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Lipid Screening and Statins for Kids?

The AAP published controversial recommendations in 2008 about treating children with high LDL-cholesterol levels.

In November 2008, the popular press reported that obese children (as young as 10) had arteries similar to those of 45-year-old adults. This report, which was based on an abstract presented at the American Heart Association meeting, followed an American Academy of Pediatrics recommendation that screening for dyslipidemia in children be expanded dramatically (JW Pediatr Adolesc Med Jul 16 2008). The AAP had recommended previously that screening be restricted to children with family histories of early atherosclerosis or high cholesterol; they now suggest that children with unknown family histories and those who are obese or nearly obese, hypertensive, or diabetic also be screened. I estimate that 60% to 70% of children will be screened based on this new recommendation.

According to the AAP, screening — with a fasting lipid profile rather than a nonfasting total cholesterol measurement — should begin as early as age 2, occur no later than age 10, and be repeated every 3 to 5 years. The most controversial recommendation is that clinicians consider prescribing statins for children age 8 or older who have elevated LDL-cholesterol levels.

On the heels of these recommendations, perspectives were published in the Lancet (Lancet 2008 Jul 19; 372:178), BMJ (BMJ 2008 Jul 23; 337:a886), and the New England Journal of Medicine (N Engl J Med 2008 Sep 25; 359:1309). Each perspective writer acknowledged the lack of data about the effectiveness and safety of statins in children. Each noted that obesity is the real culprit and that this approach reflects our failure to prevent and to treat childhood obesity successfully. However, given the overwhelming benefit of statins in adults, should they be withheld from children?

When I have discussed these recommendations with clinicians, many questions emerge: Why start screening at age 2, if treatment is not recommended until age 8? Wouldn’t beginning treatment after puberty be safer, particularly because we have no long-term safety data in young children? Why are fasting lipid profiles necessary, when nonfasting levels obviously are much easier to obtain? How well do lipid concentrations track through childhood into adulthood? Is labeling children as having elevated cholesterol a risk in itself — will this label affect their ability to obtain life and health insurance? Will insurers pay for screening and treatment?

In my view, the AAP recommendations are premature and should be implemented selectively. Only children who meet the LDL-cholesterol cutoff values and have other risk factors, such as obesity or family history, should be treated. Until more data are available, this conservative approach seems to be the reasonable course. Clinicians must decide for themselves how to discuss screening results and potential treatments with children and their families.

— Howard Bauchner, MD

Published in Journal Watch General Medicine December 29, 2008