Lipid Screening & Cardiovascular Risk¶

Learning Objectives¶

Core Knowledge & Clinical Reasoning¶

[ ] Apply universal lipid screening protocol (ages 9-11 and 17-21)
[ ] Identify indications for targeted screening in younger children (family history, obesity, high-risk conditions)
[ ] Interpret pediatric-specific lipid cut points (LDL ≥130 high, ≥160 suspect FH)
[ ] Recognize familial hypercholesterolemia and indications for genetic testing

Management Decisions¶

[ ] Prescribe lifestyle modifications using CHILD-1/CHILD-2 diets
[ ] Determine pharmacotherapy indications (age ≥10, LDL thresholds by risk factors)
[ ] Select appropriate statin therapy for pediatric patients

Communication & Counseling¶

[ ] Counsel families on cardiovascular risk reduction and atherosclerosis prevention
[ ] Explain rationale for screening even without family history (unreliability of family history)
[ ] Address concerns about statin use in children when indicated

Systems-Based Practice¶

[ ] Implement universal screening into well-child care protocols
[ ] Coordinate cascade testing for families with identified FH

Key Guidelines¶

2011 NHLBI Expert Panel: Integrated Guidelines for CV Health and Risk Reduction in Children Pediatrics. 2011;128(Suppl):S213-256 AAP Endorsed; Remains Current

Universal Screening¶

Age	Recommendation
9-11 years	Universal non-fasting lipid screen
17-21 years	Second universal screen

Rationale¶

Family history unreliable for identifying dyslipidemia
Early atherosclerosis is present and preventable
FH prevalence ~1:250 (underdiagnosed)

Targeted Screening (Ages 2-8 Years)¶

Screen if ANY of the following: - Family history of early CVD (<55 years male, <65 years female) - Family history of dyslipidemia - Parent with TC ≥240 mg/dL - BMI ≥95th percentile - Diabetes, hypertension, or tobacco use - High-risk conditions: - Chronic kidney disease - Kawasaki disease with coronary aneurysms - Solid organ transplant - Childhood cancer survivor

Lipid Cut Points for Children¶

Lipid	Acceptable	Borderline	High
Total Cholesterol	<170	170-199	≥200
LDL-C	<110	110-129	≥130
Non-HDL-C	<120	120-144	≥145
TG (0-9 years)	<75	75-99	≥100
TG (10-19 years)	<90	90-129	≥130
HDL-C	>45	40-45	<40 (low)

All values in mg/dL

Screening Method¶

Non-Fasting Lipid Panel¶

Preferred for screening
TC, HDL-C, Non-HDL-C valid non-fasting
If Non-HDL-C ≥145 or HDL <40 → repeat fasting

Fasting Lipid Panel¶

Confirm abnormal screening
Required for accurate TG and LDL-C calculation

Familial Hypercholesterolemia (FH)¶

Suspect FH if:¶

LDL-C ≥160 mg/dL (pediatric threshold)
Family history of early CVD or high cholesterol
Tendon xanthomas (rare in children)

Genetic Testing¶

Consider if LDL-C ≥190 mg/dL
Cascade testing if proband positive

Management¶

Lifestyle Modifications (All Patients)¶

CHILD-1 diet (low saturated fat, no trans fat)
Regular physical activity
Weight management if overweight/obese
Avoid tobacco exposure

Pharmacotherapy Indications¶

Age ≥10 years with: - LDL-C ≥190 mg/dL despite diet, OR - LDL-C ≥160 mg/dL + family history or other risk factors, OR - LDL-C ≥130 mg/dL + diabetes

Statins are first-line (multiple are FDA-approved for pediatric use)

2023 USPSTF Statement¶

"Insufficient evidence" to assess benefits/harms of universal screening
Does NOT recommend against screening
Acknowledges NHLBI/AAP guidance
Continues to generate controversy

Board Pearls¶

Pearl: Universal screening at 9-11 years and 17-21 years

Non-fasting lipid panel; family history is unreliable

Pearl: Pediatric LDL-C ≥160 = suspect FH

Lower threshold than adults; early detection critical

Pearl: Non-HDL-C: Most useful non-fasting marker

Calculate as: TC - HDL-C

Self-Assessment¶

Q1: A healthy 10-year-old presents for a well-child check. Mother's cholesterol is unknown. What lipid screening is indicated?

Answer

**Answer**: Universal non-fasting lipid screening **Rationale**: Per NHLBI/AAP guidelines, all children should have universal lipid screening at ages 9-11 years. This does not depend on family history, which is unreliable for identifying dyslipidemia.

Q2: A 7-year-old with BMI at 97th percentile has fasting lipids: TC 210, LDL 145, HDL 38, TG 135. What is the interpretation and management?