July 7, 2008 -- Some kids as young as 8 will need drugs to keep them from getting heart disease, according to new recommendations from the American Academy of Pediatrics.
The groundbreaking new advisory tells parents and pediatricians to screen high-risk kids for signs that they've already begun to develop heart disease. The screening test, called a fastinglipid profile, measures a child's levels of "bad" LDL cholesterol, "good" HDL cholesterol, and blood fats (triglycerides).
High-risk kids are those with a family history of high cholesterol or a family history of premature heart disease. Also included are kids who are overweight or who have high blood pressure or diabetes. Kids whose family histories are unknown should also be screened.
Treatment may be needed for kids found to be at high risk. The blood test will take a number of other risk factors into account: overweight or obesity, family history of heart disease or high cholesterol, high blood pressure, and type 1 or type 2 diabetes.
Normal and too-high cholesterol and triglyceride values for children differ from values for adults. But the AAP advisory comes with charts to help doctors understand children's results. Doctors will tell parents which children need to be screened. They'll also help parents put the results into perspective, says pediatrician Tanya Altmann, MD, a spokeswoman for the American Academy of Pediatrics and an advisor to the National Dairy Council.
"If your child does have too-high bad cholesterol, or too-low good cholesterol, your pediatrician should talk to you," Altmann tells WebMD. "In some instances, a low-fat diet and exercise is all your child needs. In other cases, a medication may be needed, in conjunction with a visit to a pediatric cardiologist."
The initial treatment for kids at risk of heart disease is weight management and improved diet. But some kids as young as 8 will need to start drug treatment. These drugs include the cholesterol-lowering statin drugs. One of these drugs, Pravachol, already is FDA approved for children born into families genetically predisposed to high cholesterol.
But the new AAP guidelines say drug treatment "should be considered" only for kids who have extremely high LDLcholesterol levels:
- LDL levels of 190 mg/dL or higher
- LDL levels of 160 mg/dL or higher if there is a family history of heart disease or two other risk factors
- LDL levels of 130 mg/dL or higher if the child has type 1 or type 2 diabetes
For kids, these are very, very high cholesterol levels, says Daphne T. Hsu, MD, chief of pediatric cardiology and co-director of the pediatric heart center at New York's Montefiore Medical Center.
"For an 8-year-old, an LDL level of 125 to 135 is higher than 95% of children -- so 160 or 190 is really high. Even most obese children will not be that high," Hsu tells WebMD.
Hsu hopes doctors won't whittle down the AAP recommendations and start prescribing drug treatment to children with less extreme cholesterol levels.
"Cholesterol-lowering drugs are really strong drugs. You should never prescribe them unless you have a really good reason," she says. "We don't know the effects of this treatment as children enter their teens. Maybe these drugs block something you need as an adolescent. It would be wrong to extrapolate this treatment recommendation to a different population of children who are not at as high risk."
Why screen kids for heart disease? Very few people actually die of heart disease until they are adults. But a slew of recent studies shows that the seeds of heart disease are sown during childhood. Fatty streaks and artery-clogging plaque build up during childhood and adolescence -- and the more heart-disease risk factors a child has, the faster this fat and plaque builds up in the arteries.
Do kids with too-high cholesterol really need to see a pediatric cardiologist?
"Well, these kids are not going to have a stroke or heart attack as a child," Hsu says. "It takes a village of people to help a family adopt a healthier lifestyle. It is good for us pediatric cardiologists to explain in more detail why children need to control their cholesterol. But lifestyle change is really difficult, and you really need a culturally sensitive program that can offer children and families the education that is best for them."
Here's an overview of the new AAP recommendations:
- All children should eat a healthy diet, according to the Dietary Guidelines for Americans, better known as the new food pyramid. This approach includes the use of low-fat dairy products.
- Children at higher risk of heart disease and with high cholesterol levels will have to change their diets. This will require nutritional counseling from a dietitian as well as increased physical activity.
- Screening is advised for kids with a family history of high cholesterol or blood fats, or a family history of premature heart disease (age 55 or younger for men, age 65 or younger for women). Screening is also recommended for kids who are overweight (at or above the 85th percentile), who smoke, or who have diabetes or high blood pressure.
- First screening is recommended after age 2, but no later than age 10. Children under 2 should not be screened.
- If the fasting lipid profile is normal, a child should be screened again in three to five years.
- For kids who are overweight or obese and who have a high blood-fat level or low level of "good" HDL cholesterol, weight management is the primary treatment. This means improved diet with nutritional counseling and increased physical exercise.
- For kids aged 8 and older with very high cholesterol levels (or high levels with a family history of early heart disease), drug treatment should be considered.
The new recommendations appear in the July issue of the journal Pediatrics.