Tuesday, July 15, 2008

New guidelines recommend cholesterol screening for overweight kids
By Maggie De Pano

The American Academy of Pediatrics (AAP) recently released new guidelines stating that children as young as 8 can be given cholesterol-lowering drugs to prevent future heart problems, but only very few of them will likely be placed on medication. More children, however, will undergo cholesterol screening.

Jennifer Li, MD

Jennifer Li, M.D., Director of Pediatrics Research at the Duke Clinical Research Institute and a pediatric cardiologist at Duke University Medical Center, says that the AAP’s new guidelines do not focus so much on the need to give younger children cholesterol-lowering drugs as on the need to monitor overweight children’s cholesterol levels. It also calls attention to the importance of diet and exercise. 

“The major change from the 1992 guidelines is that this time, the academy is not just recommending screening for children who have a family history of cardiovascular disease or other similar risk factors,” says Li. “They are also recommending screening for children who are overweight.”
 
Overweight children have a Body Mass Index (BMI) from the 85th to below 95th percentiles. BMI is a statistical measure of a person’s weight scaled according to height. Unlike adults, whose BMI are classified in relation to specific cut-off points, children are classified using pediatric growth charts that compare their BMI with that of other kids of the same sex and age. This type of measurement takes into consideration that children are still growing and developing.

Children with a BMI from the 5th to below the 85th percentile are considered normal, while children with a BMI above the 95th percentile are considered obese.

The academy’s recommendation to screen overweight children for cholesterol comes after new studies have shown that a cluster of risk factors for heart disease, referred to as “the metabolic syndrome,” is more prevalent in overweight and obese kids. Compared to those who are of normal weight, overweight and obese kids tend to have higher blood pressure, higher levels of blood sugar and triglycerides (fat), and lower levels of HDL, or “good” cholesterol. More children and adolescents also have the metabolic syndrome today than when the 1992 guidelines were released.

The 1992 guidelines also did not include targeted ages for beginning testing. The new guidelines recommend screening for cholesterol sometime after age 2 but no later than age 10, at routine check-ups. They also recommend giving low fat milk to children between 1 to 2 years and fat free milk to children older than 2 years.

The AAP did acknowledge the safety of giving cholesterol-lowering drugs to very young children. It previously recommended that drugs should only be given to children older than 10. The lower cut-off point came after the results of several clinical trials showed that some cholesterol drugs, such as statins, are well-tolerated in children as young as 8.

Very few prepubescent children, however, will meet criteria that could lead doctors to consider giving them cholesterol-lowering drugs, says Li. Drugs will only be targeted for kids who have too much LDL, or “bad” cholesterol. The cut-off point for drug intervention is an LDL level persistently above 190 ml/dL for children who have no risk factors for heart disease; 160 ml/dL for children who have any of the risk factors for heart disease except diabetes; and 130 ml/dL for children who have diabetes.

Li says most children do not fall into any of these categories. “You also have to take the whole patient into account,” she adds. “The guidelines do not mean that if a young child meets the criteria, you automatically put him on medication. No one knows at this point whether there’s a difference between giving drugs at 8, 9, 10 or older. All this says is that studies have shown that some cholesterol drugs are safe in children as young as 8.”

Drugs also need to be given in conjunction with changes in diet and physical activity, says Li. For children who are overweight or obese, the AAP still recommends weight management through better diet, increased physical activity and nutritional counseling.