Guidelines For Kids' Cholesterol Screening Create Stir

Some new recommendations to screen children for high cholesterol are creating a stir among physicians.

The American Academy of Pediatrics endorses the government guidelines by the National Heart, Lung, and Blood Institute late last year, which recommend that all 9- to 11-year-olds get screened for cholesterol.

But not everyone is on board. That's evident in the latest issue of the journal Pediatrics, which includes comments for and against the screenings.

We interviewed Dr. Matthew Gillman, a dissenting member of the panel that made these recommendations. He's a professor at Harvard Medical School and a physician at Boston Children's Hospital, Massachusetts General Hospital and Brigham & Women's Hospital.

Bob Oakes: Tell us about your concerns; what are they?

Dr. Gillman: There's really no controversy about everyone wanting to prevent premature heart disease right from the start. The controversy is really over the best way to do it.

We need the right people asking the right questions. And then in terms of the questions, [for] the cholesterol guidelines panel the key questions that we were faced with were really geared towards more aggressive screening. If you go back a couple years before that, the U.S. Preventative Service Task Force (USPSTF) came up with a more balanced view, and said that there is insufficient evidence.

So I agree that we need more evidence, and I think until we get there, we should remain faithful to Hippocrates, who said, "First, do no harm."

Why do you think the panel made this recommendation when in 2007, the USPSTF declined to do so?

The panel was faced with some new information about the fact that family history screening — which has been the recommendation for almost the past 20 years — misses some kids with high cholesterol. And some of those kids, especially the ones with the very high cholesterol levels, may go on to have heart attacks in middle age. So that's one side of the coin.

We also have to face the false positives — that's the huge number of kids with only moderately elevated cholesterol levels who will never get heart disease in middle age. And what happens then is they face sometimes-futile efforts to change behavior, and they can cost a lot to society.

So it's this balance that we're after, and we don't know quite what that balance is yet.

But respond to someone who might say in response to what you said, "isn't there some merit to identifying kids early on who may have high cholesterol, and making changes to their diets and exercise routines instead of waiting for those larger problems that you acknowledge might come down the road to develop when these kids turn into adults?"

There is absolutely some value in that, and the question is how to do it. And my guess is in the coming years, we're going to come down to a screening approach that may be family history directed [or] may be universal screening. But what we're going to try to do is identify those at very high risk.

Some of the criticism of what's been said has indicated that many panel members have disclosed ties to companies that make cholesterol-treating drugs or test for cholesterol. Do you see conflict of interest as a problem?

Conflict of interest can come into any guideline panel. And one of the conflicts of interest that can occur — not just in this panel, I'm talking more generally — is financial conflicts of interest. And they can be insidious and really not so explicit.

But I also wanted to point out the other kind of conflicts which are intellectual conflicts. Some specialists tend to see much more high-risk children and they tend to be more aggressive in treating because of the kind of patient they see.

And so my view is that panels in the future should have more generalists with sub-specialists being expert witnesses.

Were there or are there conflicts of interests from your point of view in these new recommendations for screening kids for cholesterol?

Well, I'm not going to impugn any of my fellow panel members. So I think [the panel did] a really good job of reviewing the evidence and making the best recommendations they knew. These are very smart people and very thoughtful [people].

So, what should be done now? Should the panel take another look?

Even on the panel, we agreed that this a weigh station: that panels are dynamic, that guidelines are dynamic [and] that we should be reviewing and improving them in the future. So certainly we should be modifying them as new evidence comes in.

In the meantime, do you expect that these recommendations will lead to more testing for cholesterol in the blood of kids?

My current recommendation, in the lack of further evidence right now, is to do what we've been doing for the past couple decades, which is family history-directed screening, even though we know some of the strengths and weaknesses of that.