May 7, 2012 – The National Heart Lung and Blood Institute recently updated and changed cholesterol and lipid testing for children and adolescents.  These recommendations were endorsed by the American Academy of Pediatrics and can be found at the following link:

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

Previous recommendations have included testing children ages 2 and up who have certain family history risk factors.   Here is a summary of the new recommendations:

• Age 9-11 years:  universal lipid testing for all children
• Age 2-8; 12-17: lipid testing for those at high risk including a family history of early heart disease or high cholesterol or if the patient has other risk factors such as a high BMI, Diabetes, Hypertension, Smoking etc.
• Age 18 and up:  Universal testing for lipid disorders

There is more and more evidence that atherosclerosis begins in childhood.   Studies also show that risk factors for atherosclerosis are the same as in adulthood.  Cardiovascular disease is the most common cause of death in men and women.  Noninvasive testing and autopsies of children show a strong correlation between atherosclerosis severity and extent and the intensity of risk factors including BMI, elevations in cholesterol and other risk factors known in adults.  There is also a virtual absence of atherosclerosis in those without risk factors even at the oldest age.

A type of cholesterol test known as non-HDL cholesterol matches risk for atherosclerosis.  This type of test can be measured without fasting.  A normal level is under 145 mg/dl.  Increases over this amount increase the risk for blood vessel aging.

New Recommendations regarding Non-Fat Milk

Previous guidelines have recommended that children be transitioned from breast milk or formula to Whole Cow’s Milk at 1 year of age.  New recommendations including switching to non-fat to 2% at age 1, and to non-fat milk at age 2.   We will follow this recommendation for the most part, unless there are concerns for poor growth or other recommendations made at the time of the transition.  This decision is still best left up to you and your doctor at the time of the 12 month visit.

Of particular relevance to the transition from breast milk or infant formula is the Special  Coronary Risk Factor Intervention Project. The trial enrolled 1,062 healthy 7-month-old infants who were randomized to an intervention or a control group.  After age 1 year, skim milk was recommended as the primary beverage; in the intervention group and to supplement the diet as needed with soft margarines and vegetable oils until age 24 months to maintain adequate fat intake.  The control group received basic health education and no instructions on the use of dietary fats.  The children then were followed with serial evaluations, and assessed for lipid results every 2 years and for other nutrition-related measures at irregular intervals. These dietary fat changes translated to significantly lower cholesterol levels until age 7 years.  No harmful effects were reported on growth, nutrient intake, development, or neurologic function.

Dr. Miller Comment: In 20 years of practice, I have been recommending whole milk to age 2, so this is a big change.  Changes should be evidence based and this one certainly is.  This showed significant decreases in cholesterol with no risks seen to children by switching to a lower fat milk.

With regards to Lipid Testing – Four Seasons Pediatrics will be implementing the new recommendations by doing fingerprick testing in the office.  The new non-HDL cholesterol is accurate and can be done as a screening without fasting.    We have previously found that fasting can be a significant barrier to getting the test performed.  Removing this barrier will allow us to test and identify more children who are at risk of cardiovascular disease.   Although we all should follow a reasonable approach of eating healthy, exercising, reducing screen time and reduction of beverages with sweeteners added, we are more motivated when we see that it is more important to us individually.