Is Universal Pediatric Lipid Screening Justified? YES. Damon Dixon, MD, FAAP Preventative Cardiology March 7 th, 2016

Transcription

1 Is Universal Pediatric Lipid Screening Justified? YES Damon Dixon, MD, FAAP Preventative Cardiology March 7 th, 2016

2 None Disclosures

3 What is a Pediatrician? Pediatrics is the specialty of medical science concerned with the physical, mental and social health of children from birth to young adulthood. Pediatricians encompasses a broad spectrum of health services ranging from preventative health care to the diagnosis and treatment of acute and chronic diseases.

4 General Pediatrics Screening Screening healthy population Selective screening UNIVERSAL SCREENING Newborn screen Hgb/HCT Lead levels MCAT questionaire HEADSS questionaire Hearing Vision

5 Prevention Strategies 1. Primordial Prevention > Prevent the development of RISK FACTORS 2. Primary Prevention > Prevent the Disease 3. Secondary Prevention > Early disease state & prevent symptomatic manifestation 4. Tertiary Prevention > Attempt to minimize the adverse impact of the disease

6 Prevalence of Common Pediatric Diseases Disease Inheritance Prevalence PKU AR 1/14,000 1/20,000 Galactosemia AR 1/60,000 CAH AR 1/15,000 1/20,000 Congenital Hypothyroid Multifactorial 1/3000 CF AR 1/3500 Heterozygous FH AR 1/500

7 Evolution of Pediatric Lipid Guidelines National Cholesterol Education Program (NCEP), Report of the Expert Panel on Blood Cholesterol Levels in Children & Adolescents, 1992 AAP-Cholesterol in Children (Committee on Nutrition), 1998 Lipid Screening & Cardiovascular Health in Children, 2008 Lipid Research Clinic Prevalence Study 1971 NCEP 1988 NCEP 1992 AAP 1998 USPSTF 2007 AAP 2008 NLA 2011 NHLBI 2011 AAP Bright Future 2012 USPSTF

8 40 to 60% of children would be missed with dyslipidemia

9 Morbid Obesity Rates Increased

10 USPSTF Lipid Screening Recommendations Children ages 1-20 concludes that there is (I)nsufficient evidence to recommend routine screening (2016) Did not recommend: BMI screening obesity (USPSTF, 2005)

11 Universal Lipid Screening 9 to 11 years of age

12 Screening Test Non-Fasting: Non-HDLc (TC-HDL) Sensitivity (88-96%) Specificity (98%) Fasting: Lipid Panel TC, LDL, TG, HDL VLDL TG/HDL (Obesity)

13 Pediatric Lipid Studies Korean Autopsy Study Lipid Research Prevalence Study PDAY Study Bogalusa Heart Study Muscatine Study CV Risk-Young Finns Study CARDIA Study NHANEs Statin Medication Studies DISC Study: The Dietary Intervention Study in Children STRIP Study: CATCH Study

14 Atherosclerosis Begins in Childhood

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17 Dietary counseling beginning in infancy is effective with results sustained into young adult life Sustained lower LDL-C, Lower SBP/DBP, less obesity and less insulin resistance

18 Lipid Risk Stratification Risk Factors Moderate Risk High Risk Family History - Premature CVD or Dyslipidemia BMI/Obesity >95 th percentile >97% percentile Hypertension No Rx Medications HDL-C <40mg/dl - Tobacco Use - Current Smoker Risk Conditions -Kawasaki with regressed coronary aneurysm -Kawasaki with current coronary aneurysm -Chronic Inflammatory Dz (SLE, JRA) -HIV Infection -Nephrotic Syndrome -Type I or II Diabetes -Heart Transplant -Chronic Kidney Dz/ESRD or post renal transplant

19 When to Consider Treatment 1. Failure 6-12 months of lifestyle management 2. Age > 10 years of age 3. LDL-C Level: LDL-C ( mg/dL): 2 high level risk factors or conditions 1 high + 2 moderate risk factor or conditions LDL-C ( mg/dL): Positive Family History 1 high risk factor/condition 2 moderate risk factors/conditions LDL-C (>190mg/dL) No additional factors required

20 Efficacy and Safety of Statin Therapy in Children With Familial Hypercholesterolemia: A Randomized Controlled Trial No difference in academic performance, hormones, safety, labs JAMA. 2004;292(3):

21 Statin Medications are Safe in Pediatrics Well tolerated FDA approved > 10 years of age Side-effects rare Teratogenic

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24 Conclusions Pediatricians should practice primoridal prevention Atherosclerosis begins in childhood Screening can be performed early and affect the natural course of the disease Epidemic obesity & increasing rates of morbid obesity Lipid screening can be performed Fasting or Non-fasting Effective interventions Implementation NHLBI screening guidelines are lagging Pediatricians continue to be the experts in preventative screening

25 THANK YOU!

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27 Provider Responses

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33 Principles for Screening Test 1. Condition should be an important health problem 2. Should be detectable in the early stages 3. Early detection & treatment can affect the course of the disease 4. Should be an acceptable treatment 5. The test should have a high sensitivity and positive predictive value (validity & reliability) 6. The cost of screening should be economically balanced