There is no question that dyslipidemia – abnormally elevated cholesterol or fats (lipids) in the blood – in childhood leads to early atherosclerotic cardiovascular disease (CVD) in adulthood. Studies have demonstrated that for individuals with familial hypercholesterolemia (a genetic disorder associated with an elevated risk of CVD), initial treatment during childhood reduces the risk. Therefore, it is important to screen and treat pediatric dyslipidemia. Unfortunately, the screening and management of dyslipidemia in children are underutilized and undertreated. Several factors contribute to this issue.
One possible reason is the conflicting recommendations surrounding pediatric cholesterol screening. The U.S. Preventative Services Task Force has concluded that there is insufficient evidence to support universal cholesterol screening in children. However, many other organizations, such as the American Academy of Pediatrics, the National Lipid Association and the American College of Cardiology, have endorsed the recommendations from the National Heart, Lung, and Blood Institute (NHLBI), which suggests universal screening at 9-11 years of age and again at 17-21 years of age due to documented benefits. As a result, there is widespread support for screening to detect and treat dyslipidemia in children.
In general, the primary treatment for dyslipidemia involves dietary and lifestyle modifications. This includes following CHILD-2 low-density lipoprotein cholesterol (LDL-C) and triglyceride (TG) lowering diets, which emphasize limiting 25-30% of total daily calories from fat, with less than 7% daily calories from saturated fat and less than 10% from monounsaturated fat. Avoiding trans fats and increasing fiber intake is also essential.
Reducing sugar-sweetened beverages, replacing simple carbohydrates with complex ones and increasing dietary fish consumption to boost omega-2 fatty acid intake is recommended for those with elevated triglyceride levels. Another key aspect of lifestyle modifications is encouraging at least one hour of moderate-to-vigorous physical activity daily while limiting sedentary screening time to less than two hours.
However, despite these recommendations, the management of dyslipidemia in pediatric patients remains inadequate. Guidelines and scientific statements from NHLBI and the American Heart Association stratify patient risk and management based on cardiovascular risk factors. However, both have their limitations, which are discussed in our recently published paper, “Algorithms for Treating Dyslipidemia in Youth.”
In this paper, we reviewed the existing recommendations, considered updated data and proposed several enhanced algorithms to manage dyslipidemia. One of the algorithms created was a diabetes-specific lipid algorithm since dyslipidemia is a major co-morbidity of diabetes. Additionally, we created an algorithm for complex rare lipid disorders, incorporating newer medications that have been recently approved in pediatrics. General LDL-C and high TG management is addressed with distinct CVD risk factors for patient risk stratification, along with a statin titrating guide.
We acknowledge that outcome studies are scarce in pediatrics compared to adults, which is a limitation of the pediatric algorithms. Unlike adult algorithms based on risk scores derived from CVD morbidity and mortality data, pediatrics has no risk assessment tool. Yet, creating a risk score for pediatric patients is necessary as we continue to learn more in this field. Such a risk score for pediatric patients will be instrumental in developing improved treatment algorithms for individualized dyslipidemia management in the future. Until then, we hope these practical algorithms continue to assist pediatricians in managing dyslipidemia and preventing early cardiovascular disease.
By Dr. Grace Kim, assistant professor of pediatrics – diabetes and endocrinology, and Nidhi Bansal, M.B.B.S., M.P.H., associate professor of pediatrics – diabetes and endocrinology, at Baylor College of Medicine