Pediatrics: Protecting Children’s Hearts
A cholesterol test for 10-year-olds could show early signs of cardiovascular disease, yet critics warn that this could lead to unnecessary treatment.
At the next visit to the pediatrician, parents of children ages 9 to 11 might be in for a surprise: a cholesterol test. Though heart attacks usually strike after age 60, powerful evidence now indicates that atherosclerosis—the accumulation of cholesterol, fats and other substances in the arteries that causes most heart attacks—often begins in childhood. Armed with that knowledge, an expert panel supported by the National Heart, Lung, and Blood Institute recommended in November that physicians perform baseline screening of cholesterol and other lipids in all children ages 9 to 11. Though some argue that this dramatic—and controversial—change to current recommendations will save lives in decades to come, others see it as pointless and even dangerous.
Routine screening in children will accomplish two goals, says Johns Hopkins University School of Medicine lipidologist Peter O. Kwiterovich, a member of the NHLBI panel. First, it will help identify the one in 500 children with familial hypercholesterolemia (FH), an inherited condition that causes an increased risk of heart attack before age 50. Universal screening will also identify the roughly one in four children in this age bracket who have elevated cholesterol associated with factors such as obesity, poor diet and lack of exercise.
In the past, most physicians checked a child’s cholesterol only if there was a family history of FH or early heart disease, or if the child was obese (about 40% of obese children have lipid problems). But research shows that using these parameters misses too many kids with unhealthy lipids, notes Kwiterovich, citing several studies that link high cholesterol in childhood to clinical evidence of cardiovascular disease in early adulthood.
Yet critics warn that some children diagnosed with high cholesterol will be given statins even though there has never been a clinical trial showing that taking statins in childhood prevents heart attacks decades later, or that cholesterol-lowering in kids is safe. “What is the advantage of treating high cholesterol in a 10-year-old versus a 20- or 30-year-old? Nobody knows,” says H. Gilbert Welch, a professor of medicine at Dartmouth Medical School and co-author of Overdiagnosed: Making People Sick in the Pursuit of Health. Moreover, Welch notes that cholesterol is a vital component of androgens and estrogens, the sex hormones. He worries that using drugs to block production of cholesterol in children who have not yet gone through puberty may put them at increased risk for health problems.
Kwiterovich estimates that only about 1% of children identified as having high cholesterol through universal screening will meet the NHLBI’s criteria for receiving a statin or other lipid-lowering drug. Yet some observers are convinced that a far greater number of children will eventually be given prescriptions. Inevitably, predicts Michael L. LeFevre, a professor of family medicine at the University of Missouri School of Medicine, some physicians will prescribe drug therapy for children unable to bring down their cholesterol with lifestyle changes. “The pressure is there to try to do something,” says LeFevre.
Kwiterovich finds it ironic that some of the same pediatricians who dutifully perform annual physical exams—which rarely uncover anything important—bridle at the suggestion of uncovering a potential heart concern in about 25% of patients. Kwiterovich is pleased that testing is in place. “That’s the most important thing,” he says, “rather than doing nothing.”