Pediatric Lipid Panel Goals
The primary goals for pediatric lipid panels are to maintain LDL cholesterol <130 mg/dL, non-HDL cholesterol <145 mg/dL, and triglycerides <100 mg/dL in children under 10 years and <130 mg/dL in children 10-19 years of age to reduce the risk of future cardiovascular disease. 1
Target Values for Pediatric Lipid Panels
Acceptable Lipid Levels:
- LDL cholesterol: <110 mg/dL
- Non-HDL cholesterol: <145 mg/dL
- Total cholesterol: <170 mg/dL
- Triglycerides:
- <100 mg/dL (children <10 years)
- <130 mg/dL (children 10-19 years)
- HDL cholesterol: >45 mg/dL
Borderline Lipid Levels:
- LDL cholesterol: 110-129 mg/dL
- Total cholesterol: 170-199 mg/dL
High/Abnormal Lipid Levels:
- LDL cholesterol: ≥130 mg/dL
- Non-HDL cholesterol: ≥145 mg/dL
- Total cholesterol: ≥200 mg/dL
- Triglycerides: ≥100 mg/dL (<10 years) or ≥130 mg/dL (10-19 years)
- HDL cholesterol: <40 mg/dL
Screening Recommendations
Universal Screening:
- All children ages 9-11 years
- Repeat at ages 17-21 years if initial screen was normal
Targeted Screening (earlier than age 9):
- Family history of premature cardiovascular disease (before age 55 in males, age 65 in females)
- Parent with known dyslipidemia (total cholesterol ≥240 mg/dL)
- Children with:
- Obesity
- Hypertension
- Diabetes mellitus
- Chronic kidney disease
- Heart transplant
- Kawasaki disease with coronary aneurysms
- Chronic inflammatory diseases
Management Algorithm Based on Lipid Levels
Step 1: Lifestyle Modifications (for all children with abnormal lipids)
- CHILD-1 diet: Total fat 25-30% of calories, saturated fat <10% of calories, dietary cholesterol <300 mg/day
- Physical activity: At least 1 hour of moderate-to-vigorous activity daily
- Screen time limited to <2 hours/day
- Achieve and maintain healthy weight
Step 2: More Intensive Diet Therapy (if Step 1 insufficient after 6 months)
- CHILD-2 diet: Further reduce saturated fat to <7% of calories and dietary cholesterol to <200 mg/day
- Consider addition of soluble fiber, plant stanols/sterols
Step 3: Medication Therapy (for selected patients)
- Consider in children ≥10 years of age (≥8 years in special circumstances) with:
- LDL cholesterol ≥190 mg/dL despite diet therapy
- LDL cholesterol 160-189 mg/dL with positive family history or ≥1 high-level risk factor
- LDL cholesterol 130-159 mg/dL with ≥2 high-level risk factors
Special Considerations
Non-HDL Cholesterol Importance
Non-HDL cholesterol (total cholesterol minus HDL cholesterol) is particularly valuable because:
- It can be measured in non-fasting state
- More predictive of persistent dyslipidemia and atherosclerosis than other lipid measurements 1
- Should be maintained <145 mg/dL
Combined Dyslipidemia Pattern in Obesity
- Most common pattern in childhood: mild elevation in total and LDL cholesterol, moderate-to-severe elevation in triglycerides, and low HDL cholesterol 1
- Requires comprehensive management of obesity and associated metabolic abnormalities
Severe Primary Hyperlipidemia
- Children with LDL cholesterol ≥250 mg/dL should be referred to a lipid specialist
- May require earlier pharmacologic intervention (even before age 10) in homozygous familial hypercholesterolemia or severe hypertriglyceridemia (triglycerides ≥500 mg/dL) 1
Pitfalls to Avoid
- Inadequate follow-up: Children with borderline values need repeat testing and monitoring
- Ignoring non-HDL cholesterol: Focus only on LDL cholesterol misses important risk information
- Premature medication use: Lifestyle modifications should be tried for at least 6 months before considering medication in most cases
- Overlooking secondary causes: Rule out hypothyroidism, diabetes, kidney disease, and medication effects before diagnosing primary dyslipidemia
- Failure to screen high-risk children: Children with obesity or other risk factors need lipid screening regardless of family history 2
By following these guidelines for lipid screening and management, clinicians can identify children at risk for premature cardiovascular disease and implement appropriate interventions to improve long-term cardiovascular health outcomes.