It's All About the Children

The American Academy of Pediatrics (AAP) earlier this week issued new guidelines for children in the fight against cardiovascular disease and more specifically, dyslipidemia in childhood.  And along with these recommendations, much debate and controversy has followed as a greater emphasis has been placed on "taking a pill" to combat the cholesterol problem.  Furthermore, these recommendations extend to children 2 years of age, and in some instances, 1 year of age. 

So with a link to the AAP policy report http://aappolicy.aappublications.org/cgi/content/full/pediatrics;122/1/198 I've taken the liberty of taking the summary points and sharing with you all my individual responses to each one (in italics).  And bear in mind I probably would have been affected by these guidelines (in regard to the cholesterol concerns) as an adolescent and assume not only will a good percentage of my patients be impacted by them, but potentially my own children as well.

1. Children older than 2 years of age are to follow the Dietary Guidelines for Americans, which includes the use of low-fat dairy products.  No issues here, but where I do not necessarily agree is using reduced-fat milk for children ages 1-2 years where obesity is an issue or where there is a family history of obesity, high cholesterol or cardiovascular disease (CVD).  The benefits have been well documented on the neurological and visual systems of regular whole-fat milk for a child 1-2 years of age and I plan on honoring this until definitive research tells me otherwise.
2. For those children and adolescents at higher risk for CVD and with a high concentration of low-density lipoprotein (LDL), recommendations include changes in diet with nutritional counseling and other lifestyle interventions such as increased physical activity.  More common sense than anything but important to include in the overall policy.
3. The most current recommendation is to screen children and adolescents with a positive family history of dyslipidemia or premature ( 55 years of age for men and 65 years of age for women) CVD or dyslipidemia. It is also recommended that pediatric patients for whom family history is not known or those with other CVD risk factors, such as overweight (BMI 85th percentile, <95th percentile), obesity (BMI 95th percentile), hypertension (blood pressure 95th percentile), cigarette smoking, or diabetes mellitus, be screened with a fasting lipid profile. This summary point leads into #4 and #5 so read further.
4. For the children described in summary point #3, the first screening should take place after 2 years of age but no later than 10 years of age. Screening before 2 years of age is not recommended.  My thoughts follow the next summary point.
5. A fasting lipid profile (which is a lab draw) is the recommended approach to screening, because there is no currently available noninvasive method to assess atherosclerotic CVD in children. This screening should occur in the context of well-child and health maintenance visits.  If values are within the reference range on initial screening, the patient should be retested in 3 to 5 years. At this point in time, I would have to be hard-pressed to obtain a fasting lipid profile (which is a lab draw) at these younger ages secondary to a firm belief I hold...what will I do with the information I obtain from performing this test?  I will already be implementing the dietary and physical activity measures but do I need to do a lab test to tell me that?  Even with summary point #7, there are no recommendations for medications at these younger ages (less than 8 years of age).        
6. For pediatric patients who are overweight or obese and have a high triglyceride concentration or low HDL concentration, weight management is the primary treatment, which includes improvement of diet with nutritional counseling and increased physical activity to produce improved energy balance.  As with summary point #2, more common sense than anything but important to include in the overall policy.
7. For patients 8 years and older with an LDL concentration of 190 mg/dL (or 160 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 initial goal is to lower LDL concentration to <160 mg/dL. However, targets as low as 130 mg/dL or even 110 mg/dL may be warranted when there is a strong family history of CVD, especially with other risk factors including obesity, diabetes mellitus, the metabolic syndrome, and other higher-risk situations.  I am torn with this point.  Although I value the impact of these medications in the adult population, I am not convinced there is enough research to justify using it at these younger ages except when certain lipid levels are disastrously high (e.g. Familial Hypercholesterolemia-an autosomal dominant disorder).

So while I applaud the AAP in taking these bold steps, I am not convinced current research justifies it.  But for any parent or caregiver that has a child of concern, I certainly encourage you to discuss further with your child's physician.

Dr. Jeremy