[Management of hypercholesterolemia in children: needs and concerns]

In childhood, cholesterol values are closely related to the genetic heritage of the young patient. Among familial hypercholesterolemia, it is essential to identify the monogenic and multigenic forms. In monogenic forms, heterozygotes respond poorly or partially to changes in diet and lifestyle, making pharmacological therapy necessary; in homozygote patients plasmapheresis is required, and liver transplantation is the only intervention that can impact permanently on the development of cardiovascular lesions in adulthood. Conversely, multigenic forms or familial hypercholesterolemia secondary to other diseases respond to changes in diet and lifestyle as well as to pharmacological treatment. It remains unclear how early pharmacological intervention should be implemented. In particular, the presence in children of typical histological lesions of athero- sclerosis and their interaction with cardiovascular disease in adulthood justify a prompt, although cautious, intervention. In fact, cholesterol is necessary for normal development of the organism, provided that percentile values are in the normal range according to age and sex. Two methods of intervention are identified: a population strategy that should be implemented on a large scale for advice about diet and optimal level of physical activity; and an individual strategy, in which diet advice should be followed by pharmacological treatment. Pharmacological therapy may be administered even in children over the age of 8-10 years, if necessary. In younger patients, therapeutic interventions should be restricted to children with LDL cholesterol levels >500 mg/dl. Although statins have only been studied in populations affected by severe familial hypercholesterolemia in the short term, they seem to be the most effective agents in children owing to their efficacy and limited side effects.