Your Children's Health

By Roy Benaroch, MD

The National Heart, Lung, and Blood Institute (NHBLI), a government panel that’s part of the National Institutes of Health, has issued new recommendations on reducing the risk for cardiovascular disease in children. Parts will be non-controversial—recommending low-fat or non-fat milk and stressing the importance of regular daily exercise. But pediatricians and parents may find one part a little more difficult to get used to: all children, starting at age nine, should have blood tests to check their cholesterol levels.

Cardiovascular disease (including heart attacks and strokes) is the leading cause of death in the developed world. It rarely kills children, of course. The risk of these diseases is related to blood vessels in the heart and brain getting narrow and filled with gunk, which almost always causes symptoms in older adults. But there is indirect evidence that the risks for these diseases starts in youth, and that changing lifestyles and health habits early on ought to help prevent these problems as we age.

In the world of medicine, the best evidence that something really works is the double-blind, placebo controlled study. Take a bunch of people, give half of them the medicine, give half the placebo. Don’t tell anyone which is which. Wait and see. Did one group do better than the other? A well-designed study like this is the “gold standard.” But this kind of evidence just isn’t available when you look at the relationship between what kids are doing and what their risks of heart attacks are when they’re older. You’d have to study these children for 50 years to really assess the impact of your interventions, and that’s just not possible.

Instead, the NHBLI panel used best available information from basic science studies and epidemiology to back up their recommendations. They’re probably right. Increasing exercise and decreasing the risks of obesity, hypertension, and elevated cholesterol in children will almost certainly prolong and improve the lives of adults. And almost all of their recommendations are common-sense things that could only help. What’s the harm?

Which brings us back to the one part of the recommendations that I believe is going to be problematic: Drawing blood to test cholesterol on all nine-year-olds is not an entirely benign procedure. It will be scary. It will be expensive. And for almost all of the children with elevated cholesterol, the advice will be to improve dietary and exercise habits. Which is already being recommended for all children. So what’s the point of the universal testing?

Testing will pick up the < 1% of children with extremely high cholesterols who should certainly have early medical therapy (these kids will almost always come from families who have experienced heart disease in young adults, so they should come to medical attention anyway.) Testing may also serve as an additional “wake up call” for some families. Faced with a child with a genuinely elevated cholesterol, perhaps some families will be even more motivated to make a change.

However, the opposite is also true. Most children will not have an elevated cholesterol level. Does that mean they’re at not risk for heart attacks later, and that they’re free to ignore all of the other health advice in the recommendation? Of course not. But it’s certainly possible that many families will become even less motivated to live healthy lives when faced with a normal cholesterol test.

One other aspect of the report is going to raise a few eyebrows. There were 14 members of the expert panel tasked with reviewing the best science and writing the report. Of the 14 experts, eight have significant financial ties with drug manufacturers, including many that produce and sell cholesterol-lowering drugs. The report itself does not endorse widespread use of these drugs in children. Yet with more testing done, far more attention will be paid to those numbers. What will doctors do when lifestyle and diet changes don’t lower cholesterol values? The prescription pad is sitting right there. It will be tempting.

The document is hefty, 125 pages, and is the result of a review of thousands of studies that began in 2006. It’s been endorsed by the American Academy of Pediatrics, which means that it is now the “official” recommendation of the largest community of pediatricians in the world. There’s plenty here that everyone can agree with, and I hope the media’s focus on the new cholesterol screening recommendation doesn’t distract from the overall message: there is good science supporting parents who take steps to improve their children’s cardiovascular risks. Improved diet and exercise habits, along with identifying and treating diabetes and high blood pressure, can save lives. It isn’t all about the cholesterol.