Do We Really Need to Screen All Children for High Cholesterol?

An expert panel has recently recommended that all children, regardless of family history, undergo universal screening for elevated cholesterol levels. The panel recommends that adolescents undergo lipid screening for non-fasting non-HDL-cholesterol levels or a fasting lipid panel between the ages of 9 and 11 years followed by another full lipid screening test between 18 and 21 years of age.

The guidelines, from the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, appointed by the National Health, Lung, and Blood Institute (NHLBI) and endorsed by the American Academy of Pediatrics (AAP), also recommend measuring fasting glucose levels to test for diabetes in children 10 years of age (or at the onset of puberty) who are overweight with other risk factors, including a family history, for type 2 diabetes mellitus.  They are published in the Dec 2011 issue of the journal Pediatrics.

The level of evidence supporting the “strongly recommended” cholesterol screening recommendation is graded B, which the panel defines as being based on consistent evidence from observational studies, genetic natural history studies, or diagnostic studies with minor limitations.

This could be a case of implementing a well-meaning set of guidelines based on an incomplete evidence set.  There are no randomized, controlled, clinical trials showing that the treatment of elevated cholesterol levels in children has a long-term clinical impact on cardiovascular outcomes.  And it’s difficult to justify these recommendations when the likelihood of a clinical end point of cardiovascular disease is some 30-40 years away.

Although the guidelines stress the importance of recommending dietary and lifestyle interventions, critics fear that it will be easier for healthcare providers to provide medications for those children who are deemed by screening to have elevated cholesterol. This is of some concern as well, because there are also no data to suggest that the use of lipid-lowering drugs is safe in children this young or when used for decades.

While these guidelines are meant to protect young children against the future risk of heart disease, there is already a perception that the true beneficiaries are more likely to be the companies who manufacture the cholesterol tests and medications—especially because 7 of the 14 listed authors disclosed various ties to those industries.  Given that the evidence is incomplete regarding the long-range effects of high cholesterol in asymptomatic and low-risk children or the role of statins in this population, would it not be more prudent to advise children (and their parents) to eat more fruits and vegetables, watch their weight, and get regular physical activity?


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