REVIEW URRENT C OPINION
Update on pediatric hyperlipidemia Alia Chauhan a and Pooja Paunikar b
Purpose of review The purpose of this study is to review the National Heart Lung and Blood Institute (NHBLI) guidelines on screening and management of hyperlipidemia in children and to discuss the critics concerns regarding universal screening. Recent findings Data derived from the National Health and Nutrition Examination Survey has shown favorable trends in serum lipid levels among children and adolescents aged 6–19 years between 1988–1994 and 2007– 2010. Mean total cholesterol (TC) decreased from 165 to 160 mg/dl, and the prevalence of elevated TC decreased from 11.3 to 8.1%. However, between 2007 and 2010, approximately 20% of children aged 9–11 years had either low high-density lipoprotein cholesterol (HDL-C) or high non-HDL-C This warrants additional evaluation as per the NHBLI guidelines. Summary The NHBLI guidelines present physicians with a balanced perspective for screening and managing hyperlipidemia in children. These guidelines provide a schematic approach that helps primary care physicians to make treatment decisions. The hope is that this will lead to decreased healthcare system expense and overall improved health through early identification and intervention. Keywords BMI, cardiovascular, estimated energy requirement, familial hypercholesterolemia, high-density lipoprotein, hyperlipidemia, low-density lipoprotein
INTRODUCTION Several studies have shown that atherosclerosis begins in childhood and can lead to coronary heart disease in adults. They have also demonstrated a strong correlation between pediatric hyperlipidemia, carotid intimal thickening, and cardiovascular events in adults. The Cardiovascular Risk in Young Finns Study [1] showed that male participants who presented with several risk factors (high low-density lipoprotein cholesterol (LDL-C), increased BMI, and high SBP) at ages 12–18 years had an approximately 0.1 mm higher carotid artery intimal thickness than adults, as compared with those who did not have risk factors in adolescence. These findings suggest that having these cardiovascular risk factors early in life may start the process of atherosclerosis in the arteries, and eventually lead to cardiovascular disease in adults. The Princeton – Lipid Research Clinics followup study [2] followed cardiovascular risk factors in a random sample of children ages 6–18 years and again 26 years later (mean age 38 years). They found that elevated triglyceride levels persisted into young www.co-pediatrics.com
adulthood with increased incidence of cardiovascular disease as adults. Familial hypertriglyceridemia was found in 64% of these patients, with elevated triglyceride levels found in at least one parent or sibling after the child was screened and identified as a hyperlipidemic. Early cardiovascular disease was also found in the parent with hypertriglyceridemia. This study did not find a correlation between lowdensity lipoprotein (LDL) and adult cardiovascular risk; however, many of these adults were taking lipid-lowering medication at the time of the study. Children and young adults with high triglyceride levels were found to have low high-density lipoprotein (HDL) and maintained these levels into adulthood. a
Family Medicine Residency Program at North Shore-LIJ Southside Hospital, Hofstra North Shore-LIJ School of Medicine and bNSLIJ Southside Hospital in Bay Shore, New York, New York, USA Correspondence to Alia Chauhan, MD, FAAP, Department of Pediatrics, Southside Hospital, 301 East Main Street, Bayshore, NY 11706, USA. Tel: + 1 631 968 4285; e-mail: [email protected] Curr Opin Pediatr 2014, 26:252–258 DOI:10.1097/MOP.0000000000000078 Volume 26 Number 2 April 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Update on pediatric hyperlipidemia Chauhan and Paunikar
KEY POINTS Family history-directed screening may qualify only 25–55% children and adolescents for screening. Universal screening would help to identify children with heterozygous familial hypercholesterolemia. Critics are concerned that the new recommendations may result in an epidemic of lipid-lowering drug therapy and promote parental anxiety, vulnerable child syndrome, and eating disorders in affected children. The CHILD 1 diet and lifestyle change are first steps for identified dyslipidemia, cardiovascular risk factors, and moderate-to-high-risk conditions. The CHILD 2 diets are based on specific abnormal lipid parameters.
The Pathobiological Determinants of Atherosclerosis in Youth study [3] included individuals ages 15–34 years who died of accidental causes. Autopsy data showed a strong correlation among high cholesterol, hypertension and development of fatty streaks, and fibrous plaques in coronary vasculature at an early age. The Bogalusa Heart Study (1998) [4], a postmortem study, included individuals aged 6–30 years at the time of death. It reported that the extent to which arterial intimal surfaces were covered with fatty streaks and fibrous plaques increased with age. This was also significantly correlated with antecedent serum triglyceride, very LDL-C, blood pressure,and obesity. Among adolescents age 12–19 years, 20.3% had an abnormal lipid level; boys were more likely than girls to have at least one lipid abnormality (24.3 vs. 15.9%) [5]. The evidence from these studies emphasizes the need for early recognition and intervention for hyperlipidemia in pediatric populations to prevent cardiovascular disease in adults.
CURRENT SCREENING RECOMMENDATIONS Previous recommendations from the National Cholesterol Education Program (NCEP) issued in 1992 [6] indicated screening for children based on family history of premature cardiovascular disease or elevated serum cholesterol. In 2007, the US Preventive Services Task Force [7] presented systematic evidence on screening and treatment for hyperlipidemia in children after reviewing multiple studies. They reported that between 25 and 55% of children and adolescents qualify for screening based on family history,
depending on the sensitivity of the specific family history question. They concluded that the evidence is insufficient to recommend for or against screening for lipid disorders in childhood. The Expert Panel on Integrated Guidelines for Cardiovascular Risk Reduction, commissioned by the National Heart Lung and Blood Institute (NHBLI), released a report in November 2011. The Expert Panel believes that family history-directed screening in children for hyperlipidemia would fail to identify many children with elevated LDL-C levels. Universal screening would capture more children with an unknown family history. A perfect example would be familial hypercholesterolemia with a frequency of 1 : 500, which demonstrates a strong link between childhood lipid levels and cardiovascular events [8]. In familial hypercholesterolemia, high levels of LDL-C are present at an early age. Almost 51% of untreated affected men develop clinical cardiovascular disease by 50 years of age, and 5% by 30 years of age [9]. The new guidelines from NHBLI [10] recommend (Table 1): (1) Birth–2 years: no screening. (2) 2–8 years: no routine lipid screening. If the family history is positive for elevated cardiovascular risk or the child has a high-level risk factor or condition, measure fasting lipid profile twice (at least 2 weeks but no more than 12 weeks apart) and average the values. (3) 9–11 years: universal screening with nonfasting plasma lipid profile and the calculation of nonhigh-density lipoprotein cholesterol (HDL-C). If non-HDL-C is greater than 145 mg/dl, obtain two fasting lipid panels (at least 2 weeks but no more than 12 weeks apart) and average the values. (4) 12–16 years: no routine screening. If new knowledge of positive family history, new risk factor or new high-risk condition is identified in the patient, obtain two fasting lipid panels (at least 2 weeks but no more than 12 weeks apart) and average the values. (5) 17–21 years: universal screening with nonfasting plasma lipid profile and the calculation of non-HDL-C. If non-HDL-C is greater than 145 mg/dl, obtain two fasting lipid panels (at least 2 weeks but no more than 12 weeks apart) and average the values. In summary, universal screening of children is recommended between ages 9 and 11 years and again between ages 17 and 21 years, followed by a comprehensive scheme for further evaluation and treatment. The cut points for plasma lipid and
1040-8703 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-pediatrics.com
253
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Office pediatrics Table 1. 2011 Lipid Screening Guidelines from the National, Heart, Lung and Blood Institute Age
Recommendation
Birth–2 years
No screening
2–8 years
No routine lipid screening If family history is positive/child has a high level risk factor or condition: Obtain two fasting lipid panels and average the values
9–11 years
Universal screening with non fasting plasma lipid profile Calculate non-HDL-C: If HDL-C >145 mg/dl, obtain two fasting lipid panels and average the values
12–16 years
No routine screening If new knowledge of positive family history, new risk factor or new high-risk condition is identified in the patient: Obtain two fasting lipid panels and average the values
17–21 years
Universal screening once with nonfasting plasma lipid profile Calculate non-HDL-C: If HDL-C >145 mg/dl, obtain two fasting lipid panels and average the values
Interval between fasting lipid panel measurements at least 2 weeks but no more than 12 weeks apart
lipoprotein levels children and adolescents are shown in Table 2. In the past, screening recommendations relied on elevated LDL cholesterol. However, the NHBLI guidelines recommend a nonfasting lipid profile as the parameter for universal screening. Non-HDL-C is obtained by subtracting HDL from total cholesterol (TC). The Bogalusa Heart Study (2006) [11], a longitudinal cohort study, demonstrated that nonHDL-C is a better predictor of dyslipidemia in adults than LDL cholesterol. Individuals participated as 5–14-year-old children and then again as adults 27 years later. The study reported that adverse levels of non-HDL-C, as compared with LDL cholesterol, persisted from childhood into adulthood.
CRITICS AGAINST UNIVERSAL SCREENING: Critics from California [12] stated that the NHBLI recommendations are based on ‘expert opinion’, and the ‘concept’ that early identification and treatment will reduce the cardiovascular disease risk. The argument posed is that the evidence used to justify such screening is not as strong as implied by the NHLBI. The screening recommendations were made without providing estimates of cost, health benefit, and harm that might result from universal screening. They also express concern that the NHLBI Expert Panel members had conflicts of interest with industry. In response to these critics, Expert Panel members [13 ] published that the ‘commentary of Newman et al. regarding recommendations for lipid screening in childhood misrepresents the evidence regarding screening and the specificity and rigor of the guideline development process. A systematic process was used to review and grade the evidence. Universal screening is justified. It will help identify children with familial hypercholesterolemia, which affects about 1 in 500 people. They also stated that &
Adapted from: National Heart, Lung and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: full report. 2011. Available at: http://www.nhlbi.nih.gov/ guidelines/cvd_ped/index.htm.
Table 2. Acceptable, borderline, and high plasma lipid and lipoprotein concentrations (mg/dl) for children and adolescents Category
Acceptable
Borderline high
High
TC
< 170
170–199
200
LDL-C
< 110
110–129
130
Non-HDL-C
< 120
120–144
145
< 75
75–99
100
TG 0–9 years 10–19 years
< 90
90–129
130
Category
Acceptable
Borderline low
Low
HDL-C
> 45
40–45
< 40
The cut points for high and borderline high represent approximately the 95th and 75th percentiles, respectively. The low cut point for HDL-C represents, approximately the 10th percentile. Adapted from: National Heart, Lung and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: full report. 2011. Available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm.
254
www.co-pediatrics.com
Volume 26 Number 2 April 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Update on pediatric hyperlipidemia Chauhan and Paunikar
aneurysms, chronic inflammatory disease (e.g., systemic lupus erythematosus, juvenile rheumatoid arthritis), nephrotic syndrome, and HIV infection.
all relationships with industry were declared and reflect participation as consultants in the design of studies relevant to lipids and children. Others expressed the following concerns regarding the new recommendations: (1) It may lead to an epidemic of cholesterol screening and lipid-lowering drug therapy [14 ]. (2) An uncertain long-term risk-benefit profile [14 ]. (3) The economic costs of universal screening and the identification of mild hypercholesterolemia may produce parental anxiety and promote vulnerable child syndrome, eating disorders, and cardiac ‘nondisease’ issues in affected children [15 ]. &
&
&
As the ongoing debate over screening guidelines continues, data [16 ] derived from the National Health and Nutrition Examination Survey have shown favorable trends in serum lipid levels among children and adolescents aged 6–19 years between 1988–1994 and 2007–2010. Mean TC decreased from 165 to 160 mg/dl, and the prevalence of elevated TC decreased from 11.3 to 8.1%. However, between 2007 and 2010, approximately 20% of children aged 9–11 years had either low HDL-C or high non-HDL-C. This warrants additional evaluation as per the NHLBI Guidelines. &&
MANAGEMENT A preventive approach should be applied to the general population by promoting healthy diet and physical activity. The American Academy of Pediatrics recommends that all children engage in moderate-to-vigorous physical activity for at least 1 and 2 h/day of sedentary screen time. Individual approach lifestyle/diet change should be applied to children with elevated lipids, or with high-risk
Table 3. Conditions and risk factors to consider for treatment decisions in children with hyperlipidemia Positive family history
Angina Coronary artery bypass graft/stent/angioplasty Sudden cardiac death in parent, grandparent, aunt, or uncle (male
Update on pediatric hyperlipidemia Alia Chauhan a and Pooja Paunikar b
Purpose of review The purpose of this study is to review the National Heart Lung and Blood Institute (NHBLI) guidelines on screening and management of hyperlipidemia in children and to discuss the critics concerns regarding universal screening. Recent findings Data derived from the National Health and Nutrition Examination Survey has shown favorable trends in serum lipid levels among children and adolescents aged 6–19 years between 1988–1994 and 2007– 2010. Mean total cholesterol (TC) decreased from 165 to 160 mg/dl, and the prevalence of elevated TC decreased from 11.3 to 8.1%. However, between 2007 and 2010, approximately 20% of children aged 9–11 years had either low high-density lipoprotein cholesterol (HDL-C) or high non-HDL-C This warrants additional evaluation as per the NHBLI guidelines. Summary The NHBLI guidelines present physicians with a balanced perspective for screening and managing hyperlipidemia in children. These guidelines provide a schematic approach that helps primary care physicians to make treatment decisions. The hope is that this will lead to decreased healthcare system expense and overall improved health through early identification and intervention. Keywords BMI, cardiovascular, estimated energy requirement, familial hypercholesterolemia, high-density lipoprotein, hyperlipidemia, low-density lipoprotein
INTRODUCTION Several studies have shown that atherosclerosis begins in childhood and can lead to coronary heart disease in adults. They have also demonstrated a strong correlation between pediatric hyperlipidemia, carotid intimal thickening, and cardiovascular events in adults. The Cardiovascular Risk in Young Finns Study [1] showed that male participants who presented with several risk factors (high low-density lipoprotein cholesterol (LDL-C), increased BMI, and high SBP) at ages 12–18 years had an approximately 0.1 mm higher carotid artery intimal thickness than adults, as compared with those who did not have risk factors in adolescence. These findings suggest that having these cardiovascular risk factors early in life may start the process of atherosclerosis in the arteries, and eventually lead to cardiovascular disease in adults. The Princeton – Lipid Research Clinics followup study [2] followed cardiovascular risk factors in a random sample of children ages 6–18 years and again 26 years later (mean age 38 years). They found that elevated triglyceride levels persisted into young www.co-pediatrics.com
adulthood with increased incidence of cardiovascular disease as adults. Familial hypertriglyceridemia was found in 64% of these patients, with elevated triglyceride levels found in at least one parent or sibling after the child was screened and identified as a hyperlipidemic. Early cardiovascular disease was also found in the parent with hypertriglyceridemia. This study did not find a correlation between lowdensity lipoprotein (LDL) and adult cardiovascular risk; however, many of these adults were taking lipid-lowering medication at the time of the study. Children and young adults with high triglyceride levels were found to have low high-density lipoprotein (HDL) and maintained these levels into adulthood. a
Family Medicine Residency Program at North Shore-LIJ Southside Hospital, Hofstra North Shore-LIJ School of Medicine and bNSLIJ Southside Hospital in Bay Shore, New York, New York, USA Correspondence to Alia Chauhan, MD, FAAP, Department of Pediatrics, Southside Hospital, 301 East Main Street, Bayshore, NY 11706, USA. Tel: + 1 631 968 4285; e-mail: [email protected] Curr Opin Pediatr 2014, 26:252–258 DOI:10.1097/MOP.0000000000000078 Volume 26 Number 2 April 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Update on pediatric hyperlipidemia Chauhan and Paunikar
KEY POINTS Family history-directed screening may qualify only 25–55% children and adolescents for screening. Universal screening would help to identify children with heterozygous familial hypercholesterolemia. Critics are concerned that the new recommendations may result in an epidemic of lipid-lowering drug therapy and promote parental anxiety, vulnerable child syndrome, and eating disorders in affected children. The CHILD 1 diet and lifestyle change are first steps for identified dyslipidemia, cardiovascular risk factors, and moderate-to-high-risk conditions. The CHILD 2 diets are based on specific abnormal lipid parameters.
The Pathobiological Determinants of Atherosclerosis in Youth study [3] included individuals ages 15–34 years who died of accidental causes. Autopsy data showed a strong correlation among high cholesterol, hypertension and development of fatty streaks, and fibrous plaques in coronary vasculature at an early age. The Bogalusa Heart Study (1998) [4], a postmortem study, included individuals aged 6–30 years at the time of death. It reported that the extent to which arterial intimal surfaces were covered with fatty streaks and fibrous plaques increased with age. This was also significantly correlated with antecedent serum triglyceride, very LDL-C, blood pressure,and obesity. Among adolescents age 12–19 years, 20.3% had an abnormal lipid level; boys were more likely than girls to have at least one lipid abnormality (24.3 vs. 15.9%) [5]. The evidence from these studies emphasizes the need for early recognition and intervention for hyperlipidemia in pediatric populations to prevent cardiovascular disease in adults.
CURRENT SCREENING RECOMMENDATIONS Previous recommendations from the National Cholesterol Education Program (NCEP) issued in 1992 [6] indicated screening for children based on family history of premature cardiovascular disease or elevated serum cholesterol. In 2007, the US Preventive Services Task Force [7] presented systematic evidence on screening and treatment for hyperlipidemia in children after reviewing multiple studies. They reported that between 25 and 55% of children and adolescents qualify for screening based on family history,
depending on the sensitivity of the specific family history question. They concluded that the evidence is insufficient to recommend for or against screening for lipid disorders in childhood. The Expert Panel on Integrated Guidelines for Cardiovascular Risk Reduction, commissioned by the National Heart Lung and Blood Institute (NHBLI), released a report in November 2011. The Expert Panel believes that family history-directed screening in children for hyperlipidemia would fail to identify many children with elevated LDL-C levels. Universal screening would capture more children with an unknown family history. A perfect example would be familial hypercholesterolemia with a frequency of 1 : 500, which demonstrates a strong link between childhood lipid levels and cardiovascular events [8]. In familial hypercholesterolemia, high levels of LDL-C are present at an early age. Almost 51% of untreated affected men develop clinical cardiovascular disease by 50 years of age, and 5% by 30 years of age [9]. The new guidelines from NHBLI [10] recommend (Table 1): (1) Birth–2 years: no screening. (2) 2–8 years: no routine lipid screening. If the family history is positive for elevated cardiovascular risk or the child has a high-level risk factor or condition, measure fasting lipid profile twice (at least 2 weeks but no more than 12 weeks apart) and average the values. (3) 9–11 years: universal screening with nonfasting plasma lipid profile and the calculation of nonhigh-density lipoprotein cholesterol (HDL-C). If non-HDL-C is greater than 145 mg/dl, obtain two fasting lipid panels (at least 2 weeks but no more than 12 weeks apart) and average the values. (4) 12–16 years: no routine screening. If new knowledge of positive family history, new risk factor or new high-risk condition is identified in the patient, obtain two fasting lipid panels (at least 2 weeks but no more than 12 weeks apart) and average the values. (5) 17–21 years: universal screening with nonfasting plasma lipid profile and the calculation of non-HDL-C. If non-HDL-C is greater than 145 mg/dl, obtain two fasting lipid panels (at least 2 weeks but no more than 12 weeks apart) and average the values. In summary, universal screening of children is recommended between ages 9 and 11 years and again between ages 17 and 21 years, followed by a comprehensive scheme for further evaluation and treatment. The cut points for plasma lipid and
1040-8703 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-pediatrics.com
253
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Office pediatrics Table 1. 2011 Lipid Screening Guidelines from the National, Heart, Lung and Blood Institute Age
Recommendation
Birth–2 years
No screening
2–8 years
No routine lipid screening If family history is positive/child has a high level risk factor or condition: Obtain two fasting lipid panels and average the values
9–11 years
Universal screening with non fasting plasma lipid profile Calculate non-HDL-C: If HDL-C >145 mg/dl, obtain two fasting lipid panels and average the values
12–16 years
No routine screening If new knowledge of positive family history, new risk factor or new high-risk condition is identified in the patient: Obtain two fasting lipid panels and average the values
17–21 years
Universal screening once with nonfasting plasma lipid profile Calculate non-HDL-C: If HDL-C >145 mg/dl, obtain two fasting lipid panels and average the values
Interval between fasting lipid panel measurements at least 2 weeks but no more than 12 weeks apart
lipoprotein levels children and adolescents are shown in Table 2. In the past, screening recommendations relied on elevated LDL cholesterol. However, the NHBLI guidelines recommend a nonfasting lipid profile as the parameter for universal screening. Non-HDL-C is obtained by subtracting HDL from total cholesterol (TC). The Bogalusa Heart Study (2006) [11], a longitudinal cohort study, demonstrated that nonHDL-C is a better predictor of dyslipidemia in adults than LDL cholesterol. Individuals participated as 5–14-year-old children and then again as adults 27 years later. The study reported that adverse levels of non-HDL-C, as compared with LDL cholesterol, persisted from childhood into adulthood.
CRITICS AGAINST UNIVERSAL SCREENING: Critics from California [12] stated that the NHBLI recommendations are based on ‘expert opinion’, and the ‘concept’ that early identification and treatment will reduce the cardiovascular disease risk. The argument posed is that the evidence used to justify such screening is not as strong as implied by the NHLBI. The screening recommendations were made without providing estimates of cost, health benefit, and harm that might result from universal screening. They also express concern that the NHLBI Expert Panel members had conflicts of interest with industry. In response to these critics, Expert Panel members [13 ] published that the ‘commentary of Newman et al. regarding recommendations for lipid screening in childhood misrepresents the evidence regarding screening and the specificity and rigor of the guideline development process. A systematic process was used to review and grade the evidence. Universal screening is justified. It will help identify children with familial hypercholesterolemia, which affects about 1 in 500 people. They also stated that &
Adapted from: National Heart, Lung and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: full report. 2011. Available at: http://www.nhlbi.nih.gov/ guidelines/cvd_ped/index.htm.
Table 2. Acceptable, borderline, and high plasma lipid and lipoprotein concentrations (mg/dl) for children and adolescents Category
Acceptable
Borderline high
High
TC
< 170
170–199
200
LDL-C
< 110
110–129
130
Non-HDL-C
< 120
120–144
145
< 75
75–99
100
TG 0–9 years 10–19 years
< 90
90–129
130
Category
Acceptable
Borderline low
Low
HDL-C
> 45
40–45
< 40
The cut points for high and borderline high represent approximately the 95th and 75th percentiles, respectively. The low cut point for HDL-C represents, approximately the 10th percentile. Adapted from: National Heart, Lung and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: full report. 2011. Available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm.
254
www.co-pediatrics.com
Volume 26 Number 2 April 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Update on pediatric hyperlipidemia Chauhan and Paunikar
aneurysms, chronic inflammatory disease (e.g., systemic lupus erythematosus, juvenile rheumatoid arthritis), nephrotic syndrome, and HIV infection.
all relationships with industry were declared and reflect participation as consultants in the design of studies relevant to lipids and children. Others expressed the following concerns regarding the new recommendations: (1) It may lead to an epidemic of cholesterol screening and lipid-lowering drug therapy [14 ]. (2) An uncertain long-term risk-benefit profile [14 ]. (3) The economic costs of universal screening and the identification of mild hypercholesterolemia may produce parental anxiety and promote vulnerable child syndrome, eating disorders, and cardiac ‘nondisease’ issues in affected children [15 ]. &
&
&
As the ongoing debate over screening guidelines continues, data [16 ] derived from the National Health and Nutrition Examination Survey have shown favorable trends in serum lipid levels among children and adolescents aged 6–19 years between 1988–1994 and 2007–2010. Mean TC decreased from 165 to 160 mg/dl, and the prevalence of elevated TC decreased from 11.3 to 8.1%. However, between 2007 and 2010, approximately 20% of children aged 9–11 years had either low HDL-C or high non-HDL-C. This warrants additional evaluation as per the NHLBI Guidelines. &&
MANAGEMENT A preventive approach should be applied to the general population by promoting healthy diet and physical activity. The American Academy of Pediatrics recommends that all children engage in moderate-to-vigorous physical activity for at least 1 and 2 h/day of sedentary screen time. Individual approach lifestyle/diet change should be applied to children with elevated lipids, or with high-risk
Table 3. Conditions and risk factors to consider for treatment decisions in children with hyperlipidemia Positive family history
Angina Coronary artery bypass graft/stent/angioplasty Sudden cardiac death in parent, grandparent, aunt, or uncle (male
