**5. Screening for dyslipidaemia in children**

Usually, screening tests are performed on people who do not show any symptoms of disease to detect health problems or illnesses. The key goal of screening is early detection, to reduce the risk of illness, or to identify it early enough to treat it more effectively. Childhood lipid disorder screening is focused on the rationale for reducing the risk and severity of cardiovascular disease (CVD) in adulthood by early detection and management of paediatric dyslipidaemia. Universal screening for dyslipidaemia became the recommended practice in 2011 [25]. Currently, in most parts of Africa, screening for hyperlipidemia in children and adolescents is not routinely performed in clinical settings. However, it is appropriate to become aware of the latest guidelines for the diagnosis and treatment of dyslipidaemia by child health practitioners. The National Cholesterol Education Program Expert Panel on Blood Cholesterol in Children and Adolescents issued the first guidelines for paediatric lipid screening in 1992 [26]. By 2011, when the American Heart Association [27] and the American Academy of Paediatrics included parameters to identify high and moderate risk individuals as seen in **Table 3**, thereafter, the guideline developed over several years with modifications [29].

The findings of National Heart Lung and Blood Institute (NHLBI) panel which performed a systematic review and grading of evidence related to the screening and treatment of CVD risk factors, including dyslipidaemia, were released in 2011 in a combined effort to improve the assessment and management of cardiovascular disease risk factors [30, 31]. The universal screening for lipid disorders as recommended in the guidelines means that all children between the ages of 9–11 should


*Adapted from Kwiterovich, P. O., Jr. (2008). Recognition and management of dyslipidaemia in children and adolescents. J Clin Endocrinol Metab, 93(11), 4200–4209 [28].*

#### **Table 3.**

*Risk factors and conditions for dyslipidaemia screening.*

#### *Management of Dyslipidemia*

get their lipids checked one time. This can be done by determining the plasma level of non-HDL-C with either a fasting lipid profile or a non-fasting test. This universal screening for dyslipidaemia was suggested because studies showed that 30–60 percent of children and adolescents with extreme cholesterol elevations could be missed by using only a selective screening approach based on family history [31].

The universal screening technique is specifically intended to identify children with inherited dyslipidaemia as hypercholesterolemia runs in families. However, due to lifestyle and obesity factors, children with dyslipidaemia, high triglyceride levels and low HDL-C levels may also be identified. In most cases, dyslipidaemias are clinically silent and selective screening for children with family history does not identify a significant number of children with lipid disorders [31, 32].

#### **6. Approach to diagnosis of dyslipidaemia in children**

The risk factors for dyslipidaemia are basically those that have been established to increase the likelihood of adults to develop ASCVD as listed in **Table 3**, while risk conditions are specific to paediatric guidelines and involve diseases that increase the risk of developing premature CVD [3]. There will be no noticeable clinical signs and symptoms for most children and adolescents with dyslipidaemia. The lack of clinical features is because, apart from individuals with Homozygous Familial Hypercholesterolemia (HoFH) that may have the first clinical clues in the first 10 years of life, most symptoms and signs only grow after decades [21]. Patients with HoFH are born with elevated LDL-C levels in their blood, and this is one of the reasons behind the early development of serious disease complications [21].

Physical signs, such as lipid deposits, bleeding, and atrophy, occur in the eyes, skin, and tendons. These signs may differ for each person and are therefore not necessarily invariable for the same disease. The heterozygous phenotype is generally present with tendon xanthomas, while the homozygous phenotype is present with both tendon and skin xanthomas. The characteristic lesion of familial hypercholesterolemia is the thickening of the tendons of Achilles. Symptoms caused by these deposits in the tendons and joints include chronic inflammation and joint pain, which can make it difficult for a person to live a good life. Cutaneous xanthelasmas of the eyelids can often be seen in patients with FH, but this symptom is not quite common. It should be noted that the diagnosis of xanthomas in the clinical examination is not only of diagnostic importance but may also signify the possibility of a cardiovascular event, as patients whose xanthomas have been observed in the clinical examination have been shown to suffer from more cardiovascular events. If there is a "white crescentic line" on the skin due to cholesterol accumulation, this also supports the diagnosis of hypercholesterolemia.

Of late, there are arguments surrounding universal screening of children and adolescents for dyslipidaemia, some favour universal screening, while others are against universal screening. While current data still classify approximately one third of children as having elevated lipid levels, some authors have documented the diagnosis of elevated lipid levels in many children without a family history of CVD or hypercholesterolemia [33]. Although it is more common in adults and youth with genetic disorders, selective screening may also be missed in many adults, particularly when their parents are young, free of CVD and unaware of their own lipid levels. Universal screening for these carriers can also be conducted to classify those with undiagnosed heterozygotes for familial hypercholesterolemia or those with more pronounced homozygotes who will then undergo more extensive care, including the possibility of drug therapy. In a meta-analysis, 88–96 percent of all

**115**

**Author details**

**7. Conclusion**

Ibadan, Nigeria

Bose Etaniamhe Orimadegun

provided the original work is properly cited.

therapies for children in Africa.

Department of Chemical Pathology, College of Medicine, University of Ibadan,

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: orimadegunbose@yahoo.co.uk

*Dyslipidaemia in African Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.96804*

hypercholesterolemia in the primary treatment clinic [34].

the leading cause of death for all adults under 65 [33].

resources to recognise and treat those found to be at high risk of CVD.

cases with a false-positive rate of less than 1% were detected in screening for family

Current literature tells us that risk factors for CVD are most observed in adolescence, and these risk factors are still present in adulthood. Dietary and hygienic treatment and medication are effective for those who have this disease. It is therefore necessary for all children and adolescents to perform a separate lipoprotein test for each of them. However, it can be argued that screening for people who have never smoked should be universal, given the prevalence of obesity in young Africans, the epidemic of metabolic syndrome, and the fact that CVD is quickly becoming a cause of death for individuals under 55 years of age, and will likely be

However, as noted in another publication, concerns have been raised that several longitudinal studies [33] find that when the 75th percentile for triglyceride levels in children is used as a screening cut-off point, only half of those in need of adult treatment are identified by universal lipid screening. In one study, the sensitivity was much lower when screening occurred during puberty, which is likely to indicate a transient downward shift in LDL-C during this time of rapid growth and development [35]. Another unresolved question is whether the detection of elevated TC or LDL-C in children and young adults suggests that these adults will develop premature CVD. If systematic screening for lipid and non-lipid risk factors for CVD was a standard of paediatric treatment, there would obviously be a need for national

Children and adolescents who are predisposed to dyslipidaemia are more likely to remain predisposed to dyslipidaemia throughout their lives. Interventions in childhood and adolescence are immensely helpful in helping to prevent the buildup of fatty deposits in the arteries and other cardiovascular problems later in life. Therefore, abnormalities in the lipid profile of children and adolescents, particularly those with other risk factors, must be identified early, followed, monitored, and treated, if possible. Health care providers should strive to examine, diagnose, and treat prevalent genetic conditions such as familial hypercholesterolemia that affect families for several generations. Lipid screening should be one of the routine

#### *Dyslipidaemia in African Children and Adolescents DOI: http://dx.doi.org/10.5772/intechopen.96804*

*Management of Dyslipidemia*

ous disease complications [21].

also supports the diagnosis of hypercholesterolemia.

get their lipids checked one time. This can be done by determining the plasma level of non-HDL-C with either a fasting lipid profile or a non-fasting test. This universal screening for dyslipidaemia was suggested because studies showed that 30–60 percent of children and adolescents with extreme cholesterol elevations could be missed by using only a selective screening approach based on family history [31]. The universal screening technique is specifically intended to identify children with inherited dyslipidaemia as hypercholesterolemia runs in families. However, due to lifestyle and obesity factors, children with dyslipidaemia, high triglyceride levels and low HDL-C levels may also be identified. In most cases, dyslipidaemias are clinically silent and selective screening for children with family history does not

The risk factors for dyslipidaemia are basically those that have been estab-

Physical signs, such as lipid deposits, bleeding, and atrophy, occur in the eyes, skin, and tendons. These signs may differ for each person and are therefore not necessarily invariable for the same disease. The heterozygous phenotype is generally present with tendon xanthomas, while the homozygous phenotype is present with both tendon and skin xanthomas. The characteristic lesion of familial hypercholesterolemia is the thickening of the tendons of Achilles. Symptoms caused by these deposits in the tendons and joints include chronic inflammation and joint pain, which can make it difficult for a person to live a good life. Cutaneous xanthelasmas of the eyelids can often be seen in patients with FH, but this symptom is not quite common. It should be noted that the diagnosis of xanthomas in the clinical examination is not only of diagnostic importance but may also signify the possibility of a cardiovascular event, as patients whose xanthomas have been observed in the clinical examination have been shown to suffer from more cardiovascular events. If there is a "white crescentic line" on the skin due to cholesterol accumulation, this

Of late, there are arguments surrounding universal screening of children and adolescents for dyslipidaemia, some favour universal screening, while others are against universal screening. While current data still classify approximately one third of children as having elevated lipid levels, some authors have documented the diagnosis of elevated lipid levels in many children without a family history of CVD or hypercholesterolemia [33]. Although it is more common in adults and youth with genetic disorders, selective screening may also be missed in many adults, particularly when their parents are young, free of CVD and unaware of their own lipid levels. Universal screening for these carriers can also be conducted to classify those with undiagnosed heterozygotes for familial hypercholesterolemia or those with more pronounced homozygotes who will then undergo more extensive care, including the possibility of drug therapy. In a meta-analysis, 88–96 percent of all

lished to increase the likelihood of adults to develop ASCVD as listed in **Table 3**, while risk conditions are specific to paediatric guidelines and involve diseases that increase the risk of developing premature CVD [3]. There will be no noticeable clinical signs and symptoms for most children and adolescents with dyslipidaemia. The lack of clinical features is because, apart from individuals with Homozygous Familial Hypercholesterolemia (HoFH) that may have the first clinical clues in the first 10 years of life, most symptoms and signs only grow after decades [21]. Patients with HoFH are born with elevated LDL-C levels in their blood, and this is one of the reasons behind the early development of seri-

identify a significant number of children with lipid disorders [31, 32].

**6. Approach to diagnosis of dyslipidaemia in children**

**114**

cases with a false-positive rate of less than 1% were detected in screening for family hypercholesterolemia in the primary treatment clinic [34].

Current literature tells us that risk factors for CVD are most observed in adolescence, and these risk factors are still present in adulthood. Dietary and hygienic treatment and medication are effective for those who have this disease. It is therefore necessary for all children and adolescents to perform a separate lipoprotein test for each of them. However, it can be argued that screening for people who have never smoked should be universal, given the prevalence of obesity in young Africans, the epidemic of metabolic syndrome, and the fact that CVD is quickly becoming a cause of death for individuals under 55 years of age, and will likely be the leading cause of death for all adults under 65 [33].

However, as noted in another publication, concerns have been raised that several longitudinal studies [33] find that when the 75th percentile for triglyceride levels in children is used as a screening cut-off point, only half of those in need of adult treatment are identified by universal lipid screening. In one study, the sensitivity was much lower when screening occurred during puberty, which is likely to indicate a transient downward shift in LDL-C during this time of rapid growth and development [35]. Another unresolved question is whether the detection of elevated TC or LDL-C in children and young adults suggests that these adults will develop premature CVD. If systematic screening for lipid and non-lipid risk factors for CVD was a standard of paediatric treatment, there would obviously be a need for national resources to recognise and treat those found to be at high risk of CVD.
