Obtaining labs appears to be a major barrier, Dr. de Ferranti pointed out. Nearly half of the pediatricians who responded to the survey, which was presented at the 2015 annual meeting of the Pediatric Academic Societies, reported problems with patients not returning for a fasting test, she said.
Dr. de Ferranti and her colleagues at Boston Children’s Hospital recently led a quality improvement project to implement lipid screening in their center’s urban primary care practice. Provider adherence to recommended screening, which resembled the NHLBI recommendations, was high. Almost a quarter of the approximately 1,200 patients who received test orders, however, did not complete the ordered screening test, even though it entailed nonfasting non-HDL testing.
And patients screened based on their age alone (the universal screening component) had a low rate of abnormal findings: Only 2.7% were found to have non-HDL of 145 mg/dL or greater, which was surprising to Dr. de Ferranti given the high rate of obesity (45%) in the practice’s population.
“Age-only screening, at least from our data so far, is not very productive,” she said. Only one patient had a clinical picture consistent with familial hyperlipidemia, and this patient was identified based on risk factors and not age alone.
On the other hand, mild abnormalities (non-HDL of 120-145 mg/dL) – the kind that often prompt Dr. de Ferranti to advise lifestyle modification, including a low saturated fat intake of 12-15 g/day with no trans fat, high fiber, and high intake of fresh fruits and vegetables – were common across the board.
Asked about the safety of statins in children, Dr. de Ferranti said there appears to be a 1%-2% rate of side effects in the pediatric population. “My patients have done well,” she said. “Remember, initiation of statins (involves) a discussion – it’s not an emergency. We usually don’t decide in one visit.”
Low-dose statin therapy is an option starting at age 10 years, but Dr. de Ferranti said she sometimes will start “very high risk” patients earlier, between 8 and 10 years of age.
Many of the AAP survey participants believed that statins were appropriate for patients with confirmed high LDL unresponsive to lifestyle change; about 62% agreed with statin use for young children in such situations and almost 90% for older children. Significantly fewer started statin therapy themselves (about 8% for young children and 21% for older children). About half said they refer these patients to lipid specialists, but almost a third reported limited local access.
These low rates of statin treatment or referral for those with severe LDL elevations are concerning and “suggest a missed opportunity for cardiovascular risk reduction in these high-risk children,” Dr. de Ferranti said.
Pediatricians should soon receive more guidance on lipid screening from the U.S. Preventive Services Task Force. In 2007, the task force was unable to determine the balance between potential harms and benefits for routinely screening children and adolescents for dyslipidemia, and issued an “indeterminate” recommendation. It is now reviewing the evidence and is expected to release new guidelines in the near future, she said.
Dr. de Ferranti disclosed that she has current research funding from the Patient Centered Research Institute, the New England Congenital Cardiology Research Foundation, and the Pediatric Heart Network. She also receives royalties from UptoDate, an online clinical decision support resource.