On Jan. 24, the U.S. Preventive Services Task Force (USPSTF) issued a guideline declining to recommend screening asymptomatic children and adolescents ages 20 or younger for lipid disorders, citing lack of evidence to properly assess its potential benefits and harms.
Serum lipid panel laboratory tests may be used to screen for both familial hypercholesterolemia (FH) and multifactorial dyslipidemia. Such tests measure different components of a patient’s cholesterol metabolism, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), non–high-density lipoprotein cholesterol (non–HDL-C), triglycerides, and high-density lipoprotein cholesterol (HDL-C).
However, there’s skepticism over the use of such tests to screen children and adolescents who don’t exhibit symptoms of either disorder. In 2011, the National Heart, Lung, and Blood Institute (NHLBI) and American Academy of Pediatrics (AAP) recommended screening of children ages nine to 11 for elevated cholesterol followed by another full lipid screening of adolescents between the ages of 17 and 21. The 2011 NHLBI guideline ran counter to all other guidelines existing at the time, including those issued by the USPSTF in 2007, that did not recommend lipid screening. Accordingly, the guideline drew heavy fire from the medical and scientific community, particularly for its reliance solely on observational studies and genetic natural history studies rather than randomized controlled trials.
Critics argued that universal lipid screening in children and adults would deliver no value for public health and result only in wasteful and costly overtreatment. Physicians were also skeptical, with one 2015 study finding very low levels of adherence to the NHLBI guideline’s lipid screening recommendation among primary care physicians.
In August 2016, the USPSTF issued revised screening guidelines confirming its previous view that there was not enough data currently available to support widespread cholesterol testing in asymptomatic children and adolescents. Seven years and one systematic evidence review later, the USPSTF is sticking to that original position, having reviewed 272 articles and more than 7,000 abstracts with evidence on cholesterol screening for FH and multifactorial dyslipidemia. “The current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger,” the USPSTF writes.
We are not recommending against such screening, notes the press statement accompanying the draft recommendation. We are just saying that we do not have enough evidence to make any kind of recommendation on screening youth for cholesterol disorders.
“Our recommendation highlights the need for more research on whether or not screening children for high cholesterol improves their heart health into adulthood,” noted task force member Li Li, MD, PhD, MPH, in the press release. “In the absence of this data, health care professionals should use their judgment on whether to measure the cholesterol levels of their young patients, and caregivers should share any concerns related to cholesterol or heart health.”
The draft recommendation also identifies the needs and gaps in the current research on lipid test effectiveness and potential harms:
- Long-term data on the harms of screening and treatment;
- Long-term data on the effectiveness of screening and treatment of lipid disorders in kids and adolescents to stave off premature cardiovascular disease events or death later in life; and
- Comparative effectiveness data that evaluates the best age at which to begin a lipid-lowering intervention for children and adolescents, including the harms and benefits of starting pharmacologic treatment as a child versus as a young adult.
See a longer version of this article with additional insight in the upcoming March 2023 issue of Diagnostic Testing & Emerging Technologies, posted in advance of PDF publication.