Management of Dyslipidemia in Children

Management of Dyslipidemia in Children

This content is intended for Physicians

Pediatric dyslipidemia contributes to atherosclerosis and the development of premature cardiovascular disease.  Hypercholesterolemia is defined as a low-density lipoprotein cholesterol [LDL-C] level ≥130 mg/dL [3.4 mmol/L] or total cholesterol [TC] ≥200 mg/dL).  Prevalence of familial hypercholesterolemia (FH) is reported to be 1/200.  They are a group of patients at higher risk for morbidity and early mortality. Lipid-lowering therapy in children with FH decelerates the atherosclerosis process, as assessed by subclinical vascular findings (carotid intima-media thickness). Long-term outcome data on cardiovascular outcome for the general pediatric population has yet to be established.

The practice of initiating interventions for pediatric dyslipidemia during childhood is supported by several organizations, including the American Heart Association, the American Academy of Pediatrics, the National Lipid Association, the National Cholesterol Education Program, and an expert panel sponsored by the National Heart, Lung, and Blood Institute.  These children are likely to have FH and the consequences of elevated LDL-C even in non-FH patients are likely to contribute to accelerated atherosclerosis and early CAD.

In considering patients with hyperlipidemia, American Heart Association has categorized risk factors as high, moderate, or at-risk.  Children with isolated hypercholesterolemia without other CVD risk factors or underlying conditions are generally considered “at-risk.” Since high-risk conditions are uncommon in childhood, most pediatric patients with dyslipidemia will be categorized as moderate- or at-risk.

Nonpharmacologic measures (i.e. heart-healthy lifestyle changes, including dietary modification, physical activity, weight loss, and avoidance of nicotine) are appropriate for all patients with hypercholesterolemia.

Statin remains the main pharmacologic therapy which is reserved for high-risk patients and those who do not achieve adequate response to lifestyle changes.  The decision to initiate lipid-lowering medication depends upon the age of the child, severity of dyslipidemia, and presence of other CVD risk factors.  At least two fasting lipid profile between 2 weeks to 3 months apart is recommend before making a diagnosis of hyperlipidemia.  

Children <10 years old should be managed mainly through lifestyle changes.  However, if they are considered high-risk, or LDL-C levels >400 mg/dL (10.4 mmol/L) or very elevated triglyceride (TG) levels (>1000 mg/dL [11.3 mmol/L]) or very strong family history of premature atherosclerotic CVD events, then treatment should be considered.

For children > 10 years old in a high-risk category who have LDL-C ≥130 mg/dL (3.4 mmol/L), starting both lifestyle changes and statin therapy is recommended.  For patients in the moderate-risk category, initial management consists of lifestyle changes. If the LDL-C remains ≥160 mg/dL (4.1 mmol/L) after three months of lifestyle changes, starting statin therapy is recommended. Treatment goal is LDL-C <130 mg/dL (3.4 mmol/L).  Mainstay of treatment for at-risk category patients is lifestyle changes and statin should only be considered if LDL-C remains ≥160 mg/dL (4.9 mmol/L).  In children with isolated hypercholesterolemia without other CVD risk factors, management consists of lifestyle changes and considering statin if LDL-C remains ≥190 mg/dL (4.9 mmol/L).

A heart-healthy lifestyle entails reducing saturated fat and cholesterol while increasing dietary fiber through fruits, vegetables, and whole grains. Dietary supplements (plant sterols and stanol esters) may also be effective.  Fruits, vegetables, and whole grains are a good source of fiber.  Polyunsaturated and monounsaturated fat intake should be encouraged and trans fats should be avoided. Fat should comprise approximately 30 percent of total energy intake, and saturated fats should be limited to <10 percent of total energy intake.  Consultation with a registered dietician is advised for implementation of dietary changes. 

Supplements, such as garlic and red yeast rice extract (which contain monacolins with statin-like activity), have been shown to lower cholesterol in adults. However, use in pediatrics is not recommended, because the number of monacolins a child would be exposed to is unknown and unregulated.  Fish oil supplements are not recommended for children with hypercholesterolemia, as they may increase LDL-C levels.  Daily vigorous physical activity has been associated with lower risk of CVD and better lipid levels.  Children with dyslipidemia should participate in at least as much daily physical activity as recommended for the general pediatric population.