I have a unique vantage point when it comes to the issue universal cholesterol screening in children, when compared to most pediatricians. My unique view stems from the fact that I am also an internist who deals with those children after they grow up on KFC Double Downs. The AAP\’s recommendations are supposed to be forward-thinking, addressing the increased rates of obesity in our country (in case you hadn\’t heard) and responding in kind.
The study that raised this issue recently appeared in the Journal Pediatrics, and it found the following (from a report on the study by TIME:
Among the 5,798 children who would not have been screened, nearly 10% had elevated LDL cholesterol levels (above 130 mg/dL), according to the study, published in the August issue of Pediatrics. And 1.7% had levels high enough (above 160 mg/dL) to warrant cholesterol-lowering medications. Indeed, of all the children in the study whose LDL levels were above 160, one-third were in the group who would not have been screened.
The current guidelines were put in place in the 1990s, and at the time, experts predicted that high cholesterol would be missed in as many as 25% of children, says Neal. But doctors assumed that in most cases, these children would have only slightly elevated cholesterol levels that would eventually be detected when they became adults and would be lowered with diet and exercise.
Neal\’s data show that may not be the case. Further, Neal says, the findings apply not only to heart-disease risk but also to the risk of diabetes, since high cholesterol at a young age is a strong predictor of prediabetes and diabetes. \”We worry about that because if these children don\’t change their ways, then they are going to have Type 2 diabetes,\” he says. \”It\’s something we would become more aware of if more children were screened.\”
So it seems obvious that we should be screening these children, right? I am fairly certain that many of my pediatric colleagues will become more aggressive on cholesterol screening because of this article. I think this is a mistake.
In my post, 10 Rules For Good Medicine, I stated in rule #1: ?Order as few tests as possible. No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always be answerable. If it is not, the test should not be done. The validity of this comment was debated by Dr. Centor on Kevin, MD, and I stand by that statement. We don\’t order tests to heap on guilt. We don\’t order tests to \”just know\” things. The reason to order a test is to make a decision: should I treat this patient, or should further testing be done?
In this case, I think nearly all cholesterol testing by a pediatrician is on very thin ice from an evidence standpoint, and for that reason, I don\’t check cholesterol in children or in teens unless there is a family history of premature coronary heart disease (under age 40). Furthermore, I think that any doctors who are doing so should stop until there is more evidence. But why shouldn\’t we find out if kids have high cholesterol? What\’s the harm in finding out? Here\’s the harm:
- We don\’t have a clear understanding of what high cholesterol numbers mean in children.
- We don\’t know if treating cholesterol in children reduces heart disease risk.
- We don\’t know the long-term harm in children and teens of using cholesterol-lowering medications.
Isn\’t it clear that high cholesterol causes heart disease? Isn\’t it clear that lowering cholesterol prevents heart disease?
No.
High cholesterol is associated with a higher risk of heart disease. Lowering cholesterol in certain specific situations with certain specific medications is associated with a lower rate of heart disease. We need to be very careful in this. Why? Because much of the claims of alternative medicine are based on the inference that association implies causality. It may be that cholesterol itself (LDL and HDL in particular) is one of the agents that causes heart disease, but that hasn\’t been proven. Why did Vytorin, which lowers cholesterol more than Zocor, not also lower the rate of heart attacks or fatal cardiac events? (Vytorin contains Zocor plus one other medicine that lowers cholesterol more.) The fact that it doesn\’t, suggests that cholesterol doesn\’t tell the whole story.
The bottom line? I am not testing kids for cholesterol because I don\’t want information I can\’t use. Sure, I can use it to scare parents and kids, but I don\’t think scare tactics really work. It doesn\’t change smokers\’ behavior to tell them how deadly cigarettes are. Besides, since there is no proof that giving a kid Lipitor will help him more than it harms him (you don\’t give it to girls because of birth defect risk). So you end up giving the same \”eat right and exercise\” talk you give if you hadn\’t checked cholesterol in the first place.
I\’m sure the drug companies wouldn\’t mind if kids were tested, though.
(See Gary Schwitzer\’s Coverage on this study for more perspective on it.)
I'm not arguing the medicine here, because you are the expert and I am not. However,
” 1. We don’t have a clear understanding of what high cholesterol numbers mean in children.”
Do we really have a clear picture of what high cholesterol numbers mean in adults? And if so, how do we differentiate between damage done once we are adults and damage done earlier under the same high-LDL scenario?
“2. We don’t know if treating cholesterol in children reduces heart disease risk.”
If we don't test, then we don't treat, so we don't know. How do we find out?
“3. We don’t know the long-term harm in children and teens of using cholesterol-lowering medications.”
Do we know what the long-term harm is in adults? How did we find out?
Where is the risk balance between not treating through lack of knowledge and treating without sufficient knowledge?
Interesting post. I'm MS2 (and love your blog) and just completing my epidemiology and public health course work – where we discussed screening, ethics, etc. On the surface, yes, screening without having any meaningful benefit to patient is something I'd agree we shouldn't do.
However, there could be a social utility argument – especially in the HITECH Act world of Electronic Health Records. If we don't know the longterm effects of elevated cholesterol in children, wouldn't part of the reason we don't know be because we don't have the data? Then collecting the data could have some benefit in helping epi studies… social benefit…and though it may not have immediate benefit to patient at present, could documenting that info one day provide benefit (say if we discover that elevated LDL in childhood is associated (that word) with CHD or diabetes in adulthood?)?
I guess the researcher in me wants the data, but the physician in training on my other shoulder says such hypothetical situations are weak justification for a procedure that could cost money and has risks without clear benefits…
Dr.Rob I agree completely!! But…….. in the interest of having as much information as possible for scientific purposes,it WOULD be interesting to see how these children develop.If they end up with coronary disease as an adult? Does the Cholesterol level normalize or change? In the interest of Research it would have its advantages to have this information. Whether THAT would be an advantage to the child? Maybe not now…maybe later? .
A question about medications being Tested on Children..how is that done at all?
It might be more sinful to send Mother and child to a nutritionist,where they can learn how to eat healthily and learn how to cook things that don't come in a box.I think telling parents they need to provide their children with a healthy diet is important but many simply have no idea how to do that or where to start.Education is really important. But I don't know how far that is in your hands as a Doctor.
I do think that if there is reason for them to feel guilty then let them have their guilt trip I think parents NEED to be told they are ultimately sending their children to an early grave,they should be made to understand that there is something they could do about that and then an offer to show them how should be made.Again I am not sure how far a Doctor gets help to support his/her pleas to parents in motivating them to give their children a healthy start or what insurance companies invest in prophylactic attempts to save enormous costs for the future.
Thanks for this, Doc Rob. I'm passing it on to my kids (the parents of my grandchildren) as a way of nurturing clear thinking about what tests are available vs. what they should pass on.
We have some picture of what it means in adults in specific situations: known coronary disease, stroke, diabetes; and there are also some primary prevention studies with some statins (Pravastatin, Lovastatin, and Atorvastatin) that show a reduction in “events.” So, yes there are trials that show statins do work to improve important things.
#3 is a very good point, and we operate on the best information we have at any time. Given what I have read, I think the risk of adverse effects from statins is small compared to the benefit in adults who are at high risk, and probably for adults with moderate risk as well. I give statins to people whose risk of cardiac event is over 10% over the next 10 years. There is little chance the statin will have anywhere near that high a rate of adverse events. But, many folks are not as aware of where there is and isn't evidence. I do my best to stay as up on it as I can.
Agree, but I don't think that justifies checking it. That's what academics are. If I check a test in a kid, I have to act on it somehow. Often we get information and have to ask ourselves: “now what?” It's not worth checking it on the individual basis. Parents are aware they are harming their kids, but we do need to remind them. We don't have to order a test to prove that.
Thanks.
[…] mind. And although I thoroughly agree with the stance he takes in his recent post against cholesterol screening in kids, I must take issue with his opening statement: I have a unique vantage point when it comes […]
I’ed..m confused ” I am not testing kids for cholesterol because I don’t want information I can’t use.” Data ordered & reviewed (eith history & Phys. Finding) gives valuable opportunity for awareness & lifestyle interventions. That is using information! We need to value ALL interventions beyond prescribing medications as essential to a realistic plan of care. Waiting for a generational trainwreck without devaluing your time in educational interventions..diet,excercise ,deconditioning and screening for dsylipidemia causes beyond obesity & inactivity seems very shortsighted. We,as primary care providers, have to start believing & valuing lifestyle interventions and the time to impliement and monitor as important as any medications we market.
But we should always be telling kids these things. Checking a cholesterol won’t change my stance. What if I check it and it is low? The teen is likely to think it doesn’t matter what he/she eats. Getting lab tests for “educational purposes” is likely to backfire (and often does). I order a test to help me make a decision: should I do X or Y? I get the test because I don’t have enough information to make that decision. For cholesterol, the question is: should I treat this person’s cholesterol or not? It is not: should I stress good diet, weight loss, and exercise. I will do that regardless of the test results. How does getting the test aid in my decision-making? It doesn’t, in fact it may make education more difficult.
I 100% agree with you Dr. Rob! My pediatrician just screened my 2 year old for lipids…he wasn’t fasting (in fact, he was eating/drinking milk right up until the draw) – and his total cholesterol was 215 and LDL 147. Now she wants to have him fast and check apolipoproteins so we can “have a baseline”! My son is not obese (<85th percentile for weight) and is active and has a great diet. I refuse to "restrict" a 2 year old based on these numbers! I also refuse to have his blood drawn again…(wouldn't have done it the frist time if I had known that is what she sent us for…I thought it was for a CBC and a lead level (required by daycare)). If the number is lower, that's great, and it's not going to be higher…either way, I can always give him healthier foods, so the "re-test" is not going to make much difference. Also, he is little, and it took 5 sticks to get his blood! Ouch. If she wants it, my pediatrician can go and physically restrain him at the lab. I refuse.