The Expert Panel guidelines for cardiovascular health and risk reduction in childhood,1 commissioned by the National Heart, Lung, and Blood Institute, are a valuable resource for pediatric care providers, addressing the major risk factors associated with development of atherosclerosis. Endorsed by the American Academy of Pediatrics, the recommendations correspond with the age and developmental stages in Bright Futures2 so they can be incorporated into routine health maintenance. The recommendations are presented with a summary of the evidence, allowing clinicians to apply their own knowledge and experience in deciding what is necessary for each child and family.
The Expert Panel was selected to include representatives from pediatrics, family medicine, cardiology, nutrition, and nursing. Each brought their expertise to evaluation of the evidence and recommendations that can be readily integrated into practice. For example, there are specific recommendations for safely transitioning to lower intake of energy-dense foods, such as fat-free milk. Recommended daily calories by age, gender, and activity level are provided, as well as age-specific diet recommendations that practitioners can use to promote cardiovascular health. Practical and specific recommendations like this are provided for each of the major risk factors.
Universal lipid screening is the most discussed issue in the guidelines. It was also widely debated within the subgroup reviewing the evidence, risks, and benefits, as well as by the entire panel. The consensus recommendation is to assess all children between 9 and 11 years of age with a nonfasting non–high-density lipoprotein cholesterol (non–HDL-C = total cholesterol – HDL-C) level. The primary purpose of screening is to identify the ∼1 in 500 children who are heterozygous for familial hypercholesterolemia (FH), realizing that other forms of important dyslipidemia would be identified as well. Children with FH have elevated total and low-density lipoprotein cholesterol levels from birth and are at risk for early cardiovascular disease; 5% of individuals with this condition will have a coronary artery event before 30 years of age. Previous guidelines have relied on family history to initiate screening, but the evidence shows this approach to be insufficient.3,4 The panel concluded that universal screening was necessary to detect this important, common family condition. The nonfasting non–HDL-C level is an accurate screen for dyslipidemia, and elimination of the need to be fasting should make testing easier. Age 9 to 11 years was selected because most children entering fifth or sixth grade are required to have a health maintenance examination and because low-density lipoprotein cholesterol levels fall with puberty before rising to prepuberty levels. An additional benefit to screening of children is the identification of parents who are unaware that they have FH. Knowing a child's cholesterol level can initiate family screening and a targeted lifestyle intervention.
Providers of children's health care are familiar with screening to identify disease states that do not present on physical examination. As the medical home for children and families, we use behavioral screening to identify conditions such as maternal depression, developmental delay, and autism. We assess for disease states and behaviors throughout childhood, although their sequelae may not be manifest until adulthood. An example is screening for tobacco use. Pediatric care providers are therefore well positioned to identify children with dyslipidemia who need early intervention to prevent development of premature cardiovascular disease.
The guidelines have only been available for 1 year, and it will take more time to become familiar and comfortable with the recommendations. Following the risk factor algorithms makes it clear that the guidelines only rarely recommend specialist referral. Rather, the approach is risk identification and management by the primary care practitioner. Just as those of us who care for children have learned to use various treatment modalities for diagnoses such as attention-deficit/hyperactivity disorder, implementation of these new guidelines will help us to optimize cardiovascular health for children and their families.
Conflict of Interest:
Members of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Child
- 1.↵National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: full report, 2011. Available at: www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf
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- Copyright © 2013 by the American Academy of Pediatrics