Even when guidelines are clear, doctors do not always follow national screening guidelines.  So how do they behave in situations which may be too unsettled for guidelines to reign?  Take the example of cholesterol screening for children.  The National Heart, Lung, and Blood Institute (NHLBI) comes on strong and recommends universal screening for those ages 9 to 11 years.  The American Academy of Pediatrics (AAP) toes a middle ground, and the U.S. Preventive Services Task Force (USPSTF) just doesn’t believe there’s enough evidence to recommend any pediatric lipid screening.  So how often are pediatricians screening for cholesterol levels?  
The short answer is not very often.
In the May 7 issue of JAMA we reported that, from 1995 to 2010, doctors order cholesterol test on children (ages 2-21) on only about 3 percent of primary care visits.  We used patient data from the National Ambulatory Medical Care Survey (NAMCS), which provides nationally representative estimates.  While clinicians were more likely to order cholesterol testing for children who were older, taller, obese, Black, or lived in the South or Northeast, testing was infrequent among all groups.  Testing rates increased only slightly over time: 2.5 percent in 1995 to 3.2 percent in 2010.  We concluded that “Testing rates did not appear to increase after 2007-2008, perhaps reflecting the conflicting positions of the AAP and USPSTF”.

Why would we want our children to undergo cholesterol screening in the first place? Abnormal lipid values occur in 1 in 5 U.S. children and adolescents and are associated with cardiovascular disease in adulthood. If we could detect these abnormalities at a young age, there is a chance that we might be able to prevent later disease. But the advice to the majority of these children with high cholesterol will be to focus on lifestyle modification, advice that should not require a blood test.

As the conflicting society statements suggest, the benefits of having children and adolescents undergo this additional screening are not as clear cut as some guidelines might lead us to believe.  We must consider ethical and practical questions, including how to weigh benefits against the harms and costs, how to interpret limited scientific evidence, and how quickly we should prescribe pills to treat lifestyle issues.  In a way, pediatricians are weighing in on these questions through their practices. What would you do if you were a pediatrician (or a parent for that matter)?



Avik Chatterjee
09/14/2014 11:27pm

I am a pediatrician, and do not routinely check cholesterol in 9-11 year olds, except in obese children. If I were to find elevated lipids (I have not yet, though this is likely only because of a so-far small sample size), encouraging healthy eating and physical activity would still be my first and most important intervention. As Cheryl mentions--practical concerns are paramount--do I start a 9 year old on a statin for the rest of his life?

Sheryl Rifas-Shiman
09/16/2014 9:56pm

Thanks Avik! I’m not a pediatrician. But I think we lack data about the risks and benefits of long-term statin use in children. I agree with you that it is important for pediatricians to encourage obese children to eat healthy and get regular physical activity (regardless of whether or not they do cholesterol testing).

Avik Chatterjee
09/18/2014 8:23am

Have you seen this piece that just came out? It definitely helps reassure me that statins are probably safe in children. They followed ~100 children in the Netherlands with familial hypercholesterolemia (aged 8-18) for ten years on pravastatin, and found that they were safe. http://jama.jamanetwork.com/article.aspx?articleid=1902218

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