PEDIATRICS Vol. 122 No. 4 October 2008, pp. 906-907 (doi:10.1542/peds.2008-2294)
LETTER TO THE EDITOR |
An Assessment of the New Lipid Screening Guidelines: In Reply
Stephen R. Daniels, MD, PhDDepartment of Pediatrics
Children's Hospital
Denver, CO 80218
Frank R. Greer, MD
Department of Pediatrics
University of Wisconsin School of Medicine and Public Health
Meriter Hospital
Madison, WI 53715
Nicolas Stettler, MD, MSCE
Division of Gastroenterology, Hepatology, and Nutrition
Children's Hospital of Philadelphia
Philadelphia, PA 19104
The letter by Steiner et al in reference to the recently published "Lipid Screening and Cardiovascular Health in Childhood" clinical report from the American Academy of Pediatrics (AAP) Committee on Nutrition1 makes some useful points. Perhaps most important is the difficulty of making clinical recommendations when the evidence base is less than optimum. Unfortunately, this is a situation that we face often in pediatrics, and in fact, much of what pediatricians do in the area of prevention on a daily basis has less supporting evidence than one would like.
Steiner et al provide points that are worthy of discussion. First, they ask if there is a causal relationship between childhood cholesterol levels and adult cardiovascular events? Although it is true that the definitive study has not been performed, it is also unlikely that it will be done, because this is a study with a 30- to 40-year duration. Steiner et al separate "merely atherosclerosis" from cardiovascular end points. It is doubtful that this distinction is helpful, because atherosclerosis is the proximate cause of cardiovascular events, and there is ample evidence that childhood cholesterol levels are closely linked with the development of atherosclerotic lesions early in life.2 It is also important to note that the first clinical event associated with atherosclerotic cardiovascular disease may be a sudden death. In addition, there are now studies linking risk-factor levels in childhood with markers of atherosclerosis in adulthood3 and evidence of risk-factor levels in young adulthood predicting future cardiovascular events.4,5
A concern is also expressed about adverse effects of screening. There is little evidence that such screening for cholesterol is harmful.
Perhaps most important is the question of treatment based on screening. It is true that there have been no clinical trials of treatment of cholesterol levels in childhood demonstrating a reduction in adult cardiovascular events. Again, it is unlikely that such evidence will be available. There is evidence that treatment with diet and pharmacologic agents can lower low-density lipoprotein (LDL) cholesterol levels6,7 and more recent evidence that treatment with pharmacologic agents in children with cholesterol elevation result in significantly slower progression of carotid intimal medial thickness compared with results from placebo treatment.8
Steiner et al indicate that the treatment for many children will be a healthy diet. The AAP recommendations include both a population and a high-risk strategy, both of which start with dietary changes. All children should be on a diet that is low in saturated and trans fats and includes appropriate intake of fiber, fruits, vegetables, whole grains, and low-fat diary products. However, it is clear that the dietary practice in most families is far from this ideal, and much public health work is still needed to reach these goals. The high-risk strategy for children with an elevated LDL cholesterol level is a more intensive approach to dietary change with the help of a dietitian. Without screening it would not be possible to provide this more intensive approach, and it is unlikely that this intensive diet intervention can be applied across the population.
We disagree with the statement that there is insufficient evidence of benefit of cholesterol lowering in adults. This evidence is clearly presented in the Adult Treatment Panel III of the National Cholesterol Education Program.9
Steiner et al suggest that pediatricians should follow the lead of the US Preventive Services Task Force (USPSTF). Our clinical report1 cited a USPSTF article that indicated there is insufficient evidence for or against making a recommendation for cholesterol screening in children. The USPSTF published a similar conclusion about the use of BMI to screen for obesity in children,11 an approach that is nonetheless recommended by the AAP. When there are ample data from a variety of clinical trials, the high standard of the USPSTF is useful for assessing if the evidence suggests that a prevention strategy should or should not be implemented. However, when there are too few data, the only option for the USPSTF is to observe that the evidence is insufficient to make a decision about screening (an "I" recommendation). This does not mean that the prevention strategy should not be considered. It should be remembered that a lack of evidence (an I recommendation) is not the same as evidence for a lack of effectiveness or safety. In fact, if we were to apply the USPSTF standards to all of pediatric prevention, we would have to remove much of what is currently recommended in the AAP's Bright Futures initiative. These issues are very clearly presented in an editorial by Moyer et al12 (and also cited by Steiner et al), which we would recommend all pediatricians read carefully.
Unlike the USPSTF, in clinical practice pediatricians do not have the luxury of not making decisions. When faced with a patient, they need to decide whether they will implement a preventive action based on the best available evidence. The AAP's clinical reports help pediatricians make these difficult clinical decisions in the context of imperfect data. It is instructive to examine how the recommendations of Steiner et al would work in clinical practice. For a mother who comes to the pediatrician concerned about her 13-year-old son whose father died suddenly 1 month ago at age 42 of a myocardial infarction, Steiner et al would have the pediatrician say that there is not enough evidence for us to be concerned about this teenaged boy. We would not want to know his level of LDL cholesterol and would tell his mother that, like other children his age, he should be on a healthy diet and get regular exercise. When the mother further indicates that his paternal grandfather and uncle also died in their 40s and had no other cardiovascular risk factors such as cigarette smoking, hypertension, or diabetes, their recommendation would still be inaction. We believe that our clinical report provides a better approach for this patient on the basis of the existing evidence.
We applaud Steiner et al for urging the National Institutes of Health and other funding agencies to support the kind of research needed to produce better and better clinical prevention recommendations. As they indicate, the clinical report from the AAP Committee on Nutrition provides pediatricians with the most up-to-date information on evaluation and treatment of dyslipidemia in children and adolescents. Steiner et al are also correct that conflicting recommendations from national organizations are problematic for clinicians and can confuse families. The recommendations regarding cholesterol in children from the AAP Committee on Nutrition are very consistent with those of the National Institutes of Health,13 the American Heart Association,14 and the American Diabetes Association.15
As general pediatricians, Steiner et al would choose to ignore the evidence that the process that leads to cardiovascular disease, which is the number 1 cause of mortality in our population, clearly starts in childhood and is progressive. We believe that pediatricians play an important role in the prevention of cardiovascular disease by the implementation of a healthy lifestyle in children and adolescents and the identification and amelioration of risk factors for cardiovascular disease in young patients.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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