As we treat pediatric patients, it is important for us to keep in mind that the reduction of risk factors and risk behaviors during childhood can delay the development of atherosclerosis. Resources such as the Summary Report, which is prepared by a panel of experts assembled by the National Heart Lung and Blood Institute, address the importance of cardiovascular health in our pediatric population. The Expert Panel focused on the goals of 1) prevention of risk factor development and 2) prevention of future cardiovascular disease by effective management of identified risk factors. Its conclusion is based on the premise that atherosclerosis begins in childhood and that its "extent is linked directly to the presence and intensity of known risk factors."
Premature atherosclerosis often stems from "clustering" of multiple risk factors. When multiple risk factors are present, there is a strong association with the accelerated development of atherosclerosis. One such combination we often see is tobacco use with one additional risk factor. Current studies demonstrate that childhood obesity has the same associations with obesity-related risk factor clustering as we see in adults. This information calls attention to the obesity epidemic and its relationship to future cardiovascular disease and diabetes.
One of the main risk factors we often encounter is tobacco exposure. The Expert Panel points out that since nicotine is highly addictive for children, it is possible for them to develop dependence on tobacco after only brief intermittent use. As healthcare providers, we are in the position to identify and inform our patients about adverse effects, and to guide a process that aids in cessation efforts. Primarily, this would be providing education and resources to the patients and their caregivers. Although tobacco-cessation pharmacotherapy is available for adults, such as with products like Chantix, Wellbutrin, or Zyban, there are no established safety and efficacy standards for resorting to the use of these drugs in pediatric patients. As such, any decision we make must be on an individualized basis. We should focus on counseling and support as vital parts of treatment, as well as stressing the importance to adult caregivers to act as tobacco-free role models, since secondhand smoke is a risk factor for children and fetuses.
Studies have shown a distinct correlation between lipid disorders and the onset and severity of atherosclerosis in children, adolescents, and young adults. Since dyslipidemias place children at increased risk for accelerated, early-onset atherosclerosis, evaluation should include thorough assessment of serum lipids and lipoproteins. The Expert Panel assembled a series of recommendations to assist in this assessment, which can be found on pages 38 through 58 of the summary. Of particular note are the age-specific recommendations for lipid assessment outlined in Table 9-5, specific management approaches for children with identified dyslipidemia in Figures 9-1 and 9-2, and the definitions of the risk factors and special risk conditions in Tables 9-6 and 9-7. It is important to focus on diet and physical activity as the initial approach for managing dyslipidemia in pediatric patients. For cases where we need to propose pharmacotherapy, the summary provides detailed information regarding the associated recommendations, such as guidelines for using statins, such as Lovastatin.
Since a classification of overweight or obese has such a strong association with most of the other established risk factors for cardiovascular disease, the correlation with atherosclerosis is even more prominent. Having a higher BMI during childhood can mean having an increased risk for coronary heart disease later in life. Table 10-1 of the summary points out detailed recommendations for managing overweight and obese pediatric patients. Obesity-related risk factors for pediatric patients can be lessened by improving weight status and decreasing overall body fat. When behavioral changes do not accomplish necessary goals, certain pharmacotherapy options may be introduced. For example, Xenical, in conjunction with a reduced calorie diet, is approved by the FDA for weight loss in pediatric patients age 12 years and older.
Children who have type 1 or type 2 diabetes have a greatly increased risk for accelerated atherosclerosis and early cardiovascular disease, and therefore it is of vital importance to identify these cases among our pediatric patients. We can refer to the screening algorithm from the American Diabetes Association to make assessments, which the summary includes in Table 11–1. Management of children and adolescents with diabetes and other predisposing conditions is an increasing need, due to the prevalence of vascular disease in children with type 2 diabetes. The summary addresses the categories of vascular dysfunction in children with human immunodeficiency virus infection and nephrotic syndrome, and outlines therapy goals in Figure 11–1 and in Tables 11–2 and 11–3. In some cases, treatment options may include pharmacotherapy, such as Glucophage XR, which is currently approved by the FDA for pediatric patients who are over 10 years old and who have type 2 diabetes.
PDR Network’s alerts and specific product labeling can be extremely useful when treating pediatric patients, since information regarding the potential risks of pharmacotherapy is necessary in order to balance against the clinical need. Keep current with information on products by using PDR.net. If you use an electronic health record (EHR), please ensure that it includes the PDR drug data feeds, including PDR BRIEF, which delivers updated drug information, full labeling, and safety warnings integrated into your electronic prescribing system. Drug information in EHRs is often months out of date, which is why PDR BRIEF is available at no cost to providers and EHR vendors.
Salvatore Volpe, MD, FAAP, FACP, CHCQM
Chief Medical Officer
National Heart Lung and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report. NIH Publication No. 12-7486A, October 2012.