In a recent report, the worldwide prevalence of childhood obesity was estimated to have increased by 47% between 1980 and 2013. As a result, substantial concerns have been raised about the future burden of cardiovascular (CV) disease that could ensue. The purpose of this review is to summarize and interpret (i) the evidence linking early life obesity with adverse changes in CV structure and function in childhood, (ii) the lifetime risk for CV disease resulting from obesity in childhood, and (iii) the potential effects of lifestyle interventions in childhood to ameliorate these risks.

No abstract

BackgroundPatients with a Fontan circulation have reduced exercise capacity and respiratory muscle strength. Inspiratory muscle training (IMT) improves exercise capacity and quality of life in adults with heart failure. We assessed whether 6 weeks of a home‐based program of IMT improves inspiratory muscle strength and the ventilatory efficiency of exercise in adolescent patients with a Fontan circulation.Methods and ResultsTwenty‐three adolescent participants (aged 16±2 years) with a Fontan circulation underwent 6 weeks of IMT for 30 minutes daily. Respiratory muscle strength (maximal inspiratory pressure and expiratory pressure), lung function, and exercise capacity (cardiopulmonary exercise testing) were assessed. Fourteen of 23 participants also underwent exercise cardiac magnetic resonance imaging to examine the effects of IMT on cardiac output and systemic and pulmonary blood flow. Six weeks of IMT improved maximal inspiratory pressure by 36±24 cm H2O (61±46%) with no change in maximal expiratory pressure. Ventilatory efficiency of exercise improved after 6 weeks of IMT (from 34.2±7.8 to 32.2±5.6, P=0.04). In those who underwent exercise cardiac magnetic resonance imaging, IMT increased resting cardiac output (from 4.2±1.2 to 4.5±1.0 L/min, P=0.03) and ejection fraction (from 50.1±4.3 to 52.8±6.1%, P=0.03).ConclusionsSix weeks of IMT is associated with improved inspiratory muscle strength, ventilatory efficiency of exercise, and resting cardiac output in young Fontan patients. IMT may be a simple beneficial addition to the current management of Fontan patients, potentially reducing exercise intolerance and long‐term morbidity and mortality.

A therosclerosis has been demonstrated in autopsy studies to have its origins in childhood. 1 In the young, there is a correlation between the intensity of exposure to risk factors such as cigarette smoking, hypertension, dyslipidaemia and diabetes mellitus and the extent and severity of arterial fatty streaks or raised plaques (fig 1).An important current trend that may increase the future burden of coronary heart disease (CHD) is a significant increase in the prevalence of childhood obesity. 2 In obesity, many of the risk factors for CHD are clustered together. Moreover, these risk factors usually persist or track into adulthood, so that their effect on the cardiovascular system may be present and influential for several decades.To reduce the future burden of CHD, we need to define prevention and intervention strategies that decrease the prevalence of cardiovascular risk factors in children and young adults and thereby hope to retard atherogenic processes. The purpose of this article is to review the evidence for the importance of the childhood risk factors for adult cardiovascular disease and to outline the evidence for the efficacy of primary prevention in young people. DETECTING EARLY ARTERIAL ABNORMALITIESc Studies on the impact of risk factors in childhood and on the effect of potentially beneficial interventions have been facilitated by the development of a number of non-invasive diagnostic techniques that can detect ''atherosclerosis'' at a preclinical stage (or at least the changes in arterial structure and/or function indicative of vascular damage). For example, the arterial endothelium plays a key role in atherogenesis, and clinical evaluation of the function of the endothelium is now possible through the assessment of nitric oxide-mediated vasodilatation produced by sheer stress (flow mediated dilatation (FMD)). FMD can be measured accurately and reproducibly by ultrasound. Impaired FMD has also been demonstrated in children at high risk of future CHD. 3 Measuring the velocity of the arterial pulse wave non-invasively might also be a valuable indicator of vascular ''stiffness'', and thus subsequent risk, in children.Intima media thickness (IMT), measured by ultrasound of the carotid arteries or aorta, is a structural change in the vasculature that also appears to have value as a surrogate marker of atherosclerosis. IMT is correlated with the number of cardiovascular risk factors present and it relates to the severity and extent of coronary artery disease. IMT predicts the likelihood of cardiovascular events in asymptomatic adults and increased IMT has also been demonstrated in children with known cardiovascular risk factors. 4 5 The number of risk factors present in males during late childhood and adolescence directly relates to the IMT in young adulthood, even after adjusting for contemporaneous risk factors. 5

OBJECTIVE: We hypothesized that early weight gain would be associated with incident obesity, higher blood pressure, systemic inflammation, and arterial wall thickening in later childhood. METHODS: A longitudinal birth cohort was recruited antenatally from 2 maternity hospitals in Sydney, Australia, between September 1997 and December 1999. Three hundred ninety-five nondiabetic children who were followed to age 8 years had complete data for early weight gain and arterial wall thickness. RESULTS: Independent predictors of excess early weight gain (age 0–18 months; adjusted for height gain) included male gender (0.411 kg [SE: 0.103], P < .001), fewer weeks’ gestation (−0.121 kg [SE: 0.044] per week, P = .006), birth length (0.156 kg [SE: 0.024] per cm, P < .001), and failure to breastfeed to 6 months of age (0.498 kg [SE: 0.108], P < .001). Early height-adjusted weight gain was significantly associated with later childhood overweight (odds ratio [OR]: 1.67 [95% confidence interval (CI): 1.26 to 2.20] per kg) and obesity (OR: 2.07 [95% CI: 1.53 to 2.79] per kg), excess central adiposity (OR: 1.54 [95% CI: 1.20 to 1.98] per kg), higher systolic blood pressure (1.24 mm Hg [SE: 0.33] per kg, P < .001), higher C-reactive protein (0.17 mg/dL [SE: 0.06] per 100% increase in weight gain, P = .006), and greater carotid intima-media thickness (0.012 mm [SE: 0.004] per kg, P = .002). CONCLUSIONS: Early postnatal weight gain from birth to age 18 months is significantly associated with later childhood overweight and obesity, excess central adiposity, and greater arterial wall thickness.

Objective-Atherosclerosis is found at autopsy in the arteries of adolescents and young adults. Arterial wall thickening may be assessed in vivo by ultrasound measurement of the carotid intima media thickness (CIMT), a marker of subclinical atherosclerosis. As the determinants of arterial wall thickness in childhood are unknown, we assessed the influence of cardiovascular risk factors on CIMT in 8-year-old children. Methods and Results-A community-based sample of 405 children (age 8.0Ϯ0.1 years, 49% girls) had anthropometry, family history, blood pressure (BP), and CIMT measured. A blood sample was collected for HDL and non-HDL cholesterol, apolipoproteins A1 and B, high-sensitivity C-reactive protein, bilirubin, and asymmetric dimethylarginine (ADMA, an endogenous nitric oxide inhibitor Key Words: HDL-cholesterol Ⅲ asymmetric dimethylarginine Ⅲ pediatric Ⅲ intima-media thickness Ⅲ blood pressure S tructural evidence of early atherosclerosis is commonly found in adolescents and young adults when their arteries are examined at autopsy. The extent of these lesions increases with age and with the number and severity of traditional cardiovascular risk factors. 1,2 B-mode ultrasound examination of the arterial wall, performed during life, produces a characteristic image that correlates with the histological intima-media complex. 3 In adults, the carotid artery intimamedia thickness (CIMT) is correlated with coronary and carotid atherosclerosis and is a significant predictor of future cardiovascular events. 4 For these reasons, CIMT has been used in numerous cross-sectional and intervention studies as a surrogate end point for atherosclerosis. 5 Although high-risk children, such as those with familial hypercholesterolemia and type 1 diabetes mellitus, have increased CIMT compared with healthy controls 6,7 and risk factors present in childhood are associated with CIMT in adult life, 8,9 the factors that influence CIMT in healthy children are largely unknown. We undertook a study of 8-year-old boys and girls to explore the effects of cardiovascular risk factors on arterial wall thickness in early childhood. We hypothesized that the traditional cardiovascular risk factors, such as blood pressure, lipoprotein levels, family history, and relative body weight would have an important effect on arterial wall thickness in healthy children in the first decade of life. We aimed to examine the extent to which markers of inflammation or endothelial dysfunction influenced arterial structural changes in childhood. The effects of prenatal factors, such as birth weight, pregnancy-induced hypertension, and preeclampsia, and maternal cigarette usage were also assessed.

Background We sought to characterize body composition abnormalities in young patients living with a Fontan circulation and explore potential pathophysiologic associations. Methods and Results Twenty‐eight patients with a Fontan circulation were prospectively recruited in this cross‐sectional study. Participants underwent cardiopulmonary exercise testing, dual‐energy X‐ray absorptiometry, echocardiography, and biochemical assessment. Mean age was 26±7 years. Skeletal muscle mass, estimated by appendicular lean mass index Z score, was reduced compared with reference data (−1.49±1.10, P <0.001). Percentage body fat Z score overall was within normal range (0.23±1.26, P =0.35), although 46% had elevated adiposity. Those with reduced skeletal muscle mass ( appendicular lean mass index Z score of −1 or lower) had lower percent predicted oxygen pulse (55±15 versus 76±16%, P =0.002). Overall agreement between body mass index and dual‐energy X‐ray absorptiometry to assess adiposity was fair only (weighted [linear] κ coefficient: 0.53; 95% CI , 0.34–0.73) and slight in the setting of muscle mass deficiency (weighted κ coefficient: 0.32; 95% CI , 0.13–0.50). Appendicular lean mass was independently associated with absolute peak VO 2 (β=70.6 mL /min, P =0.001). A ppendicular lean mass index Z score was inversely associated with hemoglobin ( r =−0.4, P =0.04), and the degree of muscle deficit was associated with ventricular systolic impairment. Conclusions Young patients with a Fontan circulation have a body composition characterized by reduced skeletal muscle mass, which is associated with peak exercise capacity. Increased adiposity is common despite a normal body mass index. Low skeletal muscle mass is associated with systolic dysfunction and compensatory erythrocytosis.

This was a retrospective observational study in a pediatric intensive care unit, in which 19 patients received levosimendan. There were no adverse events attributable to levosimendan and no instances where the clinical condition worsened after administration. Arterial lactate levels decreased significantly following levosimendan administration during cardiopulmonary bypass for anticipated low cardiac output. In those with established low cardiac output, trends toward improved hemodynamics were seen, with heart rate reduction, an increase in mean blood pressure, a reduction in arterial lactate, and reduced conventional inotrope use. Levosimendan was safely used in a small number of pediatric patients with established low cardiac output state who demonstrated improved hemodynamics and tissue perfusion, with a tendency to reduced conventional inotrope usage, and this warrants its evaluation as an inotrope in the pediatric population.