Amy DiPietro, M.D., is a pediatric cardiologist with Norton Children’s Heart Institute, affiliated with the UofL School of Medicine. She presented a continuing medical education lecture on pediatrics and dyslipidemia.

Cardiovascular disease is the No. 1 cause of death in the United States and is the most common cause of mortality in developing countries. While conditions such as myocardial infarction and coronary artery disease stem from atherosclerosis, people think of these as “adult diseases.” While the heart attack may not happen in a teenager, the dyslipidemia that begins in childhood almost certainly leads to atherosclerosis.

Lipids serve an important function in the body, but an imbalance of such compounds can create serious conditions over time. Dyslipidemia, sometimes called hyperlipidemia, refers to an excess of lipids in the bloodstream. This leads to significantly increased risk of cardiovascular disease and related complications, as well as atherosclerosis.

Two longitudinal studies show atherosclerosis begins in childhood, both evaluating determinants of cardiovascular health in children, following them through their teen and adult years: the Bogalusa Heart Study and the Young Finns Study. This research and the data gathered from the studies have been invaluable in understanding the long-term health impacts of dyslipidemia in children.

Why should pediatricians care about dyslipidemia?

This condition is a significant factor for cardiovascular disease and other health issues, but it is often undiagnosed in children. The lack of symptoms means it is a silent disease, progressing over time and going unnoticed until it is well advanced.

There is evidence for dyslipidemia causing atherosclerosis in children. Childhood levels of total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglycerides are predictors of coronary artery calcium and carotid intimal-media thickness.

Increases in childhood obesity are associated with increased rates of dyslipidemia, including moderate-to-severe elevation of triglycerides, normal-to-moderate increases of LDL, and decreased HDL. This translates to significantly increased risk for cardiovascular disease and associated complications later in life.

Childhood cardiovascular risk profiles predict both coronary artery calcium and carotid intimal-media thickness. Dyslipidemia in childhood with elevated LDL and triglyceride levels predict increased carotid intimal-media thickness independently and synergistically with other cardiovascular disease risk factors. Young adults with a triglyceride level greater than 200 milligrams per deciliter (mg/dL) had about five times the risk of developing coronary cardiovascular disease events 40 years later, compared with those who just had a total cholesterol of less than 172 mg/dL. Childhood dyslipidemia predicts development of metabolic syndrome, the development of Type 2 diabetes and development of adult cardiovascular disease.

Who should be screened for childhood dyslipidemia?

There is evidence of the benefit of universal screening. With rising rates of obesity, Type 2 diabetes and metabolic syndrome in kids, screening needs to be expanded to include non-HDL, elevated triglycerides, elevated LDL, hyperglycemia, insulin resistance and hypertension.

Current guidelines instruct screening protocol from birth to 21 years old and recommend screening and therapeutic strategies for each of the age groups. From birth to 2 years, no screening is recommended. From 3 to 8 years and from 12 to 16 years, screening is recommended if there are certain risk factors. From 9 to 11 and from 17 to 21, universal screening is recommended.

There are many unanswered questions in the guidelines, and the debate rages in the literature. For example, gender differences are not adequately addressed in the guidelines. The timing of puberty affects the lipid levels, and the fact that puberty can happen in a range of ages is not included.

A few practical considerations to keep in mind while staying within the guidelines:

• Obtain one initial fasting blood draw instead of two, which may eliminate the extra draw if the patient is compliant. .
• Get a direct LDL measurement if you think triglycerides will be high, such as in patients with obesity or diabetes.
• Obtain creatine kinase and liver function tests at the time of a secondary, confirmatory blood draw if you think it is warranted

How to treat dyslipidemia in pediatric patients?

Once you have confirmed elevated cholesterol after a repeat test, first consider secondary causes including exogenous (alcoholism, oral contraceptives), endocrine and metabolic conditions (hypothyroid, pregnancy), renal or hepatic causes. If secondary causes are ruled out and dyslipidemia continues, intensive lifestyle management may begin. Consider referring to a lipid specialist as well.

First-line lifestyle changes include:

• Diet modification, including a reduction in dietary sugar, saturated fats and cholesterol
• Daily physical activity and support for physical activities of preference
• Limiting sedentary activities, including screen time
• Weight loss as needed

The lifestyle changes and diet therapy must be emphasized with patient education.

If the physician is unable to educate the patient and family, they may enroll the help a nutritionist, dietitian or a physical therapist. It is important to approach this as a family effort that is not isolated to the child. If the family does not actively support and engage in these lifestyle changes, then the best positive health outcomes will be difficult to achieve.

Pharmacologic therapy of dyslipidemia is recommended in all children ages 10 and older who fail diet treatment and lifestyle changes, after six to 12 months, and have no risk factors.

If LDL is persistently greater than 190 mg/dL, despite the intervention, start LDL-lowering therapy. If the LDL is greater than 160 mg/dL and you have one risk factor, then start therapy. If the LDL is greater than 130 mg/dL and you have diabetes, that is also an indication after lifestyle management to start therapy.

• Statins are a common treatment for dyslipidemia and include atorvastatin, fluvastatin, lovastatin and pravastatin.
• Cholesterol inhibitors, such as ezetimibe, block the uptake of cholesterol.
• PCSK9 inhibitors are used when the previous two have failed.
• Bile acid sequestrants can be used alone or with statins.
• Triglyceride therapy may be used, but a lipid specialist should be guiding the use of these drugs.
• Omega-3 fatty acids are found in oily fish such as sardines, salmon and mackerel, but may be taken as a supplement.

In conclusion

Pediatric health care providers should be aware of the potential for dyslipidemia in their patient populations and understand screening recommendations, how to diagnose and how to manage the condition. Obesity and dyslipidemia are endemic in the United States and are associated with significant comorbidities and complications. Management of dyslipidemia will enable prevention of cardiovascular disease in adulthood.

What does this mean?it seems like subsequent tests are mentioned below. Maybe it is clear to a clinician but I am not sure