Health Care Guideline:
Lipid Screening in Children and Adolescents
General Implementation January 1998
Copyright © 1998 by Institute for Clinical Systems Integration
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Work Group Leader
William E. Conroy, MD, HealthSystem Minnesota
Cardiology
Tom Kottke, MD, Mayo Clinic
Endocrinology
David Kendall, MD, HealthSystem Minnesota
Family Practice
Wally Mikhail, MD, Allina Medical Group East
Donald Pine, MD, HealthSystem Minnesota
Internal Medicine
Bruce Burnett, MD, HealthSystem Minnesota
William E. Conroy, MD, HealthSystem Minnesota
Ben Bache-Wiig, MD, North Clinic
Health Education
Susan M. Hanson, RD, Institute for Research and Education
Laboratory
Colleen Crampton, MT (ASCP), HealthSystem Minnesota
Pediatrics
Rick J. Lewis, MD, HealthPartners
Measurement Advisor
Rick Carlson, MS, HealthPartners
Buyers Health Care Action Group Representative
Wendy E. Anderson, General Mills, Inc.
Facilitator
Julie Persoon, RN, ICSI
Patients ages 19 years and younger.
Potential Aims for Medical Groups When Using This Guideline
1. Increase appropriate cholesterol screening for children at risk for familial hypocholesterolemia.
Possible measures of accomplishing this aim:
a. Percentage of children receiving serum cholesterol screening who are at risk for familial hypocholesterolemia.
b. Percentage of children who are at risk for familial hypocholesterolemia who receive serum cholesterol screening.
2. Increase the use of history and exercise and nutrition assessments in the context of lipid screening.
Possible measures of accomplishing this aim:
a. Percentage of children with documented exercise and nutrition assessments.
b. Percentage of children with relevant history recorded for lipid screening.
c. Percentage of children with relevant history recorded and both exercise and nutrition assessments.
3. Decrease inappropriate cholesterol screening for children.
Possible measures of accomplishing this aim:
a. Percentage of children with serum cholesterol screening.
b. Percent of children with serum cholesterol screening without increased risk for familial hypocholesterolemia.
The only need for lipid screening in children and adolescents is to identify pediatric patients with familial hypercholesterolemia (FH), since early disease detection is crucial in order to facilitate treatment to prevent coronary artery disease. FH is an autosomal dominant disorder, affecting about 1 in 500 individuals, and appears to be the only pediatric lipid disorder that requires treatment beyond the usual lifestyle counseling recommended for all children and adolescents.
Thus, this guideline focuses on patients whose family history includes a CHD event at a young age or profound hypercholesterolemia. Its goal is to identify children and adolescents with FH through targeted cholesterol measurement in subpopulations whose members carry a higher likelihood of disease.
Clinical Algorithm & Annotations
1. Preventive Health Encounter
A preventive health encounter is a routinely scheduled well child visit in which the provider assesses the growth, development and lifestyle of the individual. The ICSI Preventive Counseling and Education and Preventive Services guidelines would be implemented at this point.
2. Age Between 2 and 19 Years and No Prior Screening?
This guideline applies to children and young adults between the ages of two and nineteen years. Children prior to the age of two years do not require lipid status assessment. Adults 20 years old or older should be screened for their lipid status under the ICSI Lipids Screening in Adults Guideline.
Once a child or adolescent has been screened any time between the ages of 2 and 19, they do not need to have the screening repeated.
3. Nutrition and Exercise Assessment; Family History Risk Factors
Please refer to the nutrition and physical activity sections of the ICSI Preventive Counseling and Education guideline.
Children and young adults at risk for familial hypercholesterolemia (FH) can be identified at any age by inquiring into the lipid status of their primary relatives. (Primary relatives include parents, adult siblings, and grandparents.)
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4. Primary Relative with a CHD Event at an Early Age?
A primary relative is a parent, grandparent or sibling. CHD event at an early age includes occurrence prior to the age of 55 in men or prior to the age of 65 in women. If the family history is unobtainable clinicians may wish to test the patient.
5. Parent with Pretreatment Total Cholesterol Greater Than 300?
Adult FH heterozygotes have pretreatment cholesterol levels in the 300-500 mg/dL range. Adult FH homozygotes have untreated cholesterol levels greater than 500 mg/dL.
Measurement of a non-fasting serum total cholesterol is recommended for children and young adults who have either a primary relative with a history of CHD prior to the age of 55 years or a parent with a history of a total cholesterol > 300 mg/dL. The NCEP guideline recommends chemical screening if parental levels are � 240 mg/dL.
7. Is Total Cholesterol Greater Than 200?
A total cholesterol of 200 mg/dL is the cutoff for individuals at risk for familial hypercholesterolemia. Total cholesterol >200 mg/dL requires further clinical assessment.
8. Measure fasting total cholesterol, HDL, Triglycerides, and calculated LDL
A fasting lipoprotein analysis will provide confirmation of any prior questionable or high screening results from non-fasting tests.
A fasting lipid panel should include a total cholesterol, HDL, triglycerides and a calculated LDL. Fasting should occur over a period of nine to twelve hours prior to the blood draw for the lipid panel.
9. Is LDL Greater Than or Equal To 164?
An LDL cholesterol of 164 mg/dl has been shown to be the most discriminating level for identifying FH. Borderline levels (155-175) should be repeated to obtain an average. Clinicians should also obtain cholesterol levels from the parents. A markedly elevated level from one parent supports the diagnosis, while normal levels from both parents rules out FH.
Once a child has been tested and found to not have FH, no further testing is necessary until the individual is age 20, at which time they enter the ICSI Lipid Screening in Adults guideline. Clinicians should continue to review and offer praise or advice concerning diet and lifestyle at each routine health visit.
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10. Case Management. Out of Guideline.
Children and young adults with an LDL >164 mg/dL are considered to have FH and require individual management. These individuals are therefore no longer considered part of this guideline.
Additional follow-up with these individuals includes screening of the entire family and referral to a lipid specialty clinic for multidisciplinary management.
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Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.
Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal (but not on a randomized, controlled trial):
Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):
Guidelines obtained from the Agency for Health Care Policy and Research (AHCPR) or other sources, position statements, panel consensus statements from the National Institutes of Health (NIH) or elsewhere, review articles, and textbook chapters that cite primary evidence are not assigned a grade because they are not primary evidence. The individual studies cited in such secondary sources can be graded according to the categories presented above.
Other Guidelines Referenced Within This Guideline
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