Dr. Peter Rawlings

New guidelines for the use of cholesterol-lowering drugs in children as young as 8 have unnerved some pediatricians.

“I have some concerns about even thinking about introducing these kinds of medicines in (kids) as young as what they are talking about,” said Dr. Peter Rawlings, a Chattanooga pediatrician and past president of the Chattanooga and Hamilton County Medical Society. “At least until they get through puberty, I’m very reticent to think about medications.”

The obesity epidemic in U.S. children has led experts at the American Academy of Pediatrics to update its guidelines, which previously set the age of 10 as the youngest age at which cholesterol-lowering statin drugs should be prescribed, if efforts to control diet and exercise failed.

Almost one out of every three children is overweight or obese, according to the U.S. Centers for Disease Control and Prevention.

The new guidelines also recommend cholesterol screening of young people starting as early as age 2 and before age 10 if the child has a family history of high cholesterol and heart attack.

Children with unknown family history also should be screened, as well as children with other risk factors such as diabetes or a body mass index — a ratio of weight to height — at or above the 85th percentile for their age.

Studies have shown that high cholesterol during childhood and adolescence correlates with cardiovascular disease in adulthood, according to an article in Pediatrics, the journal of the American Academy of Pediatrics. The article cites studies that show the process of plaque build-up inside arteries — atherosclerosis, or hardening of the arteries — can begin in young adulthood.

TO PRESCRIBE OR NOT?

The American Academy of Pediatrics still recommends weight management through diet and exercise as the first line of defense, said Dr. Jatinder Bhatia, chief of neonatology at the Medical College of Georgia in Augusta. Dr. Bhatia was on the American Academy of Pediatrics nutrition committee and helped write the new guidelines.

But drugs could be used in children with a hereditary cholesterol condition or with serious risk factors, such as obesity or diabetes.

“We’re not saying everybody has to be on statins, but if exercise and diet and behavior change doesn’t work, at least we have options,” said Dr. Bhatia.

He noted that short-term data suggests statins are safe and effective in lowering cholesterol levels.

“I believe if you have one of these risk factors, the benefit is better than the risk,” Dr. Bhatia said.

But long-term effects of statin use in children are unknown, Dr. Rawlings pointed out.

“When you’re talking about the pediatric population where things are changing so rapidly — they’re growing, they’re changing — how is this going to affect their growth? How will this affect their development neurologically? The answer is ... we really don’t know,” he said.

Dr. Billy Arant, a local pediatrician and hypertension specialist certified in lipidology — which studies cholesterol and its effects on metabolism — emphasized that the American Academy of Pediatrics’ recommendations for drug use represent a last resort tactic. For young patients who are extremely overweight but either can’t or won’t change their lifestyle, doctors may have no choice but to recommend drug use to prevent serious problems later in life, he said.

Doctors can encounter great resistance when discussing lifestyle changes with overweight children or their parents, Dr. Arant said.

“There would be many parents who would be more willing for their child to take a statin drug with unknown consequences than they are willing to create a healthy childhood environment for them,” he said.

BENEFITS VS. RISKS

At age 11, Zach Bible was put on multiple medications to control his genetic form of high cholesterol. His triglyceride levels — tested for the first time that year — were through the roof. When doctors tested his arteries to see if plaque was forming, the news was not encouraging, he said.

“They were already hardening,” said Zach, now age 16 and a rising junior at Soddy-Daisy High School.

“They told me I could have been 22 in college, playing football with my friends, and have a heart attack,” Zach said. “It kind of shocked me. To be told at 22 I could die, that’s pretty weird.”

In addition to a sugar-free diet and regular exercise, Zach likely will be on medication his whole life to control his condition. The nine pills he takes a day — two medications are taken four times daily — are a worthwhile risk, despite concerns about potential side effects of long-term use, said Zach’s mother, Andy Bible.

“I do worry about down the road, what the effects” could be, Mrs. Bible said. “I wish my child wasn’t on nine pills a day, but if it’s gonna keep him alive, then down the road we’ll just have to see if he has any (adverse) effects.”

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