Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years



Perhaps the best news about the cholesterol testing now recommended for all children aged 9-11 years by an expert panel convened by the National Heart, Lung, and Blood Institute is that children don’t have to fast before getting their blood drawn. The guidelines were published online on Nov. 13 and appear in the December issue of Pediatrics.

Dr. Stephen R. Daniels, chair of the expert panel that reviewed the guidelines, emphasized that the new approach to cholesterol screening can be accomplished with a blood test that does not require fasting, so it should be relatively easy to include in a busy practice. This strategy "ensures that children with elevated LDL (or bad) cholesterol will be identified."

Data from studies of the previous cholesterol-screening approach suggest that children with high cholesterol have often been missed, said Dr. Daniels, pediatrician-in-chief at the University of Colorado at Denver, Aurora.

Data from previous studies have shown that atherosclerosis begins in youth, and that heart attacks, strokes, and other cardiovascular problems in adulthood are often the end result of cardiovascular risk factors that went unrecognized throughout childhood, according to the report (Pediatrics 2011 Nov. 13 [doi:10.1542/peds.2009-2107C]).

The current guidelines represent the latest update since the 1990s, said Dr. Daniels.

"These guidelines are different in that they are based on a comprehensive and systematic review of the literature, they are integrated across all risk factors (hypertension, dyslipidemia, obesity, diabetes, and cigarette smoking) and lifestyle factors (diet and physical activity), and they address issues across the pediatric age range," he said in an interview.

Data from studies of the previous cholesterol-screening approach suggest that children with high cholesterol have often been missed, said Dr. Stephen R. Daniels.

The "Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report" provides details for how to reduce risk factors and help prevent cardiovascular problems in children from birth to 21 years of age, starting with a recommendation for exclusive breastfeeding of children for the first 6 months of life.

However, the most notable new element in the guidelines is universal cholesterol-screening recommendation for preadolescents.

According to the guidelines, doctors should obtain a universal lipid screen with nonfasting non-HDL cholesterol (that is, total cholesterol minus HDL cholesterol) or a fasting lipid profile (FLP) for all children at least once between the ages of 9 and 11 years, and "manage per lipid algorithms as needed." Diet and exercise are recommended as first-line treatment, but statins may be considered in children whose high cholesterol persists despite diet and lifestyle interventions.

The guidelines recommend obtaining an FLP at age 12-17 years if a child’s family history is newly positive, if a parent has dyslipidemia, or if the child has any other risk factors or high-risk conditions, and then managing per lipid algorithms as needed.

For all patients aged 18-21 years, the guidelines recommend measuring one nonfasting non-HDL or FLP, and then reviewing the results with patients and managing them with lipid algorithms per Adult Treatment Panel III as needed.

Preventive steps to reduce risk and prevent cardiovascular disease in all ages include regular physical activity, with vigorous activity 3 days a week, according to the "Physical Activity Guidelines Advisory Committee Report 2008" from the Department of Health and Human Services.

Other preventive measures include a diet low in saturated fat for all children starting at 1 year of age, as well as both practice- and school-based interventions to keep children from smoking and to help them quit.

The guidelines also recommend annual blood pressure measurement for all children starting at 3 years of age, and interpreted for age, sex, and height. The report has a chart with an algorithm and flow diagram to assist clinicians in diagnosing hypertension in children.

"The rationale for these guidelines is that there is more and more evidence for the concept that atherosclerosis begins in childhood and depends on the same risk factors we are concerned about in adults," Dr. Daniels said. "This means that we should try to prevent these risk factors from developing in the first place (primordial prevention) and identify children at higher risk, so we can work on improving their lifestyle," he added.

"Cardiovascular disease is the most common cause of death for both men and women. So, this places great importance on these issues for primary care pediatricians. The new approach to screening may actually be easier to implement than the old strategy, which requires constant updating of the family history," noted Dr. Daniels, who is also chairman and professor of pediatrics at the university.


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