Lipid abnormalities are increasingly seen in children, driven by rising rates of obesity and diabetes as well as earlier screening.
But pediatric lipid disorders differ from those seen in adults—and when not appropriately treated, can raise the risk of cardiovascular disease, including heart attacks, in young adulthood. That’s why at Children’s Hospital Los Angeles, children with lipid abnormalities are evaluated in a dedicated pediatric lipid clinic.
Sabitha Sasidharan Pillai, MD, a pediatric endocrinologist at CHLA who is Board-certified in lipid disorders, highlights five often-overlooked factors that can influence diagnosis and treatment—and explains when children should be referred to specialty care.
1. Adult lipid cutoffs do not apply to children.
Lipid values that may appear borderline or even normal by adult standards can be abnormal in pediatric patients.
Triglyceride and cholesterol thresholds vary by age, and cardiovascular risk accumulates over time when abnormalities begin in childhood. “Using adult cutoffs may delay recognition of clinically meaningful disease,” Dr. Sasidharan Pillai says.
Refer when: Lipid values are persistently abnormal for age or when interpretation using pediatric-specific cutoffs is uncertain.
2. Markedly elevated lipid levels often signal genetic disease.
Extremely high lipid values in children should raise suspicion for inherited disorders, rather thanacquired causes alone.
LDL cholesterol levels around 400 mg/dL are strongly suggestive of homozygous familial hypercholesterolemia, while fasting triglyceride levels approaching or exceeding 1,000 mg/dL may indicate familial hypertriglyceridemia.
“When LDL cholesterol levels are extremely high in a child, that should immediately raise concern for a genetic lipid disorder,” she says. “In severe cases, these children can develop atherosclerotic cardiovascular disease very early in life if they are not identified and treated.”
Refer when: LDL or triglyceride levels are markedly elevated or suggest an underlying genetic lipid disorder.
3. LDL cholesterol may be misleading when triglycerides are very high.
When triglyceride levels exceed 400 mg/dL, LDL cholesterol calculations may be unreliable, she notes.
In these cases, non-HDL cholesterol—calculated as total cholesterol minus HDL—provides a more accurate assessment of atherogenic risk. Relying on LDL alone in this setting can underestimate disease severity.
Refer when: Triglycerides are very high and lipid values are difficult to interpret using standard measures.
4. Over-the-counter omega-3 supplements are not appropriate.
“These over-the-counter supplements are not FDA-regulated and may not contain therapeutic doses,” Dr. Sasidharan Pillai says. “And in some cases, they can actually raise LDL cholesterol.”
When medication is indicated, prescription-grade omega-3 fatty acids should be used under specialist guidance, she says.
Refer when: Triglyceride levels persist despite management of underlying conditions or when pharmacologic therapy is being considered.
5. Abnormally low cholesterol levels are not always benign.
“Low cholesterol is not always protective,” she notes. “Abnormally low cholesterol levels may be due to certain rare genetic conditions, such as familial hypobetalipoproteinemia and abetalipoproteinemia. Both can lead to fat-soluble vitamin deficiencies (vitamin A, D, E and K), fatty liver disease, or cirrhosis and should not be overlooked.” These require specialist evaluation.
Refer when: Cholesterol levels are unexpectedly low, persistent, or associated with concerning clinical or laboratory findings.