Lipid Screening in Childhood for Detection of Multifactorial Dyslipidemia
What is the evidence on benefits and harms of screening adolescents and children for multifactorial dyslipidemia?
At the request of the US Preventive Services Task Force (USPSTF), a systematic review was conducted in studies published between January 1, 2005, and June 2, 2015, including a USPSTF evidence report and reference lists of relevant studies and ongoing trials. Fair- and good-quality studies in English with participants 0-20 years of age were included. Outcomes included dyslipidemia, defined as total cholesterol (TC) ≥200 mg/dl or low-density lipoprotein cholesterol (LDL-C) ≥130 mg/dl, and atherosclerosis in childhood; myocardial infarction and ischemic stroke in adulthood; diagnostic yield (number of confirmed cases per children screened); and harms of screening or treatment. Simulated diagnostic yield was calculated as initial screening yield × positive predictive value from a study with confirmatory testing.
There have been no randomized clinical trials screening children for multifactorial dyslipidemia. Based on one observational study (n = 6,500) and national prevalence estimates, the simulated diagnostic yield of screening for elevated TC varies between 4.8% and 12.3% (higher in obese children [12.3%]), and at the ages when TC naturally peaks (7.2% at age 9-11 years and 7.2% at age 16-19 years). One randomized clinical trial (n = 663) found a modest effect of intensive dietary counseling for a low-fat, low-cholesterol diet on lipid levels at 1 year in children ages 8-10 years with mild to moderate dyslipidemia; mean between-group difference in TC change from baseline was −6.1 mg/dl (95% confidence interval, −9.1 to −3.2 mg/dl; p < 0.001). Between-group differences dissipated by year 5. The intervention did not adversely affect nutritional status, growth, or development over the 18-year study period. One observational study (n = 9,245) found that TC concentration at age 12-39 years was not associated with death before age 55 years.
The diagnostic yield of lipid screening varies by age and body mass index. No direct evidence was identified for benefits or harms of childhood screening or treatment on outcomes in adulthood. Intensive dietary interventions may be safe, with modest short-term benefit of uncertain clinical significance.
The subject of lipid screening of children and adolescents has been debated for years. While an important review, the clinical application of this review is limited. By restricting dyslipidemia to total and LDL-C, the systematic review did not include the National Health and Nutrition Examination Survey (NHANES) data showing 20% of children 6-19 years have adverse levels of 1 or more lipid value (non–high-density lipoprotein cholesterol [HDL-C], low HDL-C, triglycerides) and higher in those with an elevated body mass index, and did not assess the prevalence of lipid and nonlipid risk factors for atherosclerosis in families with premature coronary heart disease. As with many European countries, the National Institutes of Health 2011 guidelines advocate universal lipid screening in childhood aimed, in part, at identifying and treating the greatest number of individuals with familial hypercholesterolemia, a group at high risk for morbidity and early mortality.
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