PEDIATRICS Vol. 122 No. 4 October 2008, pp. 904-905 (doi:10.1542/peds.2008-2103)
LETTER TO THE EDITOR |
An Assessment of the New Lipid Screening Guidelines
Michael J. Steiner, MDWallace D. Brown, MD
Department of Pediatrics
Edmund Liles, MD
Departments of Pediatrics and Internal Medicine
University of North Carolina School of Medicine
Chapel Hill, NC 27514
To the Editor.—
The recently published "Lipid Screening and Cardiovascular Health in Childhood" clinical report from the American Academy of Pediatrics (AAP) Committee on Nutrition provides a comprehensive review of cholesterol values, atherosclerosis development, and hyperlipidemia treatment options.1 However, we do not feel that the lipid screening recommendations are justified on the basis of the narrative review.
The article by Moyer et al,2 in the same issue of Pediatrics, and other similar articles have demonstrated a general analytic framework for screening tests through which we can analyze the new recommendations.3–5 Is there evidence that lipid screening of children at increased risk satisfies this framework?
- Is there a causal relationship between childhood hyperlipidemia and adult cardiovascular events (not merely atherosclerosis)? The authors of the guidelines stated that "data supporting a particular level of childhood cholesterol that predicts risk of adult CVD [cardiovascular disease] do not exist... ."1
- Are there potential adverse effects of screening or treatment? There is some evidence suggesting potential adverse effects of screening and resultant labeling6 but no evidence regarding adverse effects of the potential resultant lifelong pharmacologic treatment.
- Does treatment of a screening-identified risk factor or disease change important clinical outcomes? There have been no published data linking treatment of childhood hyperlipidemia to a reduction in cardiovascular events. In addition, the standard treatment for the vast majority of identified children will be a healthy diet and regular exercise, which should occur for children with risk factors regardless of their screening results. The authors justified many of their recommendations by using adult treatment data. Therefore, we would like to point out that even in middle-aged men, medication treatment of isolated hyperlipidemia has very modest benefit,7 and whether women with isolated hyperlipidemia benefit from treatment is debated.8,9 The widely publicized recent null study with the drug ezetimibe (Zetia) has further clouded the complex relationship between hyperlipidemia treatment, atherosclerosis prevention, and actual clinical events.10
The magnitude of the proposed screening guidelines compounds the uncertainty of its utility. Thirty-five percent to 45% of children will be screened solely on the basis of unknown family history or family history of cardiovascular disease.1 In addition, 31% of US children have a BMI at >85th percentile11 and, therefore, would also be screened.1 Although overlap exists between the children meeting each criterion, this extensive program would screen >50% of the children and adolescents in the United States. Furthermore, normal lipid results will be rechecked every 3 to 5 years, with abnormal results monitored even more frequently.1 If carefully followed, millions of fasting lipid screens will be checked annually as a result of these recommendations.
As often happens, we do not have high-quality evidence to know whether targeted cholesterol screening will help us to address the potential impending wave of cardiovascular disease attributable in part to obesity and sedentary habits acquired in childhood. We hope the AAP will continue working with the National Institutes of Health and other funding agencies to support research that explores the benefits and risks of interventions such as early identification and screening. In addition, the AAP should continue providing clinicians with the most up-to-date information available. However, the AAP should acknowledge also that because high-quality evidence is not available, a definitive screening recommendation cannot be made; therefore, a wide variety of individual clinical decisions between physicians and families are acceptable. The US Preventive Services Taskforce guidelines,5 published in Pediatrics last year, supported this approach. Conflicting recommendations from national organizations are problematic for clinicians and can confuse families.
As general pediatricians who train resident physicians and medical students in outpatient care including disease prevention and health promotion, we understand the blend of art and science that comprises clinical care. However, we also believe that practice recommendations from the leading child health organization in the country should be held to a different standard. These far-reaching, but weakly supported, recommendations seem to do something, or worse yet everything, to avoid not doing enough.
REFERENCES
1. Daniels SR, Greer FR; American Academy of Pediatrics, Committee on Nutrition. Lipid screening and cardiovascular health in childhood.
Pediatrics. 2008;122
(1):198
–208
2. Moyer VA, Nelson D; US Preventive Services Task Force. Pediatricians and the US Preventive Services Task Force: a natural partnership to enhance the health of children.
Pediatrics. 2008;122
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3. Sackett DL, Haynes RB, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, MA: Little, Brown and Company; 1985
4. Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone; 2000
5. Haney EM, Huffman LH, Bougatsos C, Freeman M, Steiner RD, Nelson HD. Screening and treatment for lipid disorders in children and adolescents: systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2007;120 (1). Available at: www.pediatrics.org/cgi/content/full/120/1/e189
6. Rosenberg E, Lamping DL, Joseph L, Pless IB, Franco ED. Cholesterol screening of children at high risk: behavioural and psychological effects. CMAJ. 1997;156 (4):489 –496[Abstract]
7. Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group.
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8. Walsh JME, Pignone M. Drug treatment of hyperlipidemia in women.
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9. Prosser LA, Stinnett AA, Goldman PA, et al. Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics.
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10. Kastelein JJP, Akdim F, Stroes ESG, et al. Simvastatin with or without ezetimibe in familial hypercholesterolemia [published correction appears in N Engl J Med. 2008;358(18):1977].
N Engl J Med. 2008;358
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11. Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003–2006.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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