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The U.S. Preventive Services Task Force released an ("I" statement) this week citing insufficient evidence for universal screening for heterozygous familial hypercholesterolemia and multifactorial dyslipidemia in children and adolescents.

The panel stated there was no proof that the screening made any impact on adult cardiovascular health. Additionally, the USPSTF statement did not include any information on heterozygous familial hypercholesterolemia (FH).

While there was adequate "short-term" evidence that pharmacotherapy, such as statins, reduced lipid levels among children with FH, there was inadequate evidence on the benefits of either medication or lifestyle interventions on children with multifactorial dyslipidemia. The panel also found inadequate evidence on the potential harms of screening for lipid disorders in children.

"The USPSTF concludes that the current evidence is insufficient and that the balance of benefits and harms of screening for lipid disorders in asymptomatic children and adolescents 20 years or younger cannot be determined," according to , chairperson of the USPSTF, and colleagues, writing in the

, the Task Force's vice-chairperson, told 番茄社区 that he believed that with additional studies, the answers to these questions can be properly established, citing a recent USPSTF recommendation for the use of aspirin in the prevention of cardiovascular disease.

"Every time we have an I statement, we really do look ourselves in the eye and ask ourselves could we ever move off an I to a letter grade, and we do believe there has been some development of evidence in this area," he said. "With properly designed studies and longitudinal follow-up, we can establish answers to these questions. Part of the problem is that pediatric studies haven't been as well-funded as adult studies, but we believe these kinds of studies are doable."

Contrary to Other Guidelines

But the Task Force view differed from established in 2011 by the National Heart, Lung, and Blood Institute and the American Academy of Pediatrics, which recommended universal screening for cholesterol levels among children and teens.

"What I heard from the primary care community is they just weren't sure which way to go, but in ensuing years, I've seen more and more of them following the guidelines to do universal screening," said , of Oregon Health & Science University in Portland, who was not involved with the USPSTF review. "The referring physicians who have sent patients to me following universal screening have found the education and the intensive discussions very beneficial, so I think that over the past 5 years, the field has demonstrated a benefit in the pediatric population."

Editorials in several JAMA journals seemed to agree with Armsby's view. , chief of pediatric cardiology at Nemours/A.I. Dupont Hospital for Children in Wilmington, Del., argued that the 2011 panel was more focused on whether screening could help prevent atherosclerosis in adolescents as opposed to reducing overt cardiovascular disease (CVD) events in adulthood.

"Recommendations of the 2011 panel were driven by the consistency of the evidence relating severely elevated cholesterol levels to premature development of atherosclerosis as well as the impossibility and ethical limitations of conducting a 40-year randomized trial to prove that lowering [LDL] cholesterol in childhood prevents CVD events," he wrote in "The 2011 ... panel was specifically concerned about individuals who were likely to have early CVD, but were not included in clinical and epidemiologic studies begun at age 40 years and later."

Another editorialist, writing in JAMA Pediatrics, drew a parallel between screening for lipid levels in adolescents and another form of screening that the USPSTF recommended: in children and adolescents.

"The questions related to obesity are more focused on short-term childhood outcomes and whether BMI can be improved in childhood by intervention," wrote , of University of Colorado at Denver, adding that obesity screening does not focus on prevention of long-term conditions such as nonalcoholic fatty liver disease or type 2 diabetes.

"Why should we screen for obesity, but have insufficient information to reach a conclusion for screening for heterozygous FH when there seem to be important parallels in these clinical entities?"

'Low-Value Care'

Some clinicians, though, backed the USPSTF's reluctance to support screening in light of the economic and emotional costs that come with diagnoses, as well as the risks that go with treatment.

"I am a Pink Floyd fan: 'Teacher, leave those kids alone,'" said , physician-in-chief of cardiology at Hartford Hospital, who had no role in the USPSTF review.

"I wish we would begin to get that straight as a medical nation, because so much of screening [in general] only results in anxiety, unnecessary testing, and inappropriate treatment. With kids in this instance, I think we run the risk of making them medically anxious and treating them early with drugs for a long period of time," he told 番茄社区.

An editorial in agreed with this view, noting that uncovering the hundreds of thousands of children with potential high cholesterol who then might be treated with statins could increase their risk of developing diabetes.

"In intermediate- and high-risk adults, increased risks of diabetes and weight gain may be outweighed by the projected benefit of CVD reduction, but in children there is near-zero benefit and much harm from the decades of increased diabetes and obesity risk one might expect from starting statin therapy in childhood," wrote , and two colleagues at the University of California San Francisco.

The editorial noted that under the NHLBI guidelines, an estimated would qualify for statin therapy.

Instead, Newman and colleagues argued for more "high-value solutions," such as lifestyle interventions related to diet, exercise, and smoking as opposed to focusing on screening.

Grossman said that the Task Force recognized the importance of diet and exercise as key to the prevention of especially multifactorial disease, which is associated with obesity. Clinicians need to make decisions about patients on an individual basis, he said.

"We need to recognize certain risks and be clear about what those risks are. It is reasonable to test certain patients for lipids, and clinicians should use this information in order to better inform their clinical judgment."

Future of Research

A by , director of preventive cardiology at Cincinnati Children's Hospital Medical Center, and , director of the preventive cardiology program at Boston Children's Hospital, argued that "novel methods" are needed to provide evidence for pediatric lipid screening and treatment. They saw a potential light at the end of the tunnel with ongoing cohort studies.

"The completion of the 40-year follow-up of that have been evaluating cardiovascular risk factors since the 1970s and 1980s will help inform the discussion about screening for lipid disorders in children and adolescents," Urbina and de Ferranti wrote. "Once these data are available, analyses could be performed to estimate the cost-benefit of screening for dyslipidemia in youth."

But Armsby argued that waiting for specific data linking screening to long-term changes in morbidity and mortality was not necessary for another concerted public health campaign that was embraced by doctors, schools, and families alike.

"We didn't educate kids about smoking because we had data that showed if we got kids to stop smoking as kids, those same kids would not develop lung cancer as adults -- we extrapolated that if smoking caused lung cancer and we stopped kids from smoking, we would have fewer kids developing lung cancer when they were older," she said. "We didn't wait for the longitudinal study."