Task Force Finds No Evidence to Support Childhood Lipid Screening

Larry Hand

August 09, 2016

ROCKVILLE, MD — The US Preventive Services Task Force (USPSTF) has concluded that insufficient evidence exists to make a recommendation on whether to screen for lipid disorders in children and adolescents 20 years old or younger[1].

The task force made its determination after reviewing two evidence reports that found no direct evidence of benefits or harms for childhood lipid screening for multifactorial dyslipidemia[2] and familial hypercholesterolemia (FH)[3].

"The USPSTF concludes that the current evidence is insufficient and that the balance of benefits and harms of screening for lipid disorders in asymptomatic children and adolescents 20 years or younger cannot be determined," the task force writes, giving a grade of "I" for insufficient as opposed to "A" for substantial benefit or "B" for moderate benefit.

The conclusion has prompted a series of opinion articles in several journals on what the lack of a recommendation means in the clinic[4–7].

Dr Samuel S Gidding (Nemours Cardiac Center, AI DuPont Hospital for Children, Wilmington, DE), who was directly involved in writing universal lipid screening recommendations adopted in 2011 by the National Heart, Lung, and Blood Institute (NHLBI) and the American Academy of Pediatricians (AAP), thinks that the task force is limited by narrow questions for research to answer.

"The USPSTF has a fairly strict evidence algorithm. They have critical questions and they do the evidence review to see if those questions can be answered," Gidding told heartwire from Medscape.

In his editorial[4] in JAMA Cardiology, he writes that the USPSTF core question was whether cholesterol measurement in a child can prevent a heart attack in adulthood and whether this measurement has any unintended consequences.

Causality criteria have been met regarding elevated LDL cholesterol being the surrogate end point for coronary heart disease (CHD), he writes, tying the genetic condition of FH to lifelong exposure to elevated LDL.

"The USPSTF should be encouraged to shift its primary question from whether cholesterol measurement in childhood prevents heart disease in adults to whether those whose high lifetime risk of CHD, based on prolonged exposure to elevated LDL-cholesterol levels, can be recognized at a young age when lowering LDL cholesterol—as the known cause of CHD—can be safely initiated," Gidding says.

"I think the [task force conclusion] leaves people with the idea that you shouldn't measure cholesterol in kids when, in fact, even if you don't agree with universal screening, there are a large number of kids who ought to have their cholesterol measured either because their parents could have cholesterolemia or they have diseases known to cause premature heart disease," he told heartwire .

On the other hand, Dr Thomas B Newman (University of California, San Francisco), coauthor of another editorial[5], in JAMA Internal Medicine, questions the cost-effectiveness of lipid screening in children.

"It's unfortunate that the US Preventive Services Task Force has chosen not to consider costs in its recommendations because value is an important consideration in deciding what things to recommend, particularly given that anything that the task force recommends needs to be covered by third-party payers," Newman told heartwire .

"We think the Preventive Services Task Force should consider value in its deliberations. Of course, that could make its statements even more controversial," he added. "The idea that we should make wide-ranging public-health recommendations that affect millions of people and just close our eyes and ignore costs is not sustainable."

"One thing we do know is the absolute risk of events before age 20, even in children who are heterozygous for familial hypercholesterolemia, is close to zero," he said.

Had the task force considered value in reaching their conclusion, Newman and colleagues write, "a grade D (a recommendation against screening) would have been appropriate."

In an editorial[6] in JAMA Pediatrics, Dr Stephen R Daniels (University of Colorado School of Medicine and Children's Hospital Colorado, Aurora) questioned why the USPSTF has recommended using body-mass index to screen for obesity in children and adolescents but not recommended lipid screening.

"Why should we screen for obesity but have insufficient information to reach a conclusion for screening for heterozygous FH when there seem to be important parallels in these clinical entities?" he writes.

The task force statement "leaves the clinician in a quandary," he continues. "The clinician must review the evidence and the gaps in evidence to decide on a course of action."

And in another opinion[7] in JAMA, Dr Elaine M Urbina (Cincinnati Children's Hospital Medical Center, OH) and Dr Sarah D de Ferranti (Boston Children's Hospital, MA) write that, in light of phenylketonuria tests newborns undergo, "it seems reasonable that clinicians should also perform screening to detect FH (and pediatric lipid disorders), a disease that is far more common and is known to cause early morbidity and mortality."

The Agency for Healthcare Research and Quality supports the USPSTF. Disclosures for the USPSTF authors are listed in the article. Gidding reported serving as a member of the scientific advisory board and the publications committee of the FH Foundation; receiving research funding from the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases as coinvestigator at the echocardiography reading centers of the CARDIA and TODAY studies; receiving honoraria from the International Atherosclerosis Society for lectures and manuscripts related to familial hypercholesterolemia; and serving as a member of the National Heart, Lung, and Blood Institute Expert Panel and the American Academy of Pediatrics Bright Futures Program that published the Integrated Guidelines for Cardiovascular Risk Reduction in Children and Adolescents in 2011. Newman and coauthors report no relevant financial relationships. Daniels is a member of a data monitoring committee for Novo Nordisk and is a member of an advisory committee for Sanofi. Urbina reports grants from the National Institutes of Health and the American Heart Association and travel support from AtCor Medical. de Ferranti reports grants from the National Institutes of Health and the New England Congenital Cardiology Research Fund and receipt of royalties from UpToDate.

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