Normal levels and trends of cardiovascular disease risk factors in childhood have been well documented by numerous epidemiologic surveys. Expected levels of blood pressure, lipids and lipoproteins, and body size can be determined by the child's physician using race- and gender-specific grids. These grids allow for the identification and follow-up of children with high-risk profiles. Evidence of increased left ventricular mass and vascular changes in renal arteries in association with childhood blood pressure level along with atherosclerotic fatty streak and fibrous plaque development in the aorta and coronary arteries shows that children with elevated risk factors are at risk for early target organ damage. These data demonstrate the potential importance of early intervention on the natural history of cardiovascular disease. Based on our own data from the Bogalusa population, as well as evidence from other epidemiologic investigations in children, the following recommendations can be made, regardless of the risk factor variable under consideration: Cardiovascular disease risk factor variables should be measured carefully and in a serial manner to classify a child as abnormal. Serial measurements serve to reduce the effect of regression to the mean and increase the predictive value of the measurements. The misclassification of normal children into the high-risk category can be avoided by serial and replicate observations. Interventions that have attendant side effects (for example, pharmacologic therapy for high blood pressure) have to be measured against the effectiveness of diet, exercise, and other aspects of primary prevention. Risk factor levels consistently greater than the ninetieth percentile deserve medical attention. Care should be taken prior to using specific grids of normal levels of cardiovascular disease risk factors in children. The measurement techniques employed on individuals should be similar to those used by the epidemiologic study to generate the grids in a reference population. The grids should become part of the child's permanent medical record, as they provide a rapid visual assessment of the cardiovascular disease risk profile over time. High-risk trackers may require more intensive follow-up and will allow for early intervention and an assessment of the efficacy of the intervention program. In conclusion, cardiovascular disease risk factor screening in childhood is quick, effective, and inexpensive. The potential payoff in prevention of adult cardiovascular disease is enormous and allows the physician to provide more comprehensive care to a pediatric population.