Pediatric lipid screening aims to identify children and adolescents with dyslipidemia, including those with more severe, genetic cases and those with mild to moderate lipid elevation due to secondary causes. Current guidelines, sponsored by the National Heart Lung Blood Institute (NHLBI), call for targeted screening in children age 2 years and older with a positive or unknown family history of dyslipidemia-related cardiovascular disease or other major risk factors and for universal screening in those aged 9-11 years and again between 17-21 years.(1) Recent reports show that overall pediatric screening rates are low, and although, rates in children meeting targeted screening criteria are higher than those overall, they are still well below that expected.(2,3,4) Irrespective of providers’ endorsement of recent universal screening recommendations, these reports suggest that strategies are needed to improve pediatric lipid screening rates. Barriers to implement lipid screening recommendations include impact on busy practice workflows, limited physician awareness of recommendations and concern over appropriate interpretation and management of increased numbers of patients with dyslipidemias.(5) Laboratorians should consider the following opportunities to help mitigate challenges providers face in implementing pediatric lipid screening recommendations:
- Develop a dialogue with pediatric providers about lipid screening.
- Universal lipid screening in children is controversial. However, improved education about current guidelines is needed among both pediatric providers and laboratorians.
- Facilitate the use of non-fasting lipid panels and report non-HDL-C.
Non-fasting, non-HDL-C is recommended by the NHLBI expert panel as the first tier approach for universal screening.(1) Despite this, non-HDL-C is likely underutilized in pediatric lipid screening.(4) Facilitating provider adoption of non-fasting screening may decrease missed screening opportunities and eliminate challenges associated with obtaining fasting labs in children.
- Report pediatric lipid test results with age-appropriate, evidence-based cutoffs.
Lipid tests in children should be reported with appropriate age-specific cutoffs, per the National Cholesterol Education Program (NCEP) and as described in the NHLBI 2011 guidelines.(1) Lipid target ranges in children differ from those in adults, with the exception of HDL. Auditing lipid reference range information available via online laboratory test catalogs from several laboratories demonstrates use of adult cutoffs for all ages is a common practice, suggesting significant improvement is needed in this area.
- Report pediatric lipid test results with guideline-based comments for decision making.
Providing interpretation guidance with recommended next steps, including easily identifying patients with lab values requiring an intensified level of care, would be of value to primary care providers, as this may aid in decision making and adherence to current recommendations for patient management. (1)
- Support implementation of point-of-care lipid testing.
Many pediatric practices are implementing point-of-care (POC) lipid testing to improve screening workflows. Studies conducted in adults show that the devices available in the US may not meet NCEP recommended assay performance criteria for imprecision and bias, but may be suitable for screening purposes.(6) Laboratorians should act as a resource to primary care providers by defining best practices in the evaluation and implementation of POC lipid testing, while creating awareness of the common limitations and sources of error in such measurements.
- Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Pediatrics. 2011 Dec;128 Suppl 5:S213-56.
- Vinci SR, Rifas-Shiman SL, Cheng JK, Mannix RC, Gillman MW, and de Ferranti SD. JAMA. 2014 May 7;311(17):1804-7.
- Margolis KL, Greenspan LC, Trower,NK, et al. Circ Cardiovasc Qual Outcomes. 2014;7:718-726.
- Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Clin Pediatr (Phila). 2015 Mar 26 [Epub ahead of print]
- Dixon DB, Kornblum AP, Steffen LM, Zhou X and Steinberger J. J Pediatr. 2014 Mar;164(3):572-6.
- Taylor JR, Lopez LM. Ann Pharmacother 2004;38:1252-7