Cholesterol Screening: What’s the Right Approach?

To screen or not to screen? For pediatricians, that question is far from answered when it comes to universal cholesterol testing. Despite an endorsement of the practice from an expert panel at the end of 2011, controversy continues to shroud the recommendation, even as more evidence emerges showing the prevalence of elevated cholesterol among children.

After several years of discussion and a thorough review of relevant research, a group of nurses, pediatricians and pediatric cardiologists recommended in November 2011 a significant change in how physicians monitor childhood cardiovascular health. The panel — convened by the National Heart, Lung, and Blood Institute — concluded that all children should undergo blood tests to check for high cholesterol between the ages of 9 and 11 and again between the ages of 17 and 21. Previously, pediatricians only screened children with family histories of heart disease or elevated cholesterol.

“There were a number of studies that showed by using that targeted approach, you actually missed a substantial number of children with high cholesterol,” says Stephen Daniels, MD, PhD, the leader of the expert panel. By identifying more children earlier, pediatricians can help them and their families change their lifestyles to reduce the risk of heart disease and stroke later in life, says Dr. Daniels, a pediatric cardiologist at the University of Colorado School of Medicine and Children’s Hospital Colorado.

Universal screening, however, hasn’t received universal acceptance. Commentaries critical of the practice were published in 2012 in Pediatrics and The Journal of the American Medical Association, while skeptics and supporters debated the issue in a roundtable discussion published in Clinical Chemistry that same year. Critics fear that costly tests may unnecessarily induce parental anxiety, distract physicians from more important priorities and result in children taking medicine they don’t need.

“Screening almost always seems like a wonderful idea up front, but as the examples of screening for prostate cancer, breast cancer and newborn metabolic abnormalities have shown, the benefits of screening are easy to imagine, but the costs and harms are often hidden,” said Louis Vernacchio, MD, MS, in the Clinical Chemistry discussion.

Experts have speculated that adoption of universal screening has been low, though data supporting the claim are not available yet. According to Dr. Daniels, researchers in Minnesota and Massachusetts have studies on the topic underway.

Meanwhile, about one in three children between the ages of 9 and 11 have borderline or high cholesterol, according to a study of 12,712 Texas children that was presented at a meeting of the American College of Cardiology in 2014. Thomas Seery, MD, the lead investigator, is a supporter of screening, saying it provides an ideal opportunity for clinicians to discuss healthy lifestyle choices with patients.

“Our findings give a compelling reason to screen all kids’ blood cholesterol,” said Dr. Seery, a pediatric cardiologist at Texas Children’s Hospital and the Baylor College of Medicine, in a press release announcing his study’s findings.

References:

1. de Ferranti, SD, Daniels, SR, Gillman, M, Vernacchio, L, Plutzky, J, Baker, AL.NHLBI integrated guidelines on cardiovascular disease risk reduction: Can we clarify the controversy about cholesterol screening and treatment in childhood? Clinical Chemistry. 2012 Dec, 58(12):1626-1630.
2. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report. National Heart, Lung, and Blood Institute. 2012.
3. Gillman, MW, Daniels, SR. Is universal pediatric lipid screening justified? The Journal of the American Medical Association. Jan 2012, 307(3): 259.
4. Newman, TB, Pletcher, MJ, Hulley, SB. Overly aggressive new guidelines for lipid screening in children: evidence of a broken process. Pediatrics. 2012 Aug, 130(2):349-352.
5. Psaty, BM, Rivara, FP. Universal screening and drug treatment of dyslipidemia in children and adolescents. The Journal of the American Medical Association. 2012 Jan, 307(3):257.