Lipid Screening in Childhood -- New Recommendations from the AAP

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Lipid Screening in Childhood — New Recommendations from the AAP

Controversial new recommendations advocate wider screening and use of statins in children.

The AAP has released a new clinical report on lipid screening in children that replaces its 1998 policy statement. Much of the background information is not new: (1) autopsy data indicate that the atherosclerotic process begins in childhood and that elevated cholesterol levels in childhood are associated with increased risk for cardiovascular disease (CVD) in adulthood; (2) lipid and lipoprotein levels rise rapidly early in life and stabilize by age 5 to levels similar to those of adolescents; and (3) currently, 35% to 45% of children are screened because of positive family history of CVD.

So, what is new since the 1998 report was published? First, the average weight of U.S. children is rising as the obesity epidemic continues. Second, the metabolic syndrome (which includes measurement of waist circumference, lipid levels, blood pressure, and fasting glucose level) is well defined and is known to be associated with CVD in adults. Third, statins are extremely useful in lowering CVD incidence in adults and have excellent safety profiles.

Besides the standard advice — that all children should follow recommended dietary guidelines, including the restriction of dietary cholesterol and saturated fats (and use of low-fat dairy products) — the new guideline calls for wider screening and recommends that cholesterol-lowering drugs should be considered in children. Highlights include:

Screening is recommended every 3 to 5 years, optimally beginning at age 2 years and certainly no later than age 10 for children with positive family histories of dyslipidemia or premature CVD (i.e., CVD diagnosed before age 55 for men and 65 for women); unknown family history; or other CVD risk factors (overweight or obesity, hypertension, cigarette smoking, or diabetes).
A fasting lipid profile is the recommended screening approach, and interpretation should be based on reference charts provided in the report.
Weight management is the primary treatment strategy for overweight or obese children with high triglyceride levels or low high-density lipoprotein levels.
"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."

Comment: This guideline is quite controversial (New York Times Jul 8 2008). Some critics believe that the recommendations are too aggressive for the few data that exist (and none are presented in the report) about either long-term benefits or risks of statin use in children. Others believe that prolonged elevation of cholesterol, beginning in childhood, could warrant drug treatment, based on encouraging data in adults and selected children with the homozygous form of familial hypercholesterolemia. With the new recommendations, I estimate that about 75% of U.S. children will qualify for screening because of weight, family history, or other CVD risk factors.

When considering statins for children, I worry about the possibility of unexpected consequences of aggressive cholesterol lowering and am reminded of a recent trial in adults with type 2 diabetes (JW Jun 6 2008) in which aggressive lowering of glycosylated hemoglobin (HbA_1c) was associated with increased mortality. In addition, because health insurers can deny coverage for preexisting conditions, I am concerned about the possible long-term implications of "labeling" a child as having elevated cholesterol. Whether to use cholesterol drugs in children epitomizes the art of medicine in my view: Each physician must understand the data, his or her own biases, and the concerns and preferences of patients and families when making recommendations about the use of statins in children.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine July 16, 2008