New Pediatric Cardiac Guidelines – What you should know
When the National Heart Lung and Blood Institute released the Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents this fall, much of the media focused on a new recommendation to screen for cholesterol in all children. With this month’s publication of the guidelines in the journal Pediatrics, some of the other new and important recommendations the expert panel made are getting more attention.
“These are the first guidelines addressing all aspects of cardiovascular health in children that are based on an independent review of the scientific evidence. The recommendations come from that evidence review with several new and important recommendations. There was so much fuss over the cholesterol screening that some of the other major points were initially overlooked,” said the coordinator for the guidelines, Rae-Ellen Kavey, M.D., M.P.H., professor of Pediatrics at the University of Rochester Medical Center and pediatric cardiologist at Golisano Children’s Hospital.
Kavey said one of those missing points was that the science review revealed a large body of evidence supporting the safety and effectiveness of a low fat diet in promoting cardiovascular health. One important study from Finland randomized children to a low saturated fat diet or to usual diet in infancy, and followed the children into their mid-teens. The children on the low saturated fat diet had lower LDL cholesterol, less obesity and lower blood pressure, all important cardiovascular benefits with no identified differences in growth or maturation. Evidence like this led to the guideline recommendation for a low saturated fat diet for all children 2 years old and older. That means only fat free milk as the recommended beverage for all children – not whole, 2 percent or 1 percent for children starting on their 2nd birthday.
Another issue the recommendations address in detail is primary hypertension in children. Pediatricians are not as accustomed to screening for hypertension in kids as PCPs are in adults. And parents need education on what is the norm for their children and what hypertension looks like in children.
“We need to not only measure blood pressure in our pediatric patients, we need to compare the results to the norms and show them to parents, just like we do with height, weight and BMI,” Kavey said. “Initial treatment for the vast majority of primary hypertension in childhood is lifestyle change. If we can catch children with blood pressure issues when they’re young, we may be able to prevent or lessen cardio-vascular problems in adulthood.”
The guidelines include charts of the blood pressure norms and recommendations for treatment at each level.
Many pediatricians have already made diabetes screening part of their routine care, but the guidelines underscored that practice. Children who are at risk for diabetes should be screened at 10 years of age. Risk factors include obesity plus two additional risk factors, including a parent with diabetes or being part of some racial/ethnic groups. The screening should be repeated every two years if the risk pattern is unchanged.
As for the new cholesterol screening, Kavey said she worries there was some information that did not get a lot of attention in the media. At 10, children are recommended to have a blood test for cholesterol screening, but it does not need to be a fasting sample. Screening can now be done on a non-fasting specimen using non-HDL cholesterol. Kavey said the guidelines provide clear algorithms for diagnosis and treatment by age and by cholesterol level, and provide diet recommendations as the first stage of management.
“Even the kids with high numbers should try diet and exercise changes first,” Kavey said. Only those very rare children with triglyerides over 500 and LDL over 250 would need an immediate referral to a specialist.
To make an appointment with Kavey, please call the Children’s Heart Center at (585) 275-6108.