Publish date: Nov 17, 2011
By: Contemporary Pediatrics Staff

For the last 20 years, lipid screening has been recommended only for children with a family history of heart disease or high cholesterol. Now, you probably should add it to your routine screening list.

The American Academy of Pediatrics (AAP) has endorsed new government-issued guidelines that suggest that the older protocol misses too many children (from 30%-60%) and instead advocate universal screening. Specifically, the new guidelines from the National Heart, Lung, and Blood Institute (NHLBI) recommend that all children be screened for high cholesterol at least once between the ages of 9 and 11 years and again between ages 17 and 21 years.

Doing the test will not be as complex as in the past: Pediatricians can use for the initial test the non-HDL cholesterol protocol, which does not require fasting. The fasting lipid profile is recommended for follow-up only if the child shows abnormal results.

Why have the recommendations changed so much? At least 2 issues were involved in the decision, according to the guidelines from NHLBI, an agency of the National Institutes of Health (NIH): One is that knowledge about the relationship between lipoprotein disorders and the onset and severity of atherosclerosis in children, adolescents, and young adults has increased significantly in the last 20 years. The other is that the significant rise in the prevalence of obesity has increased the population of children with dyslipidemia.

Cholesterol screening is just 1 part of the new guidelines, which include broader recommendations on ways to minimize cardiovascular risk factors, starting with breastfeeding and emphasizing a diet low in saturated fat beginning the first year. The guidelines also encourage regular physician activity and protection from tobacco smoke.

Both the AAP and NHLBI emphasize that the new screening recommendations should not lead to substantial increase in statin prescriptions. AAP pointed out that less than 1% of children, primarily those with genetic dyslipidemias, usually qualify for cholesterol-lowering medications. Pediatricians instead should prescribe lifestyle modifications including diet and exercise, they said.

Statin therapy should be considered only in children aged 10 years or older with low-density lipoprotein (LDL) cholesterol of 190 mg/dL or higher after a 6-month trial of lifestyle management or for children with slightly lower LDL levels (160 mg/dL-189 mg/dL) with a positive family history of premature cardiovascular disease in first-degree levels or substantial risk factors, according to the recommendations. The guidelines warn, however, that although rare at standard doses, statins can have adverse effects, including myopathy and hepatic enzyme elevation.

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