by Heidi Green
July 08, 2008

The latest recommendation on cholesterol screening from the American Academy of Pediatrics (AAP) Nutrition Committee, published in this month’s issue of Pediatrics is likely to be a hot topic in pediatric practices and parent groups this year.

The new recommendation differs from the group’s older (1998) policy statement in several ways, including:

• Calling for broader cholesterol screening. Screening should begin between the ages of 2 and 10 for children who have a family history of high cholesterol or early heart attacks (men before age 55; women before age 65), whose family history is unknown, who have diabetes, or who are at or above the 85th percentile for weight. If the result of the screening test is normal, retesting in 3–5 years is suggested. If the LDL (bad) cholesterol is high, drug treatment and lifestyle changes are to be considered.

• Calling for greater use of statin drugs in treatment. Pediatricians may prescribe medication for children as young as 8 years old under the new rules. (The old rules suggested doctors consider such drugs at the age of 10 for children who failed to lose weight after 6- to 12-months’ effort.)

• Calling for low-fat milk as early as 12 months. Pediatricians may recommend low-fat milk instead of whole milk after the first birthday if they are concerned about obesity. While children need fat for brain development, the committee concludes that children get fat from other sources.

There may be a few causes for concern about these recommendations, especially regarding the use of statin drugs:

1. We don’t know the potential risks of the medication in this population. Speaking about statin use in adults, Dr. Gerald Gau of the Mayo Clinic identified several side effects, including muscle pain to the extent that patients “can’t climb stairs,” as well as a loss of energy that leaves them feeling that “they do a little exercise and their muscles keep on hurting after they finish.” Other, not-as-common side effects include nausea, stomach upset, constipation or diarrhea and, by some accounts, memory loss.

2. We don’t know the potential risks of long-term use of statins. Since statins were approved by the Food and Drug Administration in the 1980s, we have no way of knowing what might happen to patients who stay on the drugs for decades. The AAP’s guideline offers no parameters for how long the drug might be continued by the child.

3.  The recommendation emphasizes a “pill” solution rather than a public health approach. It seems logical that the first approach should be to educate child and parents about dietary and lifestyle changes.

4. The recommendation includes no attempt at a cost-benefit analysis. Thousands of children may receive the medication, yet as Dr. Darshak Sanghavi points out, the AAP committee provides no estimate of the heart benefits (e.g., prevented heart attacks) we can expect to see.

Are there options?
WebMD suggests that the “best way” to treat cholesterol in children is through diet and exercise. (Note: WebMD isn’t out to contradict the AAP’s new recommendations; its article on this topic was written in 2005—and approved by the Cleveland Clinic’s Heart Center staff then.)

• Pay attention to total fat, saturated fat, trans fat, and cholesterol. The amount of total fat for a children age 2 and older should be 30 percent or less of daily total calories. Saturated fat should be 10 percent or less; trans fat should be avoided.

• Eat a variety of foods that provide a nutritionally balanced diet.

• Exercise regularly. Regular, aerobic exercise can help raise HDL (good) cholesterol and lower cardiovascular risk.

It is exciting to think that we can have a positive effect on the life-long heart health of our offspring by addressing their cholesterol levels in childhood. Still, I am concerned about the impact of this particular recommendation. Will pediatricians and parents be a bit more eager to adopt a pill regime rather than tackle the problem through diet and exercise? And while I am not generally anti-medication, I do feel cautious about giving my child daily doses of a drug that has never been studied with youngsters and for which long-term health implications are unknown. The best bet here seems to be prevention through physical activity and healthy diet. Parents, get those children moving—from an early age and often—and make sure to give them good things to eat.