These data, coupled with the increased risk of CVD in untreated severe hypercholester- olemia, support the use of statins in children and adolescents at ages 10 years who have and have not responded to 3 to 6 months of lifestyle therapy. Statins may be considered at age 8 years in the presence of con- cerning family history, extremely elevated LDL-C level, or elevated Lp(a), in the context of informed shared decision-making and counseling with the patient and family. The intensity of treatment should be based on the severity of the hyper- cholesterolemia and should incorporate patient/ family preference. Scant data on the use of ezeti- mibe in children with severe hypercholesterolemia show reasonable LDL-C lowering with no signifi- cant adverse effects.S4.4.4.3-13 Nonsystemic bile acid sequestrants can be useful for LDL-C lowering, but tolerability is an issue.S4.4.4.3-13 S4.4.4.3-16 4. Lipid testing during childhood can identify the severe hypercholesterolemia phenotype.S4.4.4.3-35 Severe hypercholesterolemia, which includes FH, can be identified in children and adolescents with an LDL-C level 190 mg/dL ( 4.9 mmol/L). Moreover, children and adolescents with LDL-C 160 mg/dL ( 4.1 mmol/L) and a family history of early atherosclerosis or similarly elevated cho- lesterol in 1 parent likely are those with FH and related genetic disorders associated with accel- Subclinical ath- erosclerosis data suggest divergence between affected and unaffected children and adolescents beginning at age 10 years,S4.4.4.3-28 which sup- ports screening by this age, although this topic is still considered controversial.S4.4.4.3-36 Screening is advised beginning at age 2 years if a family his- tory is suggestive of either early CVD or significant primary hypercholesterolemia. 