Every child should be tested for high cholesterol as early as age 9 - surprising new advice from a government panel that suggests screening kids in grade school for a problem more common in middle age.
The idea will come as a shock to most parents. And it's certain to stir debate.
The doctors on the expert panel that announced the new guidelines Friday concede there is little proof that testing now will prevent heart attacks decades later. But many doctors say waiting might be too late for children who have hidden risks.
Fat deposits form in the heart arteries in childhood but don't usually harden them and cause symptoms until later in life. The panel urges cholesterol screening between ages 9 and 11 - before puberty, when cholesterol temporarily dips - and again between ages 17 and 21.
The panel also suggests diabetes screening every two years starting as early as 9 for children who are overweight and have other risks for Type 2 diabetes, including family history.
The new guidelines are from an expert panel appointed by the National Heart, Lung and Blood Institute and endorsed by the American Academy of Pediatrics.
Some facts everyone agrees on:
- By the fourth grade, 10 to 13 percent of U.S. children have high cholesterol, defined as a score of 200 or more.
- Half of children with high cholesterol will also have it as adults, raising their risk of heart disease.
- One third of U.S. children and teens are obese or overweight, which makes high cholesterol and diabetes more likely.
Until now, cholesterol testing has only been done for kids with a known family history of early heart disease or inherited high cholesterol, or with risk factors such as obesity, diabetes or high blood pressure. That approach misses about 30 percent of kids with high cholesterol.
"If we screen at age 20, it may be already too late," said one of the guideline panel members, Dr. Elaine Urbina, director of preventive cardiology at Cincinnati Children's Hospital Medical Center. "To me, it's not controversial at all. We should have been doing this for years."
Elizabeth Duruz didn't want to take that chance. Her 10-year-old daughter, Joscelyn Benninghoff, has been on cholesterol-lowering medicines since she was 5 because high cholesterol runs in her family. They live in Cincinnati.
"We decided when she was 5 that we would get her screened early on. She tested really high" despite being active and not overweight, Duruz said. "We're doing what we need to do for her now, and that gives me hope that she'll be healthy."
Dr. Roger Blumenthal, who is preventive cardiology chief at Johns Hopkins Medical Center and had no role in the guidelines, said he thinks his 12-year-old son should be tested because he has a cousin with very high "bad" cholesterol who needed heart bypass surgery for clogged arteries in his 40s.
"I'm very supportive" of universal screening, he said. "The knowledge of their cholesterol numbers as well as their blood sugar levels can be very helpful for the physicians and their families about which patients are headed toward diabetes."
Dr. William Cooper, a pediatrics and preventive medicine professor at Vanderbilt University, said expanding the testing guidelines "would seem to me to make sense."
But he added: "One of the risks would be that we would be treating more kids, potentially, and we don't know yet the implications of what we're treating. Are we treating a number or are we treating a risk factor?"
That's the reason a different group of government advisers, the U.S. Preventive Services Task Force, concluded in 2007 that not enough is known about the possible benefits and risks to recommend for or against cholesterol screening for children and teens.
One of its leaders, Dr. Michael LeFevre, a family medicine specialist at the University of Missouri, said that for the task force to declare screening beneficial there must be evidence that treatment improves health, such as preventing heart attacks, rather than just nudging down a number - the cholesterol score.
"Some of the argument is that we need to treat children when they're 14 or 15 to keep them from having a heart attack when they're 50, and that's a pretty long lag time," he said.
The guidelines say that cholesterol drugs likely would be recommended for less than 1 percent of kids tested, and they shouldn't be used in children younger than 10 unless they have severe problems.
"We'll also continue to encourage parents and children to make positive lifestyle choices to prevent risk factors from occurring," steps such as diet and exercise, said Dr. Gordan Tomaselli, president of the American Heart Association. The group praised the guidelines and will host a presentation on them Sunday at its annual conference in Florida.
Cholesterol tests cost around $80 and usually are covered by health insurance. Several of the 14 doctors on the guidelines panel have received consulting fees or have had other financial ties to makers of cholesterol medicines.
Typically, cholesterol drugs are used indefinitely but they are generally safe, said Dr. Sarah Blumenschein, director of preventive cardiology at Children's Medical Center in Dallas, who had no role in the guidelines but supports them.
"You have to start early. It's much easier to change children's behavior when they're 5 or 10 or 12" than when they're older, she said.
The guidelines also say doctors should:
- Take yearly blood pressure measurements for children starting at age 3.
- Start routine anti-smoking advice when kids are ages 5 to 9, and counsel parents of infants not to smoke in the home.
- Review infants' family history of obesity and start tracking body mass index, or BMI, a measure of obesity, at age 2.
The panel also suggests using more frank terms for kids who are overweight and obese than some government agencies have used in the past. Children whose BMI is in the 85th to 95th percentile should be called overweight, not "at risk for overweight," and kids whose BMI is in the 95th percentile or higher should be called obese, not "overweight - even kids as young as age 2, the panel said.
"Some might feel that `obese' is an unacceptable term for children and parents," so doctors should "use descriptive terminology that is appropriate for each child and family," the guidelines recommend.
They were released online Friday by the journal Pediatrics.