Screening for Hypercholesterolemia in Children

Unsure what to do about screening pediatric patients for hypercholesterolemia?  The recent AAP recommendations are anything but evidence based.  Here is an editorial, written by our local Pediatric Cardiologists on a more evidence based (and sane) approach.

December 2011

As some of you may be aware, the American Academy of Pediatrics recently released a new practice guideline for “cardiovascular health” (see the full paper at http://pediatrics.aappublications.org/site/misc/2009-2107.pdf if interested). 

The AAP no longer recommends routine cholesterol testing in preschool age children, as was recommended back in 2008.  This recommendation is replaced by universal lipid profile screening at age 9-11 years and then again at age 17-21 years, even in the absence of any high-risk factors. (See table 9-5 on page S27 of the report.)

The guidelines also recommend the following, among other guidelines:

1. For elevated LDL-C (“bad cholesterol”) from 130-190 mg/dL in healthy children, repeat screening at 6 month intervals is recommended indefinitely, though no specific treatment other than diet/lifestyle modification is recommended.
2. Statin or other drug therapy is recommended for all obese children with BMI > 97^th% and moderately elevated LDL-C levels (over 160 mg/dL).
3. Statin or other drug therapy is recommended for all T2DM obese children with BMI > 97^th% and mildly elevated LDL-C levels (over 130 mg/dL).

These treatment guidelines are rated “grade B”, which indicates “overwhelmingly consistent evidence.”  Unfortunately, the guideline includes only 19 references, none of which are trials of statin therapy in any of these situations, and the guideline itself includes no verifiable epidemiological data to support these recommendations.  The same problem—lack of good data—affected the prior report in 2008.

This raises the following problem: What should our practice be?  We recently discussed these issues among members of the pediatric cardiology division (Drs. Fahey, Kane, and Sanghavi) and with Dr. Frank Domino (Prof, Family Practice) and as a group, we disagree with several features of the AAP report.  Our group made the following conclusions:

1. Routine universal lipid screening in normal pre-schoolers is not indicated.
2. A single fasting lipid screen at some point in adolescence or the early teen years is reasonable in children with no risk factors, primarily for the detection of familial hypercholesterolemia syndromes (genetic problems), which would be suggested by an LDL-C level over 190 mg/dL.
3. In the absence of any major risk factors (e.g. T1DM, nephrotic syndrome, heart transplant, NOT including obesity), we fail to see the benefit of indefinitely checking lipid profiles every six months for mildly elevated LDL-C over 130 mg/dL in children.
4. There is no clinically known benefit of statin therapy in children with elevated LDL-C levels from 130-190 mg/dL whose only other risk factor is obesity.  In addition, there is no clinically known benefit of aggressive statin therapy in any child—including those with strong risk factors—with mildly elevated LDL-C levels (130-160 mg/dL), and an argument can be made against statin therapy even when LDL-C levels in such children are 160-190 mg/dL.
5. The most effective intervention for reducing long-term cardiovascular risk (not associated with known genetic familial hypercholesterolemia) is effective diet, exercise, and risk factor reduction (no smoking), rather than an emphasis on regular lab testing and possible early statin therapy for elevated cholesterol levels in children.  This can be performed well in the primary care setting and does not necessarily require subspecialist input.
6. Prior to treatment with statins or other cholesterol lowering agents (for example, if familial hypercholesteromia is suspected), we recommend consultation with a specialist with experience in pediatric dyslipidemias.

For those of you with high interest in this issue, Dr. Sanghavi has written a skeptical viewpoint about the benefits of such guidelines and the following resources are available:

1. Detailed Q & A discussion of the epidemiological problems with the current AAP approach to high cholesterol in children: http://consults.blogs.nytimes.com/2008/07/07/readers-questions-treating-children-for-high-cholesterol/
2. Written debate with between Darshak Sanghavi and Nicholas Stettler, one of the prior guideline authors, from AAP News, FP News, and Cardiology news, available at http://www.ecardiologynews.com/index.php?id=8628&cHash=071010&tx_ttnews[tt_news]=86505 –Stettler wrote the first pro part, Sanghavi wrote the con part.
3. Audio debate between Jatinder Bhatia (another guideline author) and Darshak Sanghavi from ReachMD: http://www.reachmd.com/xmsegment.aspx?sid=3357

Of course, any of our group is available for consultations or further input on these complex and important issues.  For any questions, please feel free to contact the pediatric cardiology office at 508-856-4154 or any physicians below via email at:

Darshak Sanghavi, MD
Darshak.sanghavi@umassmemorial.org
Chief, Pediatric Cardiology, Associate Professor of Pediatrics

Michael Fahey, MD
Michaelc.fahey@umassmemorial.org
Pediatric Cardiologist, Assistant Professor of Pediatrics

David Kane, MD
David.kane@umassmemorial.org
Pediatric Cardiologist, Assistant Professor of Pediatrics

-Frank Domino, MD

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