The International Diabetes Federation (IDF), National Heart, Lung, and Blood Institute (NHBLI), American Heart Association (AHA), World Heart Federation and the International Association for the Study of Obesity published a joint statement in 2009 that provided a “harmonized” definition of metabolic syndrome (MetS). According to this joint statement, a diagnosis of the MetS is made when any 3 of the 5 following risk factors are present: enlarged waist circumference with population specific and country-specific criteria; elevated triglycerides, defined as ≥ 150 mg/dL, decreased HDL-c, defined as < 40 mg/dL in male and < 50 mg/dL in female, elevated blood pressure, defined as systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure ≥ 85 mm Hg and elevated fasting glucose, defined as blood glucose > 100 mg/dL, with the inclusion of patients taking medication to manage hypertriglyceridemia, low HDL-c, hypertension and hyperglycemia. This definition is frequently referred to as the current Harmonization definition. Pediatric metabolic syndrome (PMS) in childhood can lead to early onset of diabetes mellitus and cardiovascular diseases in adulthood. PMS among school-age children is considered to be present when at least 3 or more of the following clinical and metabolic abnormalities are present together: insulin resistance, abdominal obesity, low level of high-density lipoprotein (HDL), high triglycerides (TGs), high fasting blood glucose (FBG), and elevated blood pressure (BP). The numbers of childhood MetS are high in the US, in the Middle East and in South American countries, with the highest proportion of MetS diagnoses occurring among overweight and obese individuals. As MetS is on the rise in children and adolescents, and given the disagreement on the diagnosis of MetS in children and youth, cardio-metabolic risk evaluation should rather be based on established risk factors such as nutritional status, hypertension, dyslipidemia, IR, clinical status, and familial predisposition.