<p>In 2011, the American Academy of Pediatrics (AAP) and NHLBI recommended universal cholesterol testing at age 9 to 11 years, discussing 2 rationales. The first rationale was identification of familial hypercholesterolemia, a severe disease with a prevalence of ≈ 1:300. The long-term safety and benefits of cholesteral-lowering medications for youth with severe hypercholesterolemia have been established. These known benefits increase the value of early disease identification. The second rationale was identification of less severe dyslipidemias associated with pediatric obesity that may represent a modifiable risk for cardiovascular disease. Before 2011, pediatric cholesterol testing was most common among children with known cardiovascular risks, particularly obesity. Questions remain about the role of universal testing in pediatrics, and the United States Preventive Services Task Force has not endorsed universal testing. This uncertainty may influence guideline uptake.</p>

<p>Prior reports examining cholesterol testing in pediatric cohorts predate the 2011 guideline, evaluate specific efforts to adopt the guideline, or were unable to evaluate other cardiovascular risk factors that may be associated with testing. This study asks whether, and to what extent, universal testing has been adopted since the 2011 guideline.</p>