Cholesterol screening and family history of vascular disease.

Hypercholesterolaemia is a major risk factor for the development of coronary heart disease (CHD). Early detection and management of hypercholesterolaemia could retard the atherosclerotic process. Given that CHD and hypercholesterolaemia cluster within families, a screening strategy based on a family history of vascular disease has been advocated. Serum total cholesterol concentrations were measured in a random stratified sample of 1012 children aged from 12-15 years old participating in a coronary risk factor surveillance study in Northern Ireland. Information about vascular disease in close family members was obtained by means of a questionnaire. The study population was divided into two groups according to total cholesterol values: (i) normal, < 5.2 mmol/l (n = 822) and (ii) raised, > or = 5.2 mmol/l (n = 190). A family history identified 63 out of 190 individuals with hypercholesterolaemia yielding a sensitivity of 33.2% and specificity of 71.5%. Our data indicated that a strategy whereby only children from high risk families are screened for hypercholesterolaemia is ineffective. While primary prevention emphasising a healthy diet for all is essential, the role of universal screening deserves further appraisal.     

Screening for familial hyper-beta-lipoproteinaemia in children in hospital.

1510 plasma cholesterol estimations were made in 1391 children admitted to hospital as part of a biochemical profile. Babies under 1 year and children known to have familial hyperlipoproteinaemia were excluded. The mean concentration was 4-28 mmol/l +/- 1-04 (1 SD) (165-3 mg/100 ml +/- 38-6), and levels exceeded 5-93 mmol/l (229 mg/100 ml) in 68 children. Repeat estimations on 55 of these children showed 34 still to have values greater than 5-93 mmol/l and family studies were performed in 19 of these. In 8 children hypercholesterolaemia was secondary and no familial lipoprotein disorder was present. Familial hyper-beta-lipoproteinaemia (FH) was diagnosed in 3 children and in 2 of the families there was a history of early ischaemic heart disease. In 2 children the diagnosis was in doubt. In the remaining 6 children FH and secondary hyperlipoproteinaemia were excluded so the hypercholesterolaemia was presumably environmentally induced, possibly in association with polygenic inheritance. In the present state of knowledge screening of the childhood population for FH by means of plasma cholesterol determinations cannot be recommended. Studies of lipoproteins should, however, be made in children from families known to have FH or early coronary heart disease.     

Pinpoint skin lesions in a familial hypercholesterolaemia homozygote

The case is reported of a 2-y-old girl referred to the outpatient lipid clinic because of a tiny cutaneous xanthoma on the dorsum of the left foot and a family history of hyperlipidaemia and coronary heart disease (CHD). Fasting serum total cholesterol levels were remarkably high (27.1 mmol l(-1), 1050 mg dl(-1)) and DNA analysis confirmed homozygous familial hypercholesterolaemia (class II mutation). Serum lipids were not affected by dietary intervention and cholestyramine treatment, so low-density lipoprotein apheresis was scheduled to commence at the age of 4 y. Conclusion: An early lipid profile determination should be performed in children with a family history of premature CHD, since the physical examination may be unremarkable even in cases of severe hyperlipidaemia during the first years of life.     

Lipid profiles in Polish adolescents from high- and low-risk families: tracking unfavourable lipid levels over a one-year period

In a country with a high cardiovascular mortality rate, lipid profiles were studied in 929 adolescents (440 from affected and 489 from non-affected families for cardiovascular disease and hypercholesterolaemia). In 334 children with elevated or borderline total cholesterol level, lipid profiles were re-measured after a 1-y period. In boys from affected families, in contrast to boys from non-affected families, significantly higher total cholesterol levels (4.36 +/- 0.81 vs 4.19 +/- 0.78 mmol/L, p < 0.05) and LDL-C level (2.1 +/- 0.72 vs 1.89 +/- 0.79 mmol/L, p < 0.05) and significantly lower HDL-cholesterol levels (1.81 +/- 0.34 vs 1.93 +/- 0.38 mmol/L, p < 0.05) were found. The odds ratio for being in the most unfavourable decile for LDL-cholesterol was significantly higher for girls from affected families (2.17, p = 0.02). A relatively high HDL-C level as well as a favourable TC/HDL-C ratio was demonstrated in all groups, being lowest in boys from affected families. A significant correlation was found between baseline lipids and their values re-measured after 1 y. It is concluded that (1) adolescents with a positive family history are at increased risk for unfavourable lipid profile, (2) adolescents with elevated total cholesterol and LDL-cholesterol levels remain hypercholesterolaemic after a 1-y period and are therefore candidates for further biochemical and clinical monitoring, and (3) children with elevated total cholesterol may not be at high risk for cardiovascular disease owing to the favourable TC/HDL-C ratio. The study results do not indicate that general cholesterol screening in Polish adolescents is necessary, as the proportion of children with elevated LDL-cholesterol is relatively low.     

Screening programme for hyperlipidemia in children and adolescents. Prophylactic aspects of atherosclerosis

Atherosclerotic cardiovascular diseases (CVD), mainly coronary heart disease (CHD) remain the leading cause of death in adult populations of many countries. The following risk factors for atherosclerosis were identified: hypercholesterolemia, hypertension, cigarette smoking and obesity. Scientific reports and epidemiological studies have shown that atherosclerosis begins in childhood. Therefore consensus was obtained that the earlier the prevention begins the better results are achieved. But there are many controversies around early identification of hypercholesterolemia in children. Three options were considered: cholesterol mass screening, selective cholesterol screening and no screening at all. The most acceptable is selective screening performed in children of high risk families (CVD or hypercholesterolemia in the family). It is recommended by the US Expert Panel for the National Cholesterol Education Program for Children and Adolescents (NCEP-Peds). According to the NCEP-Peds, screening should include the following groups: I) children whose parents or grandparents have a history of CVD (under the age of 55 years), 2) children whose parents have a raised blood cholesterol concentration (above 240 mg/dl), 3) children with negative or unknown family history, but having other risk factors (hypertension, obesity, cigarette smoking, high-fat diet). The experts recommend that the examination should be performed in children after the age of 2 years. The NCEP-Peds guidelines set total cholesterol levels in serum for children and adolescents from families at risk, below 170 mg/dl, as acceptable. Total cholesterol level between 170 and 199 mg/dl is classified as borderline and 200mg/dl and above--as high.     

Hyperlipidemia in school children with family histories of premature coronary heart disease

Children starting their schooling were given a questionnaire asking about the occurrence of premature (before 50 years of age in men, 55 years in women) coronary heart disease (CHD) in first degree relatives. 1,920 of 2,069 questionnaires were answered, 140 of the 7-year-old children were reported to have a first degree relative with premature CHD, 84 of these 140 families agreed to participate in our study. In 79 of the 84 families both the child and the parent at 'high risk' were tested. In the initial test 19 of 84 children had total cholesterol (TC) levels above the 95th percentile (greater than 5.35 mmol/l). In the repeat test 12 of the 19 TC tests remained abnormal and all 12 also had LDL-cholesterol (LDL-C) levels above the 95th percentile (greater than 3.40 mmol/l). None had abnormal HDL-cholesterol or triglyceride levels. Among the high risk parents, 12 of 79 had abnormal initial blood lipid tests. In the repeat test 10 parents had both TC and LDL-C levels above the 95th percentile. In five families both the child and the parent had abnormal TC and LDL-C levels. In conclusion, a considerable proportion of children and parents with family histories of premature CHD have TC and LDL-C concentrations above the 95th percentile (in the present study, about 40 individuals in 140 high-risk families, if the parent and child considered at high risk all had agreed to participate). Prevention of heart disease should begin in childhood when patterns of life-style are developed. Identification by obtained family histories as in the current study may be a method of choice.     

Hyperlipidemia in School Children with Family Histories of Premature Coronary Heart Disease

ABSTRACT. Children starting their schooling were given a questionnaire asking about the occurrence of premature (before 50 years of age in men, 55 years in women) coronary heart disease (CHD) in first degree relatives. 1920 of 2069 questionnaires were answered, 140 of the 7-year-old children were reported to have a first degree relative with premature CHD. 84 of these 140 families agreed to participate in our study. In 79 of the 84 families both the child and the parent at 'high risk' were tested. In the initial test 19 of 84 children had total cholesterol (TC) levels above the 95th percentile (>5.35 mmol/l). In the repeat test 12 of the 19 TC tests remained abnormal and all 12 also had LDL-cholesterol (LDL-C) levels above the 95th percentile (>3.40 mmol/l). None had abnormal HDL-cbolesterol or triglyceride levels. Among the high risk parents, 12 of 79 had abnormal initial blood lipid tests. In the repeat test 10 parents had both TC and LDL-C levels above the 95th percentile. In five families both the child and the parent had abnormal TC and LDL-C levels. In conclusion, a considerable proportion of children and parents with family histories of premature CHD have TC and LDL-C concentrations above the 95th percentile (in the present study, about 40 individuals in 140 high-risk families, if the parent and child considered at high risk all had agreed to participate). Prevention of heart disease should begin in childhood when patterns of life-style are developed. Identification by obtained family histories as in the current study may be a method of choice.     

冠心病家族史儿童脂质三角的研究

目的：了解有冠心病(CHD)家族史儿童脂质三角［低密度脂蛋白-胆固醇(LDL-C),高密度脂蛋白-胆固醇(HDL-C)和甘油三脂(TG)］有无异常。方法：对83例有冠心病家族史的儿童检测血浆TG,LDL-C和HDL-C浓度,计算LDL-C/HDL-C,以无CHD家族史的健康儿童作为对照。结果：与对照组比较,有CHD家族史的儿童血TG,LDL-C浓度明显增高［(1.46±0.63) mmol/L vs (0.84±0.43) mmol/L,(2.09±1.13) mmol/L vs (0.96±0.87) mmol/L］,HDL-C水平降低［(1.48±0.48) mmol/L vs (1.72±0.53) mmol/L］,LDL-C/HDL-C升高(1.71±1.29 vs 0.96±0.68)(P1.7 mmol/L及LDL-C/HDL-C>2.5的发生率明显增高(20.5% vs 1.2%)(P均0.05)。有早发CHD家族史的儿童血TG,LDL-C水平［(1.86±0.63),(3.12±1.32) mmol/L］高于无早发CHD家族史儿童［(1.34±0.58),(1.79±0.87) mmol/L］及对照组［(0.84±0.43),(0.96±0.87) mmol/L］。有早发CHD家族史者LDL-C/HDL-C(2.85±1.21)高于无早发家族史组(1.37±1.11)和对照组(0.96±0.68)(P均<0.01),HDL-C水平［(1.11±0.26) mmol/L］低于无早发家族史者［(1.59±0.47) mmol/L］和对照组［(1.72±0.53) mmol/L］。脂质三角异常发生率(52.6%)高于无早发家族史组(10.9%)和对照组(1.2%)(P<0.01)。结论：有CHD家族史的儿童存在脂质三角异常,以有早发CHD家族史儿童明显。提示儿童期脂质三角异常与CHD家族史关系密切,有CHD家族史儿童成年后发生CHD的危险性显著增高。     

Lipid profile with paternal history of coronary heart disease before age 40

Serum lipids were measured in children and their parents from 40 families in which the father had a myocardial infarction or coronary heart disease (CHD) before age 40 years. The relationship between physical activity and serum lipid concentrations in the children was also evaluated. Twenty six men had one or more abnormal lipid value (in mmol/l): total venous cholesterol (TVC) > 6.24, triglycerides < 2.55, low density lipoprotein cholesterol (LDL-C) > 4.42, or high density lipoprotein cholesterol (HDL-C) < 0.91. There were 15 spouses with significant hyperlipidaemia (values above). In the 107 children examined, TVC mean (SD) was 4.68 (1.17), triglycerides 1.4 (0.8), LDL-C 3.0 (1.0), and HDL-C 1.18 (0.28). Altogether 42% of the children had significant hyperlipidaemia. No significant correlation was found between the degree of physical activity of the children and their LDL-C and TVC concentrations. However, a significant positive correlation was found between the degree of physical activity and HDL-C and a significant negative one with triglyceride concentrations. It is concluded that screening the progeny of young CHD patients is highly productive in identifying young people at excessive risk for future CHD. The data also suggest that promoting high degrees of activity among these children may have a positive influence on risk factors for adult onset CHD.     

Correlation of toddlers' serum lipoprotein(a) concentration with parental values and grandparents' coronary heart disease: the STRIP baby study

The correlation between lipoprotein(a) (Lp(a)) concentrations in children aged 7-24 months and their family members was determined and the association between the Lp(a) values of the children and a family history of coronary heart disease (CHD) was assessed. The Lp(a) values of the children correlated strongly with midparent Lp(a) values as early as at 7 months of age ( r = 0.54 to 0.59, p < 0.0001). This correlation was stronger than the correlation of serum total cholesterol and total cholesterol corrected for Lp(a) - cholesterol between children and parents. None of the parents had CHD. The median Lp(a) concentration of the parents with a family history of CHD was significantly higher than that of parents with no such history (111 vs 87 mg/l,p = 0.024). However. the children's Lp(a) levels were not associated with CHD in their grandparents. The genetic dependence of the Lp(a) concentration is already evident in infancy. The Lp(a) concentration in young parents, but not in their 24-month-old children, is associated with CHD in grandparents. This may be explained by a dilution of the genetic influence on Lp(a) over two generations.     

Screening for familial hypercholesterolaemia by measurement of apolipoproteins in capillary blood.

A total of 3025 families with schoolchildren aged 6-8 years were offered pilot screening for familial hypercholesterolaemia by measurement of the concentrations of apolipoproteins A-1 and B in the children''s capillary blood and by analysis of their family histories of early ischaemic heart disease. The concentrations of the apolipoproteins were determined by double rocket immunoelectrophoresis of an eluate of blood spotted on filter paper. Results were available from 2085 children. Because their B:A-1 ratio was above the 97.5 centile and their concentration of B was above the 99th centile, 54 children (2.6%) were selected to have their apolipoprotein concentrations reassessed. The 17 children (0.8%) whose values were persistently above the chosen cut off points, and all of their available first and second degree relatives, had fasting determinations of serum lipid concentrations carried out. Raised serum concentrations of low density lipoprotein cholesterol and an autosomal dominant pattern of hypercholesterolaemia were found in 12 children and 10 families, respectively, suggesting a higher incidence of familial hypercholesterolaemia than the reported 1:500. Further investigations among family members disclosed hypercholesterolaemia in 29 relatives. A family history of early ischaemic heart disease was elicited by questionnaire, and was positive in only five of the 12 schoolchildren with hypercholesterolaemia. We conclude that analysis of apolipoproteins from capillary blood spotted on filter paper is suitable for screening for familial hypercholesterolaemia, and that this method is more efficient than screening based on family history.     

Management of familial hypercholesterolaemia in children and adolescents

Familial hypercholesterolaemia is a disorder of low-density lipoprotein (LDL) cholesterol metabolism, which is associated with the onset of vascular changes associated with coronary heart disease in childhood. This disorder has co-dominant transmission with a prevalence of one in 500 in the general population. Cascade screening is the most effective method of identifying children. Children in the at-risk group should have their cholesterol levels checked between the age of 2 and 10 years. Children with LDL cholesterol levels ≥ 3.4 mmol/L are likely to suffer from this disorder, although at this level there is a significant false positive rate. Molecular genetic testing is available for the LDL receptor gene, APOB gene and the PCSK9 gene. This is the most specific test for familial hypercholesterolaemia but has a false negative rate of 20-50%. Once diagnosed, treatment should be considered in children with an LDL cholesterol level ≥ 4.9 mmol/L. If the child has two other risk factors or a positive family history, this threshold should be lowered to ≥4.1 mmol/L. Guidelines recommend that treatment should be commenced by the age of 10 years, although some advise waiting until menarche in females. Statin therapy is currently recommended as first line treatment. Randomised placebo trials have shown that statin therapy reduces LDL cholesterol levels by 25% and is not associated with increased risk of adverse events. These are short-term studies, and longer follow-up will be required to definitively prove efficacy and safety.     

Cholesterol: Should We Screen All Children or Change the Diet of All Children

Hypercholesterolemia is a major risk factor for coronary heart disease and may present during childhood. Dietary measures can reduce plasma cholesterol and may thus delay or prevent the development of the atherosclerotic process. Although plasma cholesterol concentrations measured during childhood track into adult life with a correlation coefficient of about 0.6 this in itself is insufficient to justify total population screening of children especially as the mechanisms for management and follow-up and their social, psychological and economic implications have not been adequately evaluated. Targeted screening of children in families with the genetic disorder of familial hypercholesterolaemia, where the risk of premature coronary heart disease is very high, should, however, be undertaken even though such screening may only identify half of all affected children. Dietary change designed to lower plasma cholesterol can be applied to the whole population including children over the age of 2 years, does not require pre-determination of plasma cholesterol, and is to be recommended. The effects of such change on the growth and health of children should be monitored.     

Family history fails to identify many children with severe hypercholesterolemia

Optimal strategies for identifying children with hypercholesterolemia have not been established. Several groups have advocated that testing of serum cholesterol levels be limited to those children who have family histories of hyperlipidemia or premature coronary heart disease. We studied the ability of comprehensive family histories to identify children with hyperlipidemia in a group of 114 children (mean age, 8 +/- 4 years) who were referred for treatment of hypercholesterolemia. A positive family history was defined according to guidelines of the American Academy of Pediatrics. The mean fasting total cholesterol in the children was 5.74 +/- 1.42 mmol/L (222 mg/dL). Family history was negative for hypercholesterolemia or premature coronary heart disease in 22 (22%) of 100 children with total cholesterol levels greater than the 75th percentile for their ages, in 13 (18.3%) of 71 children with total cholesterol levels greater than the 95th percentile for their ages, and in four (11.8%) of 34 children with presumed heterozygous familial hypercholesterolemia. Of the 78 children who had both hypercholesterolemia and positive family histories, hyperlipidemia was reported in 72 families, whereas premature heart disease was reported in only 27. We conclude that in a population of children referred because of known hypercholesterolemia, a detailed family history not only fails to identify many children with mild hypercholesterolemia, but also fails to identify a significant proportion of children with markedly elevated cholesterol levels. Additionally, in families of children with hypercholesterolemia, a history of hyperlipidemia is more common than a history of premature heart disease.     

High-sensitivity C-reactive protein in children at risk for coronary artery disease

AIM: To determine the value of high-sensitivity C-reactive protein (hs-CRP) in predicting risk factors for coronary heart disease (CHD) in children. METHODS: We measured hs-CRP levels in 51 children (11.79 +/- 3.14 years) with risk factors for CHD (hypercholesterolemia, hypertension, obesity, low HDL cholesterol and familial history of CHD). The results were compared with 26 children (12.98 +/- 2.59 years) without any risk factors. RESULTS: The children with risk factors had significantly higher serum levels of hs-CRP compared to the control group (3.33 +/- 4.58 vs. 0.92 +/- 1.90 mg/L, respectively, p < 0.01). CRP concentrations significantly increased in children with three or more risk factors. Hs-CRP levels correlated to body mass index (r = 0.411, p = 0.003), diastolic blood pressure (r = 0.323, p = 0.021), fibrinogen (r = 0.447 and p = 0.004) and HDL cholesterol levels (r =-0.461 and p = 0.001). Cutoff value for CRP was 1.04 mg/L with 58% sensitivity and 92% specificity. CONCLUSION: Serum hs-CRP level is a useful marker in screening the children who are under the risk of CHD in adulthood. Early identification of the children with risk factors and intervention for obesity, harmful habits and life style in childhood might decrease the incidence of coronary heart disease in adulthood.     

Lipoprotein profiles in hypercholesterolemic children

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.     

Paediatric screening for hypercholesterolaemia in Europe

Different screening strategies are currently recommended to identify children with (familial) hypercholesterolaemia in order to initiate early lipid management. However, these strategies are characterised to date by low adherence by the medical community and limited compliance by parents and children. In a literature review, the authors assess which children should undergo screening and which children are in effect identified through the currently recommended strategies. Furthermore, the authors discuss the different screening tools and strategies currently used in Europe and what is known about the negative aspects of screening. The authors conclude that currently recommended selective screening strategies, which are mainly based on family history, lack precision and that a large percentage of affected children who are at increased risk of future coronary artery disease are not being identified. The authors propose universal screening of children between 1 and 9 years of age, a strategy likely to be most effective in terms of sensitivity and specificity for the identification of children with familial hypercholesterolaemia. However, this concept has yet to be proven in clinical practice.     

Familial history of cardiovascular disease and blood lipid pattern in newborn infants

The levels of atherogenic lipid fractions are higher in children with a family history of ischemic cardiovascular disease (CD). This study was designed to examine this relationship in neonates. A total of 1276 newborns were investigated; 400 cord blood samples were collected for measurement of triglycerides (TG), total cholesterol (TC), LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C); on day 4, 1200 capillary samples were taken for TC and TG measurements. Male newborns with a positive history of CD had higher concentrations of cord blood TC (P less than 0.04) and LDL-C (P less than 0.02). On day 4 this difference in TC was no longer detectable (LDL-C not determined). A coronary heart disease (CHD) risk factor family history is sensitive (0.87) in predicting high cord blood concentrations of LDL-C, the specificity being 0.46 and the positive predicting value 0.08.     

Family history evaluation as a predictive screen for childhood hypercholesterolemia. Pediatric Practice Research Group

A study was conducted to evaluate the efficacy of family history factors as screening criteria for childhood hypercholesterolemia. When they were seen for routine care at one of eight office practices, 1005 prepubertal children underwent random serum cholesterol determinations. Parental and grandparental histories of cardiovascular risk factors and atherosclerotic complications prior to 55 years of age were also obtained. Of the initial group, 274 children had total cholesterol levels greater than or equal to 175 mg/dL, and 175 of these children returned for retesting after an overnight fast. A total of 88 children were found to have low-density lipoprotein-cholesterol (LDL-C) values greater than or equal to 90th percentile for age and sex. Maternal and paternal histories of hypercholesterolemia were significantly associated with elevated LDL-C (odds ratio = 7.3 and 2.9, respectively), but had extremely low sensitivities (0.09, 0.15) despite modest positive predictive values (0.42, 0.22). Grandparental histories of sudden death, peripheral vascular disease, and gout were associated with elevated LDL-C, but sensitivities and positive predictive values for all of these factors were less than 0.22. Family history factors most commonly recommended as criteria for cholesterol screening in children did not identify half of all the children with elevated LDL-C and did not selectively identify the most severely affected children. Adding information concerning the presence of childhood obesity did not result in appreciable improvement in LDL-C detection beyond that achieved by family history factors alone. It was concluded that if thorough identification of young children with elevated LDL-C is desired, inclusive population screening rather than a family history-based strategy would be the most effective approach.     

Individualized dietary counselling of families: serum cholesterol concentration and growth of children aged 7–13 months

We studied the effect of a change in dietary fat composition on serum total and high-density lipoprotein cholesterol and growth in healthy infants between 7 and 13 months of age. The intervention families ( n = 22) received individualized dietary counselling when the infant was 7, 8 and 10 months of age. The intervention diet was designed to have a fat content of 35–45 E%, of total energy intake in infants aged 7–12 months and 30–35 E% after 12 months of age. The ratio of saturated to monounsaturated to polyunsaturated fatty acids was designed to be 1:1:1. The children in the control group ( n = 23) were given no specific advice on the fat composition of the diet. Intake of polyunsaturated fatty acids was significantly higher in the intervention group than in the controls (5.9 E% versus 3.6 E%, p < 0.05). Serum total cholesterol concentration decreased significantly in the intervention group during the study from 4.16± 0.41 mmol/l to 3.86 ± 0,48 mmol/l ( p < 0.05). The infants of both groups grew like average Finnish children. Modification of dietary fat composition, as widely recommended for adults and older children to prevent coronary heart disease, decreases cholesterol values in infants without affecting their normal growth.