As directed by new guidelines from the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, my clinic recently started checking a non-fasting lipid panel for all ten year olds. The other day a father asked me a question I had sort of been asking myself for a few months now. Is it really necessary?
It is still a difficult question for me to answer, and it appears I am not alone. Since the release of the guidelines, the reaction has been mixed. Here’s a quick review of the arguments for and against checking cholesterol for all kids.
The overall goal of the expert panel is to reduce risk of development of cardiovascular disease in the general population. This is an important goal, given that atherosclerotic cardiovascular disease (which leads to heart attacks and strokes) remains the leading cause of death in North Americans. Symptoms of disease are rare in children, but risk factors and behaviors affecting risk start early in life. Their recommendations to reduce this risk include tracking weight-for-height and BMI, encouraging breastfeeding, and advising a smoke-free home. But, it is the recommendation to check a non-fasting lipid panel (cholesterol and triglycerides) between 9-11 years of age that has received the most attention, because it represents a big shift in practice. For a number of years now, it has been recommended to check a fasting lipid panel for children with certain risk factors (family history of cardiovascular disease, parent with high cholesterol, or child with risk factors such as obesity). Never before has it been recommended that all children have blood drawn for this test.
The rationale of the expert panel is based on the fact that a child with high cholesterol or triglycerides will not show any symptoms. With the dramatic increase of child obesity in the last decades, many more children have high cholesterol. And, roughly 1 in 500 children has some form of familial hypercholesterolemia. This form of disease often has extremely high levels of cholesterol that require treatment, but is likewise a silent disease.
This all makes a lot of sense. The problems start with a set of unintended, although anticipated, consequences. What do we do with the results of these tests? For the children with very high cholesterol, the answer is relatively clear. They will require treatment with a specialist and possibly medication. But, what of the significant segment of children who have a borderline high result? They may require repeat blood tests, not an insignificant trauma for a child. They will be labeled as having “high cholesterol”, a label that may provide motivation, but could also lead to significant anxiety and focus on food in the family. And, in the end, their treatment may be what their healthcare provider would (hopefully) have already been talking about with the family- making healthy food choices and getting at least 60 minutes of active play per day.
There are additional concerns about actual cost, in time and money, of running these tests, as well as questions that remain about whether it is safe and effective for a child to take cholesterol-lowering drugs for a long period of time.
So, this is a tough one. The guidelines are comprehensive and thoughtful; and were written by a group of experts after much research. The results could potentially be very important for a small subset of children. Yet, as a pediatrician and parent, I wonder whether this particular test passes the medical dictum of, “first do no harm”. A recent viewpoint article in the Journal of the American Medical Association asks, “Is universal pediatric lipid screening justified?” I think the jury is still out.
What do you think? Would you want to know your child’s cholesterol level? Would it help motivate or cause anxiety? Should screening be universal or targeted?