Small studies in children demonstrate similar improvements.118,119 In addition, the reduction in LVM appears to be correlated with the degree in blood pressure reduction with treatment (Fig 25.3).119 FIG 25.3 Correlation between changes in systolic blood pressure (BP) zscore and left ventricular mass index (LVMI) in children and adolescents following pharmacologic treatment for systemic hypertension (Modified from Kupferman JC, Paterno K, Mahgerefteh J, et al Improvement of left ventricular mass with antihypertensive therapy in children with hypertension Pediatr Nephrol 2010;25[8]:1513–1518.) Lifestyle modification is the initial therapy for youth with elevated blood pressure and stage 2 hypertension without LVH In infants and children, modest reductions in salt intake yield significant reductions in blood pressure.120 A randomized trial of the Dietary Approaches to Stop Hypertension (DASH) diet in adolescents with elevated blood pressure resulted in higher intakes of fruits, vegetables, and low-fat dairy products and lower intake of total fat, resulting in significant decreases in systolic blood pressure.121 There is strong evidence in adults that increased physical activity promotes reductions in blood pressure,122 with some suggestions of similar but weaker independent associations in children.123,124 In addition, physical activity promotion and reduction in sedentary activities are lifestyle recommendations for overweight and obesity in children.23 Therefore increasing physical activity should be included in the recommended lifestyle modifications for children with elevated blood pressure or hypertension Pharmacologic therapy is indicated for children who remain hypertensive despite lifestyle therapy, those who have symptomatic hypertension, those with stage 2 hypertension, and in those with hypertension at any stage with chronic kidney disease or diabetes mellitus.89 First-line medications include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, long-acting calcium channel blockers, and thiazide diuretics At present, the literature does not support the preferential use of any one class of antihypertensives in children In addition, long-term safety data are not available.23,89 Dyslipidemia The Expert Panel universally recommends a nonfasting non-high-density lipoprotein cholesterol (non-HDL-C) assessment for all children between ages 9 and 11 years old and again between 17 and 21 years old.23 Non-HDL-C (nonHDL-C = TC – HDL) measures the TC content of all atherogenic apoBcontaining lipoproteins and can be obtained in the nonfasting state.23 Childhood non-HDL-C appears to be superior to LDL-C in predicting adult dyslipidemia and nonlipid CVD risk factors.125 If a nonfasting HDL-C is not available, cutpoints for additional action for elevated levels of nonfasting TC are also provided in the guidelines Additional screening, in the form of two averaged fasting lipid profiles, should be performed between 2 and 8 years old and between 12 and 16 years old in children with a family history of premature CVD in a parent, grandparent, aunt/uncle, or sibling; a parent with a TC greater than 240 mg/dL or known dyslipidemia; if the patient has diabetes, hypertension, is overweight (for 12- to 16-year-old screening) or obese (for 2- to 8-year-old screening); if the patient smokes cigarettes; or if the patient has a moderate- or high-risk medical condition (Table 25.4) Table 25.4 Moderate- and High-Risk Medical Conditions Moderate Risk Kawasaki disease with regressed coronary aneurysms Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis) High Risk Type 1 or type 2 diabetes Chronic kidney disease/end-stage renal disease/postrenal transplant HIV infection Nephrotic syndrome Postorthotopic heart transplant Kawasaki disease with current aneurysms Modified from Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report Pediatrics 2011;128(suppl 5):S213–S256 The rationale for screening at around age 10 years is that lipid lipoprotein levels at birth are very low and increase slowly in the first 2 years of life.126,127 Levels thereafter are stable in late childhood until adolescence, where, during puberty, TC and LDL-C levels decrease before rising in late-teen years.128 Racial differences exist as well, with higher TC and HDL-C and lower levels of very LDL-C and TG seen in black children and adolescents.129 Lipoprotein level cut-off points are shown in Tables 25.5 and 25.6 Table 25.5 Normal and Abnormal Cut-Offs for Lipid, Lipoprotein, and Apolipoprotein Concentrations in Children and Adolescents Category Total cholesterol LDL cholesterol Non-HDL cholesterol Apolipoprotein B Triglycerides 0–9 years 10–19 years HDL cholesterol Apolipoprotein A-1 Acceptable (mg/dL)