Some experts stress diet and exercise should play an important role in reducing the risk of heart disease in overweight children.
Children as young as 8 with high cholesterol levels should be put on drugs to reduce their risk of heart disease, doctors in the United States have recommended.
The move by the American Academy of Paediatrics has triggered a furor, because there is little long-term data on the risks and benefits of the recommended drugs, statins, in children, and no evidence that the drugs can prevent heart attacks when they are adults.
But the number of obese and overweight children is soaring on both sides of the Atlantic and experts in the UK, who are already treating small numbers of very high-risk children with statins, say it is time wider use of the drugs was discussed.
Most doctors agree that the use of statins for some children whose genetic inheritance puts them seriously at risk of a fatal heart attack in their 20s or 30s is justified.
The UK's National Institute for Healthcare and Clinical Excellence (NICE) wants statins to be given after the age of 10 to the one in 500 children who have the FH ("familial hypercholesterolaemia") gene with a high risk of heart disease.
The American academy, however, is taking it further. It wants cholesterol screening for all children with a family history of high cholesterol or heart disease; for children whose family history is unknown; and for those with obesity, high blood pressure or diabetes between the ages of 2 and 10. Statins should be considered, it says, if any of those over the age of 8 have particularly high cholesterol levels.
The academy also says reduced-fat milk should be given to babies in whom obesity or overweight condition is considered a problem by the age of 12 months.
"We are in an epidemic," says Jatinder Bhatia, a member of the academy's nutrition committee, which made the recommendation, and professor and chief of neonatology at the Medical College of Georgia in Augusta. "The risk of giving statins at a lower age is less than the benefit you're going to get out of it."
But a number of doctors in the US have expressed strong reservations about giving drugs to children whose most urgent need is to get more exercise and eat a more healthy diet.
"Where are the data that show this is helpful in preventing heart attacks?" says Darshak Sanghavi, a paediatric cardiologist and assistant professor at the University of Massachusetts Medical School.
"How many heart attacks do we hope to prevent this way? There's no data regarding that."
Others express concern at the public health message the prescription of pills to overweight children might give, but experts in the UK say that statins are already being given to children as young as 6 who have the FH gene and that discussion of their use is welcome.
Chris Hendriksz, consultant in inherited metabolic disorders at Birmingham Children's Hospital, accepts the US guidelines are controversial but agrees with them.
"I lost an 8-year-old with hypercholesterolaemia about 15 years ago," he says. "I could never believe it could happen that early. Things like that change your view."
Hendriksz says the FH gene might not be the only genetic reason that some fathers die of a heart attack at 25 or 30. In his clinic, about a third of the children are, indeed, on statins but two-thirds on diet and lifestyle modifications only.
George Rylance, of the UK's Royal College of Paediatrics and Child Health, says he would expect the public to be worried if the college produced a statement like that of the US academy, but he welcomes their recommendation - "not only the text, but the debate it engenders", he says.
He also feels the FH gene is not the only reason why children should be prescribed statins to keep their cholesterol down. "We see families all the time where people are dying of coronary artery disease and they may not have a gene we recognize," he says.
Cathy Ross, a cardiac nurse with the British Heart Foundation, says that it is important to be sure there is a genetic component to the high cholesterol reading. "We should always eliminate other possible reasons, like a child's diet and lack of activity and weight in proportion to their height," she says.
Ross stresses parents should first be counseled on diet and exercise, adding: "You don't give an adult statins without implementing lifestyle interventions."
(China Daily 07/23/2008 page19)
