USPSTF Found Insufficient Evidence to Recommend for or Against Lipid Screening in Asymptomatic Children and Teens

Task Force vice chair David Grossman, MD, MPH; Douglas K. Owens, MD, MS; and, Robert H. Eckel, MD provide comments

The U.S. Preventive Services Task Force (USPSTF) reviewed evidence for screening asymptomatic children and adolescents for both familial hypercholesterolemia and multifactorial dyslipidemia and found that there is not enough evidence to determine the benefits or harms of screening in either case. The report was published in the August 9 issue of JAMA.
blue glove holding a test tube with the labeled words "lipid panel" shownThis final recommendation is consistent with and updates the previous recommendation statement on this topic in 2007. The Task Force graded this recommendation as an “I” statement, meaning that current evidence is insufficient to assess the balance of benefits and harms of service.

“By issuing an I statement, we are calling for more research to better understand the benefits and harms of screening and treatment of lipid disorders in children and teens and on the impact these interventions may have on their cardiovascular health as adults,” said Task Force vice chair David Grossman, MD, MPH. “In the absence of evidence, health care 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.”

In terms of detection, The USPSTF found inadequate evidence on the quantitative difference in diagnostic yield between universal and selective screening for familial hypercholesterolemia or multifactorial dyslipidemia, and found inadequate evidence on the benefits of screening for these conditions in asymptomatic pediatric patients.

Evidence on Adverse Effects of Statin Use in Children and Teens Is Inadequate
The adverse effects of long-term use of lipid lowering agents and lifestyle modification have not been adequately studied, according to the Task Force. In children or teens with familial hypercholesterolemia, only 1 study on statin use was found, which showed that short-term statin use was generally well tolerated with transient adverse effects (eg, elevated liver enzyme levels).

In addition, the appropriate age at which to initiate statin use in pediatric patients is a topic of debate, with some experts recommending starting at age 8 to 10 years and others recommending starting at age 20 years.

Commentary on the Task Force’s Recommendation
“The Task Force is a conservative body and is reluctant to make recommendations unless the data are convincingly solid,” commented Robert H. Eckel, MD, past president of the American Heart Association (2005-2006), Charles A. Boettcher Endowed Chair in Atherosclerosis, and Professor of Medicine in the Division of Endocrinology, Metabolism and Diabetes, and Cardiology at the University of Colorado Anschutz Medical Campus in Aurora, CO.

“I don’t entirely agree that the evidence is insufficient to assess the balance of benefits versus the harms for screening of lipid disorders in children and adolescents,” Dr. Eckel said. “However, the harms would only be discomfort from the needle when blood is taken or if the patient was initiated on statin treatment that wasn’t indicated or necessary and experienced a side effect.”
Young boy having his blood drawn for testingIn 2011, the National Heart, Lung, and Blood Institute (NHLBI) released guidelines for cardiovascular risk reduction in pediatrics that recommended universal lipid screening starting at age 9, Dr. Eckel explained. For pediatric patients with an LDL-C level ≥190 mg/dL on a fasting lipid panel, the NHLBI recommended initiating statin therapy in addition to a heart healthy lifestyle. 

“I am an endocrinologist/internist, and I have worked with pediatricians carefully to institute statin therapy even in children under the age of 9 years with familial hypercholesterolemia. I recently had a case involving a 5-year-old girl with an untreated LDL-C of 295 mg/dL. Wouldn’t it make sense to treat her with statin therapy early in life to prevent cholesterol buildup that may cause harm later?”

“Thus, although the Task Force takes a neutral and cautionary position on the benefits of universal screening for pediatric patients, LDL is a bad actor,” Dr. Eckel said. “I think that ultimately, we have to screen children for dyslipidemia at any age in those with familial hypercholesterolemia or whose parents have a history of early onset cardiovascular disease.”

Obesity Screening Is Recommended Starting at Age 6
“Despite this lack of evidence on lipid screening, the Task Force does recommend screening for obesity in children 6 years and older and referring them to intensive behavioral counseling on weight management,” said former Task Force member Douglas K. Owens, MD, MS, in a statement to the press. “Helping children improve their diet and physical activity, may also improve their cardiovascular health as well,” said Dr. Owens, who Professor of Health Services and Adjunct Professor of Pediatrics at the University of Washington.

The Task Force graded this recommendation on screening for obesity as a “B” statement, meaning that there is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial. The Task Force told EndocrineWeb that the recommendation on obesity screening is in the process of being updated.

In contrast, the Task Force found insufficient evidence screening for primary hypertension in asymptomatic children and adolescents in the prevention of cardiovascular disease.

August 23, 2016

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