| HOME | HELP | E-MAIL ALERTS | SEARCH |
|
PEDIATRICS Vol. 101 No. 1 January 1998, pp. 141-147
 |
ABSTRACT |
|---|
Top
Abstract
Introduction
Conclusion
References
|
|---|
This updated statement reviews the scientific justification for the recommendations of dietary changes in all healthy children (a population approach) and a strategy to identify and treat children who are at highest risk for the development of accelerated atherosclerosis in early adult life (an individualized approach). Although the precise fraction of risk for future coronary heart disease conveyed by elevated cholesterol levels in childhood is unknown, clear epidemiologic and experimental evidence indicates that the risk is significant. Diet changes that lower fat, saturated fat, and cholesterol intake in children and adolescents can be applied safely and acceptably, resulting in improved plasma lipid profiles that, if carried into adult life, have the potential to reduce atherosclerotic vascular disease.
Although the focus of this statement by the Committee on
Nutrition is on cholesterol levels in children, other risk factors for
atherosclerosis originate in childhood and should be addressed with
equal attention. Specifically, smoking should be discouraged, hypertension should be identified and treated, obesity should be
avoided and reduced, regular exercise should be encouraged, and
diabetes mellitus should be identified and treated.1
This statement, for the most part, is in concert with statements of
other experts and expert panels, including the National Cholesterol
Education Program, the American Heart Association's Council on
Cardiovascular Disease in the Young and Committee on Nutrition, the US
Department of Agriculture and the US Department of Health and Human
Services Dietary Guidelines for Americans, the US Surgeon General, the
National Research Council, and the National Cancer Institute.
Studies in animals have demonstrated that high blood cholesterol
levels promote atherosclerosis.2-4 Atherosclerosis
develops in many species fed diets that raise the total and low-density lipoprotein (LDL)-cholesterol levels. Vascular fatty streaks and fibrous plaques develop in adolescent nonhuman primates fed diets high
in saturated fatty acids and cholesterol.5,6 In monkeys with severe atherosclerosis, regression of the process occurs when the
blood cholesterol level is lowered with diet and
drugs.2,7,8
In adults, the major nutritional determinant of differences in serum
cholesterol levels between countries appears to be the proportion of
saturated fat in the diet.9-11 This also is observed in
childhood populations.11-13 Total blood cholesterol levels
in children vary geographically. In countries such as the Philippines, Italy, and Ghana, saturated fat constitutes approximately Clinical trials in adult populations have shown that lowering
cholesterol levels reduces coronary risk.2,24-26
Aggregate analysis of many clinical trials shows that lowering
cholesterol levels by diet or drugs and by primary or secondary
prevention reduces fatal and nonfatal myocardial
infarction.27 Initially, some controversy occurred about
the effectiveness of lowering cholesterol levels because a number of
trials did not find a significant reduction in total mortality after
treatment to lower the cholesterol level.2 These findings
have been clarified recently by several studies with large samples of
subjects and of long duration showing a decrease not only in the
incidence of coronary heart disease but also in mortality from all
causes.28,29
In addition, the Dietary Intervention Study in Children, a recent study
of the safety and efficacy of lower fat diets in pubertal children, was
reported by a collaborative multicenter group. In this study of 663 children 8 to 10 years of age who were followed for 3 years, an
intervention group receiving a diet with 28% of calories from total
fat, ~10% of calories from saturated fat, and 95 mg per day of
cholesterol was compared with a group that consumed 33% to 34% of
calories as total fat, 12.7% of calories as saturated fat, and 112 mg
per day of cholesterol. There were no differences in height, weight, or
serum ferritin levels in the two groups, and the intervention group had
significant, but modestly lower, levels of LDL-cholesterol levels and
maintained psychologic well-being.30
High blood cholesterol levels clearly play a role in the
development of premature coronary heart disease in adults. This has been established by many laboratory, clinical, pathological, and epidemiologic studies. It has also been shown that lowering blood cholesterol levels in adults results in a significant lowering of
coronary heart disease rates and mortality. Because no long-term studies of the relationship of blood cholesterol levels measured in
childhood to coronary heart disease in later life have been conducted,
the relationship of childhood cholesterol levels to the atherosclerotic
process must be inferred from less direct evidence.
These lines of evidence are summarized as follows:
INTRODUCTION
Top
Abstract
Introduction
Conclusion
References
DIET AND ATHEROSCLEROSIS
10% dietary intake, and the serum cholesterol level in boys 8 to 9 years of
age is generally below 160 mg/dL.13-15 In boys from
countries such as the Netherlands, Finland, and the United States, the
saturated fat intake varies from 13.5% to 17.7% of energy intake, and
serum cholesterol levels are generally >160 mg/dL. Although blood
cholesterol levels are lowest in countries in which nutrition is not
optimal and growth is delayed, there are many industrialized countries in which children have lower cholesterol levels than children in the
United States and in which normal growth is maintained (eg, Portugal,
Israel, and Italy). A range of serum cholesterol levels is found in
industrialized countries, with the United States in the top half of the
range.13,15-23
CLINICAL TRIALS
SIGNIFICANCE OF BLOOD CHOLESTEROL LEVELS IN CHILDREN AND
ADOLESCENTS
| |
STRATEGIES TO LOWER CHOLESTEROL LEVELS IN CHILDREN AND ADOLESCENTS |
|---|
To lower blood cholesterol levels in children and adolescents, two complementary approaches are recommended: a population approach and an individualized approach.
The Population Approach
The population approach is designed as the primary means for preventing coronary heart disease. It aims to lower the average level of blood cholesterol in all children and adolescents through population-wide changes in nutrient intake and eating patterns. These recommendations are directed to groups that influence the eating patterns of children and adolescents, including schools, health professionals, government agencies, the food industry, and the mass media. The advantage of this approach is that even a small reduction of the mean total and LDL-cholesterol levels in children and adolescents, if carried into adult life, could decrease substantially the incidence of coronary heart disease.
The US Department of Agriculture 1987 to 1988 Food Consumption Survey indicated that children and adolescents consume 35% to 36% of calories from total fat; 14% from saturated fat, and 193 to 296 mg per day of cholesterol.47,48 More recent US population-based data from the National Health and Nutrition Examination Survey III for persons 2 to 19 years of age indicate that mean intakes of total fat and saturated fat are 34% and 12%, respectively, and the mean cholesterol intake is ~270 mg per day.49
Nutrient Recommendations
No restriction of fat or cholesterol is recommended for
infants <2 years when rapid growth and development require high
energy intakes. A precise percentage of dietary intake from fat that supports normal growth and development while maximally reducing atherosclerosis risk is unknown. Therefore, a range of appropriate values, averaged over several days for a child or adolescent, is
recommended based on the scientific information available. Because
concerns have been expressed that some parents and their children may
overinterpret the need to restrict their fat intakes, a lower limit of
fat intake is suggested by this Committee. The Committee recognizes
that children 2 to 5 years of age are selective in their food choices.
After 2 years of age, children and adolescents should gradually adopt a
diet that, by ~5 years of age, contains 30% of calories
and 20% from fat. As they begin to consume fewer calories from
fat, children should replace these calories by eating more grain
products, fruits, vegetables, low-fat milk products or other
calcium-rich foods, beans, lean meat, poultry, fish, or other
protein-rich foods. These recommendations are for average intakes over
several days, so that if foods high in total fat, saturated fat, and
cholesterol are eaten, they can be compensated for by eating less of
these nutrients at other times. Because no single food item provides
all the essential nutrients in the amounts needed, choosing a wide
variety of food from all the food groups will ensure an adequate diet.
Specific nutrient recommendations are as follows: 1) nutritional adequacy should be achieved by eating a wide variety of foods; and 2) caloric intake should be adequate to support growth and development and to reach or maintain desirable body weight.
For a child or adolescent (2 to 18 years of age), the following
pattern of nutrient intake is recommended: 1) saturated fatty acids <10% of total calories; 2) total fat over several days
of 30% of total calories and no less than 20% of total
calories; and 3) dietary cholesterol <300 mg per day.
Because saturated fatty acids raise blood cholesterol levels,50 a major emphasis should be placed on reducing saturated fat intake to <10% of calories. A sufficiently low saturated fat intake can be achieved with a total fat intake of ~30% of calories from fat. A lower fat intake is usually not necessary and, for some children and adolescents, may make it difficult to provide enough calories and minerals for optimal growth and development.
| |
THE INDIVIDUALIZED APPROACH |
|---|
The individualized approach to lowering cholesterol levels calls on the cooperative effort of health care professionals to identify and treat children and adolescents at highest risk of having high blood cholesterol levels as adults and increased risk of coronary heart disease.
Selective Screening
Figures 1 and 2 present the algorithms for selective screening.
|
|
Children and adolescents who have a family history of premature cardiovascular disease or have at least one parent with a high blood cholesterol level are at increased risk of having high blood cholesterol levels as adults and increased risk of coronary heart disease and, therefore, are recommended for selective screening in the context of regular health care. This focus is supported by strong evidence of familial aggregation of coronary heart disease, high blood cholesterol levels, and other risk factors.
The following are specific recommendations for selective screening of children and adolescents in the context of their continuing health care.
55 years of age, underwent diagnostic coronary
arteriography and were found to have coronary atherosclerosis. This
includes those who have undergone balloon angioplasty or coronary
artery bypass surgery.
55 years of age, had a documented myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease,
or sudden cardiac death.
Optional cholesterol testing by practicing physicians may be appropriate for children who are judged to be at higher risk for coronary heart disease independent of family history (Table 1). For example, adolescents who smoke, consume excessive amounts of saturated fats and cholesterol, or are overweight may also be tested at the discretion of their physician. For parents who do not know their cholesterol levels, pediatricians should strongly encourage them to have their levels measured.
|
What Should Be Measured
The focus of the individualized approach is to detect and treat the child or adolescent with hypercholesterolemia whose elevated LDL-cholesterol level is likely to indicate increased risk in adulthood. The screening protocol varies according to the reason for testing. This protocol is suggested to limit the need for more sophisticated analyses. If screening is performed because a parent has a cholesterol higher than 240 mg/dL, the initial test should be a measurement of total cholesterol. If the child's level is higher than 200 mg/dL, a fasting lipoprotein analysis should be obtained to measure HDL-cholesterol and LDL-cholesterol levels. If the total cholesterol is borderline (170 to 199 mg/dL), a second measurement should be obtained and averaged with the first result. If the average is borderline or high, a fasting lipoprotein analysis should be obtained.
If the patient is being tested because of a documented family history of premature cardiovascular disease, the initial test should be a lipoprotein analysis that requires a 12-hour fast to obtain accurate triglyceride levels, which are necessary for the computation of LDL-cholesterol levels. The acceptable borderline and high levels for total and LDL-cholesterol are given in Table 2.
|
Management
Because there is considerable variability in some children, once a lipoprotein analysis is obtained, it should be repeated so that an average LDL-cholesterol level can be calculated. The average LDL-cholesterol level determines the steps for risk assessment and treatment. Follow-up of the averaged LDL-cholesterol determinations is as follows:
1. Acceptable LDL-cholesterol level (<110
mg/dL)
Provide education on the eating pattern recommended for all
children and adolescents and on other risk factors; repeat lipoprotein
analysis in 5 years.
2. Borderline LDL-cholesterol (110 to 129 mg/dL)Provide advice about risk factors for cardiovascular
disease; initiate the American Heart Association Step-One diet and
other risk factor intervention; reevaluate in 1 year.
3. High LDL-cholesterol (
130 mg/dL)Examine for
secondary causes (thyroid, liver, and renal disorders) and familial
disorders, screen all family members, initiate Step-One diet, followed
by the Step-Two diet, if necessary.
Step-One and Step-Two Diets
The Step-One diet calls for the same nutrient intake recommended
for the population approach to lower cholesterol levels, ie, 30% and
no less than 20% of calories from total fat; <10% of total calories
from saturated fat; 10% of calories from polyunsaturated fat; and no
more than 300 mg per day of cholesterol. What makes the diet
therapeutic is prescription in a medical setting with monitoring and
follow-up by a health professional. If careful adherence to this diet
for at least 3 months does not result in a lower LDL-cholesterol level
to the acceptable range, the Step-Two diet should be prescribed. Often
children who have been determined to have high LDL-cholesterol levels
have instituted a diet similar to the Step-One diet and require
counseling to adopt the Step-Two diet.51
The Step-Two diet requires detailed assessment of current eating
patterns and instruction by a physician, registered dietitian, registered nurse, nutritionist, or other appropriately trained health
professional. It aims to induce an eating pattern that includes no more
than 30% and no less than 20% of calories from total fat; <7% of
total calories from saturated fat; 10% of calories from
polyunsaturated fat; and no more than 200 mg per day of cholesterol. This eating pattern requires careful planning to ensure adequacy of
nutrients, vitamins, and minerals, and often requires the services of a registered dietitian or other qualified nutrition professional.
Drug Therapy
Drug therapy should be considered only for children >10
years of age after an adequate trial of diet therapy (for 6 to 12 months) and whose LDL-cholesterol level remains 190 mg/dL
or whose LDL-cholesterol level remains 160 mg/dL
and there is a family history of premature cardiovascular
disease (55 years of age) or two or more other risk
factors (Table 1) are present in the child or adolescent after vigorous
attempts have been made to control these risk factors.
The recommended drugs for the treatment of hypercholesterolemia and high LDL-cholesterol levels in children are the bile acid sequestrants cholestyramine and colestipol, which bind bile acids in the intestinal lumen. They have documented efficacy, relative freedom from adverse effects, and are apparently safe when administered to children. Other pharmacologic agents are not recommended for routine use in children and adolescents except in consultation with a lipid specialist.
| |
CONCLUSION |
|---|
|
Top
Abstract
Introduction
Conclusion
References
|
|---|
To promote lower cholesterol levels in all healthy children (2 to 18 years of age) in the United States, the following pattern of nutrient intake is recommended.
Pediatricians should identify children at highest risk for the
development of accelerated atherosclerosis by screening cholesterol levels in children who have a parental or grandparental history (55
years of age) of a documented myocardial infarction, angina pectoris,
peripheral vascular disease, cerebrovascular disease, or sudden cardiac
death, or a parent with a high blood cholesterol level (240 mg/dL).
In addition, for children and adolescents whose parental history is
unobtainable, particularly those with other risk factors, physicians
may measure cholesterol levels to determine those in need of
nutritional and medical advice.
A precise percentage of dietary intake from fat that supports normal growth and development while maximally reducing atherosclerosis risk is unknown. Therefore, a range of appropriate values, averaged over several days for a child or adolescent, is recommended based on the scientific information available.
COMMITTEE ON NUTRITION, 1996 TO 1997
William J. Klish, MD, Chair
Susan S. Baker, MD
William J. Cochran, MD
Carlos A. Flores, MD
Michael K. Georgieff, MD
Marc S. Jacobson, MD
Alan Lake, MD
LIAISON REPRESENTATIVES
Donna Blum
US Department of Agriculture
Suzanne S. Harris, PhD
International Life Sciences Institute
Van S. Hubbard, MD
National Institute of Diabetes & Digestive & Kidney Diseases
Ephraim Levin, MD
National Institute
of Child Health & Human Development
Ann Prendergast, RD,
MPH
Maternal & Child Health Bureau
Alice E. Smith, MS,
RD
American Dietetic Association
Elizabeth Yetley, PhD
Food and Drug Administration
AAP SECTION LIAISON
Ronald M. Lauer, MD
Section on Cardiology
| |
FOOTNOTES |
|---|
Material in this statement is adapted from the Report of the Expert Panel on Blood Cholesterol in Children and Adolescents of the National Cholesterol Education Program.52 It has been modified to reflect additional considerations of the Committee on Nutrition of the American Academy of Pediatrics.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
| |
ABBREVIATIONS |
|---|
LDL, low-density lipoprotein. HDL, high-density lipoprotein.
| |
REFERENCES |
|---|
|
Top
Abstract
Introduction
Conclusion
References
|
|---|
National Heart, Lung, and Blood Institute Collaborative Lipid Group
Trends in serum cholesterol levels among US adults aged 20 to 74 years: data from the National Health and Nutrition Examination Surveys, 1960 to 1980.
JAMA.
1987;
257:937-942 [Abstract] The following policy statement is a revision:
Statement of retirement:
This article has been cited by other articles:
 |
|
 |
|
  A. D. Flouris, B. E. Faught, and P. Klentrou Cardiovascular disease risk in adolescent smokers: evidence of a `smoker lifestyle' J Child Health Care, September 1, 2008; 12(3): 221 - 231. [Abstract] [PDF]
|
|
|
|
 |
|
 S. R. Daniels, F. R. Greer, and and the Committee on Nutrition Lipid Screening and Cardiovascular Health in Childhood Pediatrics, July 1, 2008; 122(1): 198 - 208. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Denney-Wilson, L. L. Hardy, T. Dobbins, A. D. Okely, and L. A. Baur Body Mass Index, Waist Circumference, and Chronic Disease Risk Factors in Australian Adolescents Arch Pediatr Adolesc Med, June 1, 2008; 162(6): 566 - 573. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. G. Magnussen, O. T. Raitakari, R. Thomson, M. Juonala, D. A. Patel, J. S.A. Viikari, J. Marniemi, S. R. Srinivasan, G. S. Berenson, T. Dwyer, et al. Utility of Currently Recommended Pediatric Dyslipidemia Classifications in Predicting Dyslipidemia in Adulthood: Evidence From the Childhood Determinants of Adult Health (CDAH) Study, Cardiovascular Risk in Young Finns Study, and Bogalusa Heart Study Circulation, January 1, 2008; 117(1): 32 - 42. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Velasquez-Mieyer, C. P. Neira, R. Nieto, and P. A. Cowan Review: Obesity and cardiometabolic syndrome in children Therapeutic Advances in Cardiovascular Disease, October 1, 2007; 1(1): 61 - 81. [Abstract] [PDF]
|
|
|
|
 |
|
 E. T. Rhodes, C. B. Ebbeling, A. F. Meyers, C. T. Bayerl, W. L. Ooi, M. F. Bettencourt, and D. S. Ludwig Pediatric Obesity Management: Variation by Specialty and Awareness of Guidelines Clinical Pediatrics, July 1, 2007; 46(6): 491 - 504. [Abstract] [PDF]
|
|
|
|
|
|
E. M. Haney, L. H. Huffman, C. Bougatsos, M. Freeman, R. D. Steiner, and H. D. Nelson Screening and Treatment for Lipid Disorders in Children and Adolescents: Systematic Evidence Review for the US Preventive Services Task Force Pediatrics, July 1, 2007; 120(1): e189 - e214. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. de Ferranti, D. Shapiro, R. Markowitz, E. Neufeld, N. Rifai, and H. Bernstein Nonfasting Low-Density Lipoprotein Testing: Utility for Cholesterol Screening in Pediatric Primary Care Clinical Pediatrics, June 1, 2007; 46(5): 441 - 445. [Abstract] [PDF]
|
|
|
|
 |
|
 A. D Flouris, C. H Canham, B. E Faught, and P. Klentrou Prevalence of cardiovascular disease risk in Ontario adolescents Arch. Dis. Child., June 1, 2007; 92(6): 521 - 523. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Belay, P. F. Belamarich, and C. Tom-Revzon The Use of Statins in Pediatrics: Knowledge Base, Limitations, and Future Directions Pediatrics, February 1, 2007; 119(2): 370 - 380. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. M. Kim, J. Park, H.-S. Kim, D. H. Kim, and S. H. Park Obesity and Cardiovascular Risk Factors in Korean Children and Adolescents Aged 10-18 Years from the Korean National Health and Nutrition Examination Survey, 1998 and 2001 Am. J. Epidemiol., October 15, 2006; 164(8): 787 - 793. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. G. Hoppin, E. S. Katz, L. M. Kaplan, and G. Y. Lauwers Case 31-2006 -- A 15-Year-Old Girl with Severe Obesity. N. Engl. J. Med., October 12, 2006; 355(15): 1593 - 1602. [Full Text] [PDF]
|
|
|
|
 |
|
 C. Sirikulchayanonta, P. Pavadhgul, R. Chongsuwat, and S. Srisorrachata A preliminary study of hyperlipidemia in Bangkok school children Asia Pac J Public Health, September 1, 2006; 18(3): 15 - 19. [PDF]
|
|
|
|
 |
|
 M. L. Stone, M. E. Craig, A. K. Chan, J. W. Lee, C. F. Verge, and K. C. Donaghue Natural History and Risk Factors for Microalbuminuria in Adolescents With Type 1 Diabetes: A longitudinal study. Diabetes Care, September 1, 2006; 29(9): 2072 - 2077. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. A. Friedman, J. A. Morrison, S. R. Daniels, W. F. McCarthy, and D. L. Sprecher Sensitivity and Specificity of Pediatric Lipid Determinations for Adult Lipid Status: Findings From the Princeton Lipid Research Clinics Prevalence Program Follow-up Study Pediatrics, July 1, 2006; 118(1): 165 - 172. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. R. Srinivasan, M. G. Frontini, J. Xu, and G. S. Berenson Utility of Childhood Non-High-Density Lipoprotein Cholesterol Levels in Predicting Adult Dyslipidemia and Other Cardiovascular Risks: The Bogalusa Heart Study Pediatrics, July 1, 2006; 118(1): 201 - 206. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Castro-Gago, M. I. Novo-Rodriguez, M. O. Blanco-Barca, A. Urisarri-Ruiz de Cortazar, J. Rodriguez-Garcia, S. Rodriguez-Segade, and J. Eiris-Punal Evolution of Serum Lipids and Lipoprotein (a) Levels in Epileptic Children Treated With Carbamazepine, Valproic Acid, and Phenobarbital J Child Neurol, January 1, 2006; 21(1): 48 - 53. [Abstract] [PDF]
|
|
|
|
 |
|
 J. T. Mallare, A. H. Karabell, P. Velasquez-Mieyer, S. R.S. Stender, and M. L. Christensen Current and Future Treatment of Metabolic Syndrome and Type 2 Diabetes in Children and Adolescents Diabetes Spectr, October 1, 2005; 18(4): 220 - 228. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Zhang, J. R. Hebert, and M. F. Muldoon Dietary Fat Intake Is Associated with Psychosocial and Cognitive Functioning of School-Aged Children in the United States J. Nutr., August 1, 2005; 135(8): 1967 - 1973. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. S. Boyd, J. Koenigsberg, B. Falkner, S. Gidding, and S. Hassink Effect of Obesity and High Blood Pressure on Plasma Lipid Levels in Children and Adolescents Pediatrics, August 1, 2005; 116(2): 442 - 446. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Ishinaga, A. Ueda, T. Mochizuki, S. Sugiyama, and T. Kobayashi Cholesterol Intake Is Associated with Lecithin Intake in Japanese People J. Nutr., June 1, 2005; 135(6): 1451 - 1455. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. L Braunschweig, S. Gomez, H. Liang, K. Tomey, B. Doerfler, Y. Wang, C. Beebe, and R. Lipton Obesity and risk factors for the metabolic syndrome among low-income, urban, African American schoolchildren: the rule rather than the exception? Am. J. Clinical Nutrition, May 1, 2005; 81(5): 970 - 975. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Zhang, M. F. Muldoon, R. E. McKeown, and S. P. Cuffe Association of Serum Cholesterol and History of School Suspension among School-age Children and Adolescents in the United States Am. J. Epidemiol., April 1, 2005; 161(7): 691 - 699. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Quattrin, E. Liu, N. Shaw, B. Shine, and E. Chiang Obese Children Who Are Referred to the Pediatric Endocrinologist: Characteristics and Outcome Pediatrics, February 1, 2005; 115(2): 348 - 351. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. B. Newman If It's Not Worth Doing, It's Not Worth Doing Well Pediatrics, January 1, 2005; 115(1): 196 - 196. [Full Text] [PDF]
|
|
|
|
 |
|
 W. A Prescott Jr, D.-a. D Streetman, and D. S Streetman The Potential Role of HMG-CoA Reductase Inhibitors in Pediatric Nephrotic Syndrome Ann. Pharmacother., December 1, 2004; 38(12): 2105 - 2114. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Sankar Initial treatment of epilepsy with antiepileptic drugs: Pediatric issues Neurology, November 23, 2004; 63(10_suppl_4): S30 - S39. [Abstract] [Full Text]
|
|
|
|
 |
|
 |
