Preventive pediatric cardiology.

We are in an epidemic of childhood obesity. It used to be rare for us in pediatrics to see type 2 diabetes in children, but now we see patients with type 2 diabetes literally every week. Much of the increase in type 2 diabetes is secondary to the obesity epidemic in the United States. There is data to show that the incidence of obesity in our patients with congenital heart disease is similar to the population in general, and that is very sad. Many of these patients have been seen in Pediatric Cardiology on multiple outpatient occasions and have gone through multiple surgeries and yet we have done a very poor job at controlling the risk factors for acquired heart disease later in life. It is sad to see a child with an innocent murmur and know that this child has a very good chance as he gets older to have hypertension, hyperlipidemia, and possible coronary disease. To have taken infants through critical surgeries and have them grow and develop and yet become obese with hypercholesterolemia and hypertriglyceridemia is not a very good result in the care system that we have provided. Most people go into Pediatric Cardiology because they are interested in congenital heart disease. There are very few good established preventive pediatric cardiac programs in the United States, and there are very few people in Pediatric Cardiology that are interested in providing that kind of care. Preventive pediatric cardiology involves more than just obesity and diabetes. It involves issues of hypertension, hyperlipidemia, acquired heart disease, rheumatologic heart disease, vascular issues, and patients who have had their coronaries altered by congenital cardiac surgeries. In most academic institutions, we really should be having a preventive cardiology clinic every single day, formatted in terms of hypertension, hyperlipidemia, Kawasaki’s disease, inflammatory vascular issues, rheumatologic heart disease, and patients with congenital heart disease whose surgeries have required moving or redistributing coronary arteries, in addition to patients with coronary artery anomalies. The other problem is, not only are there not very many good preventive pediatric cardiology programs, but the reimbursement for these programs is woefully inadequate. Insurance companies just do not seem to want to pay for preventive medicine, and seeing large cohorts of patients in the above categories is not financially lucrative, given the fact that there are few major diagnostic tests that need to be done in these patients other than serial laboratory evaluations. It is time to rethink preventive cardiology in pediatric patients, both with and without cardiac disease. Now with the new recommendations from the Academy of Pediatrics and NIH to screen all children ages 9 to 11 for hypercholesterolemia, the emphasis will be in both cardiology and primary care to provide good preventive cardiovascular counseling. This counseling involves not only measuring the lipids but also making sure that the patient’s blood sugar and blood pressure are normal, that the patient has an appropriate diet, that the patient is exercising properly, and that there are no other familial and genetic risk factors for acquired cardiac disease. We must be able to get funding for these preventive measures. All of congenital heart disease is dwarfed by the huge amount of acquired cardiac disease in adults, particularly the ravages of atherosclerosis, which clearly begin in childhood. It is only with a focused determined effort in the pediatric cardiac community that we can alter or modify the risk factors for early coronary disease in adults. It is only with diversified programs with people interested and skilled in dealing with children with lipid disorders and hypertension that we can alter the natural history of adult-acquired disease in this country. It is time for Pediatric Cardiology to step up and form coordinated, well-functioning, skilled preventive cardiology programs in the 87