The American Academy of Pediatrics (AAP) released new guidelines for lipid screening and cholesterol management for children. We spoke with Sarah de Ferranti, MD, MPH, director of the Preventive Cardiology Clinic, about the changes.
Sarah de Ferranti, MD, MPH
How do the new AAP guidelines differ?
They call for screening more kids earlier and more frequently. They suggest we screen not only children with family history of early heart disease or high cholesterol, but also those whose family
histories are unknown. They also suggest we screen kids who
are overweight, have high blood pressure, diabetes, are insulin
resistant or have other risk factors of heart disease. Fasting lipid profiles are recommended, starting at age 2, and should be
repeated every three to five years.
What are the guidelines for diagnosis?
High cholesterol has traditionally been defined as total cholesterol over 200, borderline 170 to 200, normal under 170; high low-
density lipoprotein (LDL) cholesterol is 130 and above, borderline 110 to 129, normal under 110. But we need to look at the whole profile, including high-density lipoprotein (HDL), triglyceride level, risk factors and family history.
What are the guidelines for managing cholesterol?
The first line treatment should always be optimization of children's diets. You want to normalize their weight and have them follow diet and exercise practices that will increase HDL. If a patient has high LDL cholesterol, you want to lower saturated fat in her diet. If her profile shows high triglycerides and low HDL, I recommend minimizing refined carbohydrates. They should always avoid
The AAP guidelines recommend children eat low-fat dairy products. Do you agree?
Switching from whole milk to one percent is a reasonable choice for a toddler who has a BMI or weight for age that's off-the-charts. Children who have risk factors or documented elevated LDL are candidates for this lower saturated fat diet, which should be
initiated around age 6 or 7 months. I do not recommend a diet
low in fat at that age, just one that's low in saturated fats.
When should pediatricians use medications?
Diet and exercise should be tried for at least six months. If that fails in someone with LDL cholesterol over 190 and no other risk
factors, you could treat her with medication. Or if someone has a
family history of early atherosclerotic disease, or two or more
cardiovascular risk factors and an LDL above 160, you could consider medication. There are also high-risk diseases that should prompt earlier medication treatment at lower cutoffs. If someone has diabetes, either type 1 or 2, their LDL should be below 130.
What do you recommend for management?
Monthly weight checks in the pediatrician's office can be helpful
for weight management. For a pure cholesterol problem, ask the
family to make dietary changes and recheck the lipids in three months. If you feel like you're getting some traction, but more work needs to be done, check in another three months. If you're not getting a response, the family may need support from a
nutritionist. You can safely monitor patients with mild lipid profile
abnormalities every year. If someone has risk factors that led to screening, but has a normal lipid profile, she should be rechecked in three to five years.
When should pediatricians refer?
If a child has cholesterol values that include an elevated LDL or an elevated triglycerides level, she could be referred. Or if a patient has extremely elevated levels (an LDL over 200) she may need a referral. Most pediatricians aren't comfortable starting children on statin therapy. Kids with triglycerides over 1,000 are at risk for
pancreatitis and need to be seen relatively quickly. We are happy
to see children in the Preventive Cardiology Clinic.
Are statins safe?
The concern is that they affect the steroid synthesis pathway, and people worry that reducing the throughput of that pathway would put kids at risk for growth abnormalities, either pubertal or
developmental. We don't have any evidence to support this, but we should use them with patients who are extremely affected with high LDL levels. The concern is that doctors will start putting all overweight kids on statins instead of working with them to change their diet and exercise. In fact, most overweight kids have high
triglycerides, not high LDL, and statins are not the drug of choice for hypertriglyceridemia. We use statins for extremely resistant cases where there is an underlying genetic or familial propensity
in addition to the lifestyle issues.
If a patient is on statins, what should doctors monitor?
There's a risk for elevations in the liver function tests, alanine
aminotransferase and aspartate aminotransferase and risk of
rhabdomyolysis, or less severe muscle side effects. Our practice is to test a baseline ALT and AST and creatine kinase level, and then to get a fasting lipid profile, along with those tests four weeks after starting medications, then four weeks after that. Should they have any changes in urine, like brown urine, they should be evaluated.
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Video of Dr. Ferranti talking about statins: childrenshospital.org/ferrantivideo