Pediatric AHA Scoring

Pediatric Scoring Changes

Each component uses an age-appropriate rule. Some are defined only from a certain age; before then, the component is NA and does not count toward min_components.

AHA suggests that the composite for a child be the average of whatever components are available and appropriate for measurement. Laboratory values are often unavailable in children, and the NHANES analysis that accompanied the advisory averaged as few as three components, so set min_components appropriately for your cohort.

Deriving growth-chart and blood-pressure percentiles

For some pediatric samples, you will need blood-pressure percentiles and/or growth chart data.

add_pediatric_references() derives the percentile inputs from raw measurements, using the packages cdcanthro (CDC and WHO growth charts) and pedbp (AAP 2017 blood-pressure percentiles). It needs sex, height, and weight, and uses age_months or age * 12.

measurements <- tibble(
  id = c("toddler", "school_age", "teen"),
  age = c(1.5, 8.25, 15.5),
  sex = c("male", "female", "male"),
  height_cm = c(82, 128, 172),
  weight_kg = c(11.5, 27, 64)
)

measurements |>
  add_pediatric_references() |>
  select(id, bmi_percentile, bmi_percent_of_p95, infant_weight_percentile,
         systolic_bp_p90, systolic_bp_p95)
#> # A tibble: 3 × 6
#>   id    bmi_percentile bmi_percent_of_p95 infant_weight_percen…¹ systolic_bp_p90
#>   <chr>          <dbl>              <dbl>                  <dbl>           <dbl>
#> 1 todd…           NA                 NA                     76.3            99.7
#> 2 scho…           60.9               78.8                   NA             110. 
#> 3 teen            68.5               79.6                   NA              NA  
#> # ℹ abbreviated name: ¹​infant_weight_percentile
#> # ℹ 1 more variable: systolic_bp_p95 <dbl>

Blood-pressure references are returned only for ages 1 to 12, and only when height is known.

Rapid infant weight gain compares visits, so it cannot be derived from one row. With longitudinal data, compute it from infant_weight_z within each child:

visits |>
  add_pediatric_references() |>
  arrange(child_id, age) |>
  mutate(
    infant_weight_z_change = infant_weight_z - lag(infant_weight_z),
    .by = child_id
  )

AHA compares against the z-score at prior routine visits, for example since age 1 month; choose the comparison visit to match your study design.

School-age children and adolescents (6-19 yrs)

From age 6, diet uses all 16 MEPA items and the adult scoring bands. Weekly moderate and vigorous minutes count once each (adults count vigorous minutes twice). The pediatric nicotine categories describe any nicotine product: "never" = never tried, "former" = tried but not within 30 days, and "current" = combustible use within 30 days. Blood pressure switches to the adult bands at 13, while the other components stay pediatric through age 19.

A preschool child (2-5 yrs)

At ages 2-5, ten of the MEPA items are scored, at 10 points per item met, with pediatric thresholds:

• vegetables: green_leafy_vegetables + other_vegetables, 2+ per day
• fruit: berries + other_fruit, 14+ per week (2 per day)
• whole_grains 3+ and olive_oil 1+ per day
• fish 1+ and nuts 4+ per week
• meat, butter_cream, and sweets_and_pastries 3 or fewer per week; for children under 6, sweets should include sugar-sweetened beverages
• fast_food 2 or fewer times per month

chicken, cheese, beans, alcohol, and sex are not used before age 6 and may be omitted from data containing only young children.

This example also uses active play in minutes per day and blood-pressure percentiles. The 90th and 95th percentiles (systolic_bp_p90 and so on) are the child’s reference values for age, sex, and height, in mmHg.

preschooler <- tibble(
  id = "preschooler",
  age = 4,
  # Servings per day
  green_leafy_vegetables = 1,
  other_vegetables = 1,
  whole_grains = 2,
  olive_oil = 1,
  # Servings per week
  berries = 7,
  other_fruit = 14,
  sweets_and_pastries = 2,
  meat = 2,
  fish = 1,
  nuts = 2,
  butter_cream = 1,
  # Times per week
  fast_food = 0.25,
  active_play_minutes = 160,
  smoking_status = "never",
  current_inhaled_nds = FALSE,
  secondhand_smoke_home = FALSE,
  sleep_hours = 13.5,
  bmi_percentile = 60,
  bmi_percent_of_p95 = 82,
  systolic_bp = 108,
  diastolic_bp = 60,
  systolic_bp_p90 = 103,
  systolic_bp_p95 = 107,
  diastolic_bp_p90 = 63,
  diastolic_bp_p95 = 67,
  antihypertensive_treatment = FALSE
)

preschooler |>
  score_le8(min_components = 5) |>
  select(mepa_total, ends_with("_score"), n_components, le8_category)
#> Warning: ! Some LE8 components could not be calculated for any observations.
#> ✖ Blood lipids
#> ✖ Blood glucose
#> ℹ Overall LE8 composite scores will use the available components, subject to
#>   `min_components`.
#> # A tibble: 1 × 12
#>   mepa_total diet_score physical_activity_score nicotine_score sleep_score
#>        <int>      <dbl>                   <dbl>          <dbl>       <dbl>
#> 1          8         80                      90            100          90
#> # ℹ 7 more variables: bmi_score <dbl>, blood_lipids_score <dbl>,
#> #   blood_glucose_score <dbl>, blood_pressure_score <dbl>,
#> #   le8_composite_score <dbl>, n_components <int>, le8_category <chr>

Eight of the ten items are met (80 points); mepa_total counts items met on the screener for the child’s age. Sleep is half an hour above the 10-13 hour range (90 points). The systolic pressure of 108 mm Hg is at or above this child’s 95th percentile (107 mm Hg) but below 95th + 12 mm Hg, which is stage 1 (50 points). Lipids and glucose were not measured, so the composite averages six components; the warning says so.

Infants and toddlers (6-23 months)

From 6 to 23 months, diet uses six items: vegetables, fruit, and whole grains (at least once a day before 12 months, twice a day from 12 months), no sweets or sugar-sweetened beverages, no fast food, and the milk source recommended for age. milk_source is the one column used only at these ages: "human", "cow", "formula", or "other". Human milk meets the item before 12 months, and human or cow’s milk from 12 months.

Weight uses the WHO weight-for-length (or BMI-for-age) percentile together with the change in its z-score since the prior routine visit. An increase of 0.67 or more counts as rapid weight gain.

infant <- tibble(
  id = "infant",
  age = 0.75,
  age_months = 9,
  green_leafy_vegetables = 0.5,
  other_vegetables = 0.5,
  berries = 3,
  other_fruit = 4,
  whole_grains = 1,
  sweets_and_pastries = 0,
  fast_food = 0,
  milk_source = "human",
  smoking_status = "never",
  current_inhaled_nds = FALSE,
  secondhand_smoke_home = TRUE,
  sleep_hours = 13,
  infant_weight_percentile = 98.5,
  infant_weight_z_change = 0.4
)

infant |>
  score_le8(min_components = 4) |>
  select(mepa_total, ends_with("_score"), n_components, le8_category)
#> Warning: ! Some LE8 components could not be calculated for any observations.
#> ✖ Blood lipids
#> ✖ Blood glucose
#> ℹ Overall LE8 composite scores will use the available components, subject to
#>   `min_components`.
#> # A tibble: 1 × 12
#>   mepa_total diet_score physical_activity_score nicotine_score sleep_score
#>        <int>      <dbl>                   <dbl>          <dbl>       <dbl>
#> 1          6        100                      NA             80         100
#> # ℹ 7 more variables: bmi_score <dbl>, blood_lipids_score <dbl>,
#> #   blood_glucose_score <dbl>, blood_pressure_score <dbl>,
#> #   le8_composite_score <dbl>, n_components <int>, le8_category <chr>

age_months is optional; when supplied it sets the pediatric age bands more precisely than age * 12. Physical activity and blood pressure are not scored before age 1, so they are NA here regardless of the inputs.

Where the sources conflict

The advisory’s main table and its supplement are not always consistent. essential8 follows the more specific rule and documents each choice in ?score_le8:

• Ages 2-5 use the supplement’s 10 points per item met rather than Table 1’s banded 0-10 scale (for example, 7 items score 70 rather than 80).
• The supplement describes the 16-item MEPA questionnaire as, “used in older children and adults”, so ages 6-19 use the adult bands.
• At 6-23 months, weight at or above the 99.7th percentile with rapid gain scores 0, the supplement’s explicit worst state, rather than the 25 its listed decrements would give.
• Nineteen-year-olds use the 13-18 year sleep range (8-10 hours), the last range AHA lists for the pediatric column.
• The packaged NHANES diet references describe adults, so they are refused for children. Use percentiles in diet_value or a pediatric reference.