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USPSTF: Data inconclusive on lipid disorder screening for children, teens
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The U.S. Preventive Services Task Force has issued a recommendation on lipid disorder screening in primary care on children and adolescents aged 20 years or younger, concluding that the current evidence is insufficient to assess the balance of benefits and harms.
The new announcement updates the 2007 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for lipid disorders among children, adolescents and young adults, which similarly failed to find sufficient data to recommend either for or against the practice. However, one difference in the 2016 recommendation is a new focus on screening for familial hypercholesterolemia, in addition to multifactorial dyslipidemia.
“Screening in children and adolescents may identify those with undiagnosed familial hypercholesterolemia or multifactorial dyslipidemia,” Kirsten Bibbins-Domingo, MD, MPH, a member of the USPSTF from the University of California, San Francisco, and colleagues wrote in the recommendation statement published in JAMA. “However, the clinical benefits and risks among children and adolescents identified with and treated among children and adolescents identified with and treated for dyslipidemia have not been sufficiently studied, making a role of screening in children and adolescents uncertain.”
USPSTF members conducted two evidence reviews on screening for lipid disorders among children and adolescents. The first focused on screening for heterozygous familial hypercholesterolemia while the second reviewed screening for multifactorial dyslipidemia. Both reviews sought fair- and good-quality English-language studies with participants aged 0 to 20 years, published between Jan. 1, 2005, and June 2, 2015. Data sources included MEDLINE, Cochrane Central Register of Controlled Trials and PubMed. Surveillance was conducted through April 2016.
Main outcomes and measures in the familial hypercholesterolemia review included myocardial infarction and ischemic stroke in adulthood, lipid concentrations and atherosclerosis in childhood, diagnostic yield of screening, and any harm caused by screening or treatment.
According to the researchers, universal lipid screening offered a diagnostic yield of 0.14% to 0.48% for detecting familial hypercholesterolemia in childhood. However, there was no direct evidence suggesting a relationship between screening and familial hypercholesterolemia outcomes in childhood or adulthood. In addition, the evidence suggested that lipid-lowering treatment of children with familial hypercholesterolemia improves lipid levels up to 50% with few short-term harms. Still, there was no evidence to assess lifelong usage, and no direct evidence on the relationship between either lipid levels or treatment in childhood or adulthood.
“Screening can detect familial hypercholesterolemia in children, and lipid-lowering treatment in childhood can reduce lipid concentrations in the short term, with little evidence of harm,” Paula Lozano, MD, MPH, of the Group Health Research Institute, at the Kaiser Permanente Research Affiliates Evidence-Based Practice Center in Seattle, and colleagues wrote. “There is no evidence for the effect of screening for familial hypercholesterolemia in childhood on lipid concentrations or cardiovascular outcomes in adulthood, or on the long-term benefits of harms of beginning lipid-lowering treatment in childhood.”
Outcomes and measures in the multifactorial dyslipidemia review included dyslipidemia (total cholesterol ≥ 200 mg/dL or LDL ≥ 130 mg/dL) and atherosclerosis in childhood, MI and ischemic stroke in adulthood, diagnostic yield, and harms of screening or treatment.
According to the researchers, the diagnostic yield of lipid screening varied by age and BMI, with no direct evidence for the benefits or harms of childhood screening or treatment on outcomes in adulthood. Lozano and colleagues additionally concluded that intensive dietary interventions may be safe, “with modest short-term benefits of uncertain clinical significance.”
In a related editorial published in JAMA Pediatrics, Stephen R. Daniels, MD, PhD, of the University of Colorado School of Medicine, Aurora, wrote that, as an I-grade recommendation, the USPSTF announcement is neither an endorsement nor a rejection of lipid disorder screening in children and adolescents.
In addition, he noted that such screenings are recommended by the AAP, the American Heart Association, the National Heart, Lung, and Blood Institute, and the National Lipid Association.
“An I statement leaves the clinician in a quandary,” Daniels wrote. “The clinician must review the evidence and the gaps in the evidence to decide on a course of action.” – by Jason Laday
References:
Daniels SR. JAMA Pediatr. 2016;doi:10.1001/jamapediatrics.2016.2315.
Lozano P, et al. JAMA. 2016;doi:10.1001/jama.2016.6176.
Lozano P, et al. JAMA. 2016;doi:10.1001/jama.2016.6423.
US Preventive Services Task Force. JAMA. 2016;doi:10.1001/jama.2016.9852.
Disclosure: Bibbins-Domingo reports having consulted for the Institute for Clinical and Economic Review on the cost-effectiveness of a new class of lipid-lowering drugs. No other authors reported any relevant financial disclosures. Daniels reports being a member of a data monitoring committee for Novo Nordisk, and membership of an advisory committee for Sanofi.