**Background:** Children and adolescents with congenital heart disease (CHD) are at increased risk for overweight, obesity, and adverse cardiometabolic markers. Breakfast consumption and its composition may influence these risks, but data on breakfast patterns in this population are scarce. This study aimed to identify the prevalence of breakfast skipping, describe breakfast patterns, and evaluate their associations with sociodemographic, clinical, lifestyle, cardiometabolic, and nutritional markers in children and adolescents with CHD.
**Methods:** A cross-sectional study was conducted from January to July 2017 in two reference hospitals in southern Brazil. Participants were 232 children and adolescents aged 5–18 years with CHD who had undergone a cardiac procedure. Dietary assessment used three 24-hour recalls on non-consecutive days. Breakfast skipping was defined as not having breakfast on at least one of the three days. Breakfast patterns were derived using principal component analysis from 19 food groups among the 169 participants who consumed breakfast on all three recall days. Sociodemographic, clinical, and lifestyle data were collected. Nutritional markers included waist circumference and body composition (air displacement plethysmography). Cardiometabolic markers included fasting glucose, total cholesterol, HDL-c, LDL-c, non-HDL-c, triglycerides, hs-CRP, and blood pressure. Multiple linear regression was performed with adjustments for age, sex, maternal education, sedentary behavior, postoperative time, family history of obesity, CHD classification, and waist circumference.
**Key Results:** Among 232 participants (mean age 10.2 years, SD 3.7; 52.5% female), 27% skipped breakfast. Breakfast skipping was associated with family history of obesity (52.4% vs. 29% among breakfast consumers; p=0.001) and acyanotic CHD (66.6% vs. 65.6%; p=0.01). Four breakfast patterns were identified, explaining 37.0% of total breakfast variability: Pattern 1 (milk, ultra-processed bread, chocolate milk; 11.2% variability) was associated with younger age (p=0.001) and higher maternal education (p=0.01); Pattern 2 (margarine and processed bread; 9.3% variability) showed no significant associations; Pattern 3 (cold meats/sausages, cheeses, butter/cream; 8.6% variability) was associated with older age (p=0.003) and longer postoperative time (p=0.04); Pattern 4 (fruits/fruit juices, breakfast cereals, yogurts, homemade cakes/pies and sweet snacks; 8.0% variability) was associated with younger age (p=0.001) and higher maternal education (p=0.002). In multiple linear regression, no significant associations were found between breakfast skipping or any breakfast pattern and any cardiometabolic or nutritional marker after full adjustment. For example, for Pattern 3 (cold meats/sausages, cheeses, butter/cream) and body fat percentage, the adjusted β was 0.21 (95% CI: −0.72 to 1.17; p=0.65). For breakfast skipping and body fat percentage, the adjusted β was 2.88 (95% CI: −0.61 to 5.85; p=0.07).
**Clinical Implications:** This is the first study to characterize breakfast patterns specifically in children and adolescents with CHD. The high prevalence of breakfast skipping (27%) and the identification of four breakfast patterns dominated by ultra-processed foods raise concerns for long-term cardiovascular health in this already vulnerable population. Although no statistically significant associations were found between breakfast patterns and cardiometabolic or nutritional markers in this cross-sectional analysis, the nutritional composition of the identified patterns—high in saturated fats, trans fats, and added sugars, and low in fiber and micronutrients—may contribute to future cardiovascular risk. These findings support the need for targeted nutritional interventions and food education to promote healthier breakfast habits, emphasizing fresh and minimally processed foods while reducing ultra-processed food consumption. Longitudinal studies with additional biomarkers are warranted to further investigate these relationships.