Key Practice Point
#1
Recommendation
Due to limited research in pediatric dyslipidemia, dietary and lifestyle recommendations for pediatric dyslipidemia are extrapolated from adult dyslipidemia recommendations.
For children with elevated LDL-C, suggested dietary and lifestyle strategies include a diet high in fibre, polyunsaturated fatty acids (PUFA) and monounsaturated fatty acids (MUFAs), low in saturated fats, no trans fats, along with five hours or more of moderate to vigorous physical activity per week.
More specifically, for children with familial hypercholesterolemia (FH), suggested dietary and lifestyle strategies include ≤30% of total energy from total fat, ≤10% of total energy from saturated fat, <300 mg/day dietary cholesterol, replacement of saturated fats with MUFA and PUFA, minimum of five servings of fruit and vegetables per day, consume food containing stanols and sterols consistently (individual choice), avoid omega-3 fatty acid supplementation, be physically active, achieve and maintain a “healthy weight” and avoid smoking.
For children with elevated triglycerides (TG), suggested dietary and lifestyle management strategies include a diet low in simple carbohydrates and added sugars, high in fibre, PUFA and MUFA, moderate complex carbohydrates, five hours or more of moderate to vigorous physical activity per week, and weight loss as necessary.
At eight to 10 years of age, pharmacological treatment may be required for children with elevated LDL-C at high risk for cardiovascular disease (CVD) with consideration for fat-soluble vitamins and folic acid supplementation (amount not specified) for children receiving long-term bile acid sequestrants. Pharmacological treatment or prescription omega-3 fatty acids (approximately 4 g/day EPA + DHA) may be suggested for elevated TG.
Evidence Summary
Based on limited research in pediatric cardiovascular risk reduction, the 2019 American Heart Association (AHA) provided management considerations for children and adolescents with primary or secondary causes of dyslipidemia who are at high risk for CVD. The practical interim guidance aligns with adult guidelines for which heart healthy lifestyle strategies are the foundation for all individuals.
Lifestyle management considerations for youth with elevated low density lipoprotein cholesterol (LDL-C) include:
- a diet high in fibre, polyunsaturated fatty acids (PUFA) and monounsaturated fatty acids (MUFAs), low in saturated fats and no trans fats
- five hours or more of moderate to vigorous physical activity per week.
If LDL-C ≥3.37 mmol/L and the individual is at high risk for CVD, simultaneous initiation of pharmacological (e.g. statins) and lifestyle treatment is suggested to achieve LDL-C <2.59 mmol/L. If LDL-C ≥4.15 mmol/L and the individual is at moderate risk or at risk, lifestyle treatment is suggested for three and six months, respectively, to achieve LDL-C <3.37 mmol/L. If this goal is not achieved, the addition of pharmacological treatment is suggested.
Lifestyle management considerations for youth with elevated triglycerides (TG) include:
- a diet low in simple carbohydrates and added sugars, high in fibre, PUFA and MUFA, and moderate in complex carbohydrates
- five hours or more of moderate to vigorous physical activity per week
- weight loss as necessary.
If repeat testing confirms TG >11.3 mmol/L, lifestyle treatment and prescription omega-3 fatty acids (approximately 4 g/day EPA + DHA) or pharmacological treatment is suggested.
Based on low quality evidence, the 2018 Canadian Cardiovascular Society (CCS) position statement on the evaluation and management of familial hypercholesterolemia (FH) suggests that all individuals (adults and children) with FH follow a healthy lifestyle, as recommended by CCS guidelines for adults with dyslipidemia (i.e. healthy eating, healthy body weight, stress management, smoking cessation).
Grade of Evidence C Although a healthy lifestyle is of the utmost importance in managing and preventing CVD risk factors, it does not adequately reduce LDL-C levels in children with FH; therefore, statin therapy is suggested for children age eight to 10 years with LDL ≥4.8 mmol/L or ≥4.1 mmol/L with a family history of premature CVD or other risk factors.
Grade of Evidence BBased on limited data, the 2019 National Institute for Health and Care Excellence (NICE) guideline on FH identification and management recommends that all individuals (adults and children) with FH:
- consume a diet with ≤30% of total energy from total fat, ≤10% of total energy from saturated fat, <300 mg/day dietary cholesterol and replace saturated fats with MUFA and PUFA
- consume a minimum of five servings of fruit and vegetables per day
- consume food containing stanols and sterols consistently (individual choice)
- avoid omega-3 fatty acid supplementation
- be physically active
- achieve and maintain a “healthy weight”
- avoid smoking.
Consideration for pharmacological therapy is suggested by 10 years of age to reduce LDL-C, along with fat-soluble vitamins and folic acid supplementation (amount not specified) for those receiving long-term bile acid sequestrants.
Grade of Evidence C
Remarks
The causes of childhood dyslipidemia can be categorized as primary or secondary. Primary causes are a result of genetic disorders (e.g. FH), while secondary causes are a result of exogenous (e.g. obesity) or endogenous (e.g. diabetes) factors.
AHA categorizes conditions according to CVD risk in youth as follows:
- High Risk: homozygous FH, type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), end stage kidney disease (ESKD), Kawasaki disease with persistent aneurysms, solid-organ transplant with vasculopathy, childhood cancer survivor (stem cell recipient)
- Moderate Risk: severe obesity (BMI ≥120% of the 95th percentile for age and sex), heterozygous FH, hypertension, coarctation, Lp(a), pre-dialysis CKD, aortic stenosis, childhood cancer survivor (chest radiation)
- At Risk: obesity, (BMI≥95th percentile for age and sex), insulin resistance with co-morbidities, white coat hypertension, chronic inflammatory conditions, congenital heart disease and coronary anomalies, childhood cancer (cardiotoxic chemotherapy), Kawasaki disease with regressed aneurysms.