Checking cholesterol levels in children is now routine

Atherosclerotic heart disease is the leading cause of death in the United States although this disease rarely occurs in children. However, risk factors like excess weight, high blood pressure (hypertension) and high cholesterol (hypercholesterolemia or hyperlipidemia) begin in childhood and interventions to prevent these risk factors can lessen the risk of heart attacks and stroke later in life.

New guidelines

In December 2011, the National Heart, Lung, and Blood Institute of the National Institutes of Heatlh published guidelines for reducing cardiovascular risk factors in children and adolescents in the journal Pediatrics.^1,2 These new guidelines provide recommendations for cholesterol and triglyceride screening based on a child or adolescent's age and their risk factors for cardiovascular disease and high cholesterol.   Different definitions were used for defining elevated cholesterol and triglycerides at different ages.

What are the different types of lipids

Lipid is another word for fat. The two types of lipids that are analyzed in the blood are triglycerides and cholesterol.

Cholesterol is further divided into HDL, (high-density lipoprotein) or good cholesterol and LDL (low-density lipoprotein) or bad cholesterol. HDL is a good cholesterol because it lowers your risk of heart attack and stroke. You can raise your HDL cholesterol if you quit smoking, lose excess weight, take Niacin and exercise. LDL is the bad cholesterol. A high LDL cholesterol increases your risk of heart disease and stroke. A low fat diet, exercise and weight loss can lower LDL. Many medicines are available that primarily work by lowering LDL cholesterol. Subsets of HDL "good" cholesterol (Apolipoprotein A-1) and LDL "bad"  cholesterol (Apolipoprotein B) are included in the children and adolescent guidelines.

Triglycerides are another type of fat in your blood that increase the risk of heart disease and stroke later in life.

When and how to screen for elevated lipids

Age 2 to 8 years

No routine screening is recommended at this age.

Only screen children with a fasting lipid profile (FLP) using the average FLP from two separate measurements if they have any one of the following Significant Risk Factors:

• a parent, grandparent, aunt/uncle or sibling with a heart attack, angina, cardiac bypass, cardiac stent or angioplasty and they were a < 55 year old male or < 65 year old female when the event occurred
• a parent with a total cholesterol ≥ 240 mg/dl or known dyslipidemia (lipid or cholesterol disorder)
• the child has diabetes, hypertension, or a body mass index (BMI)³ ≥ 95th percentile for their age and height

Age 9 to 11 years

Universal screening is recommended at this age. 

Screen all children with a NON-fasting lipid profile.  Calculate their non-HDL cholesterol.  This is calculated by taking the Total Cholesterol and subtracting the HDL cholesterol. 

• If the non-HDL cholesterol is ≥ 145 mg/dl (and possibly if the HDL is < 40 mg/dl), obtain two Fasting Lipid Profiles and average them
• OR obtain a single Fasting Lipid Profile (FPL) and only repeat the FPL if the LDL is ≥ 130 mg/dl and possibly if one of the following is present (non-HDL cholesterol  ≥ 145 mg/dl, HDL cholesterol < 40 mg/dl, triglycerides ≥ 100 mg/dl)

Age 12 to 16 years

No routine screening is recommended at this age.

Measure fasting lipid profile twice and average the results if they have any of the following Significant Risk Factors:

• a parent, grandparent, aunt/uncle or sibling with a heart attack, angina, cardiac bypass, cardiac stent or angioplasty and they were a < 55 year old male or < 65 year old female when the event occurred
• a parent with a total cholesterol ≥ 240 mg/dl or known dyslipidemia (lipid or cholesterol disorder)
• the child has diabetes, hypertension, or a body mass index (BMI)³ ≥ 85th percentile for their age and height or a medical condition that places them at moderate or high risk for a high cholesterol level
• cigarette smoking

Age 17 to 19 years

Universal screening recommended once between ages 17 and 21 years.

Screen all at this age with a NON-fasting lipid profile.  Calculate their non-HDL cholesterol.  This is calculated by taking the Total Cholesterol and subtracting the HDL cholesterol. 

• If the non-HDL cholesterol is ≥ 145 mg/dl (and possibly if the HDL is < 40 mg/dl), obtain two Fasting Lipid Profiles and average them
• OR obtain a single Fasting Lipid Profile and only repeat the FPL if the LDL is ≥ 130 mg/dl and possibly if one of the following is present (non-HDL cholesterol  ≥ 145 mg/dl, HDL cholesterol < 40 mg/dl, triglycerides ≥ 130 mg/dl)

Age 20 or 21 years

Universal screening is recommended if no screening was performed at 17 to 19 years old. 

Screen at this age with a NON-fasting lipid profile.  Calculate their non-HDL cholesterol.  This is calculated by taking the Total Cholesterol and subtracting the HDL cholesterol.

• If the non-HDL cholesterol is ≥ 190 mg/dl (and possibly if the HDL is < 40 mg/dl), obtain two Fasting Lipid Profiles and average them
• OR obtain a single Fasting Lipid Profile and only repeat the FPL if the LDL is ≥ 160mg/dl and possibly if one of the following is present (non-HDL cholesterol  ≥ 190 mg/dl, HDL cholesterol < 40 mg/dl, triglycerides ≥ 150 mg/dl)

Definitions of Cholesterol or Lipid Levels at Different Ages

Acceptable, Borderline and High Lipid Levels if 2 to 19 years old

Cholesterol Type	Low (mg/dl)	Acceptable (mg/dl)	Borderline-High (mg/dl)	High (mg/dl)
Total cholesterol	-	< 170	170-199	≥ 200
LDL cholesterol	-	< 110	110129	≥ 130
Non-HDL cholesterol	-	< 120	120-144	≥ 145
Apolipoprotein B	-	< 60	90-109	≥ 110
Triglycerides   (0-9 years old)		< 75	75-99	≥ 100
Triglycerides   (10-19 years)	-	< 90	90-129	≥ 130
HDL cholesterol	< 40	> 45	40-45	-
Apolipoprotein A-1	< 115	> 120	115-120	-

 

Acceptable, Borderline and High Lipid Levels if 20 to 24 years old

Cholesterol Type	Low (mg/dl)	Borderline - Low (mg/dl)	Acceptable (mg/dl)	Borderline - High (mg/dl)	High (mg/dl)
Total cholesterol	-	-	< 190	190-224	≥ 225
LDL cholesterol	-	-	< 120	120-159	≥ 160
Non-HDL cholesterol	-	-	< 150	150-189	≥ 190
Triglycerides	-	-	< 115	115-149	≥ 150
HDL cholesterol	< 40	40-44	> 45	-	-

 

The takeaway message

Cholesterol screening is now a routine part of well child visits. Knowing these numbers can help parents make earlier lifestyle interventions so their children can lessen their risk of heart disease and stroke as they become adults.