EVIDENCE-BASED ANSWER
Children should be screened for hyperlipidemia when there is a history of familial hypercholesterolemia (strength of recommendation [SOR]: C).
No clear evidence supports screening all children or just those with family history of cardiovascular disease (CVD) or hyperlipidemia (SOR: C).
CLINICAL COMMENTARY
With no clear medical treatment for childhood dyslipidemia, screening provides little help
Walter Foliaco, MD
Chesterfield Family Practice, Midlothian, Va
There is no clear evidence to support screening children with or without familial hypercholesterolemia for hypercholesterolemia. In an era where judicious use of medical dollars is a must, screening for hypercholesterolemia would also be cost-prohibitive. Other than stressing exercise and nutrition, there is no clear medical treatment that is FDA-approved for dyslipidemia among children, so screening would provide very little help in the management of this population.
Patients with a strong family history of lipid disorders or familial hypercholesterolemia should have more directed education on cholesterol and their need to treat in early adulthood; however, at this time there is very little evidence to support screening in this population. Aggressive promotion of age-appropriate exercise and a healthy lifestyle should be the thrust of our intervention until more evidence-based information shows that screening and treatment improves morbidity and mortality.
This Clinical Inquiry emphasizes the need to do more research in pediatric hypercholesterolemia, to better counsel our patients not only in screening but ultimately in earlier medical intervention.
Evidence summary
Screening for hyperlipidemia using total cholesterol and low-density lipoprotein (LDL) cholesterol is recommended for adults after the age of 35 years for men and 45 years for women.1 Younger adults (men aged 20–35 and women aged 20–45) should be screened for lipid disorders if they have other risk factors for CVD.1
Children with heterozygous familial hypercholesterolemia, an autosomal dominant disorder with a prevalence of 1 in 500, are at increased risk of cardiovascular morbidity and mortality in adulthood. One quarter of males with familial hyper-cholesterolemia suffer fatal coronary heart disease (CHD) by age 50 years.2
The use of statins by children with familial hypercholesterolemia for up to 2 years is safe and lowers LDL cholesterol.3 Longer use by children has not been studied, so no comment can be made about long-term safety and decreased CHD morbidity and mortality.
One systematic review and cost-effectiveness analysis investigated the appropriateness and cost-effectiveness of screening methods for familial hypercholesterolemia beginning at the age of 16 years.4 The authors identified potential screening strategies from 6 cross-sectional studies and applied these to a decision analysis. Screening of first-degree relatives of those with familial hypercholesterolemia was most effective in detecting cases of familial hypercholesterolemia (number needed to screen [NNS]=3; cost per case detected=$232; cost per life-year gained=$5397).
Universal screening of all 16-year-olds was also cost-effective (cost per life-year gained=$4839), but resulted in a much larger NNS and cost of detection (NNS=1365, cost per case detected=$16,999). The authors concluded that case finding through screening of first-degree relatives was the most cost-effective strategy overall.
In contrast to children affected with familial hypercholesterolemia, the relationship of blood cholesterol levels in children without familial hypercholesterolemia to CHD later in life has not been established. A paucity of data exists that links lowering of cholesterol in childhood with reduced CHD morbidity and mortality in adulthood. Therefore, the benefits of detecting and treating childhood hyperlipidemia without familial hypercholesterolemia are not known. Despite the lack of patient-oriented outcomes research in this area, 2 guidelines recommend screening all children for hyperlipidemia.5,9