Universal cholesterol screening recommended for kids

By Deborah Kotz, Globe Staff

In a sweeping set of new guidelines designed to protect children from future heart disease, a panel of experts convened by the government recommended today that all children have a cholesterol screening blood test between the ages of 9 and 11.

The intent is to identify children early on who are at risk of heart disease as adults and encourage them to change their diet and get more exercise, but critics said they feared many children would also be placed on drugs to lower cholesterol. The panel said the latest evidence suggests that control of high cholesterol levels throughout childhood will substantially reduce heart disease risk later in life.

“We came up with these new guidelines based on a number of studies showing that the current approach to cholesterol screening misses children with substantially elevated levels who could benefit from changing their diet or increasing their physical activity,” said Dr. Stephen Daniels, chair of the expert panel that reviewed the guidelines and pediatrician-in-chief at Children’s Hospital Colorado.

But some experts say they worry that a greater number of children will be put on cholesterol-lowering statins at younger ages -- and possibly kept on them for years or decades without knowing what benefits or risks they’ll incur from the drugs.

“The guidelines aren’t well thought out and represent an irrational exuberance for testing,” said Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic. He pointed out that no studies have been performed to show that universal cholesterol screening improves health outcomes in children.

Daniels responded that the intent of the guidelines is to identify children who have a genetic predisposition to elevated cholesterol, and they’re not necessarily obese or inactive. With the levels set for treatment in the guidelines, he added, fewer than 1 percent of children screened would be eligible for medication. “The concept that this will lead to many, many children being treated with a pharmacologic agent is wrong,” he said.

The guidelines were issued by a panel of hospital- and university-based physicians convened by the National, Heart, Lung and Blood Institute, and were published online by Pediatrics, the journal of the American Academy of Pediatrics.

The academy, the nation’s leading group of pediatricians, released a statement today saying it endorses the recommendations, which “will give health care providers an integrated road map to address all the major cardiovascular risk factors as part of regular well-child visits.” The guidelines include advice on breastfeeding, screening for high blood pressure, and management of obesity.

Until now, the academy and other medical groups advised screening only in certain high-risk children such as those with a family history of high cholesterol or early heart disease and those who are overweight or have diabetes or high blood pressure.

The age recommendation is based on the biology of cholesterol levels. “During adolescence cholesterol levels go down,” said Daniels, “so measurements are harder to interpret. The readings we get from ages 9 to 11 are more reflective of the levels we’ll see into adulthood.”

Many pediatricians will follow their group’s recommendation, and Dr. Sarah de Ferranti, director of preventive cardiology at Children’s Hospital Boston, said she supports them. “The screening we did in the past wasn’t working since parents may not be aware of their family history and some genetic disorders aren’t easily identified by that history,” she said.

While she said there’s reason for some concern over an increased use of statins that may come from more testing, “I don’t think an overuse of statins will happen since those of us who prescribe them use them rarely and only after a good solid try at lifestyle changes.”

The guidelines recommend that children ages 9 to 11 whose total cholesterol level is elevated get retested with a more specific test -- which requires 12 hours of fasting beforehand -- to measure their exact level of LDL, or “bad” cholesterol. Those with an LDL level at or above 130 milligrams per deciliter should receive dietary counseling that maps out an eating plan rich in fruits, vegetables, and lean protein and low in foods rich in saturated fat, such as red meat and whole-milk dairy foods. They’re also encouraged to get an hour of exercise every day.

If those approaches don’t work after six months to lower cholesterol levels, medications can be tried. “Usually these are the kids who have genetic predispositions,” said de Ferranti. While obesity can lead to higher cholesterol levels, it only has a minor effect on raising LDL -- which is what statin therapy targets -- while having a stronger effect on lowering “good” HDL cholesterol levels and raising triglycerides, another lipid associated with diabetes.

For this reason, both de Ferranti and Daniels agreed that overweight children with high cholesterol typically shouldn’t be placed on statins to reduce their levels.

Deborah Kotz can be reached at dkotz@globe.com. Follow her on Twitter @debkotz2.