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Pediatric Cholesterol Screening and Treatment

​Angie Mae Rodday, MS1, 2 Laurel Leslie, MD, MPH1, 2 Karen O'Connor, BS3 Susan Parsons, MD, MRP1, 2 Stephen Daniels, MD, PhD4 and Sarah de Ferranti, MD, MPH5.

1Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States; 2Departments of Medicine and Pediatrics, Tufts University School of Medicine, Boston, MA, United States; 3Department of Research, American Academy of Pediatrics, Elk Grove Village, IL, United States; 4Department of Pediatrics, Children's Hospital Colorado, Denver, CO, United States and 5Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.

Presented at the 2015 Pediatric Academic Societies Annual Meeting.

Background: In 2011 the NHLBI published guidelines endorsed by the AAP recommending selective cholesterol screening in children ages 2-21 years with risk factors and universal screening at ages 9-11 and 17-21 years. Information on current practice is sparse.

Objective: Determine pediatricians' knowledge, practices, attitudes, and barriers regarding cholesterol screening and treatment, and examine practices by child age.

Methods: National Periodic Survey of 1627 randomly-selected, non-retired AAP members in 2013-14 (response rate=43%). Analysis was restricted to 451 pediatricians who provided health supervision to ages 9-11 or 17-21. McNemar tests were used for comparisons.

Results: Pediatricians were more likely to be aware of the AAP 2008 cholesterol statement (90%) than the 2011 NHLBI guidelines (61%, p<.05). At least 2/3rd screened selectively, with obesity being a common cause; screening was less common for high-risk family history. Few pediatricians conducted universal screening at ages 9-11 (18%) and 17-21 (31%). For all indications, patients age 17-21 were more likely to be screened than those age 9-11 (all p<.05). Screening was a low priority for 23% of respondents and nearly half (47%) reported obtaining labs as a barrier. Diet/exercise was the most common treatment for high LDL-C (200 mg/dL); however, respondents reported lack of access to healthy food/exercise (55%), adherence to diet/exercise (84%), and insurance coverage (42%) as patient barriers. Although most pediatricians believed statins were appropriate for confirmed high LDL-C unresponsive to lifestyle (61% for age 9-11, 89% for age 17-21), few (<10%) started statins. Up to 46% referred to lipid specialists, but 29% reported limited local access.

The table presents practices endorsed most/all of the time (*p<.05 comparing ages).

​Age 9-11
​Age 17-21
Universal Screening
​Healthy patients*
Selective Screening
​Patients with any risk factor*
​   Obese*62%74%
​   Family History (heart attack/stroke)*
​    Family History (high cholesterol)*
Treatment for LDL-C=200
​Lipid specialist referral*

Conclusions: Nearly 2/3rd of pediatricians were aware of the NHLBI guidelines, yet <1/3rd conducted universal screening. Gaps between guidelines and practice—related to patient/family, provider, health systems or societal factors—should be addressed.