Usually, pediatricians check children’s cholesterol levels twice: between ages 9 and 11 and again between ages 17 and 21. If a parent is diagnosed with high cholesterol, we often check the child at that time as well. Children rarely have symptoms of high cholesterol (hyperlipidemia), but our goal is to get it under control before it starts to harden the blood vessels and cause symptoms. High cholesterol can lead to a variety of types of heart and blood flow problems. These include heart attack, coronary artery disease, congestive heart failure, peripheral artery disease, and stroke.

The cholesterol test, called a lipid panel, checks to see the levels of fat (lipids) in your blood. Cholesterol is a waxy substance in your blood—and it isn’t inherently bad. Your body needs a certain amount of it to build healthy cells. There are basically two types of lipids in your blood: triglycerides and cholesterol. Cholesterol comes in two types: low-density lipoproteins or LDL (which we call bad cholesterol) and high-density lipoproteins or HDL (the good kind of cholesterol).

The problem isn’t having some cholesterol in your blood. It’s having too much. Doctors get concerned in several situations: 

• High LDL cholesterol (called hypercholesterolemia): This condition increases the fatty deposits in your arteries—and the risk of blockages.
• High triglyceride levels: This can contribute to hardening of the arteries or thickening of the artery walls (arteriosclerosis), but more acutely can increase risk of inflammation in the pancreas.
• High overall cholesterol level: This can indicate elevated risk of heart problems in the future.
• Low HDL cholesterol: Less common than the other concerns, this condition means your blood lacks the tools to clean up cholesterol deposits, which can lead to worsening of blockages.

Several environmental/lifestyle and genetic factors increase your child's risk of developing high cholesterol. 

Environmental and lifestyle factors include:

• High-fat diet
• Lack of exercise
• Obesity

Genetic factors and conditions include:

• Familial hypercholesterolemia; Isolated elevated LDL (bad cholesterol) in the setting of positive family history of early events or hypercholesterolemia. Patients with this genetic problem are at significantly higher risk of developing heart disease in their young adult age. Genetic testing is available for selected patients. We typically treat this with a combination of diet and medications.

• Abnormal levels of lipids, such as cholesterol or triglycerides (familial combined dyslipidemia), which can increase risk of early heart disease. Patients often have other health issues such as obesity, diabetes, and/or thyroid problems.

• Severely high levels of triglycerides (hypertriglyceridemia), which can cause life-threatening pancreatitis. We typically treat this with dietary changes. Occasionally medications are needed.

• Sitosterolemia, a rare form of high cholesterol that leads to hardening of the arteries (atherosclerosis). We treat this with medication and changes in diet.

• Lysosomal acid lipase deficiency, which causes the body to have difficulty breaking down cholesterol and fats. This rare genetic condition can lead to liver failure and heart attack. We often treat this using enzyme replacement therapy.

Treatments

You can treat high cholesterol in two basic ways: by helping your child make lifestyle changes and through medication. Your doctor may recommend a combination of the two.

Lifestyle changes include:

• Diet: Eat plenty of fruits and vegetables (at least five a day); drink at least four glasses of water daily; eat three balanced meals every day—which means don’t skip breakfast. Avoid sugar-sweetened drinks and treats.
• Exercise: Aim for about 60 minutes of active play on most days. Limit non-educational screen time to two hours or less each day; this includes video games and phone apps.  You can break it up into 10- or 15-minute increments.
• Body weight: Your child should lose weight if they are overweight or obese. The goal is to maintain a healthy weight.
• Stress management: Trying to decrease or manage stress can help the whole family. You can help your children lower their stress levels by letting them know they can talk to you—without forcing them to do so—and by listening before responding. Your child’s doctor may also screen for depression and stress and refer for counseling if they think it would be helpful. 

Your doctor may also prescribe medication, if appropriate. There are several types of drugs that lower cholesterol or prevent it from forming:

Statins: Also known as HMG CoA reductase inhibitors, these work in your liver to prevent cholesterol from forming. We have used these medications in children for more than 20 years and their safety profile is similar or better than in adult patients who take these medications.

Selective cholesterol absorption inhibitors: This medication, rarely used, prevents your intestines from absorbing cholesterol.

Resins: Also known as bile acid sequestrants or bile acid-binding drugs, these medications help your intestines get rid of cholesterol.

Fibrates (fibric acid derivatives): These drugs can lower your triglyceride level and increase your HDL. They aren’t helpful in lowering LDL cholesterol.

Niacin (nicotinic acid): This drug helps your liver produce fewer lipids.

PCSK9 inhibitors: These affect the proteins in your liver to lower LDL cholesterol.

Marine-derived omega-3 polyunsaturated fatty acids: Also called omega-3 fish oils or omega-3 fatty acids, these medications can lower triglyceride levels.