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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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4Cholesterol

Coronary heart disease (CHD) is the major cause of death in the United States. The atherosclerotic process that leads to CHD often begins in childhood. Because unfavorable lipoprotein levels are linked to early atherosclerotic changes in children, and because children with high cholesterol levels are at increased risk of having high cholesterol levels as adults, identifying such children and intervening to decrease their cholesterol levels have been suggested as a means of preventing CHD in adulthood.

Children from higher risk families (with a pattern of hypercholesterolemia or premature CHD in the adult members) who have elevated serum cholesterol levels appear to be at a particularly increased risk for CHD when they reach adulthood. This association is the basis for some of the recommendations made by major authorities for the selective screening of children for elevated cholesterol. For the general pediatric population over age 2 years, counseling to encourage a reduced intake of dietary fat, especially saturated fats, is recommended.

Children identified with high cholesterol levels may be considered for dietary or drug interventions to lower their cholesterol level. In the Dietary Intervention Study in Children (DISC), diet produced a significant reduction in cholesterol levels without adverse effects on growth and development, but the effects of drug treatment over periods of 40 years or more have not been established.

See chapter 20 for information on nutrition counseling in children/adolescents.

Recommendations of Major Authorities

  • Canadian Task Force on the Periodic Health Examination --
  • There is insufficient evidence to recommend for or against routine cholesterol screening of children and adolescents. Individual clinical judgment should be exercised to determine the need for screening.
  • National Heart, Lung, and Blood Institute's National Cholesterol Education Program Expert Panel on Blood Cholesterol Levels in Children and Adolescents; American Academy of Pediatrics; Bright Futures; and American Medical Association --
  • Universal screening of children and adolescents for cholesterol levels is not recommended. Children older than 2 years of age who have a parent with a total cholesterol level of 240 mg/dL or greater should be screened for both total serum cholesterol and HDL cholesterol levels. Children (older than age 2 years) and adolescents with a family history of premature cardiovascular disease (ie, a parent or grandparent who, at age 55 years or younger, had a documented myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death, or underwent diagnostic coronary arteriography and was found to have atherosclerosis, or underwent coronary artery bypass surgery or angioplasty) should be screened for lipoprotein levels after a 12-hour fast. In children whose family history is not obtainable, screening may be indicated, especially if risk factors for coronary artery disease are present (eg, high blood pressure, smoking, overweight, or excessive consumption of saturated fat and cholesterol).
  • US Preventive Services Task Force --
  • There is insufficient evidence to recommend screening of children and adolescents. For adolescents who have a family history of very high cholesterol, premature CHD in a first-degree relative (before age 50 years in men or age 60 years in women), or major nonlipid risk factors for CHD (eg, smoking, hypertension, diabetes), screening may be recommended on other grounds, because of the greater absolute risk attributable to high cholesterol levels in such persons and the potential long-term benefits of early lifestyle interventions in young persons with high cholesterol levels. Recommendations against screening of children may be made on other grounds, including the costs and inconvenience of screening and follow-up, greater potential for adverse effects of treatment, and the uncertain long-term benefits of small reductions in childhood cholesterol levels.

Basics of Cholesterol Screening

1.

Children may eat a normal diet before total cholesterol screening. Children undergoing lipoprotein analysis should fast, ingesting nothing but water for 12 hours before the blood sample is taken.

2.

Do not screen children who are acutely ill, including those with infectious diseases. Do not screen pregnant adolescents.

3.

A venous sample obtained with the patient in the sitting position yields the most accurate results; recumbency lowers lipid levels. Documentation of position is important when comparing follow-up measurements.

4.

Take into account the cholesterol-raising effect of certain medications, including corticosteroids, isotretinoin, thiazides, anticonvulsants, beta blockers, and certain anabolic steroids. If a patient meeting screening criteria takes one of these drugs, a potential strategy is to perform the test, and if the result is elevated, consider the magnitude of the elevation and the ease and safety of suspending medication for retesting in the absence of drugs.

5.

The laboratory used for analysis should participate in a program of external standardization to ensure compliance with standards of precision and accuracy. The National Cholesterol Education Program's Laboratory Standardization Panel recommends that bias not exceed ±5% from the true value and that the intralaboratory coefficient of variation not exceed ±5%.

6.

The National Cholesterol Education Program has recommended protocols for assessing cholesterol levels in the screening of children (Figures 4.1 and 4.2).

Figure 4.1 Assessment and Follow-up of Total Cholesterol Measurements.

Figure

Figure 4.1 Assessment and Follow-up of Total Cholesterol Measurements. From: National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, Md: National Institutes (more...)

Figure 4.2 Assessment and Follow-up of Lipoprotein Analysis.

Figure

Figure 4.2 Assessment and Follow-up of Lipoprotein Analysis. From: National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, Md: National Institutes of Health, (more...)

Patient Resources

  • Step by Step: Eating to Lower Your High Blood Cholesterol; So You Have High Blood Cholesterol; Parents Guide: Cholesterol in Children -- Healthy Eating is a Family Affair. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm
  • Growing up Healthy: Fat, Cholesterol, and More. This brochure provides health and eating guidelines for children 2 to 6 years old. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016.

Provider Resources

  • Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

  1. American Academy of Pediatrics. Prudent life-style for children: dietary fat and cholesterol. Pediatrics. . 1986; 78:521–525. [PubMed: 3748694]
  2. American Academy of Pediatrics. Pediatric Nutrition Handbook. .3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 1993.
  3. American Academy of Pediatrics, Committee on Nutrition. Statement on cholesterol. Pediatrics. . 1992; 90:469–473. [PubMed: 1518712]
  4. American Medical Association. Rationale and recommendation: hyperlipidemia. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Il: American Medical Association; 1994: chap 9.
  5. Bao W, Srinivasan SR, Wattigney WA, Bao W, Berenson GS. Usefulness of childhood low-density lipoprotein cholesterol level in predicting adult dyslipidemia and other cardiovascular risks. Arch Intern Med. . 1996; 156:1315–20. [PubMed: 8651840]
  6. Canadian Task Force on the Periodic Health Examination. Lowering the blood total cholesterol level to prevent coronary heart disease. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 54.
  7. The Dietary Intervention Study In Children Collaborative Research Group. Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol. JAMA. . 1995; 273:1429–35. [PubMed: 7723156]
  8. Diller PM, Huster GA, Leach AD, Laskamziski PM, Sprecher DL. Definition and application of the discretionary screening indicators according to the National Cholesterol Education Program for children and adolescents. J Pediatr. . 1995; 426:345–52. [PubMed: 7869190]
  9. Garcia RE, Moodie DS. Routine cholesterol surveillance in childhood. Pediatrics. . 1989; 84:751–755. [PubMed: 2640549]
  10. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994.
  11. Kuehl KS. Cholesterol screening in childhood. Targeted versus universal approaches. Ann NY Acad Sci. . 1991; 623:193–199. [PubMed: 2042826]
  12. National Cholesterol Education Program. Recommendations for Improving Cholesterol Measurement. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1990. US Department of Health and Human Services, Public Health Service publication NIH 90-2964.
  13. National Cholesterol Education Program, Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1991. US Department of Health and Human Services, Public Health Service publication NIH 91-2732.
  14. Newman WP, Wattigney W, Berenson G. Autopsy studies in United States children and adolescents. Relationship of risk factors to atherosclerotic lesions. Ann NY Acad Sci. . 1991; 623:17–25. [PubMed: 2042824]
  15. Newman TB, Browner W, Hulley SB. The case against childhood cholesterol screening. JAMA. . 1990; 264:3039–3043. [PubMed: 2243432]
  16. Resnicow K, Berenson G, Shea S, Srinivasan S, et al. The case against the "case against childhood cholesterol screening.". JAMA. . 1991; 265:3003–3005. [PubMed: 1805810]
  17. Resnicow K, Morley-Kotchen J, Wynder E. Plasma cholesterol levels of 6585 children in the United States; results of the know your body screening in five states. Pediatrics. . 1989; 84:969–976. [PubMed: 2587152]
  18. US Preventive Services Task Force. Screening for blood cholesterol.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 2.
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