1/14/2013 Pediatric Cardiovascular Disease and the Future of our Children Linda Alwine FNP-BC Objectives Identify the prevalence and epidemiology of h

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1 Pediatric Cardiovascular Disease and the Future of our Children Linda Alwine FNP-BC Objectives Identify the prevalence and epidemiology of hyperlipidemia. Identify risk factors that lead to the development of pediatric hyperlipidemia and cardiac disease Verbalize an understanding of treatment methods and approach to caring for children with the risk of developing cardiac disease Verbalize an understanding of the NP role in primary prevention if childhood hyperlipidemia and cardiovascular disease. 1

2 Prevalence and Epidemiology In a study conducted by the National Health and Nutrition Examination Survey ( NHANES) from : Prevalence of dyslipidemia was higher in adolescents with greater body mass index ( 85 th -95 th percentile) Numbers increased from 14.2 % % Source (Ferranti, S & Newberger, J ( 2012) Definition and screening for dyslipidemia in children ) So what does this mean? Defining the numbers Total cholesterol- <170 Low density lipoprotein-<110 Non-HDL HDL-C <120 Triglycerides-(children 0-9 years) <75 Triglycerides- (adolescents years) <90 HDL-C <45 2

3 Risk factors: Obesity Smoking Familial history of premature coronary artery disease in a first degree relative Familial history of Hyperlipidemia Inactivity Poor diet Risk factors continued: Hypertension High risk Diseases ( diabetes type 1 &2, chronic renal issues,) What do we do? Lipid screening- Look at family history- Recommended age for first screening is 9-11 years old before puberty because this is a stable time for lipid assessment for children. ( Ferranti, S & Newberger J (2012) Definition and screening for dyslipidemia in children) Second Screening performed around years of age after most individuals reach puberty as to avoid changes in HDL-C and LDL-C that occur during puberty and growth. 3

4 What can we do? Children with one or more known atherosclerotic risk factors or with an underlying primary disease associated with the increased risk if CVD should be screened as early as 2 years of age. Which test May use fasting lipid profiles or non fasting non HDL for universal screening in children. Which test? In children without any known risk factors for CVD a Non HDL-C testing is the preferred method. a. Non- HDL includes all cholesterol l present in lipoprotein particles that are considered atherogenic including LDL-C, lipoprotein (a), intermediate density lipoprotein,, and very low density lipoprotein. 4

5 Selective screening For Children that fall under the following criteria, ( family hx of CVD, known dyslipidemia or TC >240, tobacco smoke exposure, HTN, Elevated BMI) a fasting lipid profile is recommended. If the Non HDL-C test is abnormal the National Heart Lung and blood institute recommends that fasting lipid profiles be measured at least twice at intervals between two weeks and three months. Controversy in Screening Universal screening should not be performed on children because there is limited benefits to screening and this is uncertain. There is a lack of evidence that t universal screening and therapy in children to prevent early CVD reduces this risk factor. The use of statins in children carries the risk of rhabdomyolysis. Treatment Thorough History! Physical exam Fasting Lipid panel Non HDL-C if patient does not fit the screening criteria. 5

6 Prevention and education Promotion of a healthy lifestyle Good Nutrition ( keep in mind cultural differences!) a. Breastfeeding first 6 months of life. b. Total fat intake limited to 30 percent of calories. Dietary cholesterol less than 300 mg per day. Fat intake should not be limited in infants younger than 12 months of age unless medically necessary. Increased intake of fruits and vegetables. Yes, there is a pediatric version of the DASH diet. Reduce intake of sugar. The only vitamin supplementation is Vitamin D ( 400 IU per day) Prevention and Education Physical activity- Vigorous activity for at least 60 minutes a day) Avoid smoke exposure Encourage routine child check-ups. Pediatric Food Pyramid Type: JPG Images may be subject to copyright. 6

7 Pediatric Food Groups The Five Food Groups for Kids What Do Kids Need, and How Much? Kids need to eat a wide variety of foods to get the nutrients essential to their health. A good rule of thumb is to make sure every meal contains at least three of the five food groups, and every snack contains at least two groups. Knowing your way around the five groups is a great way to be sure you re making the most of every meal and snack. The Five Food Groups: Recommended Daily Servings for Children1 2 to 3 Years*4 to 8 Years*9 to 13 Years*Food Choices2Grains (oz)34 (girls) 5 (boys)5 (girls) 6 (boys)1 slice of bread, 1 cup of ready-to-eat cereal, or 1/2 cup of cooked rice, cooked pasta, or cooked cereal = 1 ounce Vegetables (c)11 (girls) 1-1/2 (boys)2 (girls) 2-1/2 (boys)1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw leafy greens = 1 cup Fruits (c)11-1/21-1/21 cup of fruit or 100% fruit juice, or 1/2 cup of dried fruit = 1 cup Milk/Dairy (c)2231 cup of milk or yogurt, 1-1/2 ounces of natural cheese, or 2 ounces of processed cheese = 1 cup Meat/Beans (oz)23 (girls) 4 (boys)51 ounce of meat, poultry, or fish, 1/4 cup cooked dry beans, 1 egg, 1 tablespoon of peanut butter, or 1/2 ounce of nuts or seeds = 1 ounce Medication??? The American Academy of Pediatrics recommends pharmacologic intervention in patients lees than 8 years old only when the have persistent LDL concentrations of 500 mg or greater. This is usually a familial issue. For patients greater than 8 years of age Medication Recommended treatment options include bile-acid sequestrants and statins. Statin use is limited to the children who have the familial history ( homozygous gene for high cholesterol) The following drugs were studied for use in children: Pravastatin, Simvastatin, Atorvastatin, and Rosuvavstatin. 7

8 Doses: Pravastatin: Children mg once daily, adolescents years- 40 mg po once daily, adolescents >18 years 40 mg po once daily. Heterozygous familial hyperlipidemia- children years 10 mg po once daily. Rosuvastatin: ( heterozygous familial hyperlipidemia)5-20 mg ( max dose is 20 mg may need to adjust at intervals usually 4 weeks) May need to consider lower dose with populations that are predisposed to myopathy ) ie Asian cultures) Doses: Simvastatin: heterozygous familial hypercholesteremia years of age 10 mg po once daily. Increase dose intervals of 4 weeks or more to max of 40 mg gp per day. Hyperlipidemia- children less than 10 years old 5 mg po in the evening increase to 10 mg po once daily after 4 weeks then to 20 mg once daily after 8 weeks. Children >10 10 mg po once daily in evening, increase to 20 mg po after 6 weeks then 40 mg po once daily after 12 weeks. Doses:Bile Acid Sequestrants Not usually recommended due to side effects of constipation and bloating. Usually poor compliance results. 8

9 Case Studies An 8 year old male presents to your office with his mother. History of family illnesses includes CVD, HTN and diabetes. Mom says she just cant seem to get her child to slim done. She reports that he eats pop-tarts for breakfast, Chicken mcnuggets for lunch,and at night because mom and dad both work, Kentucky fried chicken is usually a popular food item Vital signs: 130/80 pulse 72 Resp14. height is 4 ft 11 inches weight is 160 lbs. What would you do with this situation? Case Studies: 4 year old Ricardo presents with his mother at a well child check. Knowing that Ricardo s family is from Mexico their diet is rich in tortillas, beans, fruits and vegetables. Ricardo s mother reports that he seems to be gaining weight. He is 4 years old is 39 inches tall and weighs 55 pounds. There is a family history of diabetes. What other information do you need? Summary: Pediatric obesity is becoming an epidemic. We need to educate and identify children at risk. Testing is reserved for those with familial history of CVD, diabetes, smoke exposure and Hypertension. Begin with changes in lifestyle for these children Be proactive! Medication should only be used for those who have the heterozygous gene for high cholesterol. 9

10 Questions? Bibliography Ferranti, S & Newburger, J ( Oct.2012) Definition and screening for dyslipidemia in children. Ferranti, S & Newberger,J ( Oct. 2012) Management of pediatric dyslipidemia. Ferranti, S & Newberger,J ( Oct. 2012) Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children. Elland, L & Lutrell P.( July 2010 ) Use of statins for dyslipidemia in the pediatric population Journal of Pediatric Pharmacology July- Sept 15 (3) Uptodate: 2012 www. Uptodate.com Pediatric Food Pyramid. (2013) Five Food Groups for Kids ( 2013) 10