American Academy of Pediatrics: Statement on Cholesterol

1. An elevated serum cholesterol value, cigarette smoking, hypertension, obesity, diabetes mellitus, and lack of physical activity are independent risk factors for coronary vascular disease. The risk of coronary artery disease in adults can be reduced by adopting a prudent lifestyle in which smoking is avoided, intake of saturated fat and cholesterol is decreased, weight is controlled, physical activity is increased, and treatment for hypertension and diabetes is obtained. 2. Atherosclerosis begins in childhood, and the degree of atherosclerotic changes correlates with blood cholesterol levels, smoking, and hypertension. However, coronary vascular disease is rare before the third decade, and coronary vascular lesions appear to be reversible during the third and fourth decade of life or later with appropriate diet and drug treatment. Serum cholesterol level is an imperfect predictor of future coronary vascular disease. 3. Nutritional adequacy should be achieved by eating a wide variety of foods, and energy (calories) should be adequate to support growth and to reach or maintain desirable body weight. Recommended dietary goals for all children more than 2 years of age include: an average daily intake of 30% of total calories from fat, less than 10% of total calories from saturated fatty acids, and less than 300 mg of cholesterol per day. A lower intake of fat is not recommended. The AAP believes that recommendations that call for 'less than' 30% of calories from fat may lead to the inappropriate use of more restrictive diets. Skim or low- fat milk is not recommended in the first 2 years of life because of the high protein and electrolyte content and low calorie density of these milks. 4. The Academy continues to endorse the selective screening of children more than 2 years of age whose risk of developing coronary vascular disease can be identified by family history. This screening should include the following groups: (1) Children whose parents or grandparents have a history of coronary or peripheral vascular disease before the age of 55 years should have a serum lipid profile that includes determination of low density lipoprotein (LDL) cholesterol value. Blood should be drawn after a 12-hour fast. (2) Children whose parents have a blood cholesterol level greater than or equal to 240 mg/dL should be screened for total blood cholesterol level (nonfasting). (3) Children and adolescents with several risk factors for future coronary vascular disease (eg, smoking, hypertension, physical inactivity, obesity, and diabetes mellitus) whose family history cannot be ascertained may be screened at the discretion of the physician for a total blood cholesterol level. 5. When possible, identification and elimination of other risk factors for coronary vascular disease (eg, smoking, hypertension, obesity, diabetes mellitus) are recommended for everyone, including those who are screened, regardless of the results. A diet (Step I Diet) supervised by a health professional is the first therapy recommended for hypercholesterolemic children. The diet is one in which the intake of saturated fats is less than 10% of total calories, with no more than 30% of calories as fat and less than 300 mg of cholesterol per day. If after repeated testing the desired serum lipid levels are not achieved, the intake of saturated fats should be reduced to less than 7% of total calories, with no more than 30% of calories as fat and the cholesterol amount reduced to less than 200 mg/day (Step II Diet). 6. Drug therapy can be considered in children more than 10 years of age if after an adequate trial of diet therapy (6 months to 1 year) the LDL cholesterol value remains greater than 190 mg/dL in the absence of other risk factors. If the level remains greater than 160 mg/dL in children with a family history of heart disease or two or more risk factors of cardiovascular disease, drug therapy is also recommended. Bile acid sequestrants such as cholestyramine and colestipol are the only drugs recommended because there is limited experience in the use of other cholesterol-lowering agents in children. Other drugs such as niacin, hydroxymethylglutaryl coenzyme A (HMG CoA) reductase inhibitors, probucol, gemfibrozil, thyroxine, and clofibrate are not recommended for routine use because very little data exist concerning safety and efficacy of these drugs in children. The AAP recommends that all lipid- lowering agents, including the bile acid sequestrants, be used with caution because they all have the potential for interfering with growth as well as producing other significant side effects. Clinical trials of these agents should be carried out in children to determine both safety and efficacy before their widespread use is endorsed. If lipid-lowering drugs are required, children should be monitored closely, particularly during the vulnerable period of adolescent growth.