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eLetters to:
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- FROM THE AMERICAN ACADEMY OF PEDIATRICS:
Stephen R. Daniels, Frank R. Greer and the Committee on Nutrition
- Lipid Screening and Cardiovascular Health in Childhood
Pediatrics 2008; 122: 198-208
[Abstract]
[Full text]
[PDF]
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eLetters published:
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Comparison with the adult guidelines
- E-P. Barrette
(8 July 2008)
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Evidence based guidelines?
- Martin Lalinec-Michaud
(22 July 2008)
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STATINS IN CHILDREN: MORE SHADE THAN LIGHT.
- Zemira Cannioto, Federico Marchetti
(23 July 2008)
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Omissions from new lipid screening guidelines
- Costan G. Magnussen
(24 December 2008)
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Comparison with the adult guidelines |
8 July 2008 |
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E-P. Barrette, Associate Professor of Medicine Washington University School of Medicine
Send letter to journal:
Re: Comparison with the adult guidelines
epbarrette{at}im.wustl.edu E-P. Barrette
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The new pediatric guidelines have proposed considering pharmacologic
treatment for children with an LDL that is persistently > 160 mg/dl
despite diet therapy and who are also obese. This will potentially create
a dilemma for teenagers as they transition to adulthood and see an
internist. Consider an obese 16 year old who does not smoke, has no
hypertension, has an HDL which is above 40 mg/dl, and has adult parents
who are in their 40's. The parents are both on statins for lipid control
but neither has had a cardiovascular event. The child has a fasting
glucose that is not in the diabetic range. Based on the new pediatric
guidelines if this child has a LDL that was persistently 175 mg/dl,
his/her physician would probably recommend a statin. However, if this
child is seen in an internal medicine clinic two years later, based on the
most recent update for the National Cholesterol Education Program (note
1), pharmacologic treatment should only be considered for an LDL greater
than 190 mg/dl based on this individual's risk profile.
If this prototypical adolescent is started on a statin, an internist
will be faced with the decision whether to continue this medication or
reassess lipids and possibly decide the adult guidelines are more
applicable at age 18. Since the adult guidelines only count hypertension,
cigarette smoking, family history of premature coronary heart disease, or
low HDL cholesterol (less than 40 mg/dl), and age (men older than 44,
women older than 54) as cardiovascular risk factors, it is the new
inclusion of obesity which is distinct from the adult guidelines and thus
creates this dilemma.
One should consider that the 10 year risk of coronary death or
myocardial infarction for a 20 year old man with no smoking, no treatment
for hypertension and a systolic blood pressure of 135 mm Hg, and a total
cholesterol of 300 mg/dl and a HDL of 40 mg/dl is only 1% (note 2). Many
obese teenagers with an LDL between 160 and 190 who will be started on a
statin will have a total cholesterol much lower than 300 and will also
have a very low risk of a cardiac event over the next 15 years.
I look forward to further recommendations from the American College
of Physicians and the National Cholesterol Education Program on what may
be the best age to consider starting pharmacotherapy for elevated
cholesterol.
note 1
Grundy SM, Cleeman JI, Merz CNB, Brewer HB, Clark LT, Hunninghake DB,
Pasternak RC, Smith SC, Stone NJ, Implication of Recent Clinical Trials
for the National Cholesterol Education Program Adult Treatment Panel III
Guidelines. Circulation 2004;110:227-239.
note2
Risk assessment tool for estimating 10 year risk of developing hard
CHD (myocardial infarction and coronary death) accessed July 7, 2008
http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof
Conflict of Interest:
None declared |
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Evidence based guidelines? |
22 July 2008 |
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Martin Lalinec-Michaud, General Practitioner Laval University, Quebec, Canada
Send letter to journal:
Re: Evidence based guidelines?
martin.lalinec-michaud{at}mfa.ulaval.ca Martin Lalinec-Michaud
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I was interested in reading this clinical report of the AAP on lipid screening. I
do believe like the authors that cardiovasular health of children should be
taken into account and that the obesity epidemic is very concerning.
I have not seen the level of evidence that can be attributed to the guideline
proposed.
Will we be contributing to an increased wellbeing and health of children by
screening high risk individuals and treating those affected? I have not seen
the data that supports this, in the article.
I think that following the recommendations to screen and treat individuals
according to the criterion cited here will lead to increased physician visits, lab
tests and treatment based on expert opinion mainly. So increased healthcare
spending for what results? Maybe the criterion could be stricter until data
shows a clear benefit without too much of the side effects/danger that we are
bound to see in developing humans and with the very long term duration of
treatment.
I believe that money would be better spent at the root of the obesity
epidemic (lifestyle, activity, diet), not lower down when collateral damages are
done or ongoing, especially when it has not been supported by data.
I am concerned that, contrary to many authors of article in peer reviewed
journals and to myself writing this commentary, there is no disclosure of
competing interests by the authors.
I look forward for continuing interest in this area and further development of
guidelines and strategies to help physician, parents and children dealing with
higher cardiovascular risks.
Conflict of Interest:
None declared |
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STATINS IN CHILDREN: MORE SHADE THAN LIGHT. |
23 July 2008 |
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Zemira Cannioto, Paediatrician Department of Pediatrics, IRCCS Burlo Garofolo, Trieste, Italy, Federico Marchetti
Send letter to journal:
Re: STATINS IN CHILDREN: MORE SHADE THAN LIGHT.
zemira79{at}hotmail.com Zemira Cannioto, et al.
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Dear Editor,
We read with interest the new guidelines on cholesterol screening and treatment in childhood recently issued by the American Academy of Pediatrics (1).
Compared to the previous statement (2), the most important innovation regards the fact that statins are now recommended to younger patients too (8 years and older instead of 10 years and older) within the same risk categories.
However, we believe that given the paucity of long term efficacy and poor safety data available to date, there are still too many concerns regarding the using of statins in children.
In this term, it’s important to underline that almost all clinical trials developed in children have considered patients affected by Familial Hypercolesterolemia. In this particular condition the strong correlation with adult-onset cardiovascular disease (CVD) appeared so well demonstrated to justify a prompt pharmacological intervention (3). The same condition might be assumed individually in children with severe non familial hypercolesterolemia in presence of multiple cardiovascular risk factors.
However, crucial concerns about statins treatment persist for overweight/ mildly obese children with non familial hypercolesterolemia. We believe that in this kind of patients (certainly the more one) efficacy data on primary end point (such as mortality and morbility for CVD) and long term safety data are required before recommending such an extended pharmacological approach.
That especially considering the lenght of treatment (potentially for life) and therefore the possibility of adverse effects related to the exposure to a major cumulative dose in children than in adults and also problems dealing with compliance to treatment. Clinical trials in children and adolescents “have shown statins to be safe” but only in a short-term with a mean time of treatment of 27 weeks (range 6-96 weeks) (4).
So far, according to the efficacy, clinical trials demonstrated the power of statins in lowering cholesterol and in some cases in improving vascular structure and function. However, we believe that the lack of strong evidence in terms of primary prevention of adult-onset CVD forces a prudential prescription of statins especially considering that the use of statins in primary prevention of cardiovascular events appears to be controversial in adults too (5).
We hope, otherwise, that future data from RCT on hypercholesterolemic children/adolescents treated for long time could reinforce the statement of a prompt statin treatment in childhood according to a strong evidence of efficacy and safety profile.
References:
1.Stephen R. Daniels, Frank R. Greer and the Committee on Nutrition Lipid Screening and Cardiovascular Health in Childhood Pediatrics 2008; 122: 198-208
2.American Academy of Pediatrics, Committee on Nutrition. Cholesterol in childhood. Pediatrics. 1998;101(1 pt 1):141–147
3.Rodenburg J, Vissers MN, Wiegman A, et al. Statin treatment in children with Familial Hypercolesterolemia: the younger, the better. Circulation 2007; 116: 664-68
4.Arambepola C, Farmer AJ, Perera R, Neil HA. Statin treatment for children and adolescents with heterozygous familial hypercholesterolaemia: a systematic review and meta-analysis. Atherosclerosis 2007;195(2):339-47
5.Moride Y, Hegele RA, Langer A, McPherson R, Miller DB, Rinfret S. Clinical and public health assessment of benefits and risks of statins in primary prevention of coronary events: resolved and unresolved issues. Can J Cardiol. 2008;24(4):293-300.
Conflict of Interest:
None declared |
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Omissions from new lipid screening guidelines |
24 December 2008 |
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Costan G. Magnussen, Academic Menzies Research Institute
Send letter to journal:
Re: Omissions from new lipid screening guidelines
cmagnuss{at}utas.edu.au Costan G. Magnussen
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To the Editor.—
The update of lipid screening guidelines for pediatrics reported by
Daniels, Greer, and the American Academy of Pediatrics Committee on
Nutrition1 has some important omissions. The first regards the
consideration of lipid and lipoprotein cut-points to denote normal,
borderline-, and high-risk concentrations. The authors correctly state
that the previous ‘fixed’ cut-points issued by the National Cholesterol
Education Program (NCEP)2 may be limited as they do not account for age-
and sex-specific differences in lipid and lipoprotein concentrations.
However, in their discussion, they do not mention the work by Jolliffe and
Janssen3 who proposed age- and sex-specific cut-points from growth curve
data that were linked to the established NCEP Adult Treatment Panel
dyslipidemia thresholds,4 and the work by myself and colleagues that has
attempted to determine if these cut-points predict adult risk any better
than the original NCEP cut-points.5, 6 Instead, the authors propose yet
another set of cut-points for classification based on percentiles from the
Lipid Research Clinics Prevalence Study.7 This may add to the confusion
around which cut-points should ultimately be adopted. The proposed new cut
-points have a number of limitations that were not properly considered.
For example, the lipid and lipoprotein distributions were derived from
white children7 and as such, should be applied to biracial populations
with caution. Data from the Bogalusa Heart Study have not only shown
differences in the distribution of lipid and lipoprotein levels by race,
but that dynamic changes in blood lipid and lipoprotein levels that occur
at the onset of puberty are differentially influenced by race.8, 9 In
addition, although the authors recommend lipid screening to commence from
the age of two years, the proposed cut-points begin from age five. How
then should the blood lipid and lipoprotein concentrations of children
aged from two to four years be classified?
Second the authors have not considered non-HDL cholesterol in the
revised guidelines. Because the measurement of non-HDL cholesterol averts
certain limitations of LDL cholesterol measurement (including the
requirement of samples to be from fasting individuals) it is increasingly
being used in clinical research involving adult populations,10, 11 and has
also been specified as a secondary target for therapy among patients with
the metabolic syndrome or diabetes mellitus in the NCEP Adult Treatment
Panel recommendations.4 The failure to mention non-HDL cholesterol in the
revised guidelines for pediatric populations is puzzling considering that
available data have shown child non-HDL cholesterol to be a better
predictor of adult dyslipidemia and non-lipid CVD risk factors in
adulthood such as hyperinsulinemia, and hyperglycemia than LDL
cholesterol;12 non-HDL to be strongly predictive of metabolic-related risk
factors such as triglycerides, HDL cholesterol, adiposity, and HBA1c in
childhood;13, 14 youth with Type 1 and Type 2 diabetes commonly have
elevated non-HDL cholesterol;15, 16 and the prevalence of high non-HDL
cholesterol levels in youth with Type 1 diabetes increases with poor
glycaemic control and duration of diabetes.14 These findings suggest that
childhood non-HDL cholesterol levels have a place in the prediction of,
and thus screening for, dyslipidemia and nonlipid CVD risk factors,
particularly metabolic-related abnormalities.
REFERENCES
1. Daniels SR, Greer FR. Lipid screening and cardiovascular health in
childhood. Pediatrics. 2008;122(1):198-208.
2. National Cholesterol Education Program (NCEP): highlights of the
report of the Expert Panel on Blood Cholesterol Levels in Children and
Adolescents. Pediatrics. 1992;89(3):495-501.
3. Jolliffe CJ, Janssen I. Distribution of lipoproteins by age and
gender in adolescents. Circulation. 2006;114(10):1056-1062.
4. Third Report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III) final report.
Circulation. 2002;106(25):3143-3421.
5. Magnussen CG, Raitakari OT, Thomson R, et al. Utility of currently
recommended pediatric dyslipidemia classifications in predicting
dyslipidemia in adulthood: evidence from the Childhood Determinants of
Adult Health (CDAH) study, Cardiovascular Risk in Young Finns Study, and
Bogalusa Heart Study. Circulation. 2008;117(1):32-42.
6. Magnussen CG, Venn A, Thomson R, et al. The association of
pediatric LDL-cholesterol and HDL-cholesterol dyslipidemia classifications
and change in dyslipidemia status with carotid intima-media thickness in
adulthood: Evidence from the Cardiovascular Risk in Young Finns Study, the
Bogalusa Heart Study, and the Childhood Determinants of Adult Health
(CDAH) Study. J Am Coll Cardiol. In Press.
7. Tamir I, Heiss G, Glueck CJ, et al. Lipid and lipoprotein
distributions in white children ages 6-19 yr. The Lipid Research Clinics
Program Prevalence Study. J Chronic Dis. 1981;34(1):27-39.
8. Berenson GS, McMahan CA, Voors AW, et al. Cardiovascular Risk
factors in Children: The Early Natural History of Atherosclerosis and
Essential Hypertension New York, NY: Oxford University Press; 1980.
9. Berenson GS, Srinivasan SR, Cresanta JL, et al. Dynamic changes of
serum lipoproteins in children during adolescence and sexual maturation.
Am J Epidemiol. 1981;113(2):157-170.
10. Frost PH, Davis BR, Burlando AJ, et al. Serum lipids and
incidence of coronary heart disease. Findings from the Systolic
Hypertension in the Elderly Program (SHEP). Circulation. 1996;94(10):2381-
2388.
11. Frost PH, Havel RJ. Rationale for use of non-high-density
lipoprotein cholesterol rather than low-density lipoprotein cholesterol as
a tool for lipoprotein cholesterol screening and assessment of risk and
therapy. Am J Cardiol. 1998;81(4A):26B-31B.
12. Srinivasan SR, Frontini MG, Xu J, et al. Utility of childhood non
-high-density lipoprotein cholesterol levels in predicting adult
dyslipidemia and other cardiovascular risks: the Bogalusa Heart Study.
Pediatrics. 2006;118(1):201-206.
13. Srinivasan SR, Myers L, Berenson GS. Distribution and correlates
of non-high-density lipoprotein cholesterol in children: the Bogalusa
Heart Study. Pediatrics. 2002;110(3):e29.
14. Edge JA, James T, Shine B. Longitudinal screening of serum lipids
in children and adolescents with Type 1 diabetes in a UK clinic
population. Diabet Med. 2008;25(8):942-948.
15. Kershnar AK, Daniels SR, Imperatore G, et al. Lipid abnormalities
are prevalent in youth with type 1 and type 2 diabetes: the SEARCH for
Diabetes in Youth Study. J Pediatr. 2006;149(3):314-319.
16. Schwab KO, Doerfer J, Hecker W, et al. Spectrum and prevalence of
atherogenic risk factors in 27,358 children, adolescents, and young adults
with type 1 diabetes: cross-sectional data from the German diabetes
documentation and quality management system (DPV). Diabetes Care.
2006;29(2):218-225.
Conflict of Interest:
None declared |
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