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The purpose of this study was to determine whether cholesterol screening and nutritional counseling can reduce cholesterol concentrations in populations of otherwise unrecognized hypercholesterolemic children. A large pediatric practice in Parma Heights, Ohio, has conducted cholesterol surveillance of children over 2 years of age since 1986. The importance of cholesterol and other recognized risk factors for the progression of atherosclerosis is discussed with all families, and the American Heart Association's Step-One diet is recommended. The present study examines data from a cohort of 894 children (473 boys, 421 girls) who had cholesterol concentrations above 185 mg/dL (4.79 mmol/L) (the 90th percentile) at baseline and, after counseling, had a repeat measurement an average of 2.2 years later. Their mean ages were 7 years at the first testing and 9.2 years at the second. Children who had cholesterol concentrations above 200 mg/dL (5.18 mmol/L) (the 95th percentile) had lipoprotein profiles done, and if their LDL cholesterol exceeded 130 mg/dL (3.37 mmol/L) (the 95th percentile), they were referred to a nutritionist, and family members were advised to have their blood lipids analyzed.Mean cholesterol concentration for all 894 children over this time period decreased by 9.4% (19.5 mg/dL [0.51 mmol/L]; 95% CI = 17.5 mg/dL [0.45 mmol/L] to 21.5 mg/dL [0.56 mmol/L]; P

A 10-day course of amoxicillin at a dosage of 40 mg per kilogram per day was compared with conventional (lower dosage) penicillin V therapy in the treatment of culture-proven Group A streptococcal pharyngitis in children 3 to 18 years of age in a prospective, randomized, and singleblinded study. Children had to have signs and symptoms compatible with the diagnosis of streptococcal pharyngitis and to have a throat swab positive for Group A streptococci. A second throat culture was obtained 10 to 14 days after the completion of therapy. Serotyping was performed to help differentiate carrier states from reinfections. Of 161 children enrolled, 113 were evaluable; 55 received penicillin and 58 received amoxicillin. At the completion of therapy 70.9% (39/55) of patients in the penicillin group vs 87.9% (51/58) of patients in the amoxicillin group were asymptomatic (clinical cure, P=0.025). At the completion of therapy, 54.5% (30/55) of patients in the penicillin group vs 79.3% (46/58) of patients in the amoxicillin group had negative throat cultures (bacteriologic cure, P=0.005). The carrier rate (children who were well but who were still carrying the same serotype of Group A streptococcus) also differed betweent the groups: 13 (23.6%) in the penicillin group compared with six (10.3%) in the amoxicillin group. Amoxicillin at 40 mg/kg/day was significantly more effective than lower dosages of penicillin V for clinical and bacteriologic cure in the treatment of Group A streptococcal pharyngitis in children. The current perception that penicillin is declining in effectiveness may be due to inadequate dosing.

• Atherosclerosis is a process that begins in early life. Coronary heart disease is the result of complex interactions among a variety of risk factors of which hypercholesterolemia is but one. During routine screening, 500 children were identified with total cholesterol levels above the 95th percentile of 5.2 mmol/L (200 mg/dL). Lipoprotein profiles were then performed to confirm and delineate their lipid abnormalities. A definable lipid disorder was present in 85% of such children. Abnormal lipoprotein patterns included 292 children with type IIa, 99 with type IIb, and 25 with type IV phenotypes. An abnormally low high-density lipoprotein cholesterol level of less than 0.9 mmol/L (35 mg/dL) was observed in 20 children. Only 5% of patients were identified as being hypercholesterolemic because they had high-density lipoprotein cholesterol levels above the 95th percentile of 1.8 mmol/L (70 mg/dL). Thirty-two percent of children with total cholesterol levels above 5.2 mmol/L had a family member (sibling, parent, uncle, aunt, or grandparent) with a myocardial infarction prior to 55 years of age. Data from this study support universal cholesterol testing after 3 years of age and lipoprotein profiles for those with levels above 5.2 mmol/L. ( AJDC . 1991;145:147–150)

Considerable preventive medicine and anticipatory guidance can be pro¬vided for the family of a woman found to have hyperlipidemia. Precise etiological diagnosis of her lipid disorder enables the physician to give diet¬ary advice and, when appropriate, genetic counseling. For the sake of this discussion, it is assumed that hypercholesterolemia is secondary to either dietary excess or genetic factors and that other causes such as liver or kid¬ney disease, medications, or endocrine disorders, have been excluded. The purpose of this chapter is to discuss cholesterol surveillance and dietary advice for infants and children, the incidence of genetic dyslipidemias, and treatment issues for childhood hypercholesterolemia.

Several studies have documented that hypercholesterolemia is common in American children. Other studies have shown that elevated cholesterol levels in childhood remain elevated well into adult life. Autopsy studies of adolescents have also found a strong positive correlation between antemortem cholesterol levels and early atherosclerotic changes in their aortas and coronary arteries. Collectively, these studies provide strong and consistent evidence that atherosclerosis begins in childhood. The evidence is also overwhelming that lowering elevated low density lipoprotein cholesterol levels reduces the risk of heart attacks caused by coronary heart disease, at least among middle-aged men. As a result, routine cholesterol and coronary heart disease risk factor surveillance in childhood is both productive and appropriate. Premature coronary heart disease may be largely preventable and atherosclerosis, if not preventable, can be significantly delayed.

In Reply.— Dr Robertson is concerned about cholesterol screening in childhood as it relates to changing the diet of American children and subjecting a large number of children to pharmacotherapy for hypercholesterolemia. He raises several questions regarding the cost of a cholesterol screening program and whether or not there is evidence that dietary therapy (or drug therapy) will really make a difference as far as future coronary artery disease is concerned. The purpose of the cholesterol screening program was to identify children with hypercholesterolemia and to discuss with their families the various coronary risk factors which are recognized as important for future coronary artery disease.

In Reply.— Dr Feldman objects to the recommendation that all children have a cholesterol screening test, citing issues of parental anxiety, cost, and the absence of controlled clinical trials to prove the efficacy of reducing cholesterol levels in reducing all-cause mortality. The authors feel that informing parents that it is unhealthy for children to consume an excess of cholesterol and saturated fat is at least as appropriate as informing them that smoking, physical inactivity, and obesity are unhealthy.

In Reply.— Dr Dennison points out the complexity of the issue of pediatric cholesterol screening. The total cholesterol value of 200 mg/dL is the 95th percentile for children according to the lipid research clinic's population data book. The adult screening strategy was not extrapolated to the pediatric population; we simply felt that children whose total cholesterol exceeded 200 mg/dL should have a lipid profile to verify the finding and possibly to help define the lipid abnormality.

ALTHOUGH cervical lymphadenitis is a frequent finding in the pediatric age group there is little information concerning this abnormality in standard textbooks, particularly regarding its pathogenesis. The relative frequency with which the various causative agents may produce adenitis has not been well established. Tuberculous cervical lymphadenitis1 2 3 and scrofula caused by the atypical mycobacteria4 5 6 7 have been described in detail. Cat-scratch disease has also received widespread attention as a cause of regional adenitis.8 Adamson9 found a relatively high incidence of Group A streptococci in cervical lymph nodes of children in bacteriologic studies of post-mortem specimens, and cervical lymphadenitis is a frequent finding . . .

A PECULIAR facies suggesting kinship has been found in some nonfamilial cases of supravalvular aortic stenosis in childhood.1 2 3 4 5 In addition, it has been recognized that infants with idiopathic hypercalcemia have a rather characteristic "elfin" facial appearance. Recently described are a group of older children with "aortic stenosis" and an "elfin" fades. An illness during infancy in each patient was suggestive of idiopathic hypercalcemia.2 Their facies appeared identical to those of patients with supravalvular aortic stenosis described by others.1 , 3 , 4 It seems unlikely that this remarkable similarity is coincidental. Although an association between idiopathic hypercalcemia and supravalvular aortic stenosis has been alluded . . .