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AUSTRALIAN doctors have defended new US guidelines that call for a dramatic increase in lipid screening tests for children after they were dubbed “extremely aggressive” in a journal article.
In a commentary published in Pediatrics, three physician researchers from the University of California, San Francisco, wrote that the new guidelines failed to weigh the health benefits against potential harms and costs of the program. (1)
The new guidelines call for universal screening of children aged 9–11 years with a non-fasting lipid panel and targeted screening of children aged 2–8 years and 12–16 years with two fasting lipid profiles. The guidelines were written by a panel assembled by the National Heart, Lung and Blood Institute and endorsed by the American Academy of Pediatrics. (2)
Australia does not have formal guidelines for cardiovascular risk assessment in childhood. The National Vascular Disease Prevention Alliance recommendations do not suggest testing until age 45 (or age 35 for Aboriginal and Torres Strait Islander Australians).
In their commentary, the researchers said they believed the high evidence grades for the “extremely aggressive” paediatric lipid recommendations were “inaccurate and unjustified” and that the “conflicts of interest reported by panel members are too substantial to ignore”.
Under the guidelines for targeted screening, they estimated that 30%–40% of all children aged 2–8 and 12–16 would require two fasting lipid profiles, which would be a burden to families.
Australian experts have played down the criticisms. Associate Professor David Sullivan, head of the Cardiovascular Health Clinic at Royal Prince Alfred Hospital, Sydney, said that while he initially thought the guidelines were too aggressive, he now believed in their merit.
He said the new guidelines sought to address two substantial problems: inherited high cholesterol and obesity.
“The Americans are taking a proactive approach, which I think is needed, and though it is important for us to be mindful of the criticism levelled in the article, the issues have been examined extensively in familial hypercholesterolaemia and the results are extremely reassuring“, he said.
“The critics’ complaints about levels of evidence are very cynical because they know that it would be completely impractical to perform the trials that are necessary to prove the point to their level of satisfaction.”
He also noted that the authors of the article were all supported by public funding, which could be redirected if the guidelines were adopted. “I think both sides of the argument are acting in good faith, but neither can claim the moral high ground as far as this or many other health issues are concerned”, he said.
According to Dr Sullivan, family cascade screening, an alternative screening strategy that involves testing family members of people with familial hypercholesterolaemia, was not suited to the US health system but could work in Australia. “We have universal cover so we can provide population-based strategies, and family cascade screening is so cost effective that it’s an embarrassment that we haven’t implemented it”, he said.
“At present, we have no public health strategy that says this should happen. We are trying to increase awareness.”
Professor Gerald Watts, director of the Lipid Disorders Clinic at Royal Perth Hospital, agreed that familial hypercholesterolaemia should remain the main focus in Australia.
However, he noted that although the universal approach being taken in the US was much more aggressive, it was being led by the rising tide of obesity there.
“In theory it’s a good idea but it needs to be tried, tested and funded”, he said.
Professor Peter Clifton, head of nutritional intervention at Baker IDI Heart and Diabetes Institute, Melbourne, said he agreed with the commentary’s authors about the lack of evidence for treatment in children.
“I wouldn’t be treating these children unless they had a very strong family history or had proven familial hypercholesterolaemia”, he said.
– Amanda Bryan
1. Pediatrics 2012; Published online: July 23.
2. National Heart Lung and Blood Institute. Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents.
Posted 30 July 2012
IHD is not just a disease of “old people”, it is similar to arthritis – although common in old people, but there is juvenile arthritis.
Development of IHD can take many years without any clinical symptoms and signs.
In high risk families with early onset of angina or AMI at age of 30-40, the deposit of cholesterol in the arteries may start at very young age.
Screening of blood lipids in the children from these families and reducing the elevated cholesterol early (either by diet or medication) is critical in prevention of the early onset of IHD in these children.
I have found elevated cholesterol levels in several teenagers who have a family history of early onset of IHD. I think If we do not screen them early, it will be too late…