Special CME Issue - West Virginia State Medical Association

Screening Children for Hyperlipidemia by Primary Care
Physicians in West Virginia
Collin John, MD, MPH
William Neal, MD
Department of Pediatrics, West Virginia University
Abstract
Background: Hyperlipidemia is a well
known risk factor for coronary artery
disease. Several studies have shown that
the initial stages of atherosclerosis, one of
the major manifestations of
hyperlipidemia, may be present as early
as age two. Despite this known risk,
screening children for hyperlipidemia is
sporadic at best. In 2008, the American
Academy of Pediatrics (AAP) published a
policy update with regards to
recommendations for screening children
for hyperlipidemia. The crux of the
recommendation is to obtain a fasting lipid
panel on children between the ages of
two and ten with a known family history of
hyperlipidemia, known traditional risk
factors for cardiovascular disease
(including a family history of premature
CAD), and/or an unknown family history.
This study was undertaken to assess the
current practices of family practitioners
and pediatricians in West Virginia with
regards to screening for hyperlipidemia in
children after the policy update.
Design and Methods: A thirteen item
survey consisting of demographic
questions and questions focusing on
screening children for hyperlipidemia was
constructed, pilot tested, and then
distributed to practicing family
practitioners and pediatricians all
throughout West Virginia. A total of 178
family practitioners and 104 pediatricians
returned a completed survey. The data
was analyzed with regard to screening
practices in general, as well as
differences in screening related to
practitioner type.
Results: Of the total sample of
practitioners (n=282), 42% routinely
offered screening for hyperlipidemia to
children between the ages of two and ten
with any known traditional risk factors for
cardiovascular disease. Pediatricians
were statistically more likely to routinely
offer screening according to the AAP
guidelines than family practitioners.
Additionally, 28% of the sample offered
screening to children between the ages of
two and ten with only a positive family
history of hyperlipidemia. 40% of the
sample was familiar with the new AAP
policy update.
Conclusion: A minority of sampled
practitioners offered screening for
hyperlipidemia to children in concordance
with the 2008 policy statement published
by the AAP. This result may stem from
lack of knowledge regarding the AAP
guideline or the persistence of conflicting
viewpoints regarding screening children
for hyperlipidemia in general.
Introduction
Coronary artery disease continues
to be the leading cause of mortality
among adults in the United States. 1
The major underlying cause of
CAD is atherosclerosis. There are
several risk factors associated with
the development of atherosclerosis,
one of which is the presence of
dyslipidemia. Elevated levels of lowdensity
lipoprotein and triglycerides
with or without concomitant
depressed levels of high density
lipoprotein have been repeatedly
shown to be associated with the
development of atherosclerosis in
multiple adult based studies. 1
While coronary artery disease is
a disease of adulthood, the initial
stages of atherosclerosis begin in
childhood. The Bogalusa Heart Study
analyzed the extent of atherosclerosis
among deceased children during
autopsy, and illustrated a strong
association between the extent of
atherosclerosis and LDL, HDL, and
serum triglyceride concentrations
in this age group. 2 As a result of
this study, the National Cholesterol
Education Program published
a series of recommendations
regarding screening children for
hyperlipidemia in 1992 that was
adopted by the American Academy
of Pediatrics. 3 They recommended
selective screening for children who
met the following criteria: a family
history of coronary artery disease
or myocardial infarction in a first
degree relative less than 55 years
of age, a family history of a parent
with elevated total cholesterol (>240
mg/dl), or an unknown family
history. 3 The PDAY study, published
in 2000, confirmed the association
between dyslipidemia in youth and
early onset atherosclerosis unearthed
in the Bogalusa Heart Study. 4
Despite this evidence, controversy
exists for screening children for
hyperlipidemia. In 2007, the United
States Preventive Services Task Force
gave lipid screening in children
an “I” recommendation stating
that “evidence is insufficient to
recommend for or against routine
screening for lipid disorders in
infants, children, adolescents, or
Objectives
In 2008, the American Academy of Pediatrics released new guidelines with regards to screening children for hyperlipidemia. The
authors undertook this study to assess the practices of screening children for hyperlipidemia by primary care providers in West
Virginia with respect to these guidelines.
30 West Virginia Medical Journal