Screening for cholesterol and lipids in childhood
On November 13, 2011, three major medical societies announced new recommendations for screening children for elevated cholesterol levels.
Major medical societies are endorsing the concept of treating elevated cholesterol levels with powerful medications at younger and younger ages.
In this instance, the American Academy of Pediatrics, the American Heart Association, and the National Heart, Blood, and Lung Institute (part of the NIH), all are agreeing that drugs such as Lipitor should be used in children before puberty.
There are several reasons to agree with these recommendations, but one reason suggests the recommendations are flawed and should not be followed, yet. What is missing is any evidence that treating high cholesterol at young ages leads to longer or better life later on.
Does lowering cholesterol at age 10 help someone be healthier at age 50 than lowering cholesterol at age 20?
This is important, because if someone starts a drug like Lipitor at age 10, they will have daily exposure to that drug during the critical years of puberty, and, compared to starting such treatment at age 20, will have 10 extra years of drug exposure.
Elevated cholesterol has been an interest of mine for many years. In the late 1980's, I practiced in Boston, and led a cholesterol screening clinic there. I helped form the New England Pediatric Preventive Cardiology Network, which came to include such clinics at Harvard, Yale, Dartmouth, and Brown. We eventually published our experiences in Boston.
Why look at cholesterol in childhood?
I got interested in this issue because it is well known that the arteries begin to clog with fat deposits as early as 2 years of age. So it made sense to stop the clogging before the arteries get clogged. It still makes sense to do that. The key question is what actually succeeds in keeping the vessels from clogging?
With that goal in mind, we drew lipid panels on every child whose family had a history of heart attack or bypass surgery prior to age 55-60 years old. We were able to find close to 100 children, some as young as 2-3 years old, with quite elevated cholesterol levels, sometimes as high as 400!
So we had a purpose in mind, stop arteries from clogging early. We had a way to find those at highest risk, those with a positive family history of early age heart attacks or clogging. And, we did succeed in finding children with very seriously elevated cholesterol levels.
Why not look at cholesterol in children?
But then we found the problem. Here we had several dozen young children with very high cholesterols in whose families many people had suffered serious heart attacks in young adulthood. It was obvious this group could benefit from treatment, right? Not so.
First we attempted to lower cholesterol by strict dietary control: no cholesterol, very low fat, high fiber, in the diet. Every family consulted with a skilled dietician, but even with extremely strict diets, we could not lower cholesterols more than 10%. That meant a child with a cholesterol of 290 could not get below 260 with diet alone.
Then we tried a variety of relatively safe medications, like cholestyramine, that bind cholesterol but do little to interfere with the body's chemistry. These drugs had little impact.
The only class of drugs left that would make a real difference were statins, like Lipitor. But these drugs are very powerful, could have significant side effects. It was not clear then that it would be safe to put a 3 year old on them for their entire childhood.
When all was said and done, we had created a group of children whose families now knew their cholesterol was dangerously high, but but nothing to do to really help.
Thoughts on Effective Screening Programs
What I learned from this experience is that a good screening program really has to fulfill all steps of being useful to really be useful. Those steps are:
- The condition being screened has to be important. No sense in screening for how long your hair can grow, finding that out does not improve anyone's health.
- The condition being screened for must have a treatment that makes a difference, and a treatment that is safe and available when the test comes back abnormal. This is where our clinic in Boston ran into an obstacle.
- The timing of treatment should make a difference in actual outcome. It makes little sense to screen if treating the condition leads to the same outcome whether one treats early in the course or later in the course of the condition.
When it comes to cholesterol, only one of the three key criteria for a good screening program is present- a high cholesterol is an important problem.
But the safety of treating young children with a very powerful category of medications, statins, is simply not yet known.
And perhaps most worrisome, no one actually knows if treating someone for high cholesterol at age 10 will indeed lead to a better or healthier life than starting treatment at age 20.
For both these reasons, it seems like a bad idea to screen young children for cholesterol elevations much before puberty- we do not know if the key drugs used are safe at this age, and we do not know if someone is better off starting treatment at the earlier age.
- A major recommendation came out Sunday, November 13, 2011- young children should be screened for high cholesterol and if found to be high enough, start the powerful drugs in the category of statins.
- Proof of safety of statins in young children is not established, so starting such a drug will commit a child to taking a potentially dangerous drug every day for many, many years, during development.
- Most importantly, because it is not known at all whether starting treatment for high cholesterol in childhood yields a healthier adulthood, we do not even know if any benefit comes from starting statins as such early ages.
- Therefore, Advanced Pediatrics is not recommending that young children be screened for high cholesterol or other lipid abnormalities. Clearly if a specific child has a problem requiring a look at the lipid profile, such testing makes good sense, but not as a test required of all children.
Dr. Arthur Lavin
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