Daniel Slip Id Screening 2008
Daniel Slip Id Screening 2008
Daniel Slip Id Screening 2008
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/122/1/198
Health in Childhood
Stephen R. Daniels, MD, PhD, Frank R. Greer, MD, and the Committee on Nutrition
ABSTRACT
This clinical report replaces the 1998 policy statement from the American Acad-
emy of Pediatrics on cholesterol in childhood, which has been retired. This report www.pediatrics.org/cgi/doi/10.1542/
peds.2008-1349
has taken on new urgency given the current epidemic of childhood obesity with
doi:10.1542/peds.2008-1349
the subsequent increasing risk of type 2 diabetes mellitus, hypertension, and
All clinical reports from the American
cardiovascular disease in older children and adults. The approach to screening
Academy of Pediatrics automatically expire
children and adolescents with a fasting lipid profile remains a targeted approach. 5 years after publication unless reaffirmed,
Overweight children belong to a special risk category of children and are in need revised, or retired at or before that time.
of cholesterol screening regardless of family history or other risk factors. This The guidance in this report does not
report reemphasizes the need for prevention of cardiovascular disease by following indicate an exclusive course of treatment
or serve as a standard of medical care.
Dietary Guidelines for Americans and increasing physical activity and also includes
Variations, taking into account individual
a review of the pharmacologic agents and indications for treating dyslipidemia in circumstances, may be appropriate.
children. Pediatrics 2008;122:198–208 Key Words
lipid screening, children, cardiovascular
disease, cholesterol, lipid profile,
dyslipidemia, obesity, familial
INTRODUCTION hypercholesterolemia, statins
Cardiovascular disease (CVD) is the leading cause of death and morbidity in the Abbreviations
United States.1 Most of the clinical burden of CVD occurs in adulthood. However, CVD— cardiovascular disease
AAP—American Academy of Pediatrics
research over the last 40 years has increasingly indicated that the process of LDL—low-density lipoprotein
atherosclerotic CVD begins early in life and is progressive throughout the life HDL— high-density lipoprotein
span.2 It has also become clear that there is an important genetic component to the PDAY—Pathobiological Determinants of
disease process that produces susceptibility but that environmental factors, such as Atherosclerosis in Youth
IMT—intimal medial thickness
diet and physical activity, are equally important in determining the course of the NHANES—National Health and Nutrition
disease process. Examination Survey
This statement replaces the outdated 1998 American Academy of Pediatrics NCEP—National Cholesterol Education
Program
(AAP) policy statement “Cholesterol in Childhood,” which has been retired. New 3
VLDL—very low-density lipoprotein
data emphasize the negative effects of excess dietary intake of saturated and trans PEDIATRICS (ISSN Numbers: Print, 0031-4005;
fats and cholesterol as well as the effect of carbohydrate intake, the obesity Online, 1098-4275). Copyright © 2008 by the
epidemic, the metabolic/insulin-resistance syndrome, and the decreased level of American Academy of Pediatrics
physical activity and fitness on the risk of adult-onset CVD. In addition, more data
are now available on the safety and efficiency of pharmacologic agents used to
treat dyslipidemia. Most of these data were not available at the time of the
previous statement.
A number of studies have identified potential risk factors for adult CVD.4 The strongest risk factors include a high
concentration of low-density lipoprotein (LDL), a low concentration of high-density lipoprotein (HDL), elevated
blood pressure, type 1 or 2 diabetes mellitus, cigarette smoking, and obesity. Research in children and adolescents has
demonstrated that some of these risk factors may be present at a young age,5 and pediatricians must initiate the
lifelong approach to prevention of CVD in their patients. The focus of this report is on improving lipid and lipoprotein
concentrations during childhood and adolescence to lower the lifelong risk of CVD. The current obesity epidemic
among children has increased the need for pediatric health care professionals to be knowledgeable of the risk factors
for CVD and to implement the changes recommended in this report in practice.
viduals are modest, implementation of this approach can substituted, this will use, for each cup, respectively, 19, 39, or 63 kcal of discretionary calories and
result in substantially fewer people in the higher-risk add 2.6, 5.1, or 9.0 g of total fat, of which 1.3, 2.6, or 4.6 g are saturated fat.
c For 1-year-old children, 2% fat milk is included. If 2 cups of whole milk are substituted, 48 kcal
range for CVD.43 of discretionary calories will be used.
Dietary changes using the population approach are 1 1
d Serving sizes are⬎ ⁄4⬎ cup for 1 year of age,⬎ ⁄3⬎ cup for 2 to 3 years of age, and⬎ ⁄2⬎ cup
1
not recommended for children younger than 2 years, for ⱖ4 years of age. A variety of vegetables should be selected from each subgroup over the
because younger children are thought to require a rela- week.
e Half of all grains should be whole grains.
tively high intake of total fat to support rapid growth and
Adapted with permission from American Heart Association. Table: dietary recommendations
development.22 However, some studies have examined for children. Available at: www.americanheart.org/presenter.jhtml?identifier⫽3033999.
dietary intervention at a younger age. The ongoing Spe-
cial Turku Risk Intervention Program was a randomized
dietary intervention study beginning at approximately 7
months of age with weaning. Children in the interven- This includes use of reduced-fat milk in children after 12
tion group were maintained on a diet with total fat of months of age.
⬍30% of calories, saturated fat of ⬍10% of calories, and The American Heart Association recently provided
cholesterol intake of ⬍200 mg/day, using 1.5% cow updated dietary recommendations based on the new US
milk after 12 months of age.44 Outcomes in this study Department of Agriculture dietary guidelines for chil-
included both growth and neurologic function. No ad- dren (older than 2 years) and adolescents (Table 4),
verse effects of the intervention diet were observed on which have been endorsed by the AAP.47,48 These guide-
growth or neurologic outcomes. Other significant obser- lines include recommendations that children and ado-
vations included lowering the LDL concentrations of lescents have a balanced caloric intake with sufficient
boys and decreasing the prevalence of obesity in girls in physical activity to achieve an appropriate weight and
the intervention groups, compared with controls.45 consume more fruits, vegetables, fish, whole grains, and
Most studies of dietary intervention have been per- low-fat dairy products. It is also recommended that the
formed on older children aged 8 to 11 years.46 In the intake of fruit juice, sugar-sweetened beverages and
Dietary Intervention Study in Children, the lower satu- foods, and salt be reduced.
rated fat intervention diet was safe and resulted in sig- At the time of the earlier NCEP recommendations,
nificantly lower LDL concentrations in the dietary inter- there was less concern about trans fatty acids in pro-
vention group. It is encouraging that in both the Special cessed and preprepared foods. Trans fatty acids in the
Turku Risk Intervention Program and the Dietary Inter- diet tend to increase LDL concentration and do not raise
vention Study in Children, children who received the HDL concentration.49 Therefore, the new guidelines rec-
dietary intervention were more likely to select healthier ommend that intake of trans fatty acids be limited to
foods.44,46 The results of these studies indicate that there ⬍1% of total calories.47,48 This is easier for families to
is no harm associated with prudent diet changes, even implement, because the fat content, including total
when they are instituted in children soon after weaning. grams of trans fatty acids, is now required on all food