Cholesterol Screening in Children, Adolescents and Young Adults

The American Academy of Pediatrics recently released an update to its Recommendations for Preventive Pediatric Health Care, also known as the periodicity schedule, which will publish in the January 2016 issue of Pediatrics (published online Dec. 7). Among the updates is a new recommendation that will call for the screening of dyslipidemia, or high blood cholesterol levels, for patients between 9 and 11 years old. This recommendation is in keeping with the NLA Recommendations Part 1 and 2. Donnie Wilson, MD, FNLA, director of the Pediatric Lipid Clinic at Cook Children's Medical Center in Fort Worth, Texas, and one of the authors of Part 2 Recommendations, answered the questions below:

Why is cholesterol screening important?

• Familial hypercholesterolemia occurs in 1:200 to 1:500 individuals, including children. 
• One baby is born with familial hypercholesterolemia every minute.
• Although symptomatic coronary artery disease is rare in children, elevated blood cholesterol levels are present from birth and surrogate markers of atherosclerosis can easily be demonstrated in youth, creating the opportunity for prevention.
• Affected children are asymptomatic, usually of normal weight, and have no physical signs of hypercholesterolemia.
• In men with HeFH under 40 years of age, the relative risk for a nonfatal cardiac event is 100-fold greater than for the age-matched general population.
• In individuals with FH, the risk of a heart attack is more than 50% higher by the age of 50 for men and at least 30% higher in women by the age of 60.
• Early identification and treatment has been shown to be effective and safe in reducing CHD morbidity and mortality.

Who should you screen?

1. Children 2–18 years of age:
   1. In whom one or both biological parents are known to have hypercholesterolemia or are receiving lipid-lowering medications.
   2. Who have a family history of premature ASCVD in an expanded first-degree pedigree in men <55 or women <65 years of age.
   3. Whose family history is unknown (e.g., children who were adopted).

2. All children, regardless of general health or the presence or absence of CVD risk factors, between 9 and 11 years of age, with repeat lipid screening every five years thereafter if normal.

What should you test?

• A fasting or non-fasting lipid profile.
• Calculate the non-HDL-C to estimate all atherogenic lipoprotein particles.
• If the non-HDL-C level is ≥145 mg/dL (95^th percentile), additional follow-up is recommended.
• Two fasting lipid profiles should be obtained and the results averaged for evaluation of the CVD risk.
• Blood samples can be drawn by venipuncture or finger stick, and analyzed by point of care lipid testing, if available.
• Routine measurement of Lp(a), apo B, apo A1, and lipoprotein subclasses and their sizes by advanced lipoprotein analysis is not recommended at this time, but may be helpful in selected cases.

To be successful in busy pediatric practices, screening recommendations should include the recommended periodicity of routine visits (AAP—Bright Futures/EPSDT) and, ideally, should recommend screening in tandem with another blood draw to minimize trauma to the child, thus improving parental and patient acceptance.

For more information, contact the National Lipid Association or download the National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2. Journal of Clinical Lipidology, 9(2), 129-169. doi:10.1016/j.jacl.2015.02.003 [doi].