Universal Lipid Screening in Children and Adolescents: A Baby Step toward Primordial Prevention?

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There is clear pathologic evidence that the process of atherosclerotic cardiovascular disease (CVD)2 begins in childhood with the deposition of fatty streaks within the arterial walls and subsequently progresses into fibrous plaques throughout adolescence and early adulthood. This evidence has generated a substantial interest outside of primary and secondary CVD prevention and a focus toward primordial prevention. The recent National Heart, Lung, and Blood Institute (NHLBI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents updated recommendations for the identification, management, and treatment of all major cardiovascular risk factors in pediatrics (1). These guidelines, which have also been endorsed by the American Academy of Pediatrics (AAP), address issues related to nutrition, physical activity, tobacco, high blood pressure, lipids, obesity, and the metabolic syndrome. One major challenge of this integrated approach is accounting for the fact that the manifestation of CVD typically occurs later in life and a variety of environmental factors influence the progression or attenuation of risk. One updated NHLBI recommendation that is likely to cause controversy is the recommendation of universal screening for dyslipidemia by the age of 9–11 years and subsequently at an age of 17–21 years. Lipid screening should be performed with either a fasting lipid panel [total cholesterol, HDL cholesterol (HDL-C), triglycerides, non–HDL-C, LDL cholesterol (LDL-C)] or a nonfasting lipid panel (total cholesterol, HDL-C, non–HDL-C). Initiatives and research emerging over the past 2 decades have led to a variety of approaches and attitudes toward screening for pediatric dyslipidemias, which have produced conflicting recommendations and variations in clinical practice. In 1992, the National Cholesterol Education Program first recommended a tiered approach to pediatric lipid screening, in which a fasting lipid profile was recommended if the child had a positive family history of premature CVD or dyslipidemia, had an unknown …