PEDIATRICS Vol. 115 No. 1 January 2005, pp. 196-197 (doi:10.1542/peds.2004-2233)
If It's Not Worth Doing, It's Not Worth Doing Well: In Reply
Jennifer O'Loughlin, PhDDepartment of Epidemiology, Biostatistics, and Occupational Health,
McGill University,
Montreal, QC, Canada H3A 1A2
Gilles Paradis, MD, MSc, FRCPC
Direction de Santé Publique de Montréal-Centre,
Montreal, QC, Canada H2L 1M3
Department of Epidemiology and Biostatistics,
McGill University,
Montreal, QC, Canada H3A 1A2
Division of Preventive Medicine,
McGill University Health Center,
Montreal, QC, Canada H2L 1M3
Marie Lambert, MD, FRCPC
Division of Medical Genetics,
Ste-Justine Hospital,
Montreal, QC, Canada H3T 1C5
Department of Pediatrics,
University of Montreal,
Montreal, QC, Canada H3T 1C5
With reference to our recent report that the current American Academy of Pediatrics (AAP) recommendation to use parental history of heart disease or elevated blood cholesterol to screen youth for hypercholesterolemia is not evidence-based,1 Drs Corwin and Boney highlight the need for new practice guidelines, and Dr Newman argues against cholesterol screening. Given the lack of useful screening criteria, we believe the issue that now needs debate, especially in the context of the ongoing pediatric obesity pandemic, is: Should all children be routinely tested for elevated low-density lipoprotein cholesterol (LDL-C)? This debate should center on understanding the costs and benefits of systematic routine testing.
What are the potential costs of not systematically testing all children? Elevated LDL-C is causally related to atherosclerosis, and several studies have established that the atherosclerosis process begins in early infancy and continues into adulthood with clinical manifestations in middle age.2–7 There is ample evidence of the benefits of cholesterol reduction with diet and lipid-lowering drugs in adults, and the National Cholesterol Education Program recommends screening adults beginning at age 20. Therefore, elevated LDL-C in childhood is a problem with potentially serious consequences, and because of the obesity pandemic, this problem will likely escalate. However, unless there are clear clinical indications, most children will never be tested for LDL-C, and many potentially treatable cases will be left undetected until adulthood. The long-term impact of not treating hypercholesterolemia in childhood is not known, but adult cardiovascular disease could occur earlier and more severely among those with a longer history of untreated hypercholesterolemia.
However, the problems with universal testing are at least twofold. First, hypercholesterolemia is, in reality, a population-wide problem related in large part to lifestyle and as such requires population-based prevention strategies to reduce its public health burden. As elegantly articulated by the late Sir Geoffrey Rose,8 the challenge when dealing with diseases of mass occurrence is to move the entire population distribution curve (in this case, of LDL-C) toward lower risk (in contrast to targeting only those individuals at high risk). However, there are few effective population-based interventions. We concur with Dr Newman that, too often, population-based prevention interventions are associated with little or no change at the individual level (although theoretically at least, even small changes in blood cholesterol levels in the population at large can have a large public health impact8). In addition, we continue to lack evidence for effective individually targeted interventions such as dietary counseling for elevated cholesterol levels in youth. One hypothesis of particular interest, for example, is that blood cholesterol testing in children might potentiate dietary counseling; in a recent review, 28 of 31 studies reported positive dietary changes as a result of screening, and 18 of 21 reported improvements in blood cholesterol.9 The danger of drug treatment for hypercholesterolemia in the pediatric population must be taken seriously, although with the current recommendations (ie, that only children >10 years old with a persistent LDL-C 
190 mg% after at least 6 months of the American Heart Association [AHA] step 2 diet) very few children will likely be treated pharmacologically.10 A second issue with universal testing is that it is virtually impossible to ascertain the benefits of universal testing on cardiovascular disease mortality and morbidity, because the clinical manifestations of hypercholesterolemia in childhood will occur 40 years after any intervention is initiated. This means that it could be very difficult to empirically justify expenditures related to universal testing and consequently to sustain such a recommendation.
In the end, although the debate needs to focus on costs and benefits of universal testing, we lack evidence for the effectiveness of various prevention and treatment options, and the debate cannot occur until this evidence base is established. We believe that priority must therefore be given to funding research to develop effective and clinically useful patient-education strategies as well as population-based prevention approaches. The AAP could take the lead in advocating for randomized trial evidence to establish the costs and benefits of universal cholesterol testing in the pediatric population. In the meantime, a reasonable practice guideline is that pediatricians offer recommendations to the families of all patients beginning at age 2, for the consumption of the AHA prudent diet, and measure blood cholesterol levels only if dietary counseling according to current AHA guidelines10 can be offered. An eventual revision of the current AAP screening guidelines should take health goals to be achieved into consideration, the resources needed to achieve these goals, and measurement of the benefits of screening.
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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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