The National Heart, Lung, and Blood Institute has just issued a new clinical practice guideline for healthcare practitioners taking care of children and adolescents that attempts to decrease the development of heart disease in later life. One notable recommendation is that the panel recommends that all children aged 9 to 11 undergo blood testing for high cholesterol to assist in the early identification of high risk.
Atherosclerotic cardiovascular disease is the leading cause of death in North Americans and throughout the world. Clinical disease typically becomes evident only in middle aged to elderly people, however, the underlying causes often begin in childhood. Now there is more and more evidence suggesting that risk reduction at an early age, in childhood and adolescence, will reduce the impact of CVD in later life. With this in mind, an Expert Panel was assembled by the U.S. National Heart, Lung, and Blood Institute to develop cardiovascular health guidelines for pediatric care providers.
The guidelines are comprehensive and encourage a wide variety of actions to taken during pregnancy, at a newborn’s very first visit to the doctor, and throughout adolescence. These early steps include advising parents who smoke to quit (including moms during pregnancy), or at least keep the baby away from second-hand smoke. Another key action recommended is to encourage parents to model an active, healthy lifestyle for children starting at birth and onward.
Early screening children and adolescents for cholesterol problems is recommended primarily when there is a positive family history of cholesterol problems or other risk factors for CVD. For these children, the Expert Panel recommended a fasting blood test as early as age 1. In addition, the panel recommended that ALL children undergo a blood test for high cholesterol at age 9 to 11.
These guidelines are not without controversy. Performing a blood test on all children at age 9 to 11 is probably the most problematic. Reasons against such testing include the fact that the treatment for nearly all children, regardless of the test results, will be to improve dietary and exercise habits. In addition, children with high cholesterol levels will almost always come from families who have experienced heart disease at a young age. The question remains, is taking a blood test going to be any better than getting a good family history, and encouraging a healthy lifestyle for all patients?
Another concern is the significant financial conflicts of interest among the Expert Panel that created these guidelines. Of the 14 members of the panel, half of them declared financial conflicts of interest with pharmaceutical companies. Almost certainly greater blood testing of children will lead to more prescribing of medications. These conflicts of interest are of great concern, and it is surprising that the National Heart, Lung and Blood Institute decided not to chose 14 physicians without any financial conflicts of interest to serve on the Expert Panel. Because of this oversight, the guideline to perform blood cholesterol tests in all children is likely to be viewed by many as simple disease mongering and the guidelines will be viewed by many with great skepticism.
RECOMMENDED RESOURCES
Daniels SR et al. Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart Lung and Blood Institute. [accessed Nov 15, 2011]. You can find the new guidelines here.
Moynihan R, Cassels A. Selling Sickness: How the World’s Biggest Pharmaceutical Companies are Turning Us All Into Patients. Nation Books, 2006. This is one of the first books that examined in depth the influence of the pharmaceutical industry upon the practice of medicine.
Angell M. The Truth About Drug Companies. Random House, 2005. A former editor of the New England Journal of Medicine gives her views about the influence of pharmaceutical industries upon health care in the U.S.