Pediatric HLD: Lipids in the Little Ones

Case

Becky comes to clinic with her child, Bonnie, who is 2 years old. Becky wants to make sure we do all of the appropriate screening to keep her daughter healthy. She notes her mother had a heart attack at age 55, and she herself has a history of HTN and HLD. She asks you, the doctor, “When should we test her cholesterol levels? I was thinking she was too young at this point but wanted to get your recommendation.”

Background

Overview of lipid physiology: 

Lipid levels change over time with normal growth and maturation. Lipoproteins are very low in cord blood at birth and rise slowly in the first 2 years of life. After age 2yo, lipid and lipoprotein levels are relatively stable until adolescence. During puberty, total cholesterol and LDL–C levels decrease with increasing age before rising in the late teen years and again in the third decade of life. What’s concerning is that 20% of children aged 6-19yo have at least one abnormal lipid value, and the risk appears particularly high in adolescents with greater BMI.

Screening

Screening for lipid disorders in childhood is based on the idea that early identification and control of pediatric dyslipidemia will reduce the risk and severity of cardiovascular disease in adulthood.

• Given that lipid disorders are clinically silent in the majority of cases, the NHLBI recommends universal screening because selective screening alone (e.g., patients with known family history) misses 30-60% of patients with dyslipidemia. Furthermore, universal screening helps identify patients with familial hypercholesterolemia, a group at high risk for significant morbidity and early mortality.
  • Cholesterol screening based on risk factors is suggested for 2-10yo children with a family history of dyslipidemia or premature cardiovascular disease in male relatives <55yo and female relatives <65yo, unknown family history, overweight/obesity, hypertension, cigarette smoking, diabetes mellitus, or medical conditions associated with lipoprotein abnormalities (e.g., organ transplant, systemic lupus erythematosus, nephrotic syndrome, or protease inhibitor treatment)
• In contrast, the USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger.

Risk factors for development of atherosclerosis and early cardiovascular disease in childhood: 

Causes of Dyslipidemia

Etiology is generally divided into excessive dietary intake, primary disorders, and secondary disorders.

Primary causes: 

Secondary causes: 

Management of Dyslipidemia

First-line management is lifestyle modification promoting a heart-healthy lifestyle!

• Dietary changes: total fat <30% of calories, saturated fat <10% of calories, and cholesterol intake <300 mg/day
• Increased activity: 30-60 minutes of daily physical activity (moderate to vigorous)
• Weight loss in children with obesity: dyslipidemia benefits with only 5-10% reduction in excess weight
• Habit modification: stop smoking and avoid secondhand smoke

Medications:

• The decision to initiate lipid-lowering medication depends on the age of the child (generally at least 10yo), severity of dyslipidemia, and presence of other risk factors for cardiovascular disease. 
• The LDL-C value used in determining the need for pharmacotherapy should be based on multiple measurements rather than a single measurement. 
• There is less data on the use of statins in children compared to adults, but they appear to be well-tolerated without additional safety concerns. 

Take-Home Points!

• The NHLBI recommends universal screening at 9-11yo and 17-21yo. Start screening earlier in the presence of risk factors. 
• Always consider primary versus secondary causes of dyslipidemia. 
• Lifestyle modifications work!
• Always get at least 2 lipid panels before considering pharmacotherapy. 

Blog post based on Med-Peds Forum talk by Madeleine Ward, PGY2