Friday, November 11, 2011

Universal cholesterol screening in children: what is the evidence?

New guidelines released today by the American Academy of Pediatrics and the National Heart, Lung, and Blood Institute recommend replacing risk-based approaches to cholesterol testing with universal screening for all children at ages 9 and 17. To inform the debate that is sure to follow, we note that AFP has previously published commentaries that review the potential benefits and harms of different screening strategies. Below is our blog post on this topic from September 1, 2010.

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The September 1 issue of American Family Physician inaugurates a new editorial feature that presents two opposing views on a controversial clinical topic and asks readers to post comments online. In this issue, Dr. Robert Gauer argues that because atherosclerosis begins in childhood, using cholesterol-lowering drugs in children with hyperlipidemia is essential to prevent coronary events and cardiovascular mortality in later life. On the other hand, Dr. Michael LeFevre contends that since only 40 to 55 percent of children with elevated cholesterol levels will have persistent hyperlipidemia as adults, and the potential benefits and harms of decades of drug therapy are unknown, physicians should demand a high "evidence bar" for instituting screening and treatment.

Since hyperlipidemia causes no symptoms, these views reflect in large part the dueling guidelines of the American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) on lipid screening in children. While the AAP recommends that screening for hyperlipidemia begin at age 2 in children with a family history of hyperlipidemia, premature cardiovascular disease, or other risk factors, the USPSTF found insufficient evidence to recommend for or against screening in any group of children. [Editorial note: the AAP now recommends universal, rather than targeted, screening.]

This leaves family physicians and other clinicians who care for children with an important clinical dilemma. Should they act now based on disease-oriented evidence and extrapolation from studies of primary prevention of cardiovascular disease in adults, or should they instead wait for patient-oriented evidence from long-term followup studies of children with elevated lipid levels? Which approach do you take in your practice, and why? You are welcome to post comments here or on AFP's Facebook page; AAFP members can also post comments on the AFP web page. We look forward to the discussion!

2 comments:

  1. Kenny,
    Thanks for covering this today. When I saw this I wondered, will the next step be treating kids who eat pizza and ice cream with cholesterol-lowering drugs? (and are there any conflicts of interest on the NHLBI panel?)

    As a mother and homemaker, I can't help but think that cholesterol testing is the wrong way to go for kids without an extreme family history. Better to just provide them the right stuff - like lots of fruits, vegetables and low-cholesterol, fiber-rich foods.

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  2. Hello Kenny & Elaine. I must admit that I was just about to write in a Comment - when I noticed that Elaine's comment was virtually identical to what I was going to write .... As I reflect on my 30-plus year career as a family physician educator - I can't believe the AAP recommendation. Cholesterol-lowering medication is very expensive and definitely has side effects (as well as the potential downside of converting children into "patients"). WHERE is the evidence that treating children with cholesterol-lowering drugs at an early age will improve outcome (not just numbers but longterm outcome)? WHERE is the evidence that longterm treatment with cholesterol-lowering drugs in children is safe? And to repeat one of Elaine's questions: "Are there any conflicts of interest on the NHLBI panel?" (subquestion implied - How much do financial interests play into these recommendations - either directly or indirectly - including potentially on the part of the pharmaceutical industry)? I realize these are difficult questions - but they are essential. Wouldn't this "cholesterol epidemic" in children virtually disappear if children exercised more regularly (like they used to before computers, Facebook, smart phone messaging, and before eliminating physical education in many schools) - AND - if children ate more healthy foods? THANK YOU for listening.

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