal weight or overweight teens met either definition. Application of the definition by Cook produced a prevalence rate of 7.8% in overweight teens and 44% in obese teens. The adult definition of metabolic syndrome produced a prevalence rate of 16% in overweight teens and 26% in obese teens.

CONCLUSIONS

In the period between 1999 and 2002, the prevalence rate of metabolic syndrome varied from just >9% to as low as 2% of adolescents overall. Different definitions of metabolic syndrome generated prevalence rates in obese adolescents that varied widely from 12% to 44%. For this syndrome to be a useful construct, a more standardized set of criteria may be needed.

Vascular disease in paediatric type 2 diabetes: the state of the art

Type 2 diabetes is an emerging problem in the paediatric population. Paediatricians and paediatric endocrinologists are struggling with how to best assess, predict and treat cardiovascular risk factors in these patients. There is a notable lack of consensus in how to proceed, even among experts in the field. There are very limited data from quality trials in established paediatric type 2 diabetes. We address the available information regarding traditional and non-traditional indices of cardiovascular risk, including examination findings, biochemical markers and non-invasive imaging modalities. We discuss the utility and pitfalls of applying knowledge gained in adult medicine to the paediatric population. Potential treatment strategies are reviewed, including the currently available pharmaceutical options, with the acknowledgement that there are few drugs formally approved in the paediatric population.