Saturday, July 30, 2016

Cholesterol - something to watch in childhood

Since our office has adopted new screening protocols based on the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, we have seen many questions and resistance. I suspect the resistance is due to the fact that kids hate needles and parents aren't sure if insurance will cover the cost of labs. Some families simply have a difficult time taking kids to a draw station.

These guidelines cover additional topics, such as blood pressure and tobacco exposure, but I will only discuss the most common questions specific to the cholesterol measurements here. A lipid panel includes the total cholesterol, triglyceride level, high density lipoproteins (HDL, "good" cholesterol), and low density lipoproteins (LDL, "bad" cholesterol). Some labs include other types of lipids.

My office website discusses the basics of cholesterol.

The dietary advice is summarized nicely in CHILD-1 Diet and Nutrition Recommendations -Childhood Nutrition Basics.

Preparing for the lab draw

If your child hates needles, I understand. But some things are important, and in pediatrics we focus on prevention. If we can prevent heart attacks, strokes, and other consequences of unknown risks of heart disease, we should.

Kids can be prepared before going to the lab. NEVER say it won't hurt. Everyone perceives pain differently, but if they know it might pinch or feel like a poke they will be prepared. Remind them it only pokes for a very short time usually and holding still helps it go faster. Tell them there will be a big rubber band called a tourniquet that will squeeze the top of their arm to help make it easier for the needle to find the right spot.

Let them watch this video on lab draws.  (Warning, this video does show a blood vial being filled... some people get queasy just seeing things like this.)

You can practice at home by letting them show you how they will hold still with their arm out. They can look away and take big breaths with a strong forceful blow out each time. You can wipe the arm with a cotton ball or tissue and talk about how that part tickles. Maybe they can pretend they're blowing out candles or they can blow on a pinwheel.

Make sure they are well hydrated with water before going to the lab. Remind the phlebotomist (who draws the blood) that studies show blowing out upon the insertion of the needle has been shown to decrease pain with injections, and I suspect also with lab draws. You can also use a video on your smartphone or tablet to distract during the draw.

What affects when you should take a child for the lab?

A child should be on his or her regular diet for 4-6 weeks before testing to reflect the child's true levels. If a child vacationed and ate fast food for a week but typically eats a healthier diet, the levels will be skewed toward the more recently eaten foods. If they often eat poorly, do not alter the diet for the purpose of the lab. Get a baseline that is accurate to their lifestyle.

Illness can also affect lipid levels, so ideally children will be overall healthy when the lab is drawn. If there was a recent significant illness, waiting 4-6 weeks to draw the lab is ideal. Significant illness would be one that requires hospitalization or surgery. If oral steroids were given, it would be best to wait at least 4 weeks. An upper respiratory infection, cough, or typical short term illness should simply be resolved before the draw. You would not need to wait 4-6 weeks for these common illnesses. If you are uncertain if an illness is significant, ask your doctor.

Fasting does not affect the total cholesterol significantly, but it does affect the triglycerides. It is recommended to fast 8-12 hours before having the triglycerides checked. This is most easily done by having children drink water in the morning without food or other drinks. Take them to the lab for the lab draw and then let them eat breakfast.

If it is not possible to take kids to the lab when they have fasted, be sure the lab knows that it is a non-fasting level. They will include this with the report so the doctor can evaluate the lab values with that important information. In general I do not enforce fasting if it is too inconvenient unless there is a history of a previous elevated triglyceride. If the triglyceride level has been high on a previous lab, it is important to do a fasting level to see if it is a real risk or due to a recent meal.

Why do we need to check cholesterol in children- isn't heart disease an adult problem?

We know that obesity increases the risk of having a high cholesterol and atherosclerosis.
Elevated triglyceride levels and obesity are associated with Type 2 diabetes. Children with obesity need routine monitoring of their cholesterol along with other chronic disease indicators.

Multiple studies show that parents often perceive their children to be a healthy weight, but in reality their diet and exercise are not healthy and their height and weight do not indicate health.
We know that a family history of people with high cholesterol or certain heart conditions increases the risk. Tobacco exposure increases the risk. Certain chronic diseases increase the risk of cardiac problems. All of these can be risks in otherwise healthy appearing children.

There are a significant number of children who have no known risk factors yet have an elevated lipid level. This can put them at risk for cardiovascular disease, but if it is known, steps can be done to lower that risk.

The simple answer is atherosclerosis (clogging of arteries) can begin in childhood, but has no symptoms at the early stages when treatment is most effective. There are some people who have a genetic predisposition to this despite healthy habits and an outward appearance of health.

Screening recommendations are done by age and risk.

Many things can alter the risk of cardiovascular disease, including genetics, recent illness, puberty, obesity, blood pressure and tobacco exposure. Guidelines take into account these factors to help determine when testing should be done. If risk factors are identified, a lipid panel should be done. All children, regardless of risks should be checked at 9-11 years and again at 17-21 years of age. If the levels are normal, a lipid panel should be repeated in 5 years. If abnormal or if risk factors change, the level will need to be repeated sooner, depending on risk.

From page 8 of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report 

What are you going to do with the results?

Many parents are frustrated if we find an elevated level but then "don't do anything about it." We are doing something. We just don't start with medicines because medicines are not the best answer. We recommend a healthy diet and daily exercise. Those two things are more important than many parents realize. They can make changes that benefit your child for life. But they must be done. Making healthy changes for the entire family benefits everyone and makes it easier for a child to comply with recommendations.

Repeat levels will be required to see if the diet and exercise changes make an impact. If the results are consistently elevated or significantly elevated to require medication, a referral to a pediatric lipid specialist is indicated.

See page 53 of the guidelines

See page 54 of the guidelines

If you have questions about cholesterol screening for your child, please talk to your child's doctor. 

Other Resources:

Pediatric Lipid Disorders in Clinical Practice Workup, Henry J Rohrs, III, MD et al

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