All children should be screened for cholesterol levels between ages 9 and 11, and again between ages 17 and 21, even those who are not at an increased risk of high cholesterol and heart disease, according to new guidelines endorsed by the American Academy of Pediatrics.
Previously, experts recommended that only certain children be screened for cholesterol early in life, such as those children with a family history of high cholesterol or heart disease or children who have diabetes or are obese. But a panel of experts from the National Heart, Lung and Blood Institute now recommends that all children be screened to help pediatricians detect elevated cholesterol in their young patients, with the goal of preventing heart disease later in life.
The guidelines will be presented Sunday at a meeting of the American Heart Association and are published online today in the journal Pediatrics.
Dr. Patrick McBride, one of the authors of the guidelines, said that the old approach of testing only high-risk children simply did not work.
"Previous targeted screening missed more than 50 percent of children with high cholesterol," McBride said. "Atherosclerosis begins very early in life, even in infancy for children with genetic cholesterol problems. So increased screening is a necessary step."
The recommendations were greeted positively by many cardiologists and pediatricians, who say that earlier testing is warranted, especially in the face of increasing childhood obesity and diabetes.
"I think it is a reasonable step," said Dr. Roger Blumenthal, director of preventive cardiology at Johns Hopkins Medical Institution. "Some would say that it would [be] best to restrict testing to those with a family history of cardiovascular disease before age 16. However, I believe that it is reasonable to check a baseline glucose and lipid profile by age 13."
Previous studies have found that 10 to 13 percent of children and teens have high cholesterol, defined as a score over 200. High cholesterol is well-known as a risk factor for heart attacks and strokes, and pediatricians say knowing about risk factors like high cholesterol early in life can be an important step in averting future cardiovascular problems.
"The news of an elevated cholesterol can be used as high motivation for a family to make needed changes in their approach to family dinners, fast food, lack of activity, and sugar-sweetened beverages," said Dr. Ellen Rome, head of adolescent medicine at the Cleveland Clinic.
The new guidelines note that cholesterol testing is relatively easy for children. Blood from a simple fingerprick test can tell doctors what they need to know, and the test does not require children to fast beforehand. Many pediatricians say they already test young patients for cholesterol.
"We screen kids at 2, 5 and 10 years of age, and again after age 16," said Dr. Tanya Altmann, a pediatrician in southern California. "I do pick up many high cholesterol levels, talk at length to families about diet, nutrition and exercise, and bring them back to rescreen four to six months later."
However, some experts find the new guidelines to be a bit premature, saying they create the potential for doctors to overdiagnose a problem that may appear much later in life or not at all. In 2007, another government panel, the U.S. Preventive Services Task Force, concluded that there was not enough evidence to recommend cholesterol testing for children and teens.
"We have no clinical trials demonstrating any benefit to treatment of elevated cholesterol levels in children," said Dr. Steve Nissen, chairman of cardiovascular medicine at the Cleveland Clinic. "I do not think these guidelines are wise and they are certainly not evidence-based."
Other experts are also concerned about the government panel's endorsement of statins, a class of drugs that help lower cholesterol. The new guidelines recommend that children whose high cholesterol levels don't drop significantly after diet and lifestyle changes can take the medications, such as Zocor and Lipitor, to bring their levels down.
Statins are widely used among adults with high cholesterol, but are relatively untested in children. The American Academy of Pediatrics already says children as young as 8 can safely take the drugs, but critics say there's not enough evidence to indicate the drugs are definitely safe for children over a long period of time.
"I'm just very concerned about the premature and possibly aggressive use of medications in growing children," said Dr. Lee Goldman, dean of the faculties of health science and medicine at Columbia University. "It may well turn out to be safe and effective, but to make recommendations in the absence of any major trials in children concerns me."
McBride said less than 1 percent of children would be eligible to take statins under the new guidelines. Children and families should still try diet and exercise changes to bring cholesterol down.