The American Heart Association has published a Scientific Statement outlining the screening, diagnosis, and management of pediatric hypertriglyceridemia, including triglyceride classifications associated with the risks of acute pancreatitis and atherosclerotic cardiovascular disease and recommendations for lifestyle management.
The writing group reported that hypertriglyceridemia affects an estimated 10% to 20% of US children and adolescents, with prevalence ranging from 24% to 60% among youths with elevated body mass index. They stated that pediatric hypertriglyceridemia is linked to obesity, insulin resistance, and steatotic liver disease. Further, the writing group noted that severe elevations are associated with acute pancreatitis and may increase risk of atherosclerotic cardiovascular disease (ASCVD) later in life after prolonged exposure.
Triglyceride Thresholds and Risk Stratification
The writing group classified triglyceride levels as acceptable (130 mg/dL or lower), mildly elevated (131–400 mg/dL), moderately elevated (401–885 mg/dL), severely elevated (886–2,000 mg/dL), and very severely elevated (greater than 2,000 mg/dL).
When triglyceride levels exceed 885 mg/dL, chylomicrons begin to predominate because lipoprotein lipase–mediated clearance becomes impaired, increasing pancreatitis risk. Hyperchylomicronemia is associated with an annual pancreatitis risk of 5% at triglyceride levels above 1,000 mg/dL and up to 20% at levels above 2,000 mg/dL. For triglyceride levels below 885 mg/dL, the primary concern is atherosclerotic cardiovascular disease risk associated with very-low-density lipoprotein and other apolipoprotein B–containing lipoproteins, which can be reflected by non–high-density lipoprotein (HDL) cholesterol.
Screening and Diagnostic Considerations
Universal cholesterol screening is recommended at ages 9 to 11 years and again at 17 to 21 years and is endorsed by multiple professional societies. Selective screening is recommended among youths with obesity, kidney disease, diabetes, or hypertension.
Although nonfasting lipid panels are commonly used for screening, the writing group noted that treatment decisions are generally based on fasting triglyceride levels because triglycerides are sensitive to prandial state. An 8- to 12-hour fast may be considered for confirmatory testing.
Genetic and Secondary Etiologies
The writing group outlined a spectrum of genetic causes, including familial chylomicronemia syndrome, which has a prevalence of 1 in 100,000 to 1 in 1 million individuals and is typically characterized by triglyceride levels above 1,000 mg/dL resulting from biallelic pathogenic variants in lipolysis genes. Multifactorial chylomicronemia syndrome affects approximately 1 in 400 to 500 adults and reflects polygenic risk combined with secondary contributors.
Obesity with associated insulin resistance is identified as the leading cause of secondary hypertriglyceridemia in youths, and the degree of triglyceride elevation often correlates with obesity severity. Additional secondary causes include diabetes, endocrine disorders, drugs, kidney disease, pregnancy, and inflammatory conditions.
Lifestyle Intervention
Lifestyle modification is recommended as first-line therapy for persistent hypertriglyceridemia. For mild to moderate elevations, dietary modification and increased physical activity can reduce triglyceride levels by 27%, and 36% of affected youths may achieve normalization of their triglyceride levels.
Dietary recommendations include reducing refined carbohydrates and added sugars—limiting fat intake to 25% to 30% of total kilocalories for mild elevations and 20% to 25% for moderate elevations—and increasing intake of fruits, vegetables, whole grains, lean proteins, and sources of monounsaturated and polyunsaturated fats. Youths are advised to engage in 60 minutes of moderate to vigorous physical activity daily.
For severe hypertriglyceridemia, the primary goal is acute pancreatitis prevention. Fat intake should be restricted to 10% to 15% of total daily kilocalories for severe elevations and to a very low– or no-fat diet for very severe elevations.
Pharmacologic Therapy
No drugs are currently approved by the US Food and Drug Administration specifically for pediatric hypertriglyceridemia. Pharmacotherapy may be considered for triglyceride levels 400 mg/dL or higher that persist despite lifestyle modification or in primary genetic disorders associated with pancreatitis risk.
Potential options include omega-3 fatty acids, fenofibrate, and statins among youths aged 8 years or older with non-HDL cholesterol 145 mg/dL or higher. In adults, statins reduce triglyceride levels by 10% to 20% and are primarily used to address ASCVD risk. In hospitalized youths with very severe hypertriglyceridemia, insulin administration can reduce triglyceride levels by 80% within 24 hours.
Research Priorities
The Scientific Statement highlighted the need for adequately powered, randomized pediatric trials to assess the safety and efficacy of triglyceride-lowering pharmacotherapies and to compare specific lifestyle interventions.
“Early detection and implementation of triglyceride-lowering lifestyle strategies is key for those with mild and moderate hypertriglyceridemia, with pharmacotherapy rarely indicated,” noted lead statement author Amy L. Peterson, MD, MS, of the American Heart Association, and colleagues.
Full disclosures can be found in the statement.
