The M.D.: Do kids need a needle test for cholesterol levels?
My children hate needles — in that dread-filled way of kids who have been stuck once too often — and getting them to the doctor for shots or a blood test can be quite an ordeal. They never downright refuse to go, but there’s always plenty of whining beforehand and, sometimes, even tears.
I don’t blame them. I hate needles too. So when their pediatrician recommends a shot or a test requiring a needle stick, I want to know that there’s an awfully good reason for doing it. Usually there is. But when it comes to the lipid profile, not even pediatricians agree on whether such a test — and thus the required needle stick — is warranted.
The lipid profile measures blood levels of total, HDL (“good”) and LDL (“bad”) cholesterol, as well as levels of triglycerides. The effects that these lipids have on adults are well established and widely recognized: High levels of LDL cholesterol and triglycerides and low levels of HDL cholesterol contribute to the development of atherosclerosis and dramatically increase the risk of heart attack and stroke. Such serious consequences typically don’t arise until later in life, but the underlying damage caused by lipid abnormalities begins quite early.
In fact, the first signs of atherosclerosis often begin during childhood, when microscopic lesions called fatty streaks develop on the inner lining of the arteries. Autopsies performed on teenagers and young adults who’ve died of accidental causes reveal that approximately 70% exhibit these early signs of disease.
And, using national survey data on cholesterol and triglyceride levels, researchers at the Centers for Disease Control and Prevention recently found that 1 in 5 people ages 12 to 19 has at least one abnormal lipid level.
Some children have genetic conditions that predispose them to lipid problems — what’s usually referred to simply as “high cholesterol” — but many can primarily blame their lifestyle. Diets high in fat, particularly saturated fat, along with a lack of physical activity, adversely affect cholesterol and triglyceride levels.
Being overweight or obese also disrupts lipid levels, causing HDL cholesterol levels to fall and triglyceride levels to rise. The CDC report showed lipid abnormalities to be far more common among young people who were heavy than among their thinner peers; problems were detected in only 14% of normal weight teens, compared with 43% of obese teens.
Because artery damage begins early, many doctors recommend cholesterol screening for at least some of their young patients. But it’s unclear which children need to be tested.
“If you ask 10 different people, you get 12 different answers,” says Dr. Stephen Daniels, chairman of the pediatrics department at the University of Colorado School of Medicine. He co-wrote the American Academy of Pediatrics’ 2008 report on lipid screening in children.
The American Academy of Pediatrics stresses the importance of detecting and treating lipid abnormalities early in life and recommends screening all children considered to be at risk of cardiovascular disease, especially those with a family history of lipid disorders or premature heart disease. But the academy advocates testing other high-risk children as well, including those with diabetes or high blood pressure and those who are overweight or obese.
By screening only high-risk children, the academy hopes to detect those kids most at risk. But this strategy misses many children with lipid abnormalities simply because they aren’t tested.
For this reason, some physicians take a more aggressive approach to cholesterol screening. “My preference is to test all kids,” says Dr. Alan Lewis, a pediatric cardiologist at Childrens Hospital Los Angeles and a pediatrics professor at USC’s Keck School of Medicine. Lewis points out that it’s often difficult, if not impossible, to accurately identify who’s high-risk and who’s not, particularly when it comes to family history. A child’s parents may never have had a cholesterol level checked themselves or they may be so young that their personal health history isn’t terribly informative.
As with all screenings, a case can be made for screening everyone. That doesn’t mean it’s practical to do. Pediatricians understand that doing a cholesterol profile runs up the bill, is inconvenient — and physically hurts the patient. And some simply hesitate to add to the already long list of things that they have to do.
The U.S. Preventive Services Task Force takes the position that there isn’t sufficient evidence to recommend for or against screening for lipid disorders in children. The task force points out that a critical piece of information is missing: There’s no evidence to prove that treating lipid abnormalities in childhood reduces a person’s risk of heart disease and stroke later in life.
But, points out Daniels: “If our plan is to wait until we have that kind of data, we’ll be waiting forever. We need to work with incomplete and imperfect information.”
The data we do have seems to point in the direction of screening all children except those who are known to be at very low risk. If our pediatrician agrees, my kids can breathe a big sigh of relief. They don’t have much to worry about — at this point in their lives anyway — when it comes to cardiovascular disease.
That doesn’t mean we won’t address the issue of lipids in my house. They might not have to get a blood test, but we won’t be having premium ice cream in the freezer either.
Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.
