As for adults, the evidence that TLC will reduce serum TG levels and/or improve clinical outcomes is weak. Nonetheless, in the opi- nion of the Work Group, it is reasonable to advise children with high fasting levels of serum TGs (45.65 mmol/l [4500 mg/dl]) to adopt TLC based on similar considerations as mentioned in Guideline 5.1. Dietary changes that may reduce serum TGs include a very low-fat diet (o15% total calories), medium-chain TGs, and fish oils to replace some long-chain TGs. Dietary modification should be used judi- ciously, if at all, in children who are malnourished. Input from a social worker may be helpful if there are concerns that the patient or his/her parents are unable to safely implement TLC. Pharmacological treatment of high triglycerides: effects on risk of pancreatitis Although previous guidelines have suggested the use of fibric acid derivatives for preventing pancreatitis from severe hypertriglyceridemia, the evidence supporting the safety and efficacy of this approach is extremely weak especially in children with CKD. Therefore, the Work Group no longer recommends this approach. Evidence that very high TGs can cause pancreatitis in children comes from case reports and small series of patients with familial dyslipidemias.98,99 The safety and efficacy of lowering TGs with fibrates and niacin have not been established in adolescents; studies have been of extremely short duration and with very small sample sizes.100 102 There have been 4 trials of fish oil completed in children with glomerular causes of CKD and one trial among children on dialysis; fish oil appears to lower serum TGs after as little as but the longer-term benefits, harms, and tolerability of such treatment is unclear. Therefore, pharmacological treatment of hypertriglycer- idemia is not recommended in children with CKD. 