The Committee on Nutrition of the American Academy of Pediatrics (AAP) has developed a statement on cholesterol levels in children, which is published in the January 1998 issue of Pediatrics. The report reviews the scientific evidence for recommendations of dietary changes in all healthy children and describes the management approach for children who are at increased risk of atherosclerosis in early adult life. The following summarizes the recommended strategies to reduce cholesterol levels in children and adolescents. The strategies include those directed to the population of children at large and those directed specifically to children and adolescents with elevated cholesterol levels.

The AAP statement notes that the aim of the population approach is to lower average blood cholesterol levels in children and adolescents through changes in nutrient intake and eating patterns. According to the AAP statement, no restriction of fat or cholesterol intake is recommended in infants younger than two years of age. By five years of age, though, children should be eating a diet in which saturated fatty acids constitute less than 10 percent of the total calories, total fat intake over several days is no more than 30 percent of the total calories and no less than 20 percent of total calories, and dietary cholesterol is kept at less than 300 mg per day.

Selective Screening of At-Risk Children

Selective cholesterol screening is recommended in children and adolescents with a family history of premature cardiovascular disease or with at least one parent with a high blood cholesterol level. The AAP report specifies that cholesterol screening should be performed under the following circumstances: (1) in children and adolescents whose parents or grandparents, at 55 years of age or younger, underwent diagnostic coronary arteriography and were found to have coronary atherosclerosis (this includes parents and grandparents who have undergone balloon angioplasty or coronary artery bypass surgery); (2) in children and adolescents whose parents or grandparents, at 55 years of age or younger, had myocardial infarction, angina, peripheral vascular disease, cerebrovascular disease or sudden cardiac death; and (3) in children and adolescents with a parent whose total blood cholesterol level is 240 mg per dL (6.20 mmol per L) or higher. If the child's biologic parental history is unavailable, particularly in children with other risk factors, cholesterol levels may be measured to identify children in need of nutritional and medical advice.

Optional cholesterol testing may be appropriate for children who are judged to be at higher risk for coronary heart disease independent of family history. These children might include those who smoke, consume large amounts of saturated fats and cholesterol, have diabetes, have elevated blood pressure or are overweight. AAP also recommends that physicians strongly encourage parents who do not know their cholesterol levels to have them measured.

The AAP report states that the screening protocol varies according to the reason for testing. This variation is suggested to limit the need for more sophisticated analyses. If cholesterol screening is performed because a parent has a total cholesterol level higher than 240 mg per dL (6.20 mmol per L), the initial test should be a total cholesterol measurement. If the child's cholesterol level is higher than 200 mg per dL (5.20 mmol per L), a fasting lipoprotein analysis should be obtained to measure high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol levels. If the child's total cholesterol level is borderline-high (170 to 199 mg per dL [4.40 to 5.15 mmol per L]), a second determination should be obtained and averaged with the first result. If the average is borderline-high or high, a fasting lipoprotein analysis should be obtained.

If cholesterol screening is being performed because of a family history of premature cardiovascular disease, the initial test should be a lipoprotein analysis, which requires a 12-hour fast to obtain an accurate triglyceride level and computation of the LDL cholesterol level. An elevated LDL cholesterol level is considered to be 130 mg per dL (3.40 mmol per L) or higher, and a borderline-high LDL cholesterol level ranges from 110 to 129 mg per dL (2.85 to 3.35 mmol per L). Because of considerable variability among children, the AAP Committee on Nutrition recommends repeating the test so that an average LDL cholesterol level can be calculated.

Management

Management depends on the child's average LDL cholesterol level. For children with acceptable LDL cholesterol levels, the physician should provide education on the recommended dietary guidelines for all healthy children. Lipoprotein analysis should be repeated in five years.

In children with borderline-high LDL cholesterol levels, the physician should provide advice about the risk factors for cardiovascular disease. Step 1 of the American Heart Association diet should be recommended, and other risk factor intervention should be undertaken as appropriate. Lipoprotein analysis should be repeated in one year.

In children with elevated LDL cholesterol levels, an evaluation should be conducted to exclude secondary causes, such as thyroid, liver and renal disorders, and familial disorders. All family members should undergo screening. The Step 1 diet should be followed and, if necessary, the Step 2 diet should be instituted.

The AAP suggests drug therapy only for children 10 years of age or older after six to 12 months of diet therapy has been tried and whose LDL cholesterol level remains 190 mg per dL or higher (4.90 mmol per L or higher) or whose LDL cholesterol level remains 160 mg per dL or higher (4.15 mmol per L or higher) and there is a family history of premature cardiovascular disease (at 55 years of age or under) or two or more other risk factors are present in the child or adolescent after vigorous attempts have been made to control those risk factors. Drugs recommended by the AAP include the bile acid sequestrants cholestyramine and colestipol.