Dr. Lisa Hudgins Answers Your Questions About Cholesterol Treatment

July 8, 2008— -- Faith from Conroe, Texas, asked: My 8-year-old son, who is thin and very active, just had his cholesterol tested. His number was 204. The doctor wants him to be on a special diet. What is considered high cholesterol in children? Thank you.

Dr. Hudgins answered: Cholesterol levels in childhood are lower than adulthood. A cholesterol level greater than 200 mg/dL might be too high in a child 2-18 years of age. However, a full lipid panel with LDL cholesterol ("bad cholesterol") and HDL cholesterol ("good cholesterol") is needed, since the LDL clogs the arteries, whereas the HDL prevents the clogging. Many children with slightly elevated total cholesterol levels have an elevated HDL cholesterol and a normal LDL cholesterol. If the LDL cholesterol is greater than 130 mg/dL, he should make a greater attempt to follow a cholesterol-lowering diet, preferably with the help of a dietitian. All children from age 2 on should consume heart-healthy diets.

Lucy from Boulder, Colo., asked: My daughter was diagnosed with high cholesterol four years ago. She is now 9. At the time when we went to a pediatric cardiologist he recommended just monitoring her since she does not have any other risk factors (e.g., obesity, high blood pressure). Her diet is also pretty good. Her favorite food is corn! With AAP's recommendations, I am unclear as to if she would be a candidate for cholesterol lowering drugs. I am reluctant to start her up given the known (and unknown) side effects on children. Given she has no other risk factors, would you recommend her going on these drugs? What questions should I be asking our doctors?

Dr. Hudgins answered: I agree with the AAP recommendation that an LDL cholesterol level greater than 190 mg/dL on several occasions after optimal diet and physical activity in a child at least 8 years of age be treated with a statin. It should be emphasized that only a small number of children have cholesterol levels high enough to warrant statin therapy. Most will have one parent with a very high cholesterol (often greater than 300 mg/dL and heart disease). This genetic disorder, monogenic familial hypercholesterolemia, should be treated with a statin as early as age 7 or 8 given the rapid buildup of cholesterol in the arteries in childhood and high chance of a heart attack in early adulthood. If your daughter's LDL cholesterol level is higher than 160 mg/dL, be sure that you and her father know your lipid profiles! If your levels are normal and her levels are very high (LDL> 160 mg/dL), then a lipid specialist is needed to exclude rare disorders such as sitosterolemia.

Beth from Virginia Beach, Va., asked: Both of my children were diagnosed with high cholesterol at age 4. They were tested because of a family history. What have studies shown in regards to statin drugs affects on children's livers? This seems to be a consistent problem in adults. Shouldn't we be even more concerned with children?

Dr. Hudgins answered: There are four published and properly conducted studies of four different statins in 706 children ages 8 to 18 with LDL cholesterol levels of at least 160 mg/dL treated with drug or placebo for 1-2 years. There were no serious side effects, including effects on the liver. Four children had temporary elevations in liver function tests that went away after stopping the drug. In adults, serious problems in the liver are rare and reversible upon stopping the medicine. Since children are less likely to take other medications and to drink alcohol, they are probably at a lower risk of liver problems. Nevertheless, while on a statin, they should have a blood test for liver function every 4-6 months or if they develop persistent or severe nausea, vomiting and/or pain over the liver.

Robin, from Horsham, Pa., asked: My daughter has hereditary high cholesterol. She has been on Zocor 10mg since she was 10. She is now 15 years old and since she started menstruating her dose has been put up to 20mg. I understand most studies are done on boys. What studies are being done concerning girls/women?

Dr. Hudgins answered: Of the 706 children treated for 1-2 years with statin or placebo, only 46 were premenstrual females, but there were many more older, menstruating females. The onset and the characteristics of the menses and blood levels of various sex-related hormones were not affected. There is a need for additional studies in premenstrual females and pre-pubertal males. In adults, the drug is equally safe and effective in males and females.

Karen from Merrill, Wis., asked: My husband had a heart attack at age 40. His brother was 43 when he had one. My nephew died of a massive heart attack at age 42. My two sons, age 19 and 16 have had several checkups with cardiologist due to their family history. My eldest son: LDL 120; HDL 38; trig 202; total 198. Middle son: LDL 99; HDL 33; trig 78; total 148. They will have a recheck this month. Question, if my eldest sons results don't change a lot, would you suggest talking to the dr. about statin meds?

Dr. Hudgins answered: It is likely that your husband has a similar lipid pattern that is common in "metabolic syndrome" or "prediabetes." What were his risk factors for the heart attack? Your sons have low HDL levels and the eldest high triglycerides (assuming a 12 hour fast before the blood test). Are your husband and sons overweight? If so, weight loss, a reduction in dietary saturated/trans fat, sugars, refined starch and increased physical activity will lower the triglycerides (and LDL) and raise the HDL. Stopping cigarettes, if used, will help. Be sure that blood sugar and liver function are normal. I would emphasize this approach and not recommend statins for LDL levels this low.

Gina from New Bern, NC., asked: My concern mainly is with the health benefit of giving kids statins. I took Zocor and Tricor for about 5 years and now I have what could be severe liver problems, and the first thing my doctor did was take me off of the Zocor and the Tricor. So is it really safe to give children statins?

Dr. Hudgins answered:There are four published properly conducted studies of four different statins in 706 children ages 8-18 with LDL cholesterol levels of at least 160 mg/dL treated for 1-2 years with drug or placebo. None had any serious side effects. Four children had temporary elevations in liver function tests that went away after stopping the drug. Ten had temporary elevations in muscle tests. In adults, serious problems are rare and usually occur in combination with other drugs such as Tricor. Statins should be limited to children with very high LDL cholesterol levels (>160-190 mg/dL) after optimal diet, with careful monitoring of overall health, including liver and muscle function.

Andrea from Boise, Idaho asked: I have 2 daughters that were tested for high cholesterol when they were 6 and 8. Both have high cholesterol (205 and 208). The doctor never suggested medicine and said it was from genetics. My daughters are very thin and eat great. My oldest is now 14, 5'2" and weighs 80 lbs and is an avid runner. Should I have her checked again? My husband is on Lipitor for high cholesterol.

Dr. Hudgins answered: A full lipid panel with LDL cholesterol ("bad cholesterol") and HDL cholesterol ("good cholesterol") is needed, since many children with slightly elevated total cholesterol levels have an elevated HDL cholesterol and a normal LDL cholesterol. If the complete lipid panel has not been done, it should be done after at least 3 months of better adherence to a cholesterol-lowering diet, preferably with help from a dietitian. If the LDL cholesterol is greater than 130 mg/dL, your daughters probably have a genetic form of high cholesterol, but further lowering is still possible with dietary changes. Unless the HDL is extremely low, it is unlikely that the LDL will be high enough to consider statin therapy (>160 mg/dL).

Nancy from Rochester Hills, Mich., asked: My daughter who is 15 years old has had her cholesterol checked recently and it came back at 220. Her LDL was 147 and her HDL was 48. We have started her on a strict diet of lowfat and low cholesterol food. Are her levels high enough that we should consider statins to help her lower her cholesterol levels? Last year she was checked and her levels were 211 with the LDL at 126 and her HDL at 57. At what level do you usually recommend starting drugs?

Dr. Hudgins answered: The LDL cholesterol level should be at least 160 mg/dL on several occasions after an optimal diet before considering the use of a statin. Assuming that she does not have diabetes, your daughter's levels are not high enough to warrant statin therapy. She should strive to achieve a normal body weight, follow a cholesterol-lowering diet, get ample physical activity, and not smoke. Her repeat lipid profile will probably show an LDL cholesterol level less than the goal of 130 mg/dL. Make sure her triglycerides and HDL remain normal, especially if the "low fat" diet is high in sugar/refined starch.

D.T. from Adkins, Tex., asked: My family has a history of high cholesterol. I recently insisted my son's doctor test his cholesterol. They treated me like I was the worst mother since we had to hold down my 3 year-old to take the blood. When the results came back, it said his was 178 with 101 being his bad cholesterol. When I later asked his doctor what we should do about it, they told me to not worry about it - it really meant nothing. They told me to take fat out of his diet. He has been on a high whole grain diet since he was started on solid foods as a baby. He is not overweight either. His test was done just last month. Now I am seeing information on this. Should I go back to his doctor to have him put on medication? Everyone in my family has needed medication to control it (mine was 224 in high school)- this is in spite of no weight problems. Please advise me to best actions for my son. He turned 4 this last month. Thanks

Dr. Hudgins answered: Your son's LDL cholesterol level is normal, and, assuming that his HDL and triglycerides are normal, no treatment is needed except the "heart-healthy" diet recommended for all kids older than 2 years and ample physical activity. Sometimes the labs flag LDL levels as high based on their own criteria. Because of family history, his fasting profile should be repeated every 3-5 years or after excessive gain in body weight.

Wendy from Minneapolis, Minn., asked: Our 6 year old daughter is adopted from Guatemala. We've no information on her medical history. At 5 she was tested for cholesterol, once with fasting, once without. The results were 215 and 225. These results are high for an adult, but I've no understanding of what is the appropriate level for a child. She is very physically active. Weighs 42 pounds and is approximately 45 inches tall. She eats a balanced diet. I'm concerned she may have genetically high cholesterol. What is the appropriate scale to use when measuring a child's cholesterol?

Dr. Hudgins answered: A full fasting lipid panel with LDL cholesterol ("bad cholesterol") and HDL cholesterol ("good cholesterol") is needed, since many children with slightly elevated total cholesterol levels have an elevated HDL cholesterol and a normal LDL cholesterol. If the complete lipid panel has not been done, it should be done after at least 3 months of better adherence to a cholesterol-lowering diet, preferably with help from a dietitian. If the LDL cholesterol is greater than 130 mg/dL, your daughter probably has a mild, genetic form of high cholesterol, but further lowering is still possible with dietary changes. Unless the HDL is extremely low, it is unlikely that the LDL will be high enough to consider statin therapy (>160 mg/dL) when she turns 7 or 8.

Dr. Lisa C. Hudgins, M.D., is pediatric director of The Rogosin Institute, a premier not-for-profit medical treatment and research institute in New York, and associate professor of pediatrics in medicine and pediatrics at Weill Medical College of Cornell University.