Cholesterol Screening In Childhood Research Articles

Cascade screening for familial hypercholesterolemia from pediatric index cases diagnosed through universal screening

Heterozygous familial hypercholesterolemia (HeFH) is an autosomal dominant disorder causing elevated low density lipoprotein cholesterol (LDL-C) and premature atherosclerotic cardiovascular disease. Universal cholesterol screening in childhood leads to children serving as the index case for their family, but efficacy of cascade screening and genetic counseling in this population is not well understood. The institutional pediatric lipid clinic database was queried from 2011 to 2022 for subjects <18 years who met clinical HeFH diagnostic criteria (N = 256). Median peak LDL-C was 198 mg/dL (interquartile range 179–238 mg/dL) and 69.5 % of subjects were the index case. The number of new HeFH cases identified per index case was 3.55 ± 1.87. Genetic counseling was offered to 38.7 % of subjects and genetic testing was completed by 10.9 %, 53.6 % of whom had a pathogenic or likely pathogenic genetic variant for HeFH. Our findings highlight the effectiveness of cascade screening from pediatric index cases identified through universal screening. However, genetic counseling and genetic testing may be underutilized in this population.

Cholesterol Screening in Children: Is a Universal Approach Working?

Ample evidence supports that an individual's lifetime risk of atherosclerotic cardiovascular disease correlates to long-term, cumulative exposure to circulating cholesterol levels, beginning in childhood. Selective screening strategies based on family history fail to identify many children with hypercholesterolemia. Universal cholesterol screening in childhood is a worthwhile goal. However, cholesterol screening rates through childhood remain low. Mounting evidence clarifies the barriers to cholesterol screening in children. Specific strategies to foster universal screening in childhood have been proposed. We present an overview of the present state of childhood cholesterol screening, summarizing historical and contemporary guidelines and collating evidence of low adherence to current guidelines. We contend that novel approaches to universal cholesterol screening in childhood are warranted, and we present potential opportunities for improvement. We call for new and universal pediatric cholesterol screening guidelines.

Universal Screening of Cholesterol in Children

Atherosclerosis begins in childhood, and these early lesions are related to cardiovascular risk factors, including non-high-density lipoprotein cholesterol (HDL-C). Genetic disorders of lipid metabolism, principally familial hypercholesterolemia, have a high frequency in the population (about 1:300-1:500), and cause cardiovascular morbidity beginning in the third decade of life. The current obesity epidemic in children has worsened cardiovascular risk status. Cardiovascular risk factors present in youth often track into adulthood and are more predictive of future subclinical atherosclerosis than risk factors measured in young adulthood. Further, modification of risk factors beginning in childhood and young adulthood can lead to restoration to normal or improvement in measures of subclinical atherosclerosis measures both in those with genetic dyslipidemias and those with dyslipidemia secondary to obesity. Prior recommended selective lipid screening strategies based on family history or presence of other cardiovascular risk factors have failed to capture many with genetic dyslipidemia. Medium-term clinical trials of statin therapy for inherited dyslipidemias are safe and effective in lowering low-density lipoprotein cholesterol (LDL-C). Cholesterol screening in childhood is necessary to prevent cardiovascular morbidity in those with genetic dyslipidemias and to increase awareness of the need for behavioral intervention in those with multiple cardiovascular risk factors, often a result of the obesity epidemic.

Cholesterol Screening: Primary Prevention Comes of Age

The National Heart, Lung, and Blood Institute (NHLBI) recently published guidelines for cardiovascular health and risk reduction in children and adolescents. This broad-sweeping effort addresses everything from nutrition and diet to physical activity, high-risk diseases, and the metabolic syndrome. Perhaps most notable in the 42-page summary report1 is the recommendation for universal cholesterol screening in childhood. This represents an important departure from prior American Academy of Pediatrics guidelines,2–4 which had endorsed a selective screening approach for presumed at-risk children and adolescents.There are two principal reasons for the change in recommendations. First, the causal link between childhood dyslipidemia and adult coronary artery disease is now better supported by scientific study. Second, the increased incidence of childhood obesity has altered the prevalence of dyslipidemia. Though universal cholesterol screening in childhood had been discussed as early as the 1992 guidelines,2 proposals for universal screening were struck down in those guidelines and subsequent iterations due to lack of data. By 2008, the landscape was changing. Through studies such as Pathobiological Determinants of Atherosclerosis in Youth (PDAY),5 Cardiovascular Risk in Young Finns,6 and the Bogalusa Heart Study7 a more direct connection between childhood risk factors and adult cardiovascular disease has been described by researchers. Now, with accumulating evidence linking childhood dyslipidemia and adult atherosclerotic disease and a burgeoning population of obese children at risk for dyslipidemia, the time for universal cholesterol screening has finally come.The present guidelines recommend measuring non-HDL-C rather than LDL-C. This is, in part, due to ease of screening; the measurement of non-HDL-C is reliable, inexpensive, and does not require fasting. In addition, it appears to be a better screening tool than LDL-C in the metabolic syndrome and type II diabetes, which often accompany obesity. Since atherogenic particle numbers do not correlate well with LDL-C in these conditions (because there is less cholesterol per particle), measuring LDL-C alone can underestimate atherogenic potential.From hypertension to obesity to dyslipidemia we are witnessing a paradigm shift in the role of preventive medicine that could profoundly impact the economics of health care and the role of pediatrics in the health care landscape. For the first time, the medical community is looking to the field of pediatrics to address expensive, common, refractory adult medical conditions before they begin. We are now not only discussing primary prevention but primordial prevention — intervening on risk factors before they manifest. If you believe an ounce of prevention is worth a pound of cure, this is your time.The recommendation for universal cholesterol screening is clearly the most controversial aspect of these new guidelines. As others have pointed out, the use of lipid-lowering drugs in children with high cholesterol, presumably for many years, is not without risks.8 Further, it is not at all clear the benefit of these medications (lowered risk of cardiovascular disease and not just a lower cholesterol level) outweighs these risks in children and adolescents.

Fasting Might Not Be Necessary Before Lipid Screening: A Nationally Representative Cross-sectional Study

There are barriers to fasting lipid screening for at-risk children. Results of studies in adults have suggested that lipid testing might be reliably performed without fasting. To examine population-level differences in pediatric lipid values based on length of fast before testing. We used the National Health and Nutrition Examination Survey (1999-2008) to examine total cholesterol (TC), HDL (high-density lipoprotein), LDL (low-density lipoprotein), and triglyceride cholesterol components on the basis of the period of fasting. Young children fasted for varying times before being tested, and children older than 12 years were asked to fast; however, adherence was variable. We used ordinary least-squares regression to test for differences in lipid values that were based on fasting times, controlling for weight status, age, race, ethnicity, and gender. TC, HDL, LDL, or triglyceride values were available for 12 744 children. Forty-eight percent of the TC and HDL samples and 80% of the LDL and triglyceride samples were collected from children who had fasted ≥ 8 hours. Fasting had a small positive effect for TC, HDL, and LDL, resulting in a mean value for the sample that was 2 to 5 mg/dL higher with a 12-hour fast compared with a no-fast sample. Fasting time had a negative effect on triglycerides (β = -0.859; P = .02), which resulted in values in the fasting group that were 7 mg/dL lower. Comparison of cholesterol screening results for a nonfasting group of children compared with results for a similar fasting group resulted in small differences that are likely not clinically important. Physicians might be able to decrease the burden of childhood cholesterol screening by not requiring prescreening fasting for these components.

Educating NPs to educate patients: Cholesterol screening in pediatric primary care

Introduction: This study described practices, knowledge, and attitudes of primary care nurse practitioners (NPs) in Minnesota regarding cholesterol screening in children and adolescents. Methods: A survey including 22 questions pertaining to cholesterol screening, adapted from a telephone survey used by Arneson, Luepker, Pirie, and Sinaiko (1992), was mailed to pediatric and family NPs. Eighty-three of 221 surveys (38%) were completed, returned, and used for data analysis. Results: Although 96% of the respondents value childhood cholesterol levels as indicators of the risk of developing adult cardiovascular disease, only 64% follow the current recommendation to selectively screen cholesterol levels in patients who have a parent with hypercholesterolemia. Furthermore, only 55% of the respondents screen patients with a family history of premature cardiovascular disease, and only 58% screen patients with other cardiac risk factors. Whereas 57% of respondents correctly identified an acceptable total cholesterol level for children, only 34% correctly identified an acceptable LDL cholesterol level. Discussion: Gaps in knowledge and practice may prevent NPs from implementing recommended guidelines for childhood cholesterol screening. Educating NPs about cholesterol screening is necessary to ensure the comprehensive cardiac health assessment and management of pediatric patients. J Pediatr Health Care. (2002). 16, 60-66.

Cholesterol screening in childhood: results of a 9-year follow-up study in Swiss and Italian children in Switzerland.

Mass screening for blood cholesterol as part of routine preventive health care of children continues to be discussed in several countries. Results of longitudinal studies underline the importance of the predictive value of cholesterol levels assessed during childhood. Some countries have changed their recommendations during the past years to blood cholesterol screening for obese children only or for children of high risk families. In the Kindergarten-study Basel, a follow-up study on somatic, psychic and social development of Swiss and immigrant schoolchildren, cardiovascular risk factors were assessed at the ages of 5, 10 and 14 years. The age-specific levels of total and LDL-cholesterol found in our study were slightly higher and HDL-cholesterol lower than, for example, those found in the Bogalusa Heart Study. For total cholesterol no significant tracking correlations over the 5 and 9 year periods were found. Tracking of LDL- and HDL-cholesterol differed between nationalities and sexes. The total cholesterol/HDL-cholesterol index tracked slightly better. Italian girls showed the best 9-year tracking for HDL-cholesterol (r = 0.56). The differences between this and other studies can only partially be explained by different sampling and laboratory methods. Individual changes in cholesterol levels between the ages of 5 and 14 were marked. Sexual maturation was found to be of minor influence. Body mass index was the most consistent risk factor in our population. Changes of sex or growth hormone levels during puberty, but also changes of nutritional habits or physical activity might influence the individual cholesterol levels. Before recommendations on mass screening of cholesterol in children are made, the different longitudinal patterns of changes in cholesterol levels, and subpopulation-specific changes of nutritional habits and physical activity, should be discussed. The results of the Kindergarten study Basel suggest that attention should be paid to screening for obesity and to health education regarding nutrition and physical activity.

Cholesterol: Myth vs Reality?-Reply

We agree with the points made by Dr Newman, and, in our article, 1 we recommended against universal childhood cholesterol screening. We believe that cholesterol studies should only be performed for high-risk children. Our criteria for selecting these children are stricter than those of the 1991 National Cholesterol Education Program 2 and are outlined in the Figure. Dr Newman's important analyses, which he cited, have called attention not only to the wastefulness of some screening programs in terms of cost-effectiveness and national health care priorities but also to the detrimental effects they exert by mislabeling patients and leading to inappropriate, potentially harmful treatment. Our study, which demonstrates poor compliance with recommendations for childhood cholesterol screening and follow-up, supports his contentions. Reprint requests to Department of Pediatrics, Kaiser Permanente Medical Center, 280 W MacArthur Blvd, Oakland, CA 94611-5693 (Dr Bachman).

Cholesterol screening in children: should obesity be a risk factor?

To determine whether obesity should be added to the current American Academy of Pediatrics (AAP) criteria for cholesterol screening in childhood, the charts of 99 children referred for evaluation of either hypercholesterolemia (n = 53) or obesity (n = 45) were reviewed. Compared with obese children, nonobese hypercholesterolemic subjects were younger (8.4 vs 11.4 years) and had lower mean body mass index and % ideal body weight. Frequency of elevated (> 90th percentile for age) total and low-density lipoprotein cholesterols were similar in both groups. Fifty-three of 65 children who met the current AAP criteria were hypercholesterolemic, however, 23/76 hypercholesterolemic children failed to satisfy these screening criteria. Thirty-six of 45 obese children had cholesterol levels > 90th percentile, suggesting increased risk for hypercholesterolemia in this group. If obesity was added to the AAP criteria, 66/80 hypercholesterolemic subjects would have been identified. These modified criteria, vs AAP standards, significantly improved both their sensitivity (70 vs 87%, p < 0.02) and negative predictive value (45 vs 30%, p < 0.02). Pending further studies in larger pediatric populations, these data indicate that obesity should be considered a risk factor for hypercholesterolemia in childhood, and we recommend modifying the AAP screening criteria to include obese children.

Screening for Familial Hypercholesterolemia in Childhood

Widespread blood cholesterol screening in childhood is not an effective strategy for decreasing the burden of coronary heart disease in the US population. Screening to identify older children and adolescents at high risk for developing coronary heart disease in early adulthood makes sense, but only if it is limited to individuals with positive family histories and if the cutoff point for further diagnosis and treatment is set high enough so that the benefits clearly outweigh the risks. These conditions are met for the case of the heterozygous form of familial hypercholesterolemia, which accounts for approximately 5% of cases of premature coronary heart disease. Screening for familial hypercholesterolemia is defensible because of (1) the serious prognosis and relatively high prevalence of familial hypercholesterolemia, (2) the existence of appropriate initial screening and follow-up diagnostic tests, (3) the fact that family history-directed screening is likely to be effective in detecting affected individuals, and (4) the apparent effectiveness of intervention in adolescence for a disease that would otherwise manifest in early adulthood.

Compliance with childhood cholesterol screening among members of a prepaid health plan.

To assess compliance with cholesterol screening and intervention by children who were members of a prepaid health plan in which there was no financial barrier to intervention. Children with family histories of hypercholesterolemia, coronary heart disease, and stroke were advised to have a random cholesterol test. Those with total cholesterol levels of 4.80 mmol/L (185 mg/dL) or higher were asked to return for a fasting blood test; of this group, compliant subjects with low-density lipoprotein values of 3.25 mmol/L (125 mg/dL) or higher were offered a nutrition program. Kaiser Permanente Medical Center, Oakland, Calif. The parents of 1160 children aged 2 to 18 years who had routine pediatric appointments at Kaiser Permanente Medical Center were asked to complete screening forms on family history. Children with family histories of hypercholesterolemia, coronary heart disease, and stroke were advised to have a random cholesterol test. Subjects with total cholesterol levels of 4.80 mmol/L or higher were asked to return for a fasting test, and subjects with low-density lipoprotein levels of 3.25 mmol/L or higher were offered a nutrition program. Telephone call, letter, low-cholesterol diet, and nutrition program. Of the 1,160 subjects contacted, 529 (46%) had positive family histories. Of these subjects, random blood cholesterol levels were determined for 369 (70%); 160 (30%) did not comply. Ninety-three subjects had total cholesterol levels of 4.80 mmol/L or higher; of these, 35 (38%) did not comply with follow-up testing. Of the 58 compliant subjects, 25 (43%) had low-density lipoprotein values of 3.25 mmol/L or higher and were offered either a 3-week or a 6-week nutrition program. Only nine subjects (36%) enrolled; 16 (64%) did not comply. Parents do not comply well with a childhood cholesterol screening program that involves two blood tests and moderately intensive educational intervention. Compliance is an important component of cholesterol screening and intervention.

Childhood Cholesterol Screening: Contraindicated

WE RECENTLY presented the case against childhood cholesterol screening. 1 In short, screening children, even the 25% with a family history of high blood cholesterol or early coronary artery disease, is a waste of money that is likely to do more harm than good. Resnicow et al, 2 in The Case Against `the Case Against Childhood Cholesterol Screening,' disagree with our position. They make three important points we wish to reiterate: (1) Extrapolation of findings from... nonrepresentative adult populations to the general pediatric population should be made with extreme caution. (2) There are many empirical questions regarding the efficacy and safety of early (universal) detection and treatment of hypercholesterolemia in children that can only be answered through controlled research. (3) Any discussion regarding the early detection and treatment of hypercholesterolemia should be framed by the parameters of whether the ultimate gains, both medical and economic, outweigh the risks. Given their

The Predictive Value of Childhood Cholesterol Screening

A RECENT commentary inTHE JOURNAL, The Case Against 'the Case Against Childhood Cholesterol Screening,' by Resnicow et al, 1 questioned the methods and reasoning of our work evaluating the use of screening cholesterol levels in childhood to predict adult hypercholesterolemia. 2 Resnicow et al question our method of calculating the sensitivity and predictive value of childhood cholesterol levels in relation to adult hypercholesterolemia. We accepted the cutpoint suggested by the National Cholesterol Education Program Adult Treatment Panel for the identification of adults who require individual treatment by a health care professional. Resnicow et al are correct in indicating that this resulted in asking what percentage of adults (age 20 to 30 years) with cholesterol levels above about the 80th percentile had values greater than the 90th percentile as children. They indicate that this results in a test the sensitivity of which could not exceed 50%. While this is the

Childhood cholesterol screening

Childhood cholesterol screening

Childhood cholesterol screening: contraindicated

Childhood cholesterol screening: contraindicated

Cholesterol screening in childhood: Sixteen-year Beaver Coynty Lipid Study experience

To determine the extent to which cholesterol measured in childhood is predictive of values in adulthood, the investigators conducting the second follow-up of the Beaver County Lipid Study tracked the cholesterol values of 295 adults who had initially participated as children (ages 11 to 14 years) in a countywide school screening program. The follow-up study was conducted 16 years after the initial study, when the participants had reached a mean age of 28 years. The overall correlation (r) between baseline (1972-1973) total cholesterol values and the values found at the present follow-up was 0.44 (p less than 0.0001). Women had a higher correlation (r = 0.51) than men (r = 0.38). In addition, the efficacy of childhood screening for cholesterol levels was assessed by considering currently recommended borderline values (greater than 175 mg/dl (4.6 mmol/L) for children and greater than 200 mg/dl (5.2 mmol/L) for adults) as a "positive" test result. The sensitivity of screening at age 12 years for predicting elevated adult total cholesterol concentrations was 63%, specificity was 67%, and the predictive value of a positive test result was 47%. Comparison of false-positive results (above the borderline cutoff point as a child but not as an adult) and false-negative results (below the borderline cutoff point as a child but above it as an adult) showed that male subjects with false-positive results smoked significantly less than those with false-negative results (p less than 0.05) and had a greater improvement during the preceding 7 years in cholesterol-lowering dietary practices (p less than 0.01). Female subjects with false-positive results smoked significantly less than those with false-negative results (p less than 0.05), were less overweight (p less than 0.05), and had a lower prevalence of oral contraceptive use (p less than 0.01). These results support the potential value of screening for hypercholesterolemia in childhood on a population basis. Although some subjects were misclassified as a result of childhood screening, some of this misclassification was associated with adopting changes that a screening and intervention program would be designed to promote--nonsmoking, weight control, and a prudent diet.

The case against 'the case against childhood cholesterol screening'

The case against 'the case against childhood cholesterol screening'

Cholesterol Screening in Childhood

Annals of the New York Academy of SciencesVolume 623, Issue 1 p. 193-199 Cholesterol Screening in Childhood Targeted versus Universal Approaches KAREN S. KUEHL, KAREN S. KUEHL Georgetown University Children's Medical Center 3800 Reservoir Road, Northwest Washington, D.C. 20007Search for more papers by this author KAREN S. KUEHL, KAREN S. KUEHL Georgetown University Children's Medical Center 3800 Reservoir Road, Northwest Washington, D.C. 20007Search for more papers by this author First published: April 1991 https://doi.org/10.1111/j.1749-6632.1991.tb43728.xCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume623, Issue1Hyperlipidemia in Childhood and the Development of AtherosclerosisApril 1991Pages 193-199 RelatedInformation

The case against childhood cholesterol screening

The case against childhood cholesterol screening

Children Should Not Be Routinely Screened for High Blood Cholesterol

To the Editor .—We disagree with Dr Strong's 1 recommendation that pediatricians screen all children for high blood cholesterol. Our opposition to childhood cholesterol screening is based on an assessment of the evidence as to the benefits and adverse effects of such a policy. Proponents of screening believe that identifying children with high blood cholesterol conveys information about their risk of developing coronary heart disease (CHD) many decades later, and that this could lead to interventions that would prevent CHD more effectively if begun in childhood than if begun as an adult. However, the evidence does not support this belief. For one thing, even in carefully performed research studies the association between cholesterol measured in childhood and cholesterol measured only 10 to 20 years later is far from perfect. In the Muscatine study, 2 for example, fewer than half of the children with cholesterol in the top 10% of the