The American Academy of Pediatrics (AAP) recently updated their guidelines to include recommendations for cholesterol screening and treatment in children. To prevent
heart disease in adulthood, the physician group is advising pediatricians to aggressively address
dyslipidemia (high lipids) in at-risk children and adolescents. The new guideline, published in the July 2008 issue of the journal
Pediatrics, takes particular aim at the rise in overweight children and obesity among US youth. The goal of testing is to help identify those youth at risk of developing heart disease later in life and who may benefit from early intervention and/or treatment. However, there is no evidence that children with elevated
cholesterol levels will go on to have dyslipidemia or heart disease as adults.
Test Only Those with Risk Factors
Like the latest guidance from the American Heart Association, American Diabetes Association, and US Preventive Services Task Force, the AAP’s new guideline reflects the information learned since 1992, when the National Cholesterol Education Program’s (NCEP) children’s guideline was published. Still, the AAP stops short of recommending screening all children and advises to test only those children with one or more risk factors for heart disease. The AAP recommends testing with a fasting lipid profile in these circumstances:
Based on family history:
- If the family has a history of high cholesterol or heart disease, particularly before age 55 in women or 65 in men
- If the family history is not known
Based on the child’s own health:
- If the child is diabetic, overweight, obese, or hypertensive (that is, if he or she has high blood pressure) or if he or she smokes cigarettes
If the initial blood test results are not worrisome, the tests should be taken again in three to five years. More frequent cholesterol testing and other monitoring is done if any therapy (diet, activity, medication) is begun.
The pediatric guideline includes cut points adapted from the NCEP guidelines for children and adolescents that identify borderline and abnormal results. The following are suggested action levels—the child’s doctor will take test results and other factors into account:
Category Total Cholesterol, mg/dL LDL, mg/dL
Acceptable <170 <110
Borderline 170–199 110–129
Elevated >200 >130
Age and Other Factors
A key to success in checking children’s cholesterol is recognizing the importance of ages 2, 8, 10 and puberty as well as other factors.
- Children with risk factors need to have their first fasting lipid profile between the ages of 2 and 10 years old, advises the AAP. Children younger than 2 years old are too young to be tested.
- Before age 8, treatment for high lipid levels is limited to lifestyle changes (diet and exercise). Beyond age 8—if dietary changes do not lower the level of low-density lipoprotein cholesterol (LDL-C)—medication may be considered, the AAP advises. This is expected to occur in a small percentage of children. Even so, there are concerns about who should be treated with lipid-lowering medication and for how long. Also, how much LDL-C is too high for a child depends on a number of variables, including whether the child has diabetes, a family history of heart disease, or at least two other risk factors.
- The pediatrician has to consider puberty, ethnicity, and gender as well. Cholesterol levels are affected by these.
The fasting lipid profile is the best cholesterol screening test, says the AAP. With this test, the pediatrician can consider not only the total cholesterol level in the child’s blood but also if the amounts of LDL, high-density lipoprotein (HDL), and triglycerides are in a healthy range.
Other Guidelines
In its guideline of July 2007, the US Preventive Services Task Force emphasized that the
role of screening children was unclear. One problem noted by the Task Force is that the effectiveness of treating dyslipidemia in children to improve health outcomes “remains a critical research gap.” The AAP is stressing, however, that measures to prevent heart disease in adults must be stepped up during childhood, given America’s epidemic in childhood obesity and its diet heavy in unhealthy fats and carbohydrates. Other guidelines to note and discuss with your child’s health care provider regarding cholesterol screening and treatment in children are listed here:
Conclusion
Children with a family history and/or high blood lipid levels need, most of all, to focus on developing healthier habits—diet and physical activity—emphasizes the AAP guideline. Nutritional counseling by a dietitian may help families with these changes that can be difficult to make and sustain. For children with persistently high levels of LDL-C and for some with early heart disease in the family, pediatric health care providers may consider adding cholesterol-lowering medication on top of the lifestyle changes, says the AAP, starting at 8 years of age. However, this approach to the issue remains controversial. For more information on ways to lower lipid levels in children and adolescents, visit the Cincinnati Children’s webpage on Cholesterol Problems in Children.
Sources
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American Diabetes Association. 2007. Standards of Medical Care in Diabetes—2007 (position statement) (section VII.A.1.iii). Diabetes Care 30:S4-S41. Available on the Internet at http://intl-care.diabetesjournals.org/cgi/content/full/30/suppl_1/S4. Accessed 12 Jul 2008.
Barrette, E-P. 8 Jul 2008. Comparison with adult guidelines (eLetter). Available on the Internet at http://pediatrics.aappublications.org/cgi/eletters/122/1/198#38070. Accessed 9 Jul 2008.
Daniels, SR, Greer FR, and the Committee on Nutrition. Jul 2008. Lipid screening and cardiovascular health in childhood (clinical report). Pediatrics 122:198-208.
McCrindle, BW, et al. Apr 10 2007. Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association. Circulation 115:1948-67.
McCrindle, BW, for the Writing Group. 2007. Summary of the American Heart Association’s Scientific Statement on Drug Therapy of High-Risk Lipid Abnormalities in Children and Adolescents (editorial). Arteriosclerosis, Thrombosis, and Vascular Biology 27:982.
National Cholesterol Education Program (NCEP) Expert Panel on Blood Cholesterol Levels in Children and Adolescents. 1992. National Cholesterol Education Program: Highlights of the Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics 89:495-501. Available on the Internet at http://pediatrics.aappublications.org/cgi/content/abstract/89/3/495. Accessed 11 Jul 2008.
Parker-Pope, T. 8 Jul 2008. 8-year-olds on statins? A new plan quickly bites back. New York Times. Available on the Internet at http://www.nytimes.com/2008/07/08/health/08well.html?em&ex=1215748800&en=d8789461a8102ea9&ei=5070 through http://www.nytimes.com. Accessed 11 Jul 2008.
Urbina, EM, et al. 21 Mar 2007. Statement addresses use of cholesterol drugs in children (American Heart Association Scientific Statement). American Heart Association. Available on the Internet at http://www.americanheart.org/presenter.jhtml?identifier=3046288. Accessed 10 Jul 2008.
US Preventive Services Task Force. Jul 2007. Screening for lipid disorders in children: US Preventive Services Task Force recommendation statement. Pediatrics 120(1):e215-9. Available on the Internet at http://pediatrics.aappublications.org/cgi/content/full/120/1/e215. Accessed 12 Jul 2008.
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