The AAP (Academy of Pediatrics) is the predominant organization that helps pediatricians with guidelines that define best practice based on literature (journals) and expert opinions. Last spring the AAP published guidelines on improving the cardiovascular health of our children and ultimately the adult population. This article addresses some of the recommendations made in the guidelines. One important change is a recommendation that children 9-11 and 17-21 have their cholesterols checked routinely.

Cardiovascular (heart and blood vessel) disease is the leading cause of death in the US. We do not see the disease in children. However, if we start to work on children’s cardiovascular health, we will slow down the process when they are adults. So the American Academy of Pediatrics put together a panel of experts to create guidelines for the prevention of heart and vascular (blood vessel) disease. The goal is to promote heart and blood vessel health, identify and prevent the risk factors that lead to heart and blood vessel disease, and help manage these risk factors. The recommendations are based on data from over 1,000 studies and the consensus from experts when data is lacking.

We know that atherosclerosis, or clogged arteries, is the main cause heart attacks and strokes. (An artery is the tube that brings blood to the body and heart). We also know that there are certain risk factors related to how our bodies work and how we treat our bodies that contribute to the development of atherosclerosis. The greater the number and severity of risk factors, the worse the atherosclerosis will likely be. The major risk factors include:

Obesity

Non-healthy diet
High blood pressure
Diabetes
Blood Cholesterol levels (certain kinds)
Tobacco use (Smoking cigarettes)
Family history of early heart attacks (Men before 55 and Women before 65)

So during checkups the American Academy of Pediatrics recommends that pediatricians pay attention to these risk factors by:

Determining family history of heart disease
Preventing and treating tobacco use
Paying attention to diet and nutrition
Monitoring for obesity
Routinely checking lipid/cholesterol levels
Routinely checking blood pressure after age 3
Encouraging physical activity
Checking for diabetes as indicated
Encouraging fat intake of less than 30% and saturated fat intake limited to 7- 10%
Decrease sugar sweetened beverages

One striking new recommendation is routine lipid and cholesterol screening for all children aged 9 and 17. In the past we screened only those who had a family history of heart disease. Unfortunately, we missed 30-60% of the at-risk children. So now we have more significant screening recommendations. Some of the cholesterol screening recommendations include:

No one under 2
Aged 2-8 years -check fasting lipid profile if family history significant
Aged 9-11 check everyone non fasting and if high, check fasting lipid profile two times and average the 2 values
Aged 12-16 if new evidence of family history check 2 fasting and average
Aged 17-21 check everyone and if high check fasting x 2 and average the results

(See below for a table of the complete recommendations)

A lipid profile includes levels of different types of cholesterol because it does matter what type of cholesterol you have in your body. Several facts about the types of cholesterol include:

HDL (high density lipoprotein cholesterol) is good.
LDL and VLDL (all the cholesterol that is not HDL) is bad cholesterol.
High triglycerides can be bad but should be measured fasting because they are related to recent fat intake.
Obesity plays a role in cholesterol metabolism because the more obese one is, the more likely they have higher non-HDL cholesterol and triglyceride levels.

Treatment for high bad cholesterol includes mainly dietary changes like eating fewer foods with high cholesterol and saturated fats. If you have high bad cholesterol, your provider will recommend dietary changes, refer you to a dietician, or refer you to a cholesterol specialist. If diet management is unsuccessful and the levels are unsafe, then some of the medicines used in adults can be tried if the cholesterol levels are severe enough.

Routine visits to the primary care provider for blood pressure checks and cholesterol screening, attention to diet and nutrition, exercise, and attention to weight management can have a great impact on the future well being of your children. We do recognize that some of these healthy habits are difficult to achieve. As pediatricians, our goal is to prevent illness and we look forward to partnering with you on working toward better health with these healthy habits.

By Dr. David Hartenbach

For more information and resources, visit:

www.aap.org

http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm

http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Dietary-Recommendations-for-Healthy-Children_UCM_303886_Article.jsp

TABLE 9-5

Evidence-Based Recommendations for Lipid Assessment

Birth to 2 y	No lipid screening	Grade C Recommend
2 to 8 y	No routine lipid screening	Grade B Recommend
	Measure fasting lipid profile twice,^a average results if: Parent, grandparent, aunt/uncle, or sibling with MI, angina, stroke, CABG/ stent/ angioplasty at <55 y in males, <65 y in females Parent with TC ≥ 240 mg/dL or known dyslipidemia Child has diabetes, hypertension, BMI ≥ 95th percentile or smokes cigarettes Child has a moderate- or high-risk medical condition (Table 5-2)	Grade B Strongly recommend
	Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
9 to 11 y	Universal screening Non-FLP: Calculate non–HDL cholesterol: Non–HDL cholesterol = TC − HDL cholesterol If non-HDL ≥ 145 mg/dL ± HDL < 40 mg/dL^b: Obtain FLP twice,^a average results OR FLP: If LDL cholesterol ≥ 130 mg/dL ± non-HDL cholesterol ≥ 145 mg/dL ± HDL cholesterol < 40 mg/dL ± triglycerides ≥ 100 mg/dL if <10 y, ≥130 mg/dL if ≥10 y: Repeat FLP, average results	Grade B Strongly recommend
	Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
12 to 16 y	No routine screening^c	Grade B Recommend
	Measure FLP twice,^a average results, if new knowledge of: Parent, grandparent with MI, angina, stroke, CABG/stent/angioplasty, sudden death at <55 y in male, <65 y in female Parent with TC ≥ 240 mg/dL or known dyslipidemia Patient has diabetes, hypertension, BMI ≥ 85th percentile or smokes cigarettes Patient has a moderate- or high-risk medical condition (Table 5-2)	Grade B Strongly recommend
	Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
17 to 21 y	Universal screening once in this time period: Non-FLP: Calculate non–HDL cholesterol: Non–HDL cholesterol = TC − HDL cholesterol*	Grade B Recommend
17–19 y:	If non–HDL cholesterol ≥145 mg/dL ± HDL cholesterol < 40 mg/dL^b Measure FLP twice,^a average results OR FLP: If LDL cholesterol ≥ 130 mg/dL ± non–HDL cholesterol ≥ 145 mg/dL ± HDL cholesterol < 40 mg/dL ± triglycerides ≥ 130 mg/dL Repeat FLP, average results	Grade B Recommend
	Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
20–21 y:	Non–HDL cholesterol ≥ 190 mg/dL ± HDL cholesterol < 40 mg/dL Measure FLP twice, average results OR FLP: If LDL cholesterol ≥ 160 mg/dL ± non–HDL cholesterol ≥ 190 mg/dL ± HDL cholesterol < 40 mg/dL ± triglycerides ≥ 150 mg/dL Repeat FLP, average results	Grade B Recommend
	Use Table 9-2 for interpretation of results, Adult Treatment Panel (ATP III) algorithm for management.

Cholesterol Checks as Part of the New Heart Health Recommendations of the AAP