What Follow-Up is Needed for a Borderline Cholesterol Test?

Patient Presentation
A 9-year-old morbidly obese (78 kg) female came to clinic for a minor illness. She had gained 4.5 kilograms in the past 6 months despite receiving dietary counseling by a dietician and had missed follow-up appointments. Interval family history showed that her 50-year-old uncle had died of a myocardial infarction. Her mother also had hypercholesterolemia and was treated with statin medication. The patient had previously been screened for thyroid disease, diabetes, and kidney disease. She had not been tested for hypercholesterolemia. The laboratory evaluation showed a total cholesterol of 175 mg/dL which is borderline.

Obesity – About 15% of school age and adolescent children are obese in the U.S. and the number is increasing. A body mass index (BMI) of 85th to 95th percentile for age and sex is considered at risk of overweight, and BMI at or above the 95th percentile is considered overweight or obese. Co-morbid conditions include hypercholesterolemia and dyslipidemia, hypertension, diabetes and impaired glucose metabolism, depression and low self-esteem, obstructive sleep apnea, asthma, pickwickian syndrome, slipped capital femoral epiphysis, steatohepatitis and other conditions. Many of these co-morbidities continue into adult life. Short-term treatment may be effective but long-term outcome is more limited. Therefore prevention is imperative.

Hypercholesterolemia – Lowering cholesterol levels reduces coronary risk factors and mortality in adults. Unfortunately no long-term studies of children’s blood cholesterol and coronary risks are available and children’s risks are inferred. Therefore recommendations for screening are controversial. Currently the American Academy of Pediatrics (AAP) recommends selective blood testing for children > 2 years of age for hypercholesterolemia. Blood testing is recommended based the following risk factors:

  • Parent or grandparent < 55 years with:
    • Coronary atherosclerosis including those who have had balloon angioplasty or coronary artery bypass surgery
    • Myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease or sudden cardiac death
  • Parent with high cholesterol (>240 mg/dL)
  • Unknown family history

If total cholesterol is acceptable (< 170 mg/dL) then patient should be re-screened in 5 years. If total cholesterol is high (>200 mg/dL) then a complete lipoprotein analysis should be done. If borderline (170-199 mg/dL), then the patient should have another total cholesterol and the results averaged and the patient re-screened based upon this risk. If still borderline or high, a 12-hour fasting analysis should be obtained. This includes total cholesterol, HDL cholesterol and triglycerides. The LDL cholesterol is calculated as: LDL = Total Cholesterol – HDL – Triglycerides. There are other screening variations based upon cardiovascular risk factors that also must be considered.

The mainstay of prevention and treatment of hypercholesterolemia is exercise and nutrition. Children less than 2 years of age should have no restrictions in fat or cholesterol, but healthy normal children 2-18 years should have a diet with

  • Saturated fatty acids <10% of total calories
  • Total fat between 20-30% of total calories
  • Cholesterol <300 mg per day

For reference, 1 egg has about 200 mg of cholesterol, 1 hamburger patty or 1 cup of whole milk has about 40% total calories from fat.

Learning Point
According to the American Academy of Pediatrics (AAP) current policy statement, the patient’s borderline total cholesterol needs to be re-checked. The two test numbers should be averaged and if still borderline or high, a 12-hour fasting analysis should be obtained. Because of the patient’s premature cardiac disease the patient should have had the fasting tests initially. Fasting tests could not be done as her appointment was in the late afternoon and the doctors were concerned with follow-up. They opted for the total cholesterol only. The patient’s obesity itself requires intensive nutritional management but for hypercholesterolemia alone therapeutic diets called Step-One and Step-Two diets are recommended. Drug therapy is only recommended for children older than 10 years.

Questions for Further Discussion
1. What national organizations besides the AAP have for cholesterol screening recommendations for children?
2. How do these recommendations different from the American Academy of Pediatrics?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Obesity.

American Academy of Pediatrics Policy Statement. Cholesterol in Childhood. Pediatrics 1998:101;141-147. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b101/1/141 (cited9/30/04).

American Academy of Pediatrics Policy Statement . Prevention of Pediatric Overweight and Obesity. 2003:112;424-430. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424?fulltext=obesity&searchid=QID_NOT_SET (cited10/4/04).

Gebhardt, Susan E., and Robin G. Thomas. 2002. Nutritive Value of Foods. U.S. Department of Agriculture, Agricultural Research Service, Home and Garden Bulletin 72. Available from the Internet at: http://www.nal.usda.gov/fnic/etext/000020.html (cited 10/4/04)

Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

October 18, 2004