The US Preventive Services Task Force (USPSTF) recently concluded that there is not enough quality evidence available to recommend routine lipid screening for children and adolescents age 20 or younger, even for those with a genetic condition that predisposes them to hyperlipidemia or those with other risk factors such as obesity.
The committee’s most recent recommendation statement was published online in August in the Journal of the American Medical Association. The American Academy of Family Physicians also released its own final recommendation that found insufficient evidence to recommend for or against routine screening for lipid disorders in children and adolescents.
About 3.2% of well-child visits included lipid testing in 2010.
Specifically, the USPSTF recommendations note that:
- While short-term trials demonstrate substantial reductions in levels of low-density lipoprotein cholesterol (LDL-C) and triglycerides (TC) with medication in children with familial hypercholesterolemia, there is little evidence that such treatment directly translates into a reduced risk of premature cardiovascular disease (CVD).
- Neither lifestyle nor pharmacotherapy interventions provide intermediate- or long-term benefits for individuals age 20 or younger with multifactorial dyslipidemia.
- Most children with elevated lipids of a multifactorial origin will not progress to CVD and are subject to overdiagnosis, which could lead to anxiety or unnecessary or harmful testing.
The panel found just two “fair-quality” studies of universal screening for familial hypercholesterolemia, one with a diagnostic yield of about 1.3 cases per 1,000 persons screened (based on an LDL-C level >155 mg/dL, a TC level >260 mg/dL, or both, plus DNA evidence of a genetic mutation in a first- or second-degree relative). The second study found a diagnostic yield of 3.8 cases per 1,000 persons screened based on laboratory testing and family history.
Meanwhile, a U.S. study in 6,500 participants using a nonfasting TC threshold ≥200 mg/dL found a 5.3% prevalence of dyslipidemia. Confirmatory testing with a fasting LDL-C threshold ≥130 mg/dL found a positive predictive value of 77% and a diagnostic yield of 5.8%. Combining that study with three large, population-based studies provided a simulated diagnostic yield of 4% to 12% based on age and body mass index.
Key to the panel’s recommendation was the lack of evidence that lipid-lowering pharmacotherapy or lifestyle interventions impacted intermediate health outcomes in children and adolescents with familial hypercholesterolemia or multiple risk factors.
The panel identified several areas for research, including randomized trials of screening programs in those with familial hypercholesterolemia or multifactorial dyslipidemia, as well as long-term trials of pharmacologic and lifestyle interventions on CVD risk. USPSTF also called for longitudinal studies on the association between intermediate outcomes (premature myocardial infarction and stroke) in these children and adolescents.
“In the absence of evidence,” said USPSTF vice chair David Grossman, MD, in a news release, “healthcare professionals should continue to take each patient’s individual risks and circumstances in consideration and use their best judgment when deciding whether or not to screen.”