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Research over the past 40 years has increasingly suggested that the process of atherosclerotic cardiovascular disease (CVD) appears to begin early in life. This evidence places the management of atherosclerotic CVD in the realm of the pediatrician. In 2008, the American Academy of Pediatrics (AAP) issued a new clinical report on lipid screening and cardiovascular health in childhood, replacing a previously released statement from 1998. Published in the July 1, 2008 issue of Pediatrics, the statement reemphasizes the pediatrician’s role in the prevention of CVD by promoting a healthy diet and increasing physical activity in children and adolescents. The pharmacologic agents available for treatment are also discussed, as are indications for treating dyslipidemia in children.

Weight management is the primary recommended treatment for overweight or obese children at higher risk for CVD and with high LDL concentrations. The 2008 AAP report emphasizes the importance of diet for children older than age 2 based on the Dietary Guidelines for Americans; it also supports broader adoption of a healthier diet with low saturated fat for pediatric communities as a whole. One change from previous reports is that pediatricians and family physicians should be more flexible in recommending reduced-fat milk rather than whole milk for children between the ages of 1 and 2, particularly if there’s a concern about obesity or CVD. Current research suggests that limiting fat in children younger than 2 will not negatively affect growth or neurologic function.

Screening & Treatment Considerations

Cholesterol screening is recommended in children and adolescents with a positive family history of dyslipidemia or premature CVD (aged 55 or younger in men and 65 or younger in women). Screening is also recommended in patients whose family history is unknown or who have other CVD risk factors (eg, obesity, hypertension, smoking, or diabetes). Such patients should be screened with a fasting lipid profile.

Overweight or obese pediatric patients who have high triglyceride concentrations or low HDL concentrations should undergo weight management treatment. The 2008 AAP report recommends the consideration of pharmacologic treatment for children who are at least 8 years old and meet one of the following qualifications:

• An LDL cholesterol level of at least 190 mg/dL, with no other CVD risk factors.

• An LDL cholesterol level of at least 160 mg/dL with a family history of premature CVD or at least two other risk factors.

• An LDL cholesterol level of at least 130 mg/dL and the patient has diabetes.

Bile acid-binding resins, cholesterol absorption inhibitors, and statins are recommended medical treatments for pediatric dyslipidemia. The average cholesterol lowering by bile acid-binding resins is about 10% to 20% below baseline. Statins, several of which are FDA approved for use in children, have been well tolerated in appropriate pediatric populations, resulting in cholesterol lowering of 20% to 50% below baseline. In addition, recent studies have analyzed statin use in children as young as age 8, and some studies have lasted as long as 2 years. The data suggest that statins are effective at lowering cholesterol and reducing atherosclerosis in children with hyperlipidemia. They also demonstrate a safety profile in children similar to that of adult populations. However, it’s important to note that initiation of pharmacologic therapy in children should be a decision each family makes in conjunction with their physician after a discussion of potential risks and benefits.

Stephen R. Daniels, MD, PhD, has indicated to Physician’s Weekly that he has worked as a consultant for Abbott Laboratories and Merck-Schering Plough. He has also received grants/research aid from the National Institutes of Health and the American Heart Association.