Introduction
Research in children and adolescents show that risk factors for adult cardiovascular disease (CVD) may be present at a young age. These factors include high concentration of low-density lipoprotein (LDL), low concentration of high-density lipoprotein (HDL), elevated blood pressure, type 1 or 2 diabetes mellitus, cigarette smoking, obesity and the metabolic/insulin-resistance syndrome, and decreased level of physical activity and fitness.
The epidemic of childhood obesity in the United States is also important to consider in screening for lipid issues earlier. During the past 25 years, prevalence of pediatric obesity has tripled and recent research suggests that increasing body weight in childhood is strongly associated with the risk of cardiovascular disease in adulthood. Identification of children who are at-risk for atherosclerosis may allow intervention that can prevent or delay adult CVD.
The 2011 recommendations to identify children and adolescents (age 2-18) with abnormal lipid and lipoprotein concentrations are listed below, CLICK ON THE REFERENCE TO LINK TO THE FULL ARTICLE.
Cut Points for Total Cholesterol and LDL Concentrations in Children/Adolescents
- A healthy lifestyle for all children is recommended for the prevention of development of dyslipidemia. A low saturated fat, low cholesterol diet with balanced caloric intake is recommended, accompanied with sufficient physical activity and the consumption of fruits, vegetables, fish, whole grains, and low-fat dairy products. Intake of fruit juice, sugar-sweetened beverages and foods, and salt should be reduced. Trans fatty acids should be limited to <1% of total calories. Dietary changes are not recommended for children younger than 2 years, because younger children require fat to support appropriate growth and development. But if children between 12 months and 2 years have a positive family history of obesity, dyslipidemia, or CVD and there is concern for overweight or obesity, caregivers may use reduced-fat milk.
- Individual assessment focuses on children at high-risk, including a positive family history of CVD or a personal history of high cholesterol and LDL. Initially, at least a six month trial of lifestyle changes can be used with recommended changes in diet, nutritional counseling, and increased physical activity. But these children may eventually be candidates for pharmacologic intervention. The concentrations of LDL at which pharmacologic intervention is recommended for children age 8 or older and adolescents are below. The initial goal is to at least lower the LDL concentration <160mg/dL, but a lower goal is desirable if there is a presence of associated risk factors.
Recommendations for Pharmacologic Intervention for Dyslipidemia in Children/Adolescents (age 8-18)
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report
Pediatrics Vol. 128 No. Supplement 5 December 1, 2011 pp. S213 -S256
Medications
- Statins:
Statins inhibit the rate-limiting enzyme needed for cholesterol synthesis. Statins are generally well-tolerated. Adverse effects include increased hepatic transaminase levels, elevated creatine kinase (associated with rare rhabdomyolysis), and potential teratogenicity -- these effects should be monitored. Studies have shown statins to be safe and effective in lowering cholesterol concentrations in children.
- Bile Acid Binding Resins:
These medications bind cholesterol in bile acids in the intestinal lumen, preventing reuptake in the enterohepatic circulation. Adverse effects is limited to GI discomfort, with no systemic effects but compliance of these resins in children have shown to be poor.
- Niacin:
Niacin decreases hepatic production of very low-density lipoprotein (VLDL) and is effective in lowering LDL and triglyceride concentrations and increasing HDL concentration. Adverse effects including flushing, hepatic failure, myopathy, glucose intolerance, and hyperuricemia – making niacin an unattractive medication in pediatrics.
- Cholesterol-Absorption Inhibitors/Fibrates:
These have not been extensively studied in children.
References:
- Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report Daniel Pediatrics Vol. 128 No. Supplement 5 December 1, 2011, pp. S213 -S256
- Daniels S. et. al. (2008). "Lipid screening and cardiovascular health in childhood." Pediatrics, 122, 198-208
- Ferranti S., and Ludwig D. (2008). "Storms over statins – the controversy surrounding pharmacologic treatment of children." NEJM, 359(13), 1309-1312.