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More Youths Need Cholesterol Screening, says AAP

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December 22, 2011

A new guideline from the American Academy of Pediatrics (AAP) recommends routine cardiovascular screening with cholesterol tests for pre-adolescents and young adults. All youths should have cholesterol screening tests performed during well visits once between the ages of 9 and 11 and again between ages 17 and 21, advises the group in a supplement to the December issue of Pediatrics. A panel convened by the National Heart, Lung, and Blood Institute wrote the guidelines.

Previous AAP guidelines issued in 2008 directed pediatricians to test cholesterol only in children and young adults with a family history of heart disease or early heart disease and in those with risk factors for heart disease, including those who smoke, are diabetic, overweight, obese, or hypertensive (high blood pressure). However, an earlier start to cardiovascular prevention is necessary for all youths, the new guidelines say. Growing evidence shows that the biological processes that precede heart attacks and cardiovascular disease begin in childhood, although they don't generally cause symptoms until middle age or later.

"It is well established that a population that enters adulthood with lower risk will have less atherosclerosis and will collectively have lower cardiovascular disease rates," the guidelines say. The new recommendations come amidst growing numbers of American children who are overweight or obese and at risk for developing diabetes, high blood pressure, and other health issues. About 17% of American children are obese, the Centers for Disease Control and Prevention (CDC) estimates.

As suggested in previous guidelines, testing should include a lipid profile. Fasting prior to cholesterol screening in children is unnecessary. To avoid fasting, the panel recommends calculating non-high density lipoprotein cholesterol (non-HDL-C) levels by testing for total cholesterol (TC) and HDL-C and taking the difference between the two levels. Recommended cutoff values include:

    Acceptable (mg/dL) Borderline (mg/dL) High (mg/dL)
Children and Adolescents Total Cholesterol Less than 170 170-199 Greater than or equal to 200
  Non-HDL Cholesterol Less than 120 120-144 Greater than or equal to 145
Young Adults Total Cholesterol Less than 190 190-224 Greater than or equal to 225
  Non-HDL Cholesterol Less than 150 150-189 Greater than or equal to 190

*Adapted from "Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Summary report" Pediatrics 2011; 128

For children and young adults with unhealthy lipid levels, the guidelines recommend dietary and lifestyle changes, including more exercise, as the often-effective first steps. AAP urges caution in prescribing statins to children with high lipid levels because no studies have tested these drugs in children. But doctors should consider them for children with low-density lipoprotein cholesterol (LDL-C) levels 190 mg/dL or higher in children 10 and older if they haven't responded to lifestyle changes after 6 months. For children with risk factors, consider statins if their LDL-C levels are 130 to 189 mg/dL, the guidelines say. To determine the LDL-C level, a separate sample collected when the child has fasted is required.

Noting that family history of cardiovascular disease is often a risk factor, the guidelines suggest expanding that history to include grandparents, aunts, and uncles. A positive family history should prompt intensive attention to cardiovascular disease risk factors.

Pediatricians should review children's growth with parents. Children ages 4 and older with weight above the 85th percentile who haven't reduced that figure within six months should see a registered dietician. Additionally, pediatricians should start routine annual blood pressure checks at age 3.

The guidelines also suggest that doctors direct parents to protect children from tobacco exposure, begin anti-smoking advice at ages 5 to 9, and encourage physical activity. Children's sedentary time, including that spent in front of television or computer screens, should be limited to two hours or less each day.

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Tests: Cholesterol, HDL, LDL, Lipid Profile
Conditions: CVD

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NOTE: This article is based on research that utilizes the sources cited here as well as the collective experience of the Lab Tests Online Editorial Review Board. This article is periodically reviewed by the Editorial Board and may be updated as a result of the review. Any new sources cited will be added to the list and distinguished from the original sources used.

Christine Fend. Medical News: AHA: All Kids Need Cholesterol Tests, AAP Says. MedPage Today. Available online through http://www.medpagetoday.com. Published November 11, 2011. Accessed December 7, 2011.

Kavey R-EW, et al. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Summary report. Pediatrics 2011; 128: DOI:10.1542/peds.2009-2107C. PDF available for download at http://pediatrics.aappublications.org/site/misc/2009-2107.pdf through http://pediatrics.aappublications.org.

Ron Winslow and Jennifer Corbett Dooren. Panel Urges Cholesterol Testing for Kids. Wall Street Journal. Available online through http://online.wsj.com. Published November 12, 2011. Accessed December 7, 2011.

Rob Stein.Children 9 to 11 Should Have Cholesterol Tested. The Washington Post. Available online through http://www.washingtonpost.com. Published November 11, 2011. Accessed December 7, 2011.

Daniels S, Greer F and the Committee on Nutrition. Lipid Screening and Cardiovascular Health in Childhood. Pediatrics Vol. 122 No. 1 July 2008, Pp. 198-208 (doi:10.1542/peds.2008-1349). Available online at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;122/1/198 through http://aappolicy.aappublications.org. Accessed December 2011. 

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