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Circulation. 2019;139:e1082–e1143. DOI: 10.1161/CIR.0000000000000625 June 18/25, 2019 e1109 CLINICAL STATEMENTS AND GUIDELINES

4.4.4.3 Children and Adolescents

Recommendations for Children and Adolescents Referenced studies that support recommendations are summarized in Online Data Supplements 18 to 21.

COR LOE Recommendations

I A 1.  In children and adolescents with lipid disorders related to obesity, it is recommended to intensify lifestyle therapy, including moderate caloric restriction and regular aerobic physical activity.S4.4.4.3-1–S4.4.4.3-4

I B-NR 2.  In children and adolescents with lipid abnormalities, lifestyle counseling is beneficial for lowering LDL-C.S4.4.4.3-1–S.4.4.4.3-3,S4.4.4.3-5–S4.4.4.3-12

IIa B-R 3.  In children and adolescents 10 years of age or older with an LDL-C level persistently 190 mg/dL or higher (≥4.9 mmol/L) or 160 mg/dL or higher (4.1 mmol/L) with a clinical presentation consistent with FH (see Section 4.2.) and who do not respond adequately with 3 to 6 months of lifestyle therapy, it is reasonable to initiate statin therapy.S4.4.4.3-13–S4.4.4.3-16

IIa B-NR 4.  In children and adolescents with a family history of either early CVD* or significant hypercholesterolemia,† it is reasonable to measure a fasting or nonfasting lipoprotein profile as early as age 2 years to detect FH or rare forms of hypercholesterolemia.S4.4.4.3-17–S4.4.4.3-21

IIa B-NR 5.  In children and adolescents found to have moderate or severe hypercholesterolemia, it is reasonable to carry out reverse-cascade screening of family members, which includes cholesterol testing for first-, second-, and when possible, third-degree biological relatives, for detection of familial forms of hy percholesterolemia.S4.4.4.3-22–S4.4.4.3-24

IIa C-LD 6.  In children and adolescents with obesity or other metabolic risk factors, it is reasonable to measure a fasting lipid profile to detect lipid disorders as components of the metabolic syndrome.S4.4.4.3-25–S4.4.4.3-27

IIb B-NR 7.  In children and adolescents without cardiovascular risk factors or family history of early CVD, it may be reasonable to measure a fasting lipid profile or nonfasting non HDL-C once between the ages of 9 and 11 years, and again between the ages of 17 and 21 years, to detect moderate to severe lipid abnormalities.S4.4.4.3-19,S4.4.4.3-21,S4.4.4.3-27–S4.4.4.3-29 *Family history of early CVD is defined here as MI, documented angina, or atherosclerosis by angiography in parents, siblings, grandparents, aunts, or uncles (<55 years of age for men, <65 years of age for women). †TC ≥240 mg/dL (≥6.2 mmol/L), LDL-C ≥190 mg/dL (≥4.9 mmol/L), non–HDL-C ≥220 mg/dL (≥5.7 mmol/L), or known primary hypercholesterolemia.

Synopsis

Abnormal lipid levels are relatively common in children and adolescents, affecting approximately 1 in 5 adolescents.S4.4.4.3-25 Confirmed lipid disorders are less common but occur frequently in the presence of obesity, often accompanied by cardiovascular risk factors, and contribute to increased rates of cardiovascular and metabolic morbidity and mortality. Severe hypercholesterolemia (LDL ≥190 mg/dL (≥4.9 mmol/L)) affects ~1 in 250 children and adolescents. Testing for lipid disorders can identify both severe hypercholesterolemia and multifactorial lifestyle-related dyslipidemia. Nonfasting lipid testing is effective for initial screening purposes, and non–HDL-C is a reasonable screening test. No available evidence evaluates benefits of childhood lipid screening for modifying CVD events or associated long-term harm. However, significantly abnormal lipid levels track from childhood to adulthood. Furthermore, subclinical atherosclerosis, as measured by carotid intima-media thickness, is abnormal in children with FH. Strong evidence shows that lifestyle modification improves lipid levels in childhood without adverse effects on growth and maturation; however, effect sizes are small, and adherence may wane over time. Statins and nonstatins lower TC and LDL-C with minimal adverse effects in children and adolescents with severe hypercholesterolemia. There are scant data on pharmacological treatment of multifactorial lifestyle-related dyslipidemia.

Recommendation-Specific Supportive Text

1.	 In children and adolescents with lipid abnormalities and obesity, lifestyle-modification therapy should be intensified over and above usual therapy for childhood obesity and should include moderate caloric restriction and sufficient physical activity (eg, 30-60 minutes of moderate to vigorous activity on most days). Utilization of resources for nutritional education and counseling is encouraged. 2.	 Lifestyle-modification interventions in childhood and adolescence show short- and long-term benefits to lipid levels and subclinical atherosclerosis measures in RCTsS4.4.4.3-5–S4.4.4.3-8 and observational studies of children and adolescents with lipid disorders.S4.4.4.3-3,S4.4.4.3-9 No adverse effects on growth or maturation have been demonstrated.S4.4.4.3-6 The impact of these interventions on lipid levels and subclinical atherosclerosis is small; no studies report CVD event rates. There are likely other unmeasured health benefits of lifestyle-modification interventions for chronic disease outcomes (eg, obesity, diabetes mellitus, and cancer). These benefits support the recommendation to treat children and adolescents with lipid disorders with lifestyle-modification interventions, generally by using a family-based approach and promoting a heart-healthy diet, plenty of physical activity, avoidance of cigarette smoking, maintenance of a healthy weight, maintenance of normal blood pressure, and maintenance of normal glycemia.

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