Lipids and Kids

By Peter Galvin, MD

Lipid disorders, also called dyslipidemia or “high cholesterol,” refer to abnormal levels of cholesterol and other fats in the blood. There are two main sub-types of cholesterol: low-density lipoprotein cholesterol (LDL-C; “bad” cholesterol) and high-density lipoprotein cholesterol (HDL-C; “good” cholesterol). There is also triglyceride, another form of fat in the blood. Common lipid disorders include high LDL-C, low HDL-C, and high triglycerides. Having high cholesterol usually means having high LDL-C. Current thinking is that high LDL-C is associated with a greater risk of atherosclerosis and heart disease while high HDL-C is associated with a lower risk. Treatment goals are an LDL-C of 70 and under with the goal for HDL-C over 50 to 55.

High cholesterol, including in children, can be due to both genetic factors and lifestyle choices (including a poor diet and lack of exercise). One genetic disease that causes very high cholesterol levels in children is called familial hypercholesterolemia (FH), which has no symptoms in children. It can, if undetected and untreated, cause early heart disease in young people. In the course of my career, I have seen heart attacks, some fatal, in people in their twenties. In almost every case, they had HDL-C levels under 20 and LDL-C levels over 180 plus parents, usually fathers, who died very young from heart disease. In other words, they had undiagnosed FH.

So, obviously, the question is, should kids and adolescents be screened for lipid levels? According to the U.S. Preventive Services Task Force (USPSTF), a quasi-governmental panel of experts who make recommendations on screening for various diseases, the answer is maybe. These experts say maybe because there are very few randomized, controlled clinical trials that have looked at the risks and benefits of screening young people for high lipid levels, there is not enough information to make a fact-based recommendation. One might reasonably presume that, aside from a needle stick, screening would be beneficial, but lipid lowering medications can have side effects (for example their potential effects on the liver and muscles). Plus, statins and other newer medications have not been around long enough to assess the risks of their long-term use, and a child placed on these medications is likely to take them for the rest of his/her life.

Statins and bempedoic acid do have protective effects against the development of heart disease, separate from their ability to lower lipid levels. This is due to their anti-inflammatory properties. While FH is relatively rare, what data does exist, mostly observational studies, does show that reducing lipid levels in children with FH does have long-term benefit for this condition. So, according to the USPSTF, the evidence on screening children and adolescents for lipid disorders is still unclear. While more studies are being performed and more data accumulates, certainly if one or both of a child’s parents has FH or early-onset heart disease, screening those parents’ children would seem reasonable. In any case, the decision to screen young people for lipid disorders should be made following a discussion between the parents and the child’s doctor or pediatrician.

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