Moreover, children and adolescents with LDL-C 160 mg/dL ( 4.1 mmol/L) and a family history of early atherosclerosis or similarly elevated cho- lesterol in 1 parent likely are those with FH and related genetic disorders associated with accel- Subclinical ath- erosclerosis data suggest divergence between affected and unaffected children and adolescents beginning at age 10 years,S4.4.4.3-28 which sup- ports screening by this age, although this topic is still considered controversial.S4.4.4.3-36 Screening is advised beginning at age 2 years if a family his- tory is suggestive of either early CVD or significant primary hypercholesterolemia. Identification of a child with severe hypercholesterolemia should prompt screening of extended family members (eg, reverse-cascade screening), according to studies outside the United States demonstrating efficacy of this approach.S4.4.4.3-37 Screening for severe hypercholesterolemia on the basis of fam- ily history includes an expanded group of family members (eg, grandparents, aunts, and uncles) in addition to parents and siblings because siblings of children are unlikely to have had cardiovascular events or been identified with significant choles- 5. One advantage of measuring lipids in children and adolescents is to identify genetic abnormali- ties in lipid metabolism that may be present in other family members. Regardless of the age at which abnormalities are detected, reverse-cas- cade screening in families is highly effective for the identification of family members at risk of 6. Observational studies of children and adolescents show that obesity and other lifestyle-related behaviors and metabolic syndrome risk fac- tors including lipid abnormalities,S4.4.4.3-25,S4.4.4.3-26 and with subclinical atherosclerosis into young occur at higher rates than in lean and otherwise healthy children and adolescents. Longitudinal cohort data show mod- erate tracking of cardiovascular risk factors from childhood to adulthood in the general pediatric suggesting some persistence of the underlying pathophysiology and potential benefit of identifying lipid disorders in childhood. 7. 