Is Universal Pediatric Lipid Screening Justified? YES Damon Dixon, MD, FAAP Preventative Cardiology March 7 th, 2016
None Disclosures
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.
General Pediatrics Screening Screening healthy population Selective screening UNIVERSAL SCREENING Newborn screen Hgb/HCT Lead levels MCAT questionaire HEADSS questionaire Hearing Vision
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
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
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 2016 1971 1990 2000 2005 2010 2015 2016
40 to 60% of children would be missed with dyslipidemia
Morbid Obesity Rates Increased
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)
Universal Lipid Screening 9 to 11 years of age
Screening Test Non-Fasting: Non-HDLc (TC-HDL) Sensitivity (88-96%) Specificity (98%) Fasting: Lipid Panel TC, LDL, TG, HDL VLDL TG/HDL (Obesity)
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
Atherosclerosis Begins in Childhood
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
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
When to Consider Treatment 1. Failure 6-12 months of lifestyle management 2. Age > 10 years of age 3. LDL-C Level: LDL-C (130-160mg/dL): 2 high level risk factors or conditions 1 high + 2 moderate risk factor or conditions LDL-C (160-189mg/dL): Positive Family History 1 high risk factor/condition 2 moderate risk factors/conditions LDL-C (>190mg/dL) No additional factors required
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):331-337.
Statin Medications are Safe in Pediatrics Well tolerated FDA approved > 10 years of age Side-effects rare Teratogenic
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
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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