Overview of management of hypercholesterolemia in pediatric patients ≥10 years old

This algorithm summarizes the management of children ≥10 years old with LDL-C levels in the range of 130 to 249 mg/dL (3.4 to 6.5 mmol/L). Initial treatment decisions should be based on averaging the LDL-C values from two separate fasting lipid profiles obtained 2 weeks to 3 months apart. Children <10 years old with clinically significant hypercholesterolemia and pediatric patients with LDL-C ≥250 mg/dL (≥6.5 mm/L) should generally be referred to a pediatric lipid specialist. This algorithm is intended for use in conjunction with additional UpToDate content on dyslipidemia in children. Refer to UpToDate topics on the management of dyslipidemia in children for additional details of our approach to treatment and the overall efficacy of these treatments.

LDL-C units are mg/dL; divide by 38.67 to convert to mmol/L.

ASCVD: atherosclerotic cardiovascular disease; LDL-C: low density lipoprotein cholesterol; FH: familial hypercholesterolemia; BMI: body mass index; NAFLD: nonalcoholic fatty liver disease; PCOS: polycystic ovary syndrome; TC: total cholesterol; SLE: systemic lupus erythematosus; JIA: juvenile idiopathic arthritis; HCM: hypertrophic cardiomyopathy; TGA: transposition of the great arteries; BP: blood pressure.

* Lifestyle changes include:

Diet modification: Encourage a diet high in fiber from fruits, vegetables, and whole grains; high in polyunsaturated and monounsaturated fats; low in saturated fat; and devoid of trans fats; fat should comprise approximately 30% of total energy intake; saturated fats should be limited to <10% of total energy intake. Consultation with a registered dietician may be warranted for implementation of dietary changes.
Physical activity: Encourage at least 1 hour/day of moderate to vigorous activity; limit nonacademic screen time to about 1 hour per day.
Weight loss in obese children.
Avoidance of nicotine exposure.

For additional details, refer to UpToDate content on pediatric dyslipidemia.

¶ For details on initiating, monitoring, and titrating statin therapy in children, refer to separate UpToDate content on management of pediatric dyslipidemia.

Δ Patients who continue to have LDL-C levels ≥190 mg/dL (4.9 mmol/L) despite initial lifestyle interventions should be started on statin therapy and referred to a pediatric lipid specialist. These patients are likely to have heterozygous FH or a similar genetic lipid disorder that substantially increases the risk of premature ASCVD. Genetic testing may be warranted, and specialist care will often be beneficial. A pediatric lipid specialist is typically a pediatric cardiologist (or an endocrinologist, gastroenterologist, or general pediatrician) who has completed additional training in lipid disorders through a senior fellowship or via professional societies. If a pediatric lipid specialist is not available locally, referral to an adult lipid specialist may be helpful, particularly for adolescents.

◊ Family history of premature ASCVD is generally defined as heart attack, treated angina, interventions for coronary artery disease, sudden cardiac death, or ischemic stroke in a first-degree relative (parent or sibling) before age 55 (males) or 65 (females).

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Overview of management of hypercholesterolemia in pediatric patients ≥10 years old