From the Guidelines
Children in the US are screened for hypercholesterolemia through a two-tiered approach, with universal screening recommended for all children once between ages 9-11 years and again between 17-21 years using a non-fasting lipid profile, as recommended by the American Heart Association 1.
Screening Approach
The screening approach involves:
- Universal screening for all children once between ages 9-11 years and again between 17-21 years using a non-fasting lipid profile that measures total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides.
- Targeted screening for children ages 2-8 years and 12-16 years if they have risk factors such as family history of early cardiovascular disease, parent with known hypercholesterolemia, or if the child has diabetes, hypertension, or obesity.
Risk Factors
Risk factors that may prompt targeted screening include:
- Family history of early cardiovascular disease
- Parent with known hypercholesterolemia
- Diabetes
- Hypertension
- Obesity
Screening Tests
Either a fasting or non-fasting lipid panel can be used for targeted screenings. If the initial non-fasting test shows abnormal results (total cholesterol ≥200 mg/dL or LDL ≥130 mg/dL), a follow-up fasting lipid profile is typically performed to confirm the diagnosis.
Benefits of Screening
This screening approach helps identify both familial hypercholesterolemia, which affects approximately 1 in 250-500 children, and other forms of dyslipidemia that may require intervention. Early identification allows for lifestyle modifications or medication when necessary to reduce long-term cardiovascular risk, as supported by the American Academy of Pediatrics 1 and the American Heart Association 1.
From the Research
Screening for Hypercholesterolemia in Children in the US
- The National Heart, Lung, and Blood Institute (NHLBI) recommends cholesterol screening of all children aged between 9 to 11 and 17 to 21 years, regardless of the child's general health or the presence or absence of cardiovascular disease risk factors 2.
- Universal cholesterol screening is recommended to identify children with hypercholesterolemia, particularly familial hypercholesterolemia, in order to initiate treatment and reduce the risk of future cardiovascular disease 3.
- The diagnostic yield of universal screening for familial hypercholesterolemia in childhood is 1.3 to 4.8 cases per 1000 screened, based on two studies with a total of 83,241 participants 4.
- 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 4.
- The US Preventive Services Task Force (USPSTF) has reviewed the evidence on benefits and harms of screening adolescents and children for heterozygous familial hypercholesterolemia, but found no direct evidence on the benefits or harms of pediatric lipid screening 4, 5.
Screening Guidelines and Practices
- The NHLBI's guidelines and provider education have been shown to increase screening rates for hypercholesterolemia in children, although overall screening rates remain low 2.
- A review of pediatric dyslipidemia emphasizes the importance of screening and treatment recommendations, and notes that treatment of pediatric dyslipidemia begins with lifestyle modifications, but primary genetic dyslipidemias may require medications such as statins 3.
- The American Academy of Pediatrics recommends universal lipid screening for all children between the ages of 9 and 11, and again between the ages of 17 and 21, although the evidence for this recommendation is based on expert opinion rather than direct evidence from randomized controlled trials 5.
Treatment and Outcomes
- Statins have been shown to be effective in reducing lipid levels in children with familial hypercholesterolemia, and observational studies suggest that such treatment has long-term benefit for this condition 4, 5.
- Non-statin drug trials have also shown statistically significant lowering of lipid levels in familial hypercholesterolemia populations, although few studies are available for any single drug 4.
- The long-term benefits of lipid screening and subsequent treatment in children and adolescents are uncertain, and further research is needed to determine the effectiveness of these interventions 5.