Since 1992, the American Academy of Pediatrics (AAP) has been expanding its recommendations for childhood lipid screenings as a means to reduce the risk for early onset atherosclerosis. The most recent recommendation, from 2011, calls for universal lipid screenings on all children between 9 and 11, and then again between 17 and 21 years old.
The jury is still out as to whether this strategy is effective. Skeptics point to overworked primary care offices, excessive resource utilization, cost and burden to families. Sarah de Ferranti, MD, MPH, director of the Boston Children’s Heart Center Preventive Cardiology Clinic, is co-leading a study to model the efficacy of universal lipid screenings in adolescents and young adults according to the new AAP guidelines funded by the Patient Centered Outcomes Research Institute. As a separate effort, Boston Children’s Hospital has been assessing implications of implementing the 2011 guidelines in an academic primary care practice.
Since 2012, de Ferranti and her team have been conducting a quality improvement project on patients referred for lipid screenings by the Boston Children’s Primary Care at Longwood. “There are several implicit assumptions underlying the guidelines,” de Ferranti explains. “Our results so far suggest that many of those assumptions may not hold true for our patients. Time and additional data will tell us more.” In the meantime, de Ferranti suggests compliance with their guidelines to the fullest extent possible.
It is important to remember what’s at stake. Not only is the prevalence of pediatric lipid disorders high (1 in 5 children are affected), but numerous studies have demonstrated a correlation between lipid abnormalities in childhood and adult cholesterol disorders. One such disorder, familial hypercholesterolemia, is associated with an increased risk for heart attack between the ages 20 and 40. Several studies have shown that selective screening based on family history would miss approximately 50 percent of children with familial hyperlipidemia.
De Ferranti says there are two categories of patients with high lipid values:
- patients with a strong genetic determinant for increased lipid production
- patients who have made unhealthy lifestyle choices (poor diet and lack of exercise)
“I am more concerned about the first group,” says de Ferranti. “They tend to have extremely high lipid values. Plus, they have been exposed to those high values their entire lives, because it’s in their genes.” For children in the second group, it’s more likely that their lifestyle choices have only lasted a few years; therefore, the damage may be easier to reverse.
Patients who are genetically pre-disposed to abnormally high lipid levels should receive intensive counseling about healthy lifestyle choices. It is also important to think beyond the individual patient in this instance and ask if family members have also had lipid screenings. “Primary care providers are in the best position to provide that family-based care,” says de Ferranti.
If you have questions about lipid screening or other aspects of preventive cardiovascular care, contact Boston Children’s Preventive Cardiology Clinic.