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July 13, 2008

AAP Revises Cholesterol Screening Guidelines for Children


By Neil Osterweil

July 11, 2008 — With a decade of new data about risk factors for cardiovascular disease under its belt, the American Academy of Pediatrics (AAP) has issued new guidelines for lipid screening and cholesterol management in children.
"A number of studies have identified potential risk factors for adult cardiovascular disease," write Stephen R. Daniels, MD, PhD, and Frank R. Greer, MD, on behalf of the AAP's Committee on Nutrition in the July issue of Pediatrics. "Research in children and adolescents has demonstrated that some of these risk factors may be present at a young age, and pediatricians must initiate the lifelong approach to prevention of cardiovascular disease in their patients."
Allison Brindle, MD, an associate staff physician at the Cleveland Clinic Children's Hospital in Ohio, noted in an interview with Medscape Pediatrics, "The new guidelines are much more aggressive about both obesity prevention and diagnosis of comorbid conditions — in this case primarily looking at high cholesterol levels and implementing treatments in children." Dr. Brindle was not involved in guideline development.
One recommendation in particular, however, has raised concern among physicians and consumer health advocates: the possibility of pharmacologic intervention beginning at age 8 years — 2 full years earlier than previously recommended.
"For patients 8 years and older with [a low-density lipoprotein (LDL)] concentration of ≥190 mg/dL (or ≥60 mg/dL with a family history of early heart disease or ≥2 additional risk factors present or ≥130 mg/dL if diabetes mellitus is present), pharmacologic intervention should be considered," the guidelines recommend.
The guidelines further state that although the initial goal of pharmacologic intervention should be to lower LDL concentrations to less than 160 g/dL, it may be appropriate to treat patients with a strong family history of cardiovascular disease and other risk factors such as diabetes or obesity to targets as low as 110 mg/dL.
Some physicians warn that the AAP is being hasty in its recommendations, given the paucity of data on the long-term effects of statins in children and adolescents and uncertainties about the ultimate benefits for younger statin starters.
"To be frank, I'm embarrassed for the AAP today," Lawrence Rosen, MD, from Hackensack University Medical Center in New Jersey, told the New York Times. "Treatment with medications in the absence of any clear data? I hope they're ready for the public backlash."
The guideline authors agree with critics that it is unknown whether giving children and adolescents statins now will pay off in better cardiovascular health decades down the road. However, they point out that "recent studies of children and adolescents have established the effectiveness and safety of the available agents, including their use in prepubertal children and children between 8 and 10 years of age."
In fact, the new guidelines do not represent a radical departure from previous recommendations but, instead, are a sober reflection of a growing reality: Kids are getting fatter, laying the groundwork for a future of cardiovascular disease unless something is done to stop the cascade, specialists say.
"These recommendations are a needed update to a set of statements that were written quite some time ago, and they contain some changes or advances, but they are not a dramatic departure," said Sarah D. de Ferranti, MD, MPH, director of the preventive cardiology clinic at Children's Hospital, Boston, in an interview with Medscape Pediatrics. Dr. de Ferranti was not involved in guideline development.
"There has been a lot of excitement in the news about how we're going to start giving medications to really young kids, but that's only a part of the picture of this statement," she added.
Dr. de Ferranti pointed to other changes in the guidelines that she says are equally significant, including more frequent cholesterol screening, more simplified screening with fasting lipid profiles, and switching from saturated fat sources, such as whole milk, to low-fat dairy and nonsaturated fat diets in at-risk children aged 1 year and older.
Although fat-restricted diets are generally not recommended for children under 2 years of age, the guidelines authors cited the ongoing Special Turku Risk Intervention Program, which showed that children from age 7 months onward who were maintained on a diet with total fat making up less than 30% of calories, saturated fat making up less than 10% of calories, and cholesterol intake of less than 200 mg/day, using 1.5% cow milk after 12 months of age, fared just as well in terms of growth and neurologic development as control patients. In addition, boys in the intervention group in the study had lower LDL concentrations and girls had a decreased prevalence of obesity compared with control patients.
Statins Stat? Not so fast
Dr. de Ferranti emphasizes that the decision to prescribe statins and other lipid-lowering medications for at-risk children is not made lightly.
"Most pediatricians would not start a statin on their own, they would refer to a specialist who does this more often," she said, "and most of us who do this more often would focus on diet and lifestyle for years before starting a medicine. But the people that we are talking about starting on medicine at that young an age are usually people who have extremely elevated values, 2 to 3 times what you would expect for a child's normal LDL. I would probably start [on medication someone] who has an LDL in the 200s."
In addition to the recommendations mentioned above, the guidelines recommend that :
All children older than 2 years should follow US Department of Agriculture Dietary Guidelines for Americans.
Children aged from 12 months to 2 years who are overweight, obese, or have a family history of obesity, dyslipidemia, or cardiovascular disease should consume reduced-fat milk.
Diet changes, nutrition counseling, and exercise are recommended for children and teens with high LDL concentrations.
Screen with a fasting lipid profile for children with a positive family history of dyslipidemia or premature cardiovascular disease or dyslipidemia, as well as those with unknown family history but who have other cardiovascular risk factors, such as overweight, obesity, hypertension, cigarette smoking, or diabetes mellitus. Screenings should take place any time after age 2 years, beginning before age 10 years.
Children with fasting lipids within normal reference range should be rescreened in 3 to 5 years.
Weight management is the primary method of treating hyperlipidemia in children.
"What this statement is saying is, do not wait until adolescence if patients have a clear, very concerning lipid profile," Dr. de Ferranti said.

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