<13 Percentile-based
Use the lower of the age/sex/height percentile rule or the guideline’s absolute threshold. The higher category of systolic or diastolic BP controls.
Section 3 · Integrated cardiovascular health schedule
This visit: birth to 12 months
Eight risk domains, every well-child visit. The panel’s design intent is that none of these is a specialist referral question — all of it belongs to the primary pediatric care provider.
Apply it · Five decisions residents get asked to make
Decision tools
Each tool walks the guideline’s own algorithm and returns the next step with its evidence grade. Nothing is stored, sent, or logged — all logic runs in this page. Use it to check your reasoning, not to replace it.
Enter an age and press the button. Current screening pivots at age 2, the universal 9–11-year window, and age 19.
Enter a panel. The tool classifies every value against the pediatric cut points, then runs the LDL and triglyceride algorithms (Figures 9-1 and 9-2).
Use the current hypertension academy
The 2004/Fourth Report tool in the source upload was intentionally removed. Its categories and thresholds are obsolete. The linked academy implements the 2017 AAP office pathway and the 2022 AHA ambulatory BP update, including measurement technique, age-specific classification, follow-up timing, ABPM phenotypes, workup, and treatment.
≥13 Fixed thresholds
Normal <120/<80; elevated 120–129/<80; stage 1 130/80–139/89; stage 2 ≥140/90.
ABPM Confirm phenotype
Use ambulatory monitoring to distinguish sustained, white-coat, masked, and isolated nocturnal hypertension. BP load is no longer part of the 2022 classification.
The 2023 AAP guideline replaced staged watchful waiting
Treat overweight or obesity and associated comorbidities concurrently. Use a family-centered, nonstigmatizing chronic-care model; do not require a failed six-month lifestyle trial before offering evidence-based treatment.
Define Measure precisely
Overweight is BMI ≥85th to <95th percentile; obesity is ≥95th; severe obesity is ≥120% of the 95th percentile. Measure BMI percentile at least annually from ages 2–18.
Evaluate Find comorbidity
At age ≥10 with obesity, obtain fasting lipids and evaluate glucose metabolism and ALT; with overweight, obtain fasting lipids and add glucose/ALT when risk factors are present. Measure BP at every visit from age 3 with overweight or obesity.
IHBLT Dose matters
Provide or refer children ≥6 years—and consider ages 2–5—for intensive, family-based, multicomponent treatment. The most effective programs provide at least 26 face-to-face hours over 3–12 months.
Escalate Do not delay
Offer weight-loss pharmacotherapy from age 12 with obesity as an adjunct to behavioral treatment. Offer referral for metabolic/bariatric surgery evaluation from age 13 with severe obesity.
Historical risk-tier model
This tool reconstructs the NHLBI/Kavey high- and moderate-risk tiers for board-oriented context. It is not a current condition-specific treatment protocol. Verify targets and drug decisions against the current diabetes, CKD, transplant, Kawasaki disease, inflammatory disease, HIV, or nephrotic-syndrome guidance.
These children are managed to tighter numbers than everyone else on this page. One condition skips the six-month lifestyle trial entirely.
Know cold · The numbers behind every decision
Reference tables
These tables preserve the NHLBI framework residents still encounter. Pediatric population cut points remain useful for classification, but the 2026 FH treatment rule and current adult pathway supersede legacy medication and transition rules.
| Measure | Acceptable | Borderline | High |
|---|---|---|---|
| Total cholesterol | <170 | 170–199 | ≥200 |
| LDL cholesterol | <110 | 110–129 | ≥130 |
| Non-HDL cholesterol | <120 | 120–144 | ≥145 |
| Apolipoprotein B | <90 | 90–109 | ≥110 |
| Triglycerides, 0–9 y | <75 | 75–99 | ≥100 |
| Triglycerides, 10–19 y | <90 | 90–129 | ≥130 |
| HDL cholesterol | >45 | 40–45 | <40 (low) |
| Apolipoprotein A-1 | >120 | 115–120 | <115 (low) |
| Measure | Acceptable | Borderline | High |
|---|---|---|---|
| Total cholesterol | <190 | 190–224 | ≥225 |
| LDL cholesterol | <120 | 120–159 | ≥160 |
| Non-HDL cholesterol | <150 | 150–189 | ≥190 |
| Triglycerides | <115 | 115–149 | ≥150 |
| HDL cholesterol | ≥45 | 40–44 | <40 (low) |
| Level | Counts as |
|---|---|
| High | Hypertension requiring drug therapy · current smoker · BMI ≥97th percentile · diabetes (type 1 or 2) · CKD/ESRD/post-renal transplant · post-heart transplant · Kawasaki with current aneurysms |
| Moderate | Hypertension not requiring drugs · BMI ≥95th to <97th percentile · HDL-C <40 mg/dL · Kawasaki with regressed aneurysms · chronic inflammatory disease · HIV · nephrotic syndrome |
| Family history | MI, angina, CABG/stent/angioplasty, or sudden cardiac death in a parent, grandparent, aunt, or uncle — men <55 y, women <65 y |
| Diet | Use it when | Fat prescription | The distinguishing feature |
|---|---|---|---|
| CHILD-1 | Any of: positive family history, dyslipidemia, obesity, primary hypertension, diabetes, smoke exposure at home. Also the universal diet from age 2. | Total fat 25–30% kcal Saturated 8–10% Cholesterol <300 mg/d Trans fat: avoid |
Fat-free unflavored milk as the primary beverage from age 2. No sugar-sweetened beverages; juice capped at 4–6 oz/d. DASH-style pattern. |
| CHILD-2–LDL | Elevated LDL persisting after 3 months of CHILD-1. | Total fat 25–30% kcal Saturated <7% Monounsaturated ~10% Cholesterol <200 mg/d |
Registered dietitian referral is B strongly recommended. Optional adjuncts: plant sterol/stanol esters up to 2 g/d after age 2; psyllium 6 g/d ages 2–12, 12 g/d over 12. |
| CHILD-2–TG | Elevated triglycerides or elevated non-HDL after CHILD-1. | Same fat targets as CHILD-2–LDL | Carbohydrate is the lever, not fat: cut simple sugars, replace with complex carbohydrate, eliminate sugar-sweetened beverages, increase dietary fish. Weight loss when obesity is present. |
| When | What you check | Action threshold |
|---|---|---|
| Baseline | Hepatic panel (ALT, AST); CK when muscle symptoms or myopathy risk make it informative. Screen current medications for interactions. Address pregnancy potential. | Choose an age-approved agent and initial dose; document the monitoring plan. |
| 4 weeks | Fasting lipid profile, ALT, AST | ALT or AST >3× ULN → hold, repeat in 2 weeks |
| 8 weeks, then 3 months | Fasting lipid profile, ALT, AST | Goal LDL-C <130 mg/dL minimum; ideal <110 mg/dL |
| Any muscle symptom | Stop the drug, measure CK, ask about recent exercise | CK >10× ULN is the worrisome level |
| Maintenance | Lipids, ALT, AST every 3–4 months in year one, then every 6 months. Track height, weight, BMI, and sexual maturation at every visit. | Escalate by one dose increment (usually 10 mg) only after 3 months of compliant use. |
| Interacting drugs | Cyclosporine, niacin, fibric acid derivatives, erythromycin and other macrolides, azole antifungals, nefazodone, HIV protease inhibitors, antiarrhythmics — all via cytochrome P-450. | |
Test yourself · Eight clinic decisions
Can you apply it unaided?
Single best answer. Feedback explains why the distractors fail and names the table or figure the answer comes from — the same discipline the guideline uses on itself.
Answered 0 of 8
Honesty about vintage
What has changed since 2011
This document is fifteen years old. Most of it has held up; two sections have been formally replaced. Teach it with the amendments attached.
BP Superseded
The 2017 AAP Clinical Practice Guideline replaced the Fourth Report tables. “Prehypertension” became elevated blood pressure; normative tables were rebuilt from normal-weight children; adolescents ≥13 y use fixed thresholds; and ABPM gained a formal confirmatory role. The obsolete calculator was removed from this module and replaced by a bridge to the dedicated hypertension academy.
Lipids Reinforced and extended
The 2026 ACC/AHA multisociety dyslipidemia guideline retired the 2018 cholesterol guideline. It recommends universal screening at 9–11, repeat screening at age 19 and at least every 5 years thereafter, cascade screening from age 2 when family history is concerning, and generally permits nonfasting screening. For an FH-consistent presentation, statin therapy is recommended from age 8 when LDL-C remains ≥160 mg/dL after 3–6 months of lifestyle therapy. The USPSTF 2023 statement remains an I statement; that is uncertainty about population-level net benefit, not evidence that screening is ineffective.
Obesity Superseded
The 2023 AAP Clinical Practice Guideline moved away from watchful waiting: provide or refer for intensive health behavior and lifestyle treatment, treat comorbidities concurrently, offer pharmacotherapy as an adjunct from age 12 with obesity, and offer surgical evaluation from age 13 with severe obesity. The uploaded six-month-failure calculator was removed.
DM Screening criteria revised
The ADA table reproduced in the 2011 report required overweight plus two risk factors. The 2026 ADA Standards of Care require overweight or obesity plus one risk factor, accept A1c or an oral glucose tolerance test alongside fasting glucose, and use a minimum retesting interval of every three years when results are normal.
Diet Refreshed on a 5-year cycle
The original report cited the 2010 edition. The current Dietary Guidelines for Americans, 2025–2030 was released in January 2026. The CHILD diet remains the lipid-specific framework here; use the current federal guideline for broader nutrition counseling.
Core What has not changed
The state-of-the-science argument in Section 2 is the durable part: atherosclerosis begins in childhood, its extent tracks with the number and intensity of risk factors, those risk factors track into adult life, and effective interventions exist. That chain of inference — assembled because the definitive randomized trial is unaffordable and would take decades — is still the justification for everything pediatricians do in primary prevention.
How to read an evidence grade in this document
A well-designed RCTs or diagnostic studies in a similar population B RCTs with minor limitations, genetic natural-history studies, or overwhelmingly consistent observational evidence C observational studies D expert opinion, case reports, or first-principles reasoning.
The grade describes the evidence; the strength of recommendation is stated separately. A strong recommendation may sit on grade B or C evidence where the panel judged that high-quality evidence is impossible to obtain and benefit clearly outweighs harm — which is exactly the situation across most of pediatric primary prevention.