CASE STUDY

An 11-year-old male patient presents for an annual wellness examination. Medical history is significant for frequent ear infections as a toddler that resolved after tube placement. His review of systems is otherwise negative. Physical examination reveals normal height and weight for age with a body mass index in the 75th percentile.

CASE STUDY QUESTIONS

1. According to the U.S. Preventive Services Task Force (USPSTF) recommendation statement, which one of the following describes screening recommendations for high cholesterol for this patient?

• A. The patient should be screened as part of universal screening for this age group.

• B. The patient should not be screened, because his body mass index is normal.

• C. Screening should be delayed until the patient is a teenager.

• D. The decision to screen should made by assessing the patient's personal, family, and social history and physical examination findings.

2. The patient's mother expresses concern about his cholesterol level because the family often eats fast food. She also remembers her grandfather having a heart attack but does not remember how old he was when it occurred. Based on the USPSTF recommendation, which of the following describe how the patient's mother should be counseled?

• A. Diets high in saturated fat, a sedentary lifestyle, and obesity are risk factors for high cholesterol; therefore, routine screening for obesity and behavioral interventions to promote a healthy weight are appropriate.

• B. A genetic disorder can cause high cholesterol levels at a young age; however, high cholesterol levels are more commonly caused by diets high in saturated fat and sedentary lifestyles.

• C. Screening is not necessary because all children with high cholesterol levels have symptoms, and her son is asymptomatic.

• D. If the patient has high cholesterol from a genetic disorder called familial hypercholesterolemia, statins can lower his cholesterol levels.

3. The patient's mother asks what the benefits and harms of screening and treatment are. According to the USPSTF recommendation, which one of the following correctly answers this question?

• A. Screening can accurately detect high cholesterol in children.

• B. In children diagnosed with familial hypercholesterolemia, statins can substantially lower cholesterol levels in the short term.

• C. Identifying and treating high cholesterol in children will prevent heart attacks, strokes, and cardiovascular-related death in adulthood.

• D. The harms of screening and treatment are substantial.

• E. Treatment with statins can affect normal development and puberty.

ANSWERS

1. The correct answer is D. The USPSTF found that there is not enough evidence to determine whether screening all children for high cholesterol improves health into adulthood. This is an I statement, which means the USPSTF is neither recommending for nor against screening for lipid disorders in children or adolescents and is calling for more research in this area. In the absence of evidence, physicians should consider a patient's personal, family, and social history and physical examination findings to determine whether to screen for lipid disorders in their young patients.¹

2. The correct answers are A, B, and D. The most common lipid disorder in children and adolescents is multifactorial dyslipidemia. This condition is primarily associated with environmental factors such as diets high in saturated fat, sedentary lifestyle, and obesity.¹ Physicians should routinely screen for obesity in children and adolescents and offer behavioral interventions to promote a healthy weight.^2–4 Familial hypercholesterolemia is a genetic disorder of cholesterol metabolism characterized by very high levels of low-density lipoprotein (LDL) cholesterol early in life. Although both lipid disorders can lead to premature cardiovascular disease and death, multifactorial dyslipidemia is typically associated with lower LDL cholesterol levels and is much more common in children than familial hypercholesterolemia (prevalence of 7.1% to 9.4% vs. 0.2% to 0.4%, respectively). Statins are effective at lowering lipid levels in children with familial hypercholesterolemia. Children with lipid disorders can be asymptomatic.¹

3. The correct answer is B. The USPSTF found adequate evidence from short-term trials (with a duration of no more than 2 years) that statins substantially reduce cholesterol levels in children and adolescents with familial hypercholesterolemia. Because these trials were short term, the USPSTF found inadequate evidence regarding whether long-term treatment prevented premature heart-related events or death in adulthood. Harms from statin use were minor and did not affect growth and development.^1,5 The USPSTF found inadequate evidence regarding the accuracy of blood tests to identify children and adolescents with lipid disorders.⁵

The views expressed in this work are those of the authors and do not reflect the official policy or position of Johns Hopkins University, Stony Brook Medicine, the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, or the U.S. government.

This PPIP quiz is based on the recommendations of the USPSTF. More information is available in the USPSTF Recommendation Statements and supporting documents on the USPSTF website (https://www.uspreventiveservicestaskforce.org). The practice recommendations in this activity are available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lipid-disorders-in-children-screening.