With a simple blood test, you can screen and potentially improve and extend the lives of children and adolescents with dyslipidemia.
This is one of the few areas of cardiovascular medicine where your initial diagnosis will make such a significant difference into adulthood. Dyslipidemia occurs more frequently than does structural congenital disease, heart rhythm disorders, heart failure, and most other conditions pediatric cardiologists manage.
In addition, you no longer have to wonder if you should evaluate your patients for dyslipidemia. In December 2011, the National Heart, Lung, and Blood Institute published guidelines on dyslipidemia in pediatric patients. Universal screening for dyslipidemia is now expected when children are 9-11 years old, even if they have no risk factors. The American Academy of Pediatrics endorsed this guidance.
Of course, there are situations where you might want to check earlier. If you identify any risk factor – relevant family history, obesity, or diabetes – you don’t have to wait until a child is 9 years old. You can screen these children when they are as young as 2 or 3 years.
The good news is that the guidelines do not require a fasting lipid profile ("Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years," Pediatric News, Nov. 15, 2011). A nonfasting lipid profile reveals relevant information (except regarding HDL cholesterol), and is therefore an appropriate initial, universal screening tool. If you get a result out of the normal range or identify any new risk factors, a follow-up fasting lipid profile is warranted.
I’m glad to see that the guideline experts do not require a fasting assay. As many pediatricians can attest, overnight fasting can be very onerous for young patients and their families – especially if the well child visit is in the afternoon.
Once dyslipidemia is diagnosed, pediatricians can effectively manage most children with this condition. However, there also is a general consensus among these experts that the most severe childhood lipid abnormalities should be managed by lipid specialists. Hypercholesterolemia with a genetic etiology is worrisome, for example, especially if it’s heterozygous familial hypercholesterolemia.
Affected children will have significant elevations of LDL cholesterol – easily over 160 mg/dL and usually over 200 mg/dL. This condition affects about 1 in 500 people in the United States. Left undiagnosed and untreated, over their lifetimes about 50% of the men and 25% of the women will experience an important event – such as peripheral arterial disease or a heart attack – by the time they are 50.
If a person unknowingly grows to adulthood with heterozygous familial hypercholesterolemia, that person might experience a heart attack with no warning at age 30 (for men) or age 40 (for women).
This is all about prevention on the part of the pediatrician. Your early identification of patients with lipid abnormalities ties into "primordial prevention." In contrast to treating adults after they’ve developed cardiovascular disease, or performing "primary prevention" to prevent disease in a patient with known risk factors, pediatricians can prevent risk factors from developing in the first place. This means screening and counseling patients before they become obese, develop prehypertension, or present with prediabetes. Primordial prevention can delay or prevent a lot of these risk factors from becoming real issues.
If you identify and treat these patients with statins, you can restore normal longevity. Researchers have shown that these agents are just as safe and effective for children as they are for adults.
Dyslipidemia screening, diagnosis, and management are clinical areas where pediatricians and cardiologists can work together and make a real difference. I can’t think of anything better for pediatricians to do.
Dr. Hardin is director of the division of pediatric cardiology, and associate professor of pediatrics, at Loyola University Health System in Maywood, Ill. He had no relevant financial disclosures.