In my own view, in kids who have strong family histories of very premature heart disease or who have Familial hypercholesterolemia or other severe, genetic lipid abnormalities, the potential risk of statin drugs seems relatively small. These kids are known to have a very high risk of developing early cardiovascular disease and aggressively lowering their lipid levels (with statins) is at least reasonably likely to substantially improve their prognosis.
I come to a similar conclusion for kids who are obese and who have metabolic syndrome or type 2 diabetes, and for similar reasons. These kids appear likely to have an unfavorable prognosis without aggressive treatment, and the unknowns of statin therapy seem reasonably likely to be an acceptable risk. Parents (and the kids themselves) should realize, however, that these conditions are almost due solely to obesity (specifically, too much weight gain in the abdominal area) and that treating the effects of obesity with powerful drug therapy is far less attractive than treating the obesity itself. With sufficient weight loss and exercise, the excess risk (and the need for statins) would diminish or disappear.
Where I personally have a problem with the new recommendations is in kids who "only" have elevated LDL levels and who had lipid screening in the first place only because they were deemed overweight or obese based on their Body Mass Index (BMI), a calculation based on a person's height and weight that is used as an estimate of a person's body weight status (e.g., underweight, overweight, normal weight). While BMI generally can be used as a reasonable measure in adults, its usage as an estimate of obesity in children is filled with problems.
"Overweight" children are defined as those whose BMI places them in the 85th percentile or above for their age, and "obese" children are those in the 95th percentile or above. This label is not only arbitrary and not science-based but also varies from country to country and from time to time. Consider, for instance, that by deciding to define "overweight" at the 85th percentile, we are saying that at least 15% of American children will always be, by definition, overweight or obese, which makes alarming statements about the proportion of children who are "too heavy" somewhat less meaningful.
Furthermore, a change in a child's height of less than an inch, or a gain in weight of just a few pounds, can sometimes dramatically affect their percentile BMI score. Since growing children normally do not gain weight and height smoothly, but instead do it in spurts (in a manner that is completely inconsiderate to statisticians), it is not uncommon for normal kids to bounce around the percentile scale and spend a few months or years in the 85th percentile or higher. This means that many, if not most kids, will meet the criteria for being "overweight," and then need a lipid screening at some point in their lives as growing children.
And for kids who are defined as "overweight" by their BMI score, and whose LDL cholesterol is elevated, but who have no other significant risk factors, not only is the long-term significance of that elevated cholesterol largely unknown, but also the potential of lipid-lowering drug therapy to reduce their risk of cardiovascular disease is completely unknown. Drug therapy should be prescribed in these kids only after careful consideration of all the evidence, and a clear and frank discussion of the potential risks and benefits should be discussed with the parents and child.
In summary, while the latest recommendations of the AAP are based on the highest motives, and while in large part they are reasonable and supportable, they do provide the potential for overtreating children whose long-term risk of cardiovascular disease is not necessarily greatly elevated, and in whom the unknown risk of long-term drug therapy may not be warranted.
Parents of children who meet the new criteria for treating lipid abnormalities should weigh the potential risks and benefits of therapy in their own kids. They should also seek a doctor who will help them interpret the new guidelines (rather than simply parroting them) and help them come to a reasonable course of action that, after weighing all the necessary factors, suits the needs of their child.
Sources:
Daniels SR, Greer FR, and the Committee on Nutrition. Lipid screening and cardiovascular health. Pediatrics 2008; 122:198-208..
Flegal KM, Tabak CJ, Ogden CL. Overweight in children: definitions and interpretation. Health Education Research 2006 21(6):755-760.
McCrindle BW, Urbina EM, Dennison BA, et al. Drug Therapy of High-Risk Lipid Abnormalities in Children and Adolescents
A Scientific Statement From the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, With the Council on Cardiovascular Nursing. Circulation. 2007;115:1948-1967.
