Children with High Lp(a)
(and possibly familial hypercholesterolemia)
Lipoprotein(a), or Lp(a), is made of an LDL-like particle attached to an apolipoprotein called apolipoprotein(a). Like the "bad" cholesterol (LDL), Lp(a) appears to increase the risk of cholesterol buildup in the arteries.
The (a) part of Lp(a) seems to increase the chance of clotting and cause inflammation.
Elevated Lp(a) is extremely common. It occurs in 1 in 5 people around the world.
It’s tricky because it can be measured in two different ways. If your Lp(a) is measured in mg/dl, a normal level is less than 30 and high is greater than 50. If your Lp(a) is measured in nmol/L, a normal level is less than 75 and high is greater than 100 by some, 125 by others.
Children reach their adult Lp(a) around the age of five.
No, diet and exercise don’t change Lp(a) levels.
Your Lp(a) is determined by your genetics. You inherit one “allele” (half of a full gene) for Lp(a) from each of your parents. If your child has high Lp(a), it’s likely that you or your partner also has high Lp(a).
The first thing you should do is take a deep breath. Remind yourself that genetics are not your fault. You probably passed many wonderful traits on to your child.
You’re also living in a time of tremendous research on Lp(a). While there are not any Lp(a) lowering medications right now, there are three in clinical trials. You have knowledge, and knowledge is power.
Another step you can take is to develop a healthy eating plan for your entire family. You can also make a family commitment to lifelong exercise.
In addition to a heart-healthy diet, if you’re a smoker, quit. This can be difficult, but quitting smoking is a gift to you and your children. Children model their parents behavior, so one of the best ways to ensure your children are non-smokers, is to be a non-smoker yourself.
Unfortunately, these changes won’t alter elevated levels of Lp(a). For now, if your child has elevated Lp(a) and normal LDL cholesterol, a healthy lifestyle is recommended.
The American Academy of Pediatrics (AAP) and the National Lipid Association recommend beginning cholesterol lowering medications between the ages of 9 and 11 for children with FH.
Statins are typically the first choice, and there are many available as generic medicines today.
If your child’s LDL doesn’t fall below 130 mg/dl, you might consider adding an additional medication. In this situation your child’s health care provider might suggest a bile acid sequestrant. These work in the intestines and aren’t absorbed in the blood stream. They can lower cholesterol by 20% and are very safe. Only one, colesevelam, has been approved for pediatric use.
Finally, ezetimibe is a medication that inhibits the absorption of cholesterol from the intestines. It can lower LDL by about 20% and has been studied in children. It’s approved by the FDA for use in children over the age of 10.
If your child can’t reach their cholesterol goal with one medication, you should consider asking for a referral to a cholesterol/lipid specialist. Many children see a cholesterol specialist when they start cholesterol lowering medications but follow up with their pediatrician or family doctor once their levels are under control.
Typically, a child should see their health care provider 6 to 12 weeks after they start medication. After that, you may visit every 6 to 12 months to assess liver function. They’ll have their cholesterol checked once or twice a year. It is important to point out that liver function tests are almost never an issue for children on statins.
Statins are typically very well-tolerated by children. Very rarely some may experience muscle and joint aches. There are rare cases where they may experience muscle and liver function laboratory abnormalities. In nearly all these cases these side effects can be reversed by either stopping the drug or reducing the dose.
Some children who take bile acid sequestrants complain of gas.
Ezetimibe is also very well-tolerated, but it can occasionally cause abdominal pain or diarrhea. When ezetimibe is taken with a statin, there are very rare cases of muscle and liver function abnormalities.
Unfortunately, because FH is genetic, there is no cure. Medications help lower cholesterol in FH patients, but if they stop taking their medication, their cholesterol will rise again. Medications only work if you take them.
Stick with it. The medications are crucial. There is strong evidence that statins reduce the risk of a heart attack, strike, and death.
Your child is not at risk of a heart attack right now, but they are at risk in the future. Make it a family affair. Take your medications together!
Consider this – if you start your child on statins at 8- or 9-years-old, by the time they are in the rebellious ages of 13 and 14, taking medications will be so ingrained in them that they won’t even think to rebel against it.
This is a very common situation. Teenagers with FH are still teenagers. However, the stakes are higher for children with FH.
While it is frustrating to see your son or daughter’s eating habits deteriorate, all children had made poor dietary choices at one point or another. You can’t be a police officer. It will wear you out. You can continue to set a good example, make the foods you serve at home as healthy as possible, and they will come around.