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Prevention of atherosclerosis, a major cause of illness and death in our society, is a pediatric responsibility in 1988 and beyond. Significant cardiovascular risk factors are identifiable and alterable in children and adolescents, and are associated with arterial lesions. Cost-effective atherosclerosis prevention can be achieved by identification and treatment of high-risk children and adolescents. The pediatrician should record the family history of all patients at 2 years of age, with periodic updates. The serum cholesterol concentration can then be measured in the office if there is a commitment to quality control; otherwise, a monitored commercial laboratory must be used. It is not unreasonable to measure serum cholesterol concentrations once in all school-age patients. The majority of high-risk patients will respond to nutritional intervention and will not require pharmacotherapy. Until the efficacy and safety of the therapeutic diet are proved beyond doubt, its use should be limited to high-risk patients under pediatric supervision. Studies documenting the growth and development of children receiving dietary therapy must be a major priority of pediatric nutrition. Until that is accomplished, although some pediatricians may prefer to wait, most will use the extensive scientific evidence at hand and their clinical judgment to identify and treat their high-risk patients.