July 7, 2008 — The American Academy of Pediatrics has issued a new clinical report on lipid screening and cardiovascular health in children [1], a report that has taken on new urgency given the epidemic of childhood obesity and the subsequent increased risks of type 2 diabetes mellitus, hypertension, and cardiovascular disease, say its authors.

According to coauthors Drs Stephen Daniels (University of Colorado School of Medicine, Denver) and Frank Greer (University of Wisconsin Medical School, Madison), along with the Committee on Nutrition, the report "reemphasizes the need for prevention of cardiovascular disease by following Dietary Guidelines for Americans and increasing physical activity, and also includes a review of the pharmacologic agents and indications for treating dyslipidemia in children."

The new report is published in the July 1, 2008 issue of Pediatrics and replaces the 1998 policy statement, "Cholesterol in Childhood." New data, write the authors, emphasize the negative effects of the excess dietary intake of saturated fats, trans fats, and cholesterol, and the effects of carbohydrates, the obesity epidemic, the metabolic/insulin resistance syndrome, and the decreased level of physical activity and fitness on the risk of adult-onset cardiovascular disease.

"In addition," write Daniels and colleagues, "more data are now available on the safety and efficiency of pharmacologic agents used to treat dyslipidemia. Most of these data were not available at the time of the previous statement."

The recommendations

The new report recommends a diet for all children older than 2 years that is based on the Dietary Guidelines for Americans, which is published by the Department of Health and Human Services and the Department of Agriculture. For children or adolescents at higher risk for cardiovascular disease or with elevated low-density lipoprotein (LDL)–cholesterol levels, changes in diet based on nutritional counseling and other lifestyle modifications are also recommended. For overweight or obese pediatric patients with high triglyceride levels or low high-density lipoprotein (HDL)-cholesterol levels, weight management is the primary treatment, and includes improvement in diet with nutritional counseling and increased physical activity.

The writing committee also states that the current recommendation is to screen children and adolescents with a positive family history of dyslipidemia or premature cardiovascular disease. It is recommended that pediatric patients for whom family history is not known and those with other cardiovascular risk factors, such as being overweight, obesity, hypertension, smoking history, and diabetes mellitus, be screened with a fasting-lipid profile. Screening should take place after 2 years of age, but no later than 10 years of age.

Recommended LDL-cholesterol concentrations for pharmacologic treatment of children and adolescents 10 years and older

For those with no risk factors, treatment with pharmacologic agents should be used if LDL-cholesterol levels are persistently higher than 190 mg/dL. The cut-off point for therapy is lowered to 160 mg/dL for those with other risk factors. Although the initial goal is to lower LDL-cholesterol to levels < 160 mg/dL, targets as low as 130 mg/dL, or even 110 mg/dL, "may be warranted when there is a strong family history of cardiovascular disease, especially with other risk factors, including obesity, diabetes, mellitus, the metabolic syndrome, and other higher-risk situations," suggest the writing the committee.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Source

1. Daniels SR, Greer FR, and the Committee on Nutrition. Lipid screening and cardiovascular health. Pediatrics. 2008;122:198-208.

The complete contents of Heartwire , a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

Clinical Context

Study Highlights

• A healthful, low-fat diet should be recommended to all children older than 2 years, and some research suggests that limiting fat in children younger than 2 years has no negative effect on growth or neurologic function. Reduced-fat milk may be appropriate for children beginning at age 12 months if there is concern for overweight or obesity, or if a family history of cardiovascular disease is present.
• Only children at increased risk for future cardiovascular events should receive routine screening for serum lipid concentrations. Children and adolescents with any of the following risk factors should receive screening:
  • Family history of dyslipidemia
  • Family history of premature cardiovascular disease
  • Overweight or obese children
  • Children with hypertension
  • Children who smoke cigarettes
  • Children with diabetes mellitus
• Children who qualify for screening should receive a full fasting lipid profile.
• At-risk children should be screened after age 2 years but no later than age 10 years.
• Children with normal lipid values at screening may be retested in 3 to 5 years.
• All children with abnormal lipid levels should receive education on diet and exercise. This is particularly important for pediatric patients whose primary lipid level abnormality is a high triglyceride or low HDL cholesterol level.
• Pharmacologic treatment should be considered for children who are at least 8 years old and meet one of the following qualifications:
  • LDL cholesterol level at least 190 mg/dL
  • LDL cholesterol level at least 160 mg/dL with a family history of premature cardiovascular disease or at least 2 other risk factors present
  • LDL cholesterol level at least 130 mg/dL and patient has diabetes
• Pharmacologic treatment may be considered for LDL cholesterol levels as low as 110 mg/dL if there are very compelling indications.
• Bile acid-binding resins can reduce cholesterol levels by 10% to 20%, and these medications do not have systemic effects.
• Statins have been demonstrated to be effective in short-term studies in children and have also been demonstrated to reduce atherosclerosis in children with hyperlipidemia.
• Fibrates should be reserved for use in special clinics for children with hyperlipidemia. Because of a high rate of adverse events such as flushing (up to three quarters of treated patients) and elevated transaminase concentrations (26% of children in 1 study), niacin should be avoided for the treatment of pediatric dyslipidemia.

Pearls for Practice

• The current clinical report suggests that children and adolescents with a family history of dyslipidemia, a family history of premature cardiovascular disease, or a personal history of overweight or obesity, hypertension, cigarette smoking, or diabetes should receive routine screening for serum lipid concentrations.
• Bile acid-binding resins and statins are the most recommended medical treatments for the management of pediatric dyslipidemia, and fibrates may be used by specialists in these disorders. The use of niacin is discouraged in children.

CME/CE Test