By Michael Wood, MD, Pediatric Endocrinologist
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

With the current obesity crisis in children, growing numbers of children and adolescents with dyslipidemia, and a correlation between lipoprotein disorders and the onset and severity of atherosclerosis in children and adolescents, just as in adults, you might think that a new recommendation to screen all children for dyslipidemia between the ages of 9 and 11, and then again between ages 17 and 21, would sail through the medical community like a feather in a windstorm.

Not so. The recommendation, released earlier this year by the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, and endorsed by the American Academy of Pediatrics, has become one of the most controversial issues right now in children’s health.

In addition to the screening, the guidelines also recommend initiating statin therapy in children with LDL levels of 190 mg/dL or higher; those with LDL levels between 160 and 189 mg/dL and familial hypercholesterolemia or 2 or more moderate-level risk factors; and those with LDL levels between 130 and 159 mg/dL who also have 2 high-level risk factors, or 1 high-level and 2 or more moderate-level risk factors, or clinical CVD. Statins are approved for use in children ages 10 and older.

Given that an estimated 10% to 13% of children have elevated cholesterol levels, this screening program could result in an additional 200,000 children/adolescents being placed on statins.

The issue drew a packed audience for a debate late last month that I attended at the Pediatric Academic Society meeting between two pediatric public health heavyweights: Matthew Gilman, MD of the Harvard Medical School, who directs the obesity prevention program at the Harvard Pilgrim Health Care Institute, and Douglas S Moodie, MD, a Pediatric Cardiologist at Texas Children's Hospital in Houston.

Dr. Gilman, who served on the NHLBI committee but was one a handful of members who voted against the recommendation, also co-authored an article on the topic in The Journal of the American Medical Association critical of the recommendations. Among his concerns:

• There has not been, nor will there likely ever be, a large randomized controlled trial of screening that weighs the benefits against the harm
• Most randomized trials of lipid lowering in children/adolescents are relatively short and involve high-risk children, such as those with diabetes or familial hypercholesterolemia
• The long-term effects of children taking statins for years, possibly a lifetime, are unknown.

However, his co-author of the paper, Stephen R. Daniels, MD, PhD, of the University of Colorado School of Medicine in Aurora, noted that “universal screening and improvement of lifestyle in childhood is necessary to achieve adult low-risk status for the largest number of individuals.”

During the debate at the Society meeting, Dr. Gilman made several of the same arguments, while Dr. Moodie argued that the previous screening guidelines were ineffective, missing more than 50% of the children with a clinically significant elevation in their lipids.   Although he agreed that universal screening would lead to some false positive results and needless worry in some families (and need for more costly blood testing), the benefit of diagnosing far more children earlier would outweigh the risk.

In our clinic, we already follow the panel’s treatment guidelines, starting statin therapy in children with an LDL > 190 mg/dl, or with LDL levels between 160 and 190 mg/dL if they have other cardiovascular disease (CVD) risks, such as obesity, smoking, or a first-degree relative with a history of CVD.   We also typically start statin therapy in children with diabetes whose LDL remains greater than 130 mg/dL after a trial of dietary changes, exercise and improved diabetes control.

Nonetheless, I do have some concerns about the recommendations. One is that some doctors will place too much emphasis on the numbers, subliminally convincing parents of children with normal levels that their child is protected against CVD. These parents may then ignore the lifestyle choices that we know are so important for that protection, particularly diet and exercise.

I also worry whether pediatricians have the time and support to implement the lifestyle changes the panel recommends, including a stepped diet program and exercise and nutritional counseling.

Still, I support the recommendations.  I also applaud the panel for recommending a non-fasting cholesterol test, the Non-HDL Cholesterol (Non-HDL Cholesterol = Total Cholesterol – HDL Cholesterol), which will make the screening much easier and parents much more likely to obtain the test. If the initial screening test is high, however, children should have 2 full fasting lipid panels within 3 months before any treatment decisions are made. Those needle sticks will not be fun for parents or their children, as any pediatrician knows.

What is your opinion on universal cholesterol screening in children and adolescents? Have you implemented the guidelines in your practice? Click "Add Comment" below to join the conversation.

By Joe C. Eisenmann, PhD, Senior Translational Epidemiologist and William Stratbucker, MD, MS, Medical Director,  Healthy Weight Center, Helen DeVos Children's  Hospital, Grand Rapids Michigan

In case you were on vacation and didn’t hear, a new study from the Centers for Disease Control and Prevention predicts that by 2030, 42% of Americans will be obese. Those obese adults 18 years from now are children today, for this is where the roots of the growing obesity crisis lie. To that end, we have been operating the Healthy Weight Center at Helen DeVos Children’s Hospital since April 2009 to treat obese children and adolescents.  As part of our professional development, we conduct a monthly journal club for the entire multidisciplinary team to enhance their critical reading and research skills, and so they can stay abreast of the latest research in pediatric obesity. 

This activity made for an excellent gateway for our invited presentation of the best research papers in pediatric obesity for the National Association of Children’s Hospitals and Related Institutions (NACHRI)’s webinar series.

As you can see from the figure below, the attention paid to pediatric obesity by the research community has increased along with the epidemic.

Figure 1           Publications on Pediatric Obesity, 1940-2011



Here are some of the highlights from our presentation.

• Treatment initiation. Parent-reported adolescent health problems and a large discrepancy between a teen’s current and ideal weight actually reduced the likelihood that the patient and family would initiate treatment, while parent perception of their child’s weight category and the priority they placed on weight loss increased the likelihood of treatment initiation.¹

• Adherence with weight-loss intervention. Children who had mothers of non-white descent, a higher BMI, participated in fewer activities, did not have breakfast regularly, and did not live in families with a static adaptability structure were more likely to drop out of a lifestyle intervention for weight loss than children without those characteristics.² Key point: To reduce drop out rates, clinicians need to provide tailored interventions that target different characteristics of participants at various stages of treatment.

• Parental perceptions of weight-based terminology. This survey of 521 parents found that parents prefer the terms “weight” and “unhealthy weight” when doctors discuss their children rather than “fat,” “obese,” and “extremely obese,” which they perceive as stigmatizing, blaming, and least likely to motivate children and adolescents to lose weight.³  Key point: Watch your language when discussing weight-related issues with your patient and family.

• Exercise and cognition in overweight children. This study of 171 sedentary, overweight 7- to 11-year-old children found that those engaging in exercise (13 weeks, 20-40 minutes a day) experienced greater mental functioning improvement in areas central to cognitive development than those in a control group.⁴

• Diet types in overweight children. A low-glycemic index diet approach that used the traffic light approach (“green, yellow, red”  foods) is easy to describe to children and parents and may result in improved adherence and less hunger than the low-calorie diets typically used in most weight management centers.⁵

• Parental involvement is a must for weight loss interventions. This study compared the efficacy of a parent-centered dietary-modification program to a child-centered physical-activity program, separately and together, on various weight-related parameters in 165 overweight, prepubertal school-aged children. It found targeting calorie reduction to parents was more effective over 2 years than targeting increased physical activity interventions to children. However, either program alone or combined resulted in sustainable improvements over 2 years.⁶

• Meal replacement for overweight adolescents. Using meal replacements over 4 months significantly improved short-term weight loss compared to a conventional low-calorie diet, but the effects were short lived with no difference between the two groups at 12 months.⁷

• Text-messaging to improve weight loss in adolescents. In this qualitative study, 24 overweight adolescents in a weight management program participated in 4 focus groups to assess their action to texted weight-related messages. However, the teens also noted that mentioning unhealthy foods or behaviors would trigger them to eat those foods or engage in those behaviors. And stay away from acronyms like LOL; they were considered “too informal” for messages from healthcare providers.⁸  Key points: Teens like receiving text messages related to weight and weight loss, particularly recipe ideas, successful weight loss strategies their peers used, and requests for feedback on their progress. Keep the messages positive, encouraging, and direct, and include symbols such as exclamation points and smiley faces.

1. Dhingra et al. Predicting treatment initiation in a family-based adolescent overweight and obesity intervention. Obesity (Silver Spring). 2011;19(6):1307-10

2. de Neit J, et al. Predictors of participant dropout at various stages of a pediatric lifestyle program. Pediatrics. 2011;127(1):e164-70.

3. Puhl RM, et al. Parental perceptions of weight terminology that providers use with youth. Pediatrics. 2011;128(4):e786-793.

4. Davis CL, et al. Exercise improves executive function and achievement and alters brain activation in overweight children; A randomized, controlled trial. Health Psychol. 2011;30(1):9.

5. Siegel RM, et al. A comparison of low glycemic index and staged portion-controlled diets in improving BMI of obese children in a pediatric weight management program. Clin Ped. 2011; 50(5):459-461.

6. Collins CE, et al. Parent diet modification, child activity, or both in obese children: A randomized clinical trial. Pediatrics. 2011;127:619-627.

7. Berkowitz RI, et al. Meal replacements in the treatment of adolescent obesity; A randomized controlled trial. Obesity. 2011;19:1193-1199. 

8. Woolford SJ, et al. OMG do not say LOL: Obese adolescents’ perspectives on the content of text messages to enhance weight loss efforts. Obesity. 2011; 19(12):2382-7.

By Nancy J. Brooke, MD, pediatric allergist/immunologist

There’s a lot of excitement out there about sublingual and oral immunotherapy (SLIT and OIT), in which patients receive increasing amounts of an allergen as a liquid or tablet held under the tongue or swallowed rather than the traditional allergy shots. Patients take the therapy on a daily basis for at least 4 years.

Sublingual and oral immunotherapy has been used for years in Europe. Proponents cite the ease of use and safety record of the therapy. And, of course, what child (or parent) wouldn’t prefer an oral form of immunotherapy to multiple shots. In addition, because larger amounts of allergen are used than we use with subcutaneous immunotherapy (SCIT), patients may need fewer sessions.

The therapy has been tested in children and adults with good results, although most of the trials have been conducted in children with dust mite or grass allergies. Studies are now being conducted in children with food allergies, including cow’s milk and peanut allergies.

But I’m just not sold yet.  For one, the FDA has not approved any SLIT products, yet I know a few of my colleagues are using injectable serums off label for sublingual therapy.

Also, the European studies show best results when SLIT is used for nonsensitized patients, i.e., single grass pollen.  Unfortunately, most patients in North America are sensitized to multiple aeroallergens and the results are not as encouraging.

Compliance is also an issue, in that SLIT has to be administered on a daily basis to ensure the best outcome.  If doses are regularly missed, patients will have less than satisfactory results.

Although there are fewer reactions to SLIT, there have been serious reactions, including some that were life-threatening.  This is particularly concerning since SLIT is administered at home, and could be particularly dangerous is the patient has asthma.

Finally, given that there are no commercially available allergen preparations in the United States for SLIT, it is not generally reimbursed by insurance payors, placing the financial responsibility on the patient.

Other concerns include: 

• Few trials have compared SCIT to SLIT/OIT, so I’m hard pressed to say that one is better than the other.
• We just don’t know which patients should receive SLIT/OIT and which should stay with SCIT. For instance, can it be used in patients with asthma? What about those with multiple allergies?
• Can it prevent the development of asthma in young children as SCIT can?
• Which should be used, SLIT or OIT? A recently published study on the safety and efficacy of each for children with milk allergy found that while OIT worked better at desensitizing children to cow’s milk than SLIT alone, children receiving OIT had more systemic side effects and some lost desensitization within 1 week of stopping therapy.[1]
• How long will the effects of SLIT/OIT last after therapy ends? We know with SCIT that the effects last for years, possibly a lifetime, after discontinuation.

At this time, I do not feel comfortable instituting SLIT or OIT in my patients until there are more positive trials, the FDA approves it, and there are commercial preparations approved for its use.

What do you think about SLIT/OIT versus SCIT? Are you using them in your practice?

Nancy J. Brooke, MD, is a pediatric allergist/immunologist on staff at Helen DeVos Children’s Hospital, Grand Rapids, Michigan.