At what age should a child be screened for dyslipidemia (high cholesterol)?

Screening for Dyslipidemia in Children

Universal lipid screening should be performed once between ages 9-11 years and again between ages 17-21 years for all children without cardiovascular risk factors or family history of early cardiovascular disease. 1

Screening Recommendations Based on Risk Factors

High-Risk Children (Screen as Early as Age 2)

• Children with a family history of:
  • Early cardiovascular disease (CVD) in parents, siblings, grandparents, aunts, or uncles (<55 years for men, <65 years for women)
  • Significant hypercholesterolemia (total cholesterol ≥240 mg/dL, LDL-C ≥190 mg/dL, or known primary hypercholesterolemia)
• Children with:
  • Type 1 or Type 2 diabetes
  • Chronic kidney disease/end-stage renal disease
  • Post-organ transplantation
  • Kawasaki disease with current aneurysms

Moderate-Risk Children (Consider Earlier Screening)

• Children with:
  • Obesity
  • Hypertension
  • Smoking
  • Chronic inflammatory diseases (lupus, juvenile rheumatoid arthritis)
  • HIV infection
  • Nephrotic syndrome
  • Kawasaki disease with regressed coronary aneurysms

Screening Protocol

1. Initial Screening:

   • For high-risk children: Begin screening as early as age 2 years 1
   • For children without risk factors: Universal screening at ages 9-11 years 1

2. Follow-up Screening:

   • If initial LDL-C is ≤100 mg/dL, repeat screening at ages 9-11 years 1
   • Second universal screening at ages 17-21 years 1
   • Even if normal, repeat screening within 3 years as cardiovascular risk factors can change dramatically during adolescence 1

3. Screening Method:

   • Initial testing can be done with a non-fasting lipid profile 1
   • Non-HDL cholesterol is a practical screening test as it can be accurately calculated in a non-fasting state 1
   • Confirmatory testing with a fasting lipid panel if initial results are abnormal

Rationale for Screening Ages

• Atherosclerotic process begins in childhood 1
• Data suggest divergence between affected and unaffected children beginning at age 10 years 1
• Total cholesterol and LDL-C levels decrease 10-20% during puberty, making ages 9-11 and 17-21 optimal screening windows 1
• Universal screening is necessary as selective screening based only on family history or lifestyle factors identifies only a portion of childhood lipid abnormalities 1

Management After Screening

• If abnormal lipid profile is detected:
  1. First-line treatment: Lifestyle modifications including dietary changes and increased physical activity 1, 2
  2. For children ≥10 years with LDL-C persistently ≥190 mg/dL despite 3-6 months of lifestyle therapy, consider statin therapy 1
  3. For children with LDL-C 160-189 mg/dL with positive family history or additional risk factors, consider statin therapy after lifestyle modifications 1

Important Considerations

• Identification of a child with severe hypercholesterolemia should prompt reverse-cascade screening of family members 1
• Selective screening based only on family history misses many cases of dyslipidemia 3
• Universal screening can identify severe lipid abnormalities that may otherwise go undetected 1
• Up to 30% of children with abnormal lipid profiles have no identifiable risk factors 3

Pitfalls to Avoid

• Relying solely on family history for screening decisions (misses many cases)
• Waiting until adulthood to screen (misses opportunity for early intervention)
• Failing to repeat screening during adolescence when lipid profiles can change
• Overlooking non-fasting testing options, which can improve screening compliance

By following these evidence-based screening recommendations, clinicians can identify children with dyslipidemia early and implement appropriate interventions to reduce long-term cardiovascular risk.