Risk of heart disease appears early in childhood. Though it is not a major cause of death among children and teenagers, heart disease is one of the largest causes of death among adults. However, most risk factors that affect children can be controlled early in life, lowering the risk of heart disease in adults. This year, on the occasion of World Heart Day, the World Heart Federation, along with its members, is calling on individuals and parents to reduce their own and their family’s risk because healthy children lead to healthy adults, who in turn lead to healthy families and communities.
Incidence in Indian children
Heart disease in children are mostly birth defects or genetic or rheumatic. “In children, cardiovascular diseases (CVDs) include congenital heart disease and rheumatic heart disease,” states Dr Sunita Maheshwari, Senior Consultant, Paediatric Cardiologist, Narayana Hrudayalaya, Bangalore.
 “There are no standard guidelines for primary prevention of CVD beginning in childhood as developed in the UK or US for implementation on a national scale.” Krishna Kumar Professor & Head, Paediatric Cardiology, AIMS, Kochi |
Dr Krishna Kumar, Professor and Head, Paediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Kochi elaborates, “Congenital heart disease (CHD) prevalence at birth is 6-8/1000 as determined through large studies specifically undertaken by Indian Council of Medical Research (ICMR) for this purpose. The prevalence of critical CHD at birth is approximately 2-3/1000.”
No incidence of coronary artery disease in Indian children is known since this is not specifically looked for. “Although coronary artery disease rarely manifests in childhood, atherosclerosis, the major precursor of cardiovascular disease begins in childhood,” informs Dr Maheshwari.
 “I have come across children with hypertension, only four to five required drug treatment but in all them it was morbid obesity which was the cause.” Dr Prabhat Kumar Columbia Asia Hospital- Pune |
Adding to this, Dr Prabhat Kumar, Paediatric Cardiology, Columbia Asia Hospital, Pune says, “When we talk about CVD which is related to counterpart of adult CVD we talk about CVD on a structurally normal heart. This CVD is due to extrinsic factors having influence on a child’s heart which is mainly due to dietary factors and obesity. Hypertension in young age is the usual outcome of this. Rarely, few diseases due to faulty cholesterol metabolism coronary artery disease may occur at an early age.”
The prevalence of rheumatic heart disease (RHD) is quite variable in India. The disease is clearly on the decline in selected parts of India. “Many large institutions in South India report a decline in proportion of hospitalisations from RHD as well as a progressive reduction in the number of balloon mitral valvotomy procedures and heart valve surgeries for RHD,” informs Dr Manu Raj, Assistant Professor, Paediatric Cardiology and Public health, AIMS, Kochi. “Anecdotal reports suggest that the disease continues unabated in parts of India that have low human developmental indices,” he further adds.
Malnutrition is the missing link
It is known that obese children are at higher risk for CVD in adulthood. But researchers have found that undernourished children are also at risk of heart disease. “Malnutrition means an improper diet and technically includes under nutrition i.e. where the child does not get enough nutrition as well as over nutrition, typically called obesity,” explains Dr Maheshwari.
 “Medical nutrition therapy, physical activity, and smoking cessation (if applicable) form the cornerstone of paediatric dyslipidaemia management.” Dr Ashutosh Marwah Senior Consultant, Paediatric Cardiologist, FEHI, New Delhi |
“Under nutrition causes deficiency of various vitamins and essential factors required for maintenance of cardiovascular health, whereas over nutrition predisposes to various risk factors such as hyperlipidaemia, hypertension and diabetes mellitus,” says Dr Ashutosh Marwah Senior Consultant, Paediatric Cardiologist, Fortis Escorts Heart Institute, New Delhi.
It was hypothesised that undernourished foetuses during pregnancy may have higher incidence of diabetes and CVD in adult life. This is debatable. However, over nutrition i.e. obesity, which is also a form of malnutrition, is undoubtedly related to CVD in later life.
Ground realities
Poor cardio respiratory conditioning is also increasing among children. “Apart from a rising number of obese and inactive children in clinic, I have seen children with unusually high cholesterols. This is related to diet and in all cases, I managed them with dietary intervention,” reveals Dr Maheshwari. “I have also started seeing children with chest pain on walking up a few steps, and after investigation find it is due to poor cardio respiratory conditioning. With the increasing concrete jungles that our cities are becoming, and the increasing emphasis on ‘marks’ and tuitions, today’s children are not playing sports or exercising every day, leading to poor lung and heart conditioning. This, along with reduced hours of sleep in the Facebook generation, is leading to obesity,” she explains.
Recounting his experience, Dr P Kumar says, “I have come across children with hypertension, only four to five required drug treatment but in all them it was morbid obesity which was the cause. In other children usually dietary modification and counselling with life style modification helped.”
Screening programmes
There are no large scale screening programmes developed and implemented by the government to check risks of CVD in Indian children. “CVD in children is not a well recognised problem and is not a priority for our country. There is no large scale screening programme for this kind of CVD,” complains Dr P Kumar. “I wish!” says Dr Maheshwari.
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Time to act
“There are no standard guidelines for primary prevention of CVD beginning in childhood as developed in the UK or US for implementation on a national scale,” informs Dr K Kumar. “There are attempts to improve health of school children (by Central Health Ministry & NRHM) but these are not in the form of any formal guidelines,” he specifies. India is yet to formulate systematic evidence based guideline for CVD prevention starting from childhood. “Additionally, it must be recognised that creation of guidelines is unlikely to help unless there is a carefully thought out plan for its implementation. Large-scale national implementation is a far bigger challenge than developing a guideline,” he laments.
Risk assessment
Body mass index (BMI) is commonly used to assess obesity in children. But recent studies suggest waist circumference (WC) and weight to height ratio (WHtR) as better ways of predicting obesity. “BMI is widely used to assess the impact of obesity on cardiometabolic risk in children but it does not always relate to central obesity and varies with growth and maturation. WHtR is a relatively constant anthropometric index of abdominal obesity across different age, sex or racial groups and serves as a useful tool,” explains Dr Marwah.
“WC and WHtR have been used by many authors and have been found to be a better age independent criteria for predicting obesity in children and adolescents.
A weight: height ratio of > 0.445 is considered as overweight for both the genders, whereas a WHtR of > 0.485 in boys and WHtR of > 0.475 in girls is used to define central obesity.
In Bogalusa Heart Study (BMC Pediatrics 2010, 10:73) it was clearly shown that children without central obesity were likely to have higher levels of high-density lipoprotein (HDL) cholesterol and lower levels of low-density lipoprotein (LDL), triglycerides and insulin as compared to children with central obesity,” says Dr Marwah.
“Compared to just measuring WC, WHtR is fair to both tall and short people and is a better method to use to assess abdominal obesity. There are studies in adults showing that WHtR is as good a predictor as BMI since abdominal fat is worse than other body part fat. However, there are no major studies in kids showing this benefit. So BMI is still commonly used,” opines Dr Maheshwari. Expressing a different view Dr Raj says, “WC, BMI and WHtR are all equally good in predicting cardiovascular risk among children. It’s hard to say which of the three is better than the other two as the evidence is not clear, and studies support one or the other.”
“From a public health point of view, there is no need to debate which of the three is the best as the difference would be minimal and all three are easy to measure on a population setting. The measurement error possible in waist circumference may make WC and WHtR inferior in large screenings. (weight and height don’t have that big a measurement error in comparison to WC),” he further adds.
| Strategy | Practicalities | Downstream interventions | Recommendation |
| Nationwide newborn screening with Pulse Oxymeter | Impractical as a screening method; limited sensitivity and specificity | Very expensive, substantial resource limitations | Not recommended |
| Screening infants for CHD during immunisation visits | Potentially useful; has not been systematically tested | Expensive, important resource limitations | Consider systematically testing the recommended strategy |
| Annual clinical examination of school children (weight, height, waist circumference, BP, cardiac auscultation) followed by echocardiography for positive cases | Simple, potentially easy to implement, helps identify RHD, CHD and those at risk for adult cardiovascular disease | RHD: Penicillin prophylaxis CHD: Surgery or catheter interventions (Expensive) Lifestyle changes (inexpensive but often unsuccessful) | Consider a practical plan for phased implementation after careful consideration and deliberation |
| Source: Dr K Kumar and Dr Raj, Amrita Institute of Medical Sciences and Research Centre (AIMS), Kochi | |||
New advancements
It is said that a simple way to assess a child’s arterial health is by a calculation based on triglycerides. Researchers believe that the triglyceride to HDL ratio corresponds closely with arterial stiffness. “Yes, high triglyceride to HDL ratios have been associated with a higher incidence of heart attacks but studies in children are relatively new,” says Dr Maheshwari.
Agreeing Dr K Kumar says, “Triglyceride to HDL ratio is an emerging concept – seems good as per some studies. More evidence is needed to say that this is superior to conventional markers like BMI or WC.”
Medicine free heart management
Generally, doctors are reluctant to give medications to children who may have a risk of CVD, as they don’t have any visible diseases. “I would agree that it is not appropriate to give medications to children with risk factors for adult CVD except for some very rare exceptions,” says Dr Raj. Agreeing Dr P Kumar says, “I personally try to counsel for lifestyle modifications, and if not successful, give drugs for cholesterol lowering.”
Offering her view, Dr Maheshwari says, “In children, doctors tend to want to manage via non medical means such as diet, exercise etc., with medications being a last resort. To some extent, this makes sense as once medications are started the question is how long to continue, any side effect of long term use etc.”
Explaining the merits of lifestyle modification, Dr Marwah says, “For children and adolescents with elevated lipid levels, intensive lifestyle modification, with an emphasis on normalisation of body weight and improved dietary intake, is recommended as a first-line approach because lifestyle intervention is considered to be most effective early in life, while behavioural habits are being established. Medical nutrition therapy, physical activity, and smoking cessation (if applicable) form the cornerstone of paediatric dyslipidaemia management and are recommended for all patients with LDL-C levels greater than 110 mg/dL.”
“Only a few clinical trials have investigated the use of drug therapy for the management of paediatric dyslipidaemia, and the potential long-term effects of lipid-lowering medications on growth, development, and biochemical variables are unclear. As such, evidence-based recommendations are limited, and pharmacotherapy must be prescribed based on empiric and indirect evidence,” he further adds.
It is recommended that such lifestyle changes in children be implemented for at least six to 12 months before considering drug therapy. “In a six-year study, adolescents who maintained a high level of physical activity during the transition into adulthood exhibited higher HDL-C to total cholesterol ratios, lower serum triglyceride and insulin concentrations, and lower body fat percentages than those who were physically inactive,” informs Dr Marwah.
“When evaluating the need for lipid-lowering drug therapy in paediatric patients, both the nature of the paediatric dyslipidaemia and the potential impact of delaying treatment until adulthood must be considered,” he says. “There is general consensus that lipid-lowering medications should be used to achieve LDL-C levels less than 130 mg/dL in children and adolescents with certain types of genetic dyslipidaemia, particularly when there is an associated coronary artery disease (CAD) risk,” he explains.
As such, American Association of Clinical Endocrinologists (AACE) recommends considering drug therapy in children and adolescents older than eight years who satisfy the following criteria: LDL-C =190 mg/dL, or LDL-C =160 mg/dL and the presence of two or more cardiovascular risk factors, even after vigorous intervention like being overweight, being obese, having other elements of the insulin resistance syndrome, or a family history of premature CAD (before age 55 years).
Additionally, the American Academy of Pediatrics (AAP) recommends that paediatric patients with diabetes be considered for pharmacologic intervention if they have an LDL-C concentration of 130 mg/dL or greater.
Source: Dr Marwah, Fortis Escorts Heart Institute, New Delhi |
Road ahead
Screening children for risks and popularising healthy lifestyle by awareness programmes are simple and easy methods of avoiding a cardiovascular epidemic. Elaborating on its advantages, Dr K Kumar says, “Screening is very simple and requires measurement of simple anthropometric indices. This can be easily arranged in most schools. Since a substantial proportion of children with obesity are also hypertensive, it is important to obtain a blood pressure record annually for all school going children, particularly as they approach adolescence.” “Screening helps identify a population at risk for adult cardiovascular disease. However, downstream interventions that include counselling for lifestyle changes often have relatively limited effectiveness because of poor adherence,” he adds.
The government needs to recognise the benefits of these interventions and screening methods.
“The government could ensure that open play spaces are not encroached upon, giving children the space to exercise; help reduce pollution levels since it has been shown to increase atherosclerosis; ban smoking effectively and do public interest campaigns on diabetes and CVD prevention,” lists Dr Maheshwari.
Childhood and adolescence is the time when unhealthy lifestyle habits get inculcated so it is imperative that prevention of heart disease must begin there. Today, we have an opportunity to impact the future, to prevent heart disease. More needs to be done in screening and awareness programmes by the government. Our leaders should also wake-up to the need for essential guidelines to take the road to a healthy heart.
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