American Academy of Pediatrics (AAP) position statement, ”Lipid screening and cardiovascular disease in children”

by Ellyn Satter, Registered Dietitian and Family Therapist

To prevent heart disease, preserve your child’s positive eating attitudes and behaviors by following the division of responsibility in feeding, having regular and reliable family meals, and including a variety of high-fat and other foods. If your child is in the very-high-risk category for cardiovascular disease, follow the same feeding recommendations and consult with an RD about food selection. But be careful. No child ever ate according to a formula, and parents who try to impose such a formula condemn themselves and their child to stress and conflict around feeding. 

The AAP recommendations

Here are the recommendations from the American Academy of Pediatrics (AAP) position statement, ”Lipid screening and cardiovascular disease in childhood.”¹ 

1. All children over age 2 years follow a diet based on the Dietary Guidelines, including use of low-fat dairy products.
2. Children as young as 2 years who have risk factors for heart disease or whose family medical history is not known be screened for high total cholesterol, LDL, HDL, and triglycerides.
3. Children whose lipid levels are above the 75th percentile for age be referred for nutrition counseling in a diet that is, essentially, the Dietary Guidelines.
4. The very few children 8 or older with very high concentrations of LDL, way above the 95th percentile, be considered for statin treatment to drive levels below 160.¹

No child ever ate according to a formula 

Preserving your child’s positive eating attitudes and behaviors will do more for him in the long run than trying to impose a formula on his eating.

If your child has a particularly high risk of heart disease, and if you and your doctor have determined that he needs a special diet, I agree with the AAP recommendation that you get careful and informed dietary guidance from a registered dietitian to avoid nutritional deficiencies and poor growth. It is best if that guidance includes the feeding strategies below. Fortunately, very few children are in the very-high-risk category. For the rest, my objection to the AAP statement is the naiveté that attends laying out arbitrary guidelines for what and how much children should eat. No child ever ate according to a formula, and parents who try to impose a formula condemn themselves and their child to stress and conflict around feeding.

Pediatricians point to lack of studies on statins for children

The statin recommendation has provoked many pediatricians to complain that there is no proof that medicating children will prevent heart attacks in adults and that potential side effects of decades-long statin medication are unknown. I find myself in the surprising position of supporting the policy-makers. Target children have LDLs way above the 95th percentile,190 milligrams per deciliter or higher. Those children have inherited a tendency to errors in fat metabolism, called familial hyperlipidemia, and have a high risk of premature cardiovascular disease. The someone-we-know who died of a heart attack at age 30 was probably a victim of familial hyperlipidemia. It is a scary process, and if I were asked to make preventive-care recommendations for those children, I genuinely don’t know what I would say. 

Helping without harming with heart disease prevention

These meal-management strategies will allow both you and your child to automatically consume a balanced, moderate-fat, low-saturated-fat diet and preserve his positive eating attitudes and behaviors.^2,3 Don’t try  to restrict fat. It is not only impractical, it is irresponsible. Children depend on dietary fat to get the fatty acids they need for nerve development, to make their food taste good, and to get the concentrated calories they need to compensate for their small stomachs and high energy needs.

• Don’t try to force your child’s fat intake below 35%.
• Instead, follow the division of responsibility in feeding and have regular and reliable family meals with choices from the five food groups: meat and other proteins, breads and cereals, fruits and vegetables, milk and other full-fat dairy products, and fats and spreads such as butter and salad dressing.
• Set your child up to regulate his own fat intake by having meals with some foods that are low in fat and some high and letting him self-select fat-containing foods. Whole milk is an appropriate high-fat food throughout the growing-up years.
• Vary fat sources by choosing monounsaturated, polyunsaturated, and saturated fats.
• Allow your child to eat what and how much he wants from what you put before him.
• Enjoy your own food.