December 19th, 2011
Should All Children Age 9 to 11 Undergo Cholesterol Screening?
The NHLBI (with the endorsement of the American Academy of Pediatrics) has issued new guidelines for cholesterol testing in children. It recommends that all children age 9 to 11 should undergo cholesterol screening and that screening should be repeated at ages 17 and 21. We asked a small panel of experts to review the new guidelines and discuss whether they agree with the recommendation to do cholesterol screening for all children age 9 to 11. Here’s how they responded:
Cholesterol screening for children age 9 to 11, even though the NHLBI report emphasizes lifestyle modifications as the first line-therapy, is likely to result in the use of drug treatment in a large number of children. The findings of the statin trials in adults may well not be generalizable to children, and the studies in children are all small, short-term trials. Although the evidence that lipids are major risk factors for cardiovascular disease is strong and consistent, the risk/benefit profile for long-term drug treatment in children remains uncertain. Moreover, there appear to be no plans to evaluate this screening effort, as Frederick Rivara and I noted in a recent JAMA article.
Universal lipid screening of children will be beneficial. The most important benefit is identifying the 1 in 500 children with asymptomatic familial hypercholesterolemia (FH). Since appropriate treatment of FH reduces cardiovascular disease risk to levels approaching those in the general population, kids with FH deserve to be identified and treated. In addition, nearly 2 in 10 children have other lipid abnormalities that may be identified by universal screening. These kids deserve extra attention, follow-up, and dietary modification that targets their specific lipid profiles. Of course, lipid levels can vary with a child’s age and false positives will occur, but on balance I support the new guidelines recommending universal screening of children.
Childhood cholesterol screening is currently aimed primarily at identifying familial hypercholesterolemia (FH). FH is a relatively common disorder of high LDL (1 in 300 to 500 individuals), much more common than many diseases for which newborns are screened. And we know that lipid-lowering drugs, if started early enough, help reduce CVD risk in patients with FH.
But universal cholesterol screening of children age 9 to 11 will undoubtedly detect lifestyle-related lipid abnormalities as well. The vast majority of children with such abnormalities have high triglyceride and low HDL levels, which do not require pharmacotherapy. The fear, then, is that children with poor lifestyle habits will be prescribed statins as a “quick fix,” but NHANES data suggest that only 1% will meet medication criteria. In fact, the new NHLBI guidelines recommend that practitioners spend much more time counseling about nutrition and exercise than prescribing medications. Such post-screening lifestyle counseling could reduce the complication rate associated with the obesity epidemic, and I believe it’s the kind of care that our patients deserve.
Do you agree with the members of our panel?