The management of pediatric dyslipidemia should include weight regulation, diet optimization diet, and increased activity level, according to a review published in the Canadian Journal of Cardiology.
The development of atherosclerotic cardiovascular disease (ASCVD) generally occurs during adulthood, however the pathogenesis of ASCVD develops over a lifetime, with disordered lipid metabolism as the central causative factor. Dyslipidemia in children can be inherited or be associated with obesity caused by poor diet and insufficient physical activity. It is critical for clinicians to diagnose and implement appropriate interventions for dyslipidemia early in children. In the absence of evidence on the long-term effects of childhood dyslipidemia, clinical practice guidelines have largely been determined based on expert opinion rather than on data.
In children, normal levels are: <2.85 mmol/L (<110 mg/dL) for low-density lipoprotein (LDL), >1.17 mmol/L (>45 mg/dL) for high-density lipoprotein (HDL), <3 mmol/L (<120 mg/dL) for non-HDL cholesterol, and <1.15 mmol/L (<100 mg/dL) for triglycerides (TGs). High abnormal levels of lipids (in the 95th percentile) are: ≥3.37 mmol/L (≥130 mg/dL) for LDL and ≥3.76 mmol/L (≥145 mg/dL) for non-HDL cholesterol. Low abnormal level of HDL-cholesterol (in the 5th percentile) is <1.04 mmol/L (<40 mg/dL).
In children with dyslipidemia, levels of LDL cholesterol, TGs, and lipoprotein A are elevated. Therefore, the review authors suggest that LDL-cholesterol and triglycerides be measured in children with dyslipidemia. Fasting before blood sampling is not essential, except in the case of severe hypertriglyceridemia. In children with elevated triglycerides, the presence of familial chylomicronemia syndrome, multifactorial chylomicronemia, combined hyperlipidemia, and hypertriglyceridemia should be evaluated. Familial chylomicronemia syndrome may be diagnosed using genetic testing. An alternative method for stratifying ASCVD risk among children is to measure non-HDL cholesterol and assess their apolipoprotein B genotype.
If the clinician determines that dyslipidemia is due to downstream effects of poor diet and exercise, the review authors recommended regulating weight, optimizing diet, and increasing physical activity. When possible, these interventions should take place before any pharmacologic strategy is implemented.
Statins may be used for the reduction of LDL-cholesterol if the patient has a family history of hypercholesterolemia. There is a lack of favorable evidence for the use of triglyceride-lowering agents in children, however if the patient has very high (ie, >10 mmol/L) triglyceride levels and lifestyle interventions have not been successful, the review authors recommend that fibrate be considered to avoid pancreatitis.
At the time of publication, little clinical evidence and few randomized clinical trials were available to guide clinical management of pediatric hypertriglyceridemia or other pediatric dyslipidemias that are not familial hypercholesterolemia. Further study is needed to address this ever-growing disease state among children in order to better guide clinical practice.
Disclosure: An author declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Lazarte J and Hegele R A. Pediatric dyslipidemia-beyond familial hypercholesterolemia. Can J Cardiol 2020;S0828-282X(20)30275-0. doi:10.1016/j.cjca.2020.03.020.