The US Preventive Services Task Force (USPSTF) recently updated their 2007 recommendations on the screening for lipid disorders in children and adolescents of 20 years or younger, saying that the evidence of efficacy of screening lipid disorders risk factors for cardiovascular diseases is not sufficient to make standardized recommendations. The recommendation statement from the USPSTF was published in the Journal of the Medical Association (JAMA).

The USPSTF made the decision after reviewing the prospects of screening from the evidence reports in a review published in JAMA for heterozygous familial hypercholesterolemia (FH), a genetic disorder, and in another review that focused on screening for multifactorial dyslipidemia, mostly acquired due to various factors that can be either genetic or based on lifestyle.

The decision was made on the evidence based grounds of the universal and selective screening approaches, the effectiveness and harms of long-term treatment and the harms of screening which suggest that the evidence for the positive health outcomes associated with the improvement in the cardiovascular risks are limited.

In an editorial, it was stated that the recommendations are the same as they were in 2007. It is worth mentioning here that universal lipid screening for children and adolescents has been recommended by the National Heart, Lung and Blood Institute (NHLBI), the American Heart Association and the National Lipid Association for identifying FH, a genetic disorder that occurs in approximately 1 in every 250 individuals in the United States. According to JAMA Cardiology, it was in 2011 when the NHLBI and the American Academy of Pediatrics published guidelines for cardiovascular risk reduction in children and adolescents that recommend universal screening for blood cholesterol levels at ages 9 to 11 years and 17 to 21 years. But the USPSTF believes otherwise due to the scarcity of the scientific evidence available on the efficacy of this subject and the negative prospects of screening.

David Grossman, MD MPH, and the vice chair of the USPSTF, who is also affiliated with Group Health Research Institute, Seattle, Washington, in an interview with the Editor in Chief of JAMA, Howard Bauchner, MD, shed light on his viewpoint regarding the issue.

David believes that the long term adverse effects of the treatment options and the lack of evidence halt the US taskforce from making rash decision about the universal recommendation for the screening. He said that the effect of statins — the common treatment drugs for lipid disorders — have not been monitored in children or adolescents fewer than 20 and the present studies only provide the evidence for a follow up period of two years or so, which is totally insignificant for labeling the statin drug treatment for children as safe. Hence, it leaves the efficacy of recommendations regarding screening of lipids for all children in doubts.

Moreover, he made it clear that it would not be appropriate to make the screening of lipids for children mandatory on broader level due to the possibility of getting false positive results that can jeopardize the health status of the child by pushing into wrong treatment interventions.

Statins are the drugs that lower bad cholesterol levels in blood by inhibiting the activity of cholesterol synthesizing enzyme hydroxymethylglutaryl coenzyme A reductase in the cholesterol-synthesis pathway in the body. Upon consumption of statins the circulating LDL cholesterol gets cleared out of the system to a great extent, according to a summary report on the guidelines for lipid screening for children by the National Heart, Lung and Blood Institute (NHBLI). The report also suggests that the chances of myopathy and hepatic enzyme elevation at standard doses of statins are rare and do not pose negative effects in majority of cases.

The proof was further backed up by the evidence from a meta-analysis of statin use in children. According to which the increment in the level of hepatic enzyme and muscle toxicity did not differ between those who took statin and the placebo group. However, it was also stipulated that with the use of statins, routine monitoring of hepatic enzymes and clinical assessment for muscle toxicity should be ensured for children and adolescents on statin therapy.

In addition to statins, evidence for the use of bile acid binding sequestrants in the cases where the LDL levels are not reduced with either one of the medication also suggest that this unique combo boosts the efficacy of treatment and has no adverse effects on the health status of children, according to the same report by NHBLI.

But it should also be noted that these drugs, specifically statins, do not come without adverse effects and are associated with causing myopathy and elevates hepatic enzyme levels in the body, in addition to other mild symptoms such as nosebleeds, muscle and joint pain increased blood sugar level (hyperglycaemia), an increased risk of diabetes, and other digestive problems, accompanied by some of the rare symptoms such as visual disturbances, bleeding or bruises and jaundice, according to National Health Service, UK.

Hence, the USPSTF recommendations advise clinicians to make wise decisions according to the individual condition of every child, both in the cases of heterozygous familial hypercholesterolemia and multifactorial dyslipidemia, both of which might lead to cardiovascular diseases later in life of the high risk individuals.

USPSTF’s stance has been criticized by Dr Samuel S Gidding, MD, Nemours Cardiac Center, Hospital for Children, Wilmington, Delaware, who is of the opinion that some lipid disorders such as familial hypercholesterolemia (FH) are genetic and increase the risk of coronary heart disease in children. Screenings, therefore, are vital for such adolescent to reduce the likelihood of lethal heart disease. His views were published recently in JAMA.

 

Here is the audio link containing interview of David Grossman by Editor in Chief of JAMA.