Guidelines for Lipid Screening in Children and Adolescents: Bringing Evidence to the Debate

Abstract

* Abbreviations: CV — : cardiovascular FH — : familial hypercholesterolemia IMT — : intima media thickness LDL-C — : low-density lipoprotein cholesterol The commentary of Newman et al1 regarding recommendations for lipid screening in childhood from the expert panel guidelines commissioned by the National Heart Lung and Blood Institute2,3 misrepresents the evidence regarding screening and the specificity and rigor of the guideline development process. The expert panel developed comprehensive, integrated, and evidence-based guidelines for promotion of cardiovascular (CV) health and the identification and management of specific risk factors from infancy into young adulthood. The large, diverse, and complex evidence base that addresses CV risk beginning in childhood, and the absence of decades long event-driven clinical trials, required consideration of substantial and consistent evidence from observational studies, developing a chain of evidence. A priori, a systematic process was used to review and grade the evidence and develop the recommendations, which is explicitly described in the Full3 and Summary Reports,2 and the evidence tables are available on the National Heart Lung and Blood Institute web site.3 Atherosclerosis is a lifelong process proven to begin and progress throughout childhood and adolescence. Childhood CV risk factors track into adulthood and have been shown in many autopsy and imaging studies in diverse populations to be strongly and consistently predictive of the extent of subclinical atherosclerosis in young adults. As an example, the Pathobiological Determinants of Atherosclerosis in Youth Study of individuals aged 15 to 30 years who had died traumatically showed that a 30 mg/dL incremental increase in non-high-density lipoprotein cholesterol was the equivalent of 2 years of vascular aging.4 The Bogalusa Heart Study showed that an increasing number of childhood CV risk factors exponentially increased the atherosclerotic burden noted at autopsy after accidental death.5,6 In the Cardiovascular Risk in Young Finns Study, higher low-density lipoprotein cholesterol (LDL-C) at ages 12 to 18 years was independently … Address correspondence to Brian McCrindle, MD, MPH, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8. E-mail: brian.mccrindle{at}sickkids.ca