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Kids and Cholesterol: New Guidelines for Screening
Cardiovascular disease only seems to begin in mid to late adulthood, when blood tests announce the buildup of lipids, or fats, in the blood. But the truth is it starts much earlier. Even children can have abnormally high cholesterol levels.
A recent report, sponsored by the National Heart, Lung, and Blood Institute and endorsed by the American Academy of Pediatrics, updates guidelines for primary care pediatric providers for checking children's cholesterol.
The report reflects new information that has emerged from long-term studies of cardiovascular disease and its precursors, and the escalating concern about obesity among children and teens in the U.S. and its implications for adult cardiovascular health.
Just like the adults they will become, many children, teens, and young adults have risk factors that make them more vulnerable to cardiovascular disease as adults. These risk factors include abnormal cholesterol and lipid levels, high blood pressure, smoking, and diabetes.
While initially reversible, abnormal blood lipids ultimately cause irreversible damage. The problem starts when abnormal lipids accumulate in the lining of the blood vessels. This deposits build up and are covered by fibromuscular tissue which may clog the artery, decrease blood flow, stress the blood vessel and cause it to rupture, or break off in small pieces (plaques) which can cause heart attacks, strokes, and peripheral vascular disease.
Studies have shown that young adults who enter adulthood with fewer risk factors have later and milder cardiovascular disease. Clearly, in order to prevent heart disease in adults, prevention and modification of risk factors must start in childhood.
The biggest change recommended in the report is screening all children for elevated cholesterol rather than only those with family histories of premature cardiovascular disease (CV) or potentially inherited lipid disorders. Screening is now recommended for ALL children between ages 9-11 and again at ages 17-21.
These recommendations are informed by studies which have shown that when blood lipid measurements are found to be abnormal in childhood, they typically remain abnormal into adulthood. Other studies have shown that screening only those with a family history of cardiovascular disease misses 30-60% of children at risk because accurate family history information is so often unavailable. Screening all children will greatly improve the ability to modify the precursors of adult heart disease in the whole pediatric population.
A second big change is the recommendation that non-HDL cholesterol (total cholesterol minus HDL, the good cholesterol) be used as the primary screening measurement instead of a complete panel of blood lipid tests. Non-HDL cholesterol (basically LDL and triglycerides) has been shown to be an accurate predictor of abnormal childhood lipids that will persist into adulthood, and this test has the advantage of being a blood test that can be done without fasting.
Children identified with high LDL cholesterol and triglycerides should have a full fasting lipid profile for effective management and monitoring. (Fasting eliminates the influence of a fatty meal, for example, on blood lipid levels and so gives a more accurate reading of a person's blood fats.)
Diet and exercise are the first steps in treating children with high LDL and triglyceride levels. Children with seriously elevated blood fats should be given diets developed in consultation with and monitored by nutritionists, with carefully controlled saturated fat and cholesterol intake have been shown to be effective in reducing the levels of total and LDL cholesterol in otherwise healthy children.
A nutritionist can help ensure that a diet is balanced and contains adequate amounts of the necessary nutrients. Exercise is also important, and your pediatrician can recommend activities appropriate to your child's age and cardiovascular status.
Treating children with high bad cholesterol beyond diet and exercise must be done in conjunction with a specialist. Medication may be considered in a child older than 10 years when a child’s abnormal cholesterol does not respond to diet and exercise, and when there is a strong family history of premature cardiovascular disease and the child has other risk factors which will accelerate his development of CV disease, or when her abnormal lipids are known to be from a genetic cause. Many of the compounds and medications used by adults have not been adequately studied in children. The potential risks of medication use must be balanced against the benefits of the long-term goal of decreasing adult cardiovascular disease.
While early identification and modification of abnormal lipid profiles in children is key, attention to other child and teen factors which combine to increase adult heart disease risk is also important. Smoking abstinence/cessation, prevention of overweight and obesity, and identification and treatment of high blood pressure and diabetes are all effective and necessary preventative health measures.
Parents may wish to discuss cholesterol screening with their child’s health care provider and may wish to work with a nutritionist to identify ways to improve their children’s and their family’s diets.
The recommendations were published online ahead of print in the journal, Pediatrics.
November 30, 2011