By James M. Rippe

Many risk factors play a role in the complex process that leads to atherosclerosis. Although most people with atherosclerosis are middle-aged or older before they get a diagnosis of heart disease or experience signs such as angina, many children and adolescents actually have the fatty streaks and fibrous plaques that are the first manifestations of atherosclerosis and that eventually lead to coronary heart disease (CHD).

Because they can’t be detected by most tests, these early manifestations are called subclinical.

Finding early signs of atherosclerosis in children

Evidence that subclinical atherosclerosis begins in childhood first came to light in the early 20th century, when autopsies on young soldiers (most 18 to 20 years old) showed fatty streaks and plaques in the aorta and coronary arteries.

Since that time more studies, such as the Bogalusa Heart Study and the PDAY Study (Pathobiological Determinants of Atherosclerosis in Youth), have confirmed these early signs of atherosclerosis in children as young as two years old. Some studies suggest that infants in the womb whose mothers have cholesterol problems may have some fatty streaks in their arteries.

The Bogalusa Heart Study which followed a very large group of individuals from age 2 through age 38 puts these findings into perspective. In more than 200 study participants who died from various causes, autopsies found fatty streaks in the coronary arteries of 50 percent of children aged 2 to 15 and in the arteries of 85 percent of young adults, aged 21 to 39.

More extensive fibrous plaques, increasing with age, were observed in 8 percent of the 2- to 15-year-olds and 69 percent of the young adults aged 26 to 39.

Children and youth at greatest risk are those who are overweight or obese and inactive. These factors contribute to a clustering of risk factors such as the following: lipid (fat in the blood) problems, including higher total cholesterol and LDL cholesterol; more insulin resistance (prediabetes); and higher blood pressure. A child who has type 1 diabetes is also at increased risk.

Checking up on potential risk factors in children

Because children develop risk factors for chronic disease, including heart disease, when should your child’s regular checkups start including tests for such factors as high blood pressure or cholesterol problems?

Guidelines from the American Academy of Pediatrics recommend that all children should have their blood cholesterol levels checked once between ages 9 and 11 and then once again between ages 17 and 21. If your family has a history of high cholesterol (hypercholesterolemia), then your children should have their cholesterol levels checked before age 5. Your pediatrician will then recommend how often after to have cholesterol checked.

Very few children have high blood pressure, but some do. Your pediatrician will begin to check blood pressure when a child is about 3. The doctor will take into account the child’s age, gender, and height to evaluate the readings appropriate for your child.

Because many potential risk factors in childhood are related to being overweight (and inactive), the most important thing parents can do for children is to make heart-healthy patterns of eating and activity a part of your family’s lifestyle from the beginning. Your child’s pediatrician will evaluate your child’s weight at each checkup.

Adjustments in diet and amount of activity usually help children easily stay within a healthy weight range. If there are problems, discuss these with the pediatrician.