Dyslipidemia in Children

Intro & Screening - Lipid Patrol Start

• Definition: Abnormal pediatric lipid levels (NHLBI/AAP). Atherosclerosis risk from childhood → adult CVD.
  • LDL-C: Acc <110, Borderline 110-129, High ≥130 mg/dL.
  • Triglycerides (TG) (0-9y): Acc <75, Borderline 75-99, High ≥100 mg/dL.
  • TG (10-19y): Acc <90, Borderline 90-129, High ≥130 mg/dL.
• Types: Hypercholesterolemia, hypertriglyceridemia, low HDL-C, mixed.
• Screening:
  • Universal: 9-11 yrs & 17-21 yrs. 📌 '9-11 call for lipids, 17-21 for a clean scene'.
  • Selective (>2y): Risk factors (FamHx CVD/lipids, obesity, DM, HTN, smoking, CKD, Kawasaki+aneurysms, post-transplant).
  • Test: Fasting Lipid Profile (FLP) (preferred); Non-HDL-C (alternative).

⭐ Universal lipid screening: once at 9-11 years, again at 17-21 years.

Etiology - Root Cause Roundup

• Primary (Genetic):
  • Monogenic:
    • Familial Hypercholesterolemia (FH): AD; LDLR/APOB/PCSK9 mutations.
    • Familial Defective ApoB100.
    • Autosomal Recessive Hypercholesterolemia (ARH/LDLRAP1).
  • Polygenic hypercholesterolemia.
  • Familial Combined Hyperlipidemia (FCHL).
  • Hypertriglyceridemia: LPL/ApoCII deficiency.
• Secondary (Acquired/Lifestyle):
  • Obesity (most common).
  • Unhealthy diet (↑sat/trans fats, sugar).
  • Sedentary lifestyle.
  • Diabetes Mellitus (T1 & T2).
  • Hypothyroidism.
  • Nephrotic syndrome.
  • Cholestatic liver disease.
  • Medications (corticosteroids, isotretinoin, antipsychotics, protease inhibitors).
  • 📌 Mnemonic: 'Obese Kids Have Nasty Lipid ProfileS' (Obesity, Kawasaki, Hypothyroid, Nephrotic, Liver, PCOD, Steroids).

⭐ Familial Hypercholesterolemia (FH) is the most common genetic disorder causing severe elevations in LDL cholesterol and premature atherosclerotic cardiovascular disease.

Clinical Clues & Dx - Spotting Saboteurs

• Often asymptomatic. Family Hx: premature CAD, dyslipidemia, sudden death.
• Signs (severe/genetic, esp. FH):
  • Tendon xanthomas (Achilles, hands, feet).
  • Xanthelasmas (eyelids).
  • Arcus cornealis (< 45 yrs).
• Pancreatitis with severe ↑TG.
• Dx: Fasting lipid profile. Non-HDL-C = $TC - HDL-C$.
  • LDL-C (Friedewald): $LDL-C = TC - HDL-C - (TG/5)$; if TG < 400 mg/dL.
  • Direct LDL-C if TG ≥ 400 mg/dL.
• Exclude secondary causes: Glucose, TSH, LFTs, urinalysis.

⭐ Tendon xanthomas in a child strongly suggest Familial Hypercholesterolemia (homozygous/severe heterozygous).

Management - Lipid Takedown Plan

1. Goals:

• LDL-C: <130 mg/dL (general); <100 mg/dL (high-risk, e.g., FH, post-transplant).

2. Lifestyle Modifications (LSM) - Cornerstone:

• Diet: CHILD-1 (>2 yrs); CHILD-2 if targets unmet. Family-based approach.
• Activity: ≥60 minutes/day moderate-to-vigorous.
• Weight management; Smoking prevention.

3. Pharmacotherapy:

• Indications (Age ≥10 yrs; ≥8 for severe FH):
  • LDL-C ≥190 mg/dL (despite LSM).
  • LDL-C ≥160 mg/dL + (Family Hx early CVD or ≥2 risk factors).
  • LDL-C ≥130 mg/dL + Diabetes.
• Drugs:
  • Statins (1st line): e.g., Pravastatin, Atorvastatin (check age approvals).
  • Ezetimibe (if statin intolerant/insufficient).
  • Bile Acid Sequestrants (BAS).
  • Fibrates (for severe hypertriglyceridemia TG >500 mg/dL, post-LSM).
  • PCSK9 inhibitors (for severe refractory FH, specialist use).

4. Monitoring:

• Lipid profile, LFTs (baseline, periodic with statins), CK (if myalgia).

⭐ For children with LDL-C ≥190 mg/dL despite 3-6 months of lifestyle therapy, statin medication is typically recommended starting at age 10 years (or earlier in severe FH).

High‑Yield Points - ⚡ Biggest Takeaways

• Universal screening: ages 9-11 & 17-21 years.
• Selective screening: high-risk children (family Hx, obesity, DM).
• Lifestyle modification (diet, exercise) is first-line management.
• Statins: first-line drug if lifestyle fails; for LDL-C ≥190 mg/dL (or ≥160 mg/dL + risks).
• Target LDL-C: <130 mg/dL (general); <100 mg/dL (high-risk).
• Suspect Familial Hypercholesterolemia (FH) with very high LDL-C & family Hx.
• Rule out secondary causes (e.g., hypothyroidism, nephrotic syndrome, drugs).