Talking to Your Patients' Families about Kids and High Cholesterol

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In 2008,the American Academy of Pediatrics (AAP) released new guidelines for screening children and adolescents for high cholesterol. The growing epidemic of childhood obesity underscores the need for physicians to adopt these guidelines, which recommend screening kids earlier and more often. Here's what you need to know about the new guidelines.

UNDERSTANDING WHOM AND WHEN TO SCREEN

Research shows that a high level of low-density lipoprotein (LDL), a low level of high-density lipoprotein (HDL), high blood pressure, diabetes and obesity are among the risk factors for cardiovascular disease that may be present in young children.

These findings reinforce the need for cholesterol screenings in children and adolescents earlier and more frequently.

The new AAP guidelines recommend that physicians conduct a fasting-lipid profile for children and adolescents, ages 2 to 18, who meet one of these criteria:

• a family history of early heart disease or high cholesterol,
• an unknown family history of heart disease or high cholesterol, or
• risk factors such as being overweight, obesity, high blood pressure, diabetes, insulin resistance or smoking

For these children, lipid screenings should begin after age 2. Screening before age 2 is not recommended. If the initial lipid profile falls within acceptable ranges (total cholesterol less than 200 mg/dL and LDL cholesterol less than 110 mg/dL), screenings should be repeated every three to five years.

The AAP advises that physicians include these cholesterol screenings as part of the patient's well-child or health maintenance visit.

PARTNERING WITH FAMILIES TO MANAGE, TREAT HIGH CHOLESTEROL IN KIDS

For children who are overweight or obese, or who have a high triglyceride level or low HDL level, weight management is the best treatment approach.

This includes working with your patient's family to introduce a healthy diet—which might require the support of a nutritionist—and increased physical exercise. A revised diet should include foods that are low in total fat, saturated fat, trans fat and cholesterol.

The new guidelines also recommend the use of low-fat dairy products. For children between the ages of 12 months and 2 years who are overweight or obese, or have a family history of obesity, high cholesterol or heart disease, the use of reduced-fat milk is appropriate.

It's important to remember that a diet and exercise program that involves the entire family is the best approach to managing and treating high cholesterol in children.

In addition to diet and exercise, medication, and referral to a specialist should be considered for children 8 years or older who have:

• an LDL level at or above 190 mg/dL
• an LDL level at or above 160 mg/dL plus a family history of early heart disease, or two or more risk factors—such as high blood pressure or obesity
• type 1 or 2 diabetes with an LDL level above 130 mg/dL

There are several classes of drugs for treating high cholesterol in children and adolescents, including statins.As published by the AAP in its journal Pediatrics, a number of clinical trials have studied statin therapy in children and adolescents. While these trials generally have been short term, they have demonstrated statins to be safe and effective in lowering cholesterol.

KNOWING WHEN TO REFER TO A SPECIALIST

Physicians should consider referring children and adolescents with high cholesterol to a specialist when the patient:

• has an elevated LDL level (above 160)
• has triglycerides over 200, which puts the child at risk for pancreatitis
• is a candidate for drug therapy, based on the new AAP guidelines

Jacqueline A. Maiers, MD

Assistant Professor of Pediatrics
Indiana University School of Medicine
Pediatric Cardiology

317-274-8906
jmaiers@clarian.org