High cholesterol in children
Clinical signs of atherosclerosis — fatty build-ups in the arteries — can sometimes be seen as early as childhood. These fatty build-ups lead to a progressive narrowing and hardening of the arteries that can cause premature death or disability through heart attack or stroke.
The same risk factors that put adults at risk of developing atherosclerosis also put children at risk. These risk factors include high blood pressure, obesity, cigarette smoking, diabetes and high cholesterol. Some children will be more at risk because of a genetic (inherited) predisposition to high blood cholesterol.
High blood cholesterol levels in children make these fatty build-ups in the arteries more likely and there is evidence that the process of atherosclerosis can start in childhood and then progress slowly into adulthood.
Just as for adults, in children with high cholesterol, the higher the number of cardiovascular risk factors, the greater the risk of atherosclerosis, even though there may be no symptoms. For example, an overweight teenager who has raised cholesterol levels and smokes is likely to have more fatty deposits in their arteries than a similar aged non-smoker with a healthy body weight, who might also have an elevated cholesterol level.
Testing cholesterol in children
Most children do not need to be tested for blood cholesterol levels. However, children with diabetes or children who have a first-degree relative (parent, brother or sister) who has had coronary heart disease before the age of 60 may be tested to identify whether any steps should be taken to prevent future heart disease. Testing may also be recommended for children with a family history of high cholesterol. Testing may also be appropriate in other conditions such as liver or thyroid disease, or chronic kidney disease.
Testing is usually unnecessary for children under 2 years old, as they should not undergo dietary restrictions prior to that age because they have special nutritional needs for fat.
There is some evidence to show that testing of adolescent blood cholesterol levels can be inaccurate as the hormonal changes at puberty can mask high blood cholesterol levels. This means that there is a risk of getting a falsely low cholesterol reading, so teenagers at high risk of heart disease should be tested again after reaching young adulthood to get a more accurate result.
All children, but particularly those with elevated cholesterol levels, should be encouraged to lead an active lifestyle and follow a healthy diet. And, of course, smoking should be strongly discouraged.
A heart-healthy diet means eating less saturated fat, less total fat and less cholesterol. This can be achieved by eating lean meat, a wide variety of fruits, vegetables and wholegrain cereal products, using low-fat dairy products, eating fish 2-3 times a week, and limiting snack food, takeaway food, cakes and biscuits. Such a diet also has the added advantages of meeting the increased needs of children and teenagers for nutrients such as calcium, iron and zinc.
Research has also shown that cholesterol-lowering products enhanced with plant sterols can reduce cholesterol levels. In Australia, the foods that are approved for enrichment with plant sterols include margarine spreads, breakfast cereal, low-fat yogurt, low-fat milk, lower fat cheese and processed cheese. Most children do not need these products, but they may be useful in the diets of children with elevated cholesterol. However, studies have found that the cholesterol-lowering effect of these products is reduced in children compared with adults. Longer term studies are required to evaluate the safety of plant sterols in children.
As well as dietary restrictions, encouraging regular aerobic exercise and reducing the number of hours that children spend watching the television or using the computer can also help reduce their risk of cardiovascular disease.
Obese children and adolescents are more likely to have poorer health as adults, regardless of whether they are obese as an adult or not.
For some children, lifestyle measures alone will not be enough to reduce cholesterol levels. The choice to use medication to treat high cholesterol in children depends on various factors including age, cholesterol level and the presence or absence of other risk factors for cardiovascular disease. This decision is usually made by a cardiologist specialising in children.
A class of medicine called ‘statins’, used to treat high cholesterol in adults, can be used to treat elevated cholesterol in children. A child taking a statin medicine will need to be monitored for side effects and have blood tests periodically.
Another type of medicine that may be used is a bile-acid binding resin, but this type of medicine is often not tolerated well by children due to its side effects.
Other types of medicines used to treat high cholesterol in adults are undergoing further investigation to see whether they can be used safely in children.
2. Cardiac Society of Australia and New Zealand. Guidelines for the diagnosis and management of familial hypercholesterolaemia (reviewed 26 Nov 2010). http://www.csanz.edu.au/Portals/0/Guidelines/Practice/Diagnosis%20and%20Management%20of%20Familial%20Hypercholesterolemia.pdf (accessed Mar 2013).
3. American Heart Association. Children and cholesterol (updated 8 Feb 2012). http://www.heart.org/HEARTORG/Conditions/Cholesterol/UnderstandYourRiskforHighCholesterol/Children-and-Cholesterol_UCM_305567_Article.jsp (accessed Mar 2013).
4. Food Standards Australia New Zealand. Plant sterols (updated Nov 2011). http://www.foodstandards.gov.au/scienceandeducation/factsheets/factsheets/plantsterols2011.cfm (accessed Mar 2013).