Published online January 3, 2005
PEDIATRICS Vol. 115 No. 1 January 2005, pp. 196 (doi:10.1542/peds.2004-1971)

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If It's Not Worth Doing, It's Not Worth Doing Well

Thomas B. Newman, MD, MPH
Department of Epidemiology,
University of California,
San Francisco, CA 94143-0560

To the Editor.—

In their article on the usefulness of the American Academy of Pediatrics (AAP) recommendations for identifying youths with hypercholesterolemia, O'Loughlin et al¹ conclude that the AAP parental history criteria offer little improvement over random population screening. This is consistent with multiple previous studies showing that family history is a poor predictor of elevated cholesterol levels in children.^2–8

In fact, the original⁹ and revised¹⁰ AAP recommendations for selective screening, which are similar to those of a National Cholesterol Education Project Expert Panel,¹¹ have always been difficult to justify with data.^12,13 This is not so much because some children with high cholesterol levels will be missed, which seems to be the primary concern of O'Loughlin et al, because the large number who are "found" are not likely to benefit.¹⁴ We know that the recommended diet will have virtually no effect on these children's blood cholesterol levels.^15,16 Most will simply stop showing up for follow-up visits,¹⁷ but some will likely be treated with drugs.¹⁸ This is concerning, because the treatment could last for decades and the drugs cause cancer in laboratory animals at doses not far from those given to people.¹⁹ The AAP's selective screening recommendations seem to have resulted from a desire to do something about cholesterol in childhood while recognizing that the costs, risk of labeling, and lack of a demonstrated safe and effective treatment argue against screening everyone.

However, good intentions do not always lead to good guidelines. Although the studies by O'Loughlin et al and others demonstrate that selective screening does not do much better at identifying elevated cholesterol levels than random screening, it would be a mistake to conclude that all children should therefore be screened. If something is not worth doing, it is not worth doing well.

REFERENCES

1. O'Loughlin J, Lauzon B, Paradis G, et al. Usefulness of the American Academy of Pediatrics recommendations for identifying youths with hypercholesterolemia. Pediatrics. 2004;113 :1723 –1727[Abstract/Free Full Text]
2. Bell MM, Joseph S. Screening 1140 fifth graders for hypercholesterolemia: family history inadequate to predict results. J Am Board Fam Pract. 1990;3 :259 –263
3. Dennison BA, Kikuchi DA, Srinivasan SR, Webber LS, Berenson GS. Parental history of cardiovascular disease as an indication for screening for lipoprotein abnormalities in children. J Pediatr. 1989;115 :186 –194[CrossRef][Web of Science][Medline]
4. Dennison BA, Jenkins PL, Pearson TA. Challenges to implementing the current pediatric cholesterol screening guidelines into practice. Pediatrics. 1994;94 :296 –302[Abstract/Free Full Text]
5. Garcia RE, Moodie DS. Routine cholesterol surveillance in childhood. Pediatrics. 1989;84 :751 –755[Abstract/Free Full Text]
6. Rifai N, Neufeld E, Ahlstrom P, Rimm E, D'Angelo L, Hicks JM. Failure of current guidelines for cholesterol screening in urban African-American adolescents. Pediatrics. 1996;98 :383 –388[Abstract/Free Full Text]
7. Griffin TC, Christoffel KK, Binns HJ, McGuire PA. Family history evaluation as a predictive screen for childhood hypercholesterolemia. Pediatric Practice Research Group. Pediatrics. 1989;84 :365 –373[Abstract/Free Full Text]
8. Starc TJ, Belamarich PF, Shea S, et al. Family history fails to identify many children with severe hypercholesterolemia. Am J Dis Child. 1991;145 :61 –64[Abstract/Free Full Text]
9. American Academy of Pediatrics, Committee on Nutrition. Statement on cholesterol. Pediatrics. 1992;90 :469 –473[Abstract/Free Full Text]
10. American Academy of Pediatrics, Committee on Nutrition. Cholesterol in childhood. Pediatrics. 1998;101 :141 –147[Abstract/Free Full Text]
11. American Academy of Pediatrics. National Cholesterol Education Program: Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics. 1992;89(3 pt 2) :525 –584
12. Newman TB, Garber AM, Holtzman NA, Hulley SB. Problems with the report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Arch Pediatr Adolesc Med. 1995;149 :241 –247[Abstract/Free Full Text]
13. Newman TB, Garber AM. Cholesterol screening in children and adolescents. Pediatrics. 2000;105 :637 –638[Free Full Text]
14. Newman TB, Browner WS, Hulley SB. The case against childhood cholesterol screening. JAMA. 1990;264 :3039 –3043[Abstract/Free Full Text]
15. The Writing Group for the DISC Collaborative Research Group. Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol. The Dietary Intervention Study in Children (DISC). JAMA. 1995;273 :1429 –1435[Abstract/Free Full Text]
16. Newman TB, Hulley SB. Reducing dietary intake of fat and cholesterol in children [letter]. JAMA. 1995;274 :1424[Abstract/Free Full Text]
17. Bachman RP, Schoen EJ, Stembridge A, Jurecki ER, Imagire RS. Compliance with childhood cholesterol screening among members of a prepaid health plan. Am J Dis Child. 1993;147 :382 –385[Abstract/Free Full Text]
18. Kimm SY, Payne GH, Stylianou MP, Waclawiw MA, Lichtenstein C. National trends in the management of cardiovascular disease risk factors in children: second NHLBI survey of primary care physicians. Pediatrics. 1998;102 (5). Available at: www.pediatrics.org/cgi/content/full/102/5/e50
19. Newman TB, Hulley SB. Carcinogenicity of lipid-lowering drugs. JAMA. 1996;275 :55 –60[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Related articles in Pediatrics Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Newman, T. B. Search for Related Content PubMed PubMed Citation Articles by Newman, T. B. Related Collections Office Practice Social Bookmarking                         What's this?