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    Obesity in Children

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    Sep.15.2023

    Obesity in Children

    Synopsis

    Key Points

    • Obesity refers to an excess of body fat; clinically estimated by the relationship between height and weight, taking into account the age and sex of the child
    • Measure height and weight, calculate BMI, and determine BMI or growth percentile using appropriate growth chart at least annually (eg, at well-child visit)
    • Diagnose obesity in children aged 2 years or older with BMI at or above the 95th percentile for age and sex according to CDC growth charts; those with BMI at or above the 85th and below the 95th percentile for age and sex are overweight
    • For children younger than 2 years, sex-specific weight for length greater than 2 standard deviations above the median (above the 97.7th percentile) according to WHO growth charts may indicate abnormal or unhealthy growth; use of overweight and obesity terminology in this age group is inconsistent
    • Workup should include history, systems review, and physical examination to assess for weight-related comorbidities and complications, with additional investigations (eg, fasting lipid panel, fasting glucose level, AST and ALT levels, endocrine evaluation, genetic tests) based on the age of child, BMI, and clinical findings
    • Initial treatment consists of age-appropriate intensive lifestyle modification (ie, diet, physical activity, behavior) for child and family
    • Refer to intensive health behavior and lifestyle treatment program; pharmacologic therapy and bariatric surgery are options for severely obese adolescents who have failed to respond to behavioral approaches
    • Children with obesity are at risk for multiple complications, including type 2 diabetes, hypertension, orthopedic problems, sleep apnea, and obesity in adulthood

    Pitfalls

    • Appropriate growth curves must be used to determine BMI or growth percentile; use CDC growth charts for children and adolescents aged 2 years or older and use WHO growth charts from birth to 2 yearsr1

    Terminology

    Clinical Clarification

    • Obesity refers to an excess of body fat; in clinical practice, this is estimated by the relationship between height and weight, taking into account age and sex
    • For children and adolescents aged 2 years or older in the United States, obesity is defined as BMI at or above the 95th percentile for age and sex, according to CDC BMI reference standards r2
      • BMI at or above 120% of the 95th percentile for age and sex is considered severe obesity
      • Overweight is defined as BMI at or above the 85th percentile and below the 95th percentile for age and sex r2
    • Infants and children from birth to 2 years with sex-specific weight for length greater than 2 standard deviations above the median (above the 97.7th percentile) according to WHO growth charts may have unhealthy or abnormal growth r3r4
      • Use of overweight and obesity terminology in this age group is inconsistent across different organizations
    • Prevalence of overweight, obesity, and severe obesity in children and adolescents in the United States has been increasing over the past decade r5
    • Rates of overweight, obesity, and severe obesity in children and adolescents have been rising around the world in recent decades r6r7

    Classification

    • By severity r8
      • Class 1: BMI at or above the 95th percentile and below 120% of the 95th percentile for age and sex
      • Class 2: BMI at or above 120% of the 95th percentile and below 140% of the 95th percentile for age and sex
      • Class 3: BMI at or above 140% of the 95th percentile for age and sex
      • Severe obesity refers to class 2 and class 3 obesity r5
    • By cause
      • Primary (exogenous) obesity r9
        • Most common form of obesity in children and adolescents
        • An imbalance in energy intake and expenditure leads to accumulation of excess adipose tissue
        • Multifactorial cause with a polygenic basis; environmental factors result in weight gain in combination with other variables
      • Secondary obesity r9
        • Results from a disease or treatment (eg, hypothyroidism, growth hormone deficiency, certain medications)
        • Historically, obesity related to hormonal factors has been termed endogenous obesity
      • Monogenic obesity r9
        • Affects a minority of children with obesity
        • Alteration in single gene leads to early-onset severe obesity
        • Most common is MC4R (melanocortin 4 receptor) variant; other forms include leptin deficiency, leptin receptor variants, and POMC (pro-opiomelanocortin) mutation
        • May be associated with malformation syndromes such as Prader-Willi or Bardet-Biedl syndrome
        • Considered a subtype of secondary obesity in some classifications

    Diagnosis

    Clinical Presentation

    History

    • Determine rapidity of weight gain and any associated symptoms, such as fatigue or exercise intolerance c1c2c3
    • History of dietary intake and other factors that affect weight, including: c4
      • Nutrition r4
        • Food choices
        • Fast food
        • Caloric intake
        • Family meals
        • Snacking
        • Beverage intake (especially soda, sugared drinks, and alcohol)
        • Frequency of dining out
      • Physical activity r4
        • Involvement in sports
        • Time spent outside
        • Duration, intensity, and frequency of activity
        • Mode of transportation used to get to school
      • Sedentary activities r4c5
        • Screen time
        • Locations of screens at home (eg, in bedroom)
      • Environment
        • Access to parks
        • Availability of playground equipment, pool, and gym
        • Safety of neighborhood
      • Medications
        • Antipsychotics r4c6
        • Glucocorticoids c7
    • Inquire about risk factors for pediatric obesity
      • Maternal diabetes c8
      • Small for gestational age c9
      • Large for gestational age c10
      • Parental obesity (particularly maternal) c11c12
      • Breastfeeding duration c13
      • Weight of siblings c14
    • Other history may indicate comorbidities/associated findings in obesity
      • Developmental delay may be sign of a genetic syndrome c15
      • Early failure to thrive and hypotonia with later weight gain and voracious appetite may be signs of Prader-Willi syndrome c16c17c18c19
      • Snoring or disrupted sleep with daytime drowsiness may be sign of sleep apnea r4c20c21c22
      • Headaches may indicate hypertension or sleep apnea r4c23c24
      • Joint pain may be because of excess weight and may indicate slipped capital femoral epiphysis or Blount disease c25c26c27
      • Menstrual irregularity may result from obesity and may be sign of polycystic ovary syndrome when accompanied by acne or hirsutism r4c28c29
      • Polyuria and polydipsia may be signs of type 2 diabetes r4c30c31
      • Fatigue with dry skin, poor appetite, and cold intolerance may be signs of hypothyroidism c32c33c34c35
      • Social isolation and lack of interest in activities may be signs of depression r4c36c37

    Physical examination

    • Height and weight
      • Calculate BMI from weight and height r4
        • BMI = weight in kilograms/(height in meters)²
        • Plot BMI on appropriate CDC growth chart for children aged 2 years or older; use WHO growth charts from birth to 2 years;r10 use CDC extended BMI-for-age growth chartsr1 to document and monitor BMI values above 97th percentile r1
      • Compare weight gain with height gain r4
        • Height and height velocity are usually normal or increased in exogenous obesity c38c39
        • Short stature and decreased height velocity suggest possible endocrine cause such as hypothyroidism or growth hormone deficiencies c40c41c42c43c44c45
    • Waist circumference at level of iliac crest
      • Limited pediatric references for these measurements
    • Weight distribution: central obesity versus generalized obesity c46
      • Central obesity more commonly seen in Cushing syndrome
    • Vital signs
    • Skin findings
      • Striae caused by rapid weight gain r11
        • Violaceous striae may be sign of Cushing syndrome c47
      • Acanthosis nigricans and skin tags may indicate insulin resistance r4c48c49
      • Severe acne and hirsutism in pubertal girls suggest polycystic ovary disease r4c50c51
    • Signs associated with syndromic obesity include the following:
      • Neurodevelopmental delay c52
      • Dysmorphic facial features characteristic of Prader-Willi syndrome or Down syndrome c53c54
      • Small hands and feet c55c56
      • Polydactyly c57
      • Short stature c58
      • Tall stature and rapid growth c59c60
      • Hypotonia c61
    • Signs associated with underlying causes or complications of obesity include the following:
      • Abnormal gait; hip, knee, or foot tenderness; or limited range of motion in hip c62c63c64c65c66
      • Hepatomegaly or right upper quadrant tenderness c67c68
      • Goiter c69
      • Premature appearance of secondary sexual characteristics in females c70
      • Pseudogynecomastia (adipose tissue mimicking breast development) r11

    Causes and Risk Factors

    Causes

    • Primary (exogenous) obesity is caused by complex relationships between genetics, nutrition, physical activity, and environmental factors r9c71
    • Obesity may be secondary to a variety of disease states, including: r9
      • Endocrine conditions c72
        • Hypothyroidism c73
        • Cushing syndrome c74
        • Growth hormone deficiency c75
        • Pseudohypoparathyroidism c76
        • Neonatal hyperinsulinemia c77
      • Hypothalamic dysfunction c78
        • Resection of brain tumors, such as craniopharyngioma c79c80
      • Medications
        • Antipsychotic drugs c81
        • Glucocorticoids c82
    • Obesity may accompany several genetic syndromes or single-gene defects r9c83c84

    Risk factors and/or associations

    Age
    • Prevalence of obesity in US children aged 2 to 19 years (2017-2018) r5
      • Preschool-aged children: 13.4% c85
      • School-aged children: 20.3% c86
      • Adolescents: 21.2% c87
      • Overall: 19.3%
    • Increasing prevalence rate of obesity with increasing age is observed worldwide r6
    Sex
    • Higher incidence in males in all age groups in the United States r5c88c89
    Genetics
    • Monogenic obesity r9
      • Variant of MC4R (melanocortin 4 receptor) is associated with severe early-onset obesity, tall stature, and hyperphagia; it is the most common monogenic risk factorr12c90c91c92c93
      • Leptin deficiency and leptin receptor variants are associated with severe early-onset obesity and hypogonadotropic hypogonadism c94c95c96c97
      • Mutations in POMC (pro-opiomelanocortin) is associated with severe early-onset obesity, low plasma cortisol level, and skin and hair abnormalities c98c99c100c101
      • Mutations in PCSK1 (proprotein convertase subtilisin/kexin type 1) is associated with severe early-onset obesity and low insulin and cortisol levels c102c103c104
      • Abnormalities in genes associated with hypothalamic development (eg, SIM1, BDNF, NTRK2) have been associated with obesity in a small number of cases c105c106c107
    • Syndromic obesity
      • Several genetic syndromes are associated with obesity and neurodevelopmental abnormalities r9
        • Prader-Willi syndrome c108d1
        • Bardet-Biedl syndrome c109
        • Alström syndrome c110
        • Wolfram syndrome c111
        • Beckwith-Wiedemann syndrome c112d2
        • WAGRO syndrome c113
        • Carpenter syndrome c114
        • Cohen syndrome c115
        • Down syndrome c116d3
        • MEHMO syndrome c117
        • MOMO syndrome c118
        • Smith-Magenis syndrome c119
        • Wilson-Turner syndrome c120
        • Börjeson-Forssman-Lehmann syndrome c121
    • Primary obesity c122
      • Era of genome-wide association studies is confirming that polygenic factors are important in primary obesity and is identifying relevant loci, although much remains unknown r13
    Ethnicity/race
    • Prevalence of obesity in US children aged 2 to 19 years (2017-2018) r5
      • Non-Hispanic Asian youth: 8.7% c123
      • Non-Hispanic White youth: 16.1% c124
      • Non-Hispanic Black youth: 24.2% c125
      • Hispanic youth: 25.6% c126
    • Prevalence of children with obesity worldwide significantly varies between countries and across world regions; highest in high-income Western countries (about 15%) and lowest in sub-Saharan Africa and South Asia (below 3%) r6c127c128c129
    Other risk factors/associations
    • Prenatal risk factors
    • Childhood risk factors
    • Other factors r23
      • Excess intake of sugar-sweetened beverages c138
      • Skipping breakfast c139
      • Dining out, particularly at fast-food restaurants c140
      • Low intake of fruits and vegetables c141c142
      • Physical inactivity c143
      • Television viewing c144
    • Prevalence of childhood obesity is lowest in wealthier socioeconomic groups r24r25c145c146

    Diagnostic Procedures

    Primary diagnostic tools

    • Measure height and weight at least annually (eg, well-child visit) to calculate BMI and to determine corresponding normalized percentile using appropriate growth chart c147c148c149
      • Use CDC growth charts for children and adolescents aged 2 years or older and WHO growth charts from birth to 2 yearsr3r10
      • Use CDC extended BMI-for-age growth chartsr1 to document and monitor BMI values above 97th percentile; chart maximum BMI is 60 kg/m²
    • Diagnose obesity in children aged 2 years or older with BMI at or above the 95th percentile for age and sex r2
      • BMI at or above 120% of the 95th percentile for age and sex is considered severe obesity r5
      • BMI at or above the 85th percentile and below the 95th percentile for age and sex is considered overweight r2
    • For infants and children from birth to 2 years, sex-specific weight for length greater than 2 standard deviations above the median (above the 97.7th percentile) according to WHO growth charts may indicate abnormal or unhealthy growth; use of overweight and obesity terminology in this age group is inconsistent r3r4
    • Include history, systems review, and physical examination in initial workup to assess for weight-related comorbidities and complications
    • Although not strictly required for diagnosis, additional evaluations are based on age of child, BMI, and clinical findings r26
      • Children with obesity aged 10 years or older: obtain fasting lipid panel, fasting glucose level (or oral glucose tolerance test or hemoglobin A1c), and AST and ALT levels
      • Children with overweight aged 10 years or older: obtain fasting lipid panel
        • Obtain fasting glucose, oral glucose tolerance test, or hemoglobin A1c if additional risk factors for type 2 diabetes are present (eg, family history, history of gestational diabetes, signs of insulin resistance, use of obesogenic medication)
        • Measure AST and ALT levels if additional risk factors for NAFLD (nonalcoholic fatty liver disease) (eg, family history of NAFLD, central adiposity, signs of insulin resistance, prediabetes or diabetes, dyslipidemia, sleep apnea)
      • Children aged 2 to 9 years with obesity: consider obtaining fasting lipid panel test
        • Risk for NAFLD and diabetes is lower in children younger than 10 years, and testing for abnormal glucose metabolism or liver function is not universally recommended
      • Endocrine evaluation is indicated if specific endocrine causes of obesity are suspected
        • Endocrine assessment is not usually warranted for slightly delayed onset of puberty in boys or slightly earlier puberty in girls r11
          • Girls with obesity tend to have an earlier puberty onset (usually 8-9 years), and onset of puberty may be delayed (usually 13-14 years) in adolescent girls with severe obesity
      • Additional investigations may be indicated for evaluation of specific comorbidities or complications, including: r27
        • Radiologic evaluation for certain orthopedic complications
        • Polysomnography if sleep apnea is suspected
        • Abdominal ultrasonography for NAFLD or polycystic ovary disease
        • Genetic testing for specific syndromes associated with obesity

    Differential Diagnosis

    Most common

    • Secondary obesity c150
      • Obesity may be accompanied by signs and symptoms of underlying disorder (eg, hypothyroidism, Cushing syndrome) or associated with medication use
      • Differentiate on basis of history, physical examination, and laboratory tests (eg, thyroid function tests, cortisol levels) as directed by clinical findings
    • Monogenic obesity c151
      • Presents with severe, early-onset obesity
      • Suspect in children who have history of unexplained weight gain from infancy and are in 97th percentile or greater for weight by age 3 years
      • May be differentiated on basis of genetic testing; however, this does not alter management
    • Syndromic obesity c152
      • Occurs in the context of several neurodevelopmental syndromes, including trisomy 21 (Down) syndrome, Prader-Willi syndrome, or Bardet-Biedl syndrome
      • Differentiate on basis of history and physical examination showing characteristic dysmorphic and neurodevelopmental features of specific syndromes

    Treatment

    Goals

    • Weight loss or weight maintenance during linear growth
    • Prevention of obesity-related complications

    Disposition

    Admission criteria

    • Admit to hospital if undergoing bariatric surgery

    Recommendations for specialist referral

    • Refer to an endocrinologist if a hormonal cause of obesity is suspected or if diabetes is diagnosed
    • Refer to an appropriate specialist based on complications and suspected causes (eg, orthopedic surgeon, geneticist, psychologist)
    • Refer to a multidisciplinary obesity clinic if obesity is severe and does not improve after initial treatment stages

    Treatment Options

    Obesity is a chronic condition requiring individualized, age-appropriate long-term care, ongoing medical monitoring and treatment of associated comorbidities, and ongoing access to treatment

    • Intensive health behavior and lifestyle treatment is the cornerstone of management for obesity in children r26
      • Consists of multidisciplinary, age-appropriate intensive lifestyle modification and counseling (ie, diet, physical activity, behavior) for child and family in individual and/or group setting r28r29
      • A variety of treatment programs are available; the most effective provide face to face, family-based counseling on nutrition and physical activity over at least a 3- to 12-month period
      • Refer patients promptly to an appropriate program; there is no evidence to support watchful waiting or delaying treatment in children who have already developed obesity r26
    • Additional measures to undertake in primary care setting are as follows: r26
      • Counsel families to focus on basic healthy eating and activity habits to improve BMI
      • Identify and address modifiable risk factors for obesity (eg, frequency of dining out and eating fast food)
      • Provide information regarding resources and support in the patient's community (eg, parks and recreation programs, school wellness programs)
    • Children and adolescents with more severe obesity or significant comorbidities may require additional therapeutic options as an adjunct to health behavior and lifestyle interventions
      • Pharmacologic therapy is appropriate for adolescents and can also be offered to children aged 8 to 11 years r26r30
        • The following agents are FDA approved for treatment of obesity:
          • Orlistat r31
            • Approved for weight loss in people aged 12 years or older r32
            • Reversible pancreatic and gastric lipase inhibitor that limits absorption of dietary fat r31
            • May be considered in conjunction with lifestyle modifications in adolescents with BMI of 30 kg/m² or higher or BMI of 27 kg/m² or higher with comorbidities (eg, hypertension, hyperlipidemia, diabetes) r33
            • Results in modest additional lowering of BMI when combined with diet and exercise in adolescents with obesity versus lifestyle modifications alone r33
            • Gastrointestinal adverse effects may limit use r32
            • Orlistat decreases the absorption of some fat-soluble vitamins (A, D, E, K) and β-carotene. To ensure adequate nutrition, patients should take a daily multivitamin supplement that contains these fat-soluble vitamins. Administer the multivitamin at least 2 hours before or after the administration of orlistat r33
          • Phentermine-topiramate r34
            • Approved for treatment of obesity in people aged 12 years or older
            • Results in modest additional lowering of BMI when combined with lifestyle measures in adolescents with obesity versus lifestyle modifications alone; higher doses associated with greater effect
          • Glucagonlike peptide 1 receptor agonists (semaglutide and liraglutide)
            • Both approved for weight loss in people aged 12 years or older and are also treatments for type 2 diabetes
            • Administered by subcutaneous injection r35
            • May be considered in patients with body weight above 60 kg and BMI of 30 kg/m² or higher r35
            • Once-weekly semaglutide resulted in substantial weight loss and improvement in cardiometabolic risk factors compared with diet and exercise alone and was significantly more effective than liraglutide compared with diet and exercise r36
            • Daily injections of liraglutide resulted in modest additional lowering of BMI in obese adolescents versus lifestyle modifications alone; also associated with reduction in hemoglobin A1c and blood pressure r37r38
              • Exenatide has similar effects but is not currently approved for use for this specific indication
            • Gastrointestinal adverse events are common with both semaglutide and liraglutide but are generally mild r36r37
          • Phentermine
            • Approved for short-term use (a few weeks) for weight loss in people aged 17 years or older r39
            • Sympathomimetic; results in appetite suppression r39
            • May be considered in conjunction with lifestyle modifications in adolescents with BMI of 30 kg/m² or higher or BMI of 27 kg/m² or higher with comorbidities (eg, hypertension, hyperlipidemia, diabetes) r39
            • Results in modest additional lowering of BMI when combined with diet and exercise in adolescents with obesity versus lifestyle modifications alone r40
        • Other agents with potential weight loss benefits
          • Metformin is a first line treatment of glycemic control in adolescents with type 2 diabetes and has limited beneficial effect on weight and insulin resistance in adolescents with obesity without type 2 diabetes r41
          • Lisdexamfetamine is a stimulant medication similar to phentermine approved for children aged 6 years or older with attention-deficit/hyperactivity disorder and indication for treatment of binge-eating disorder in patients aged 18 years or older; has been used off-label for children with obesity r26
        • It is unknown whether pharmacologic treatment of obesity in adolescents has durable long-term weight loss effects and leads to overall reduction in risk of atherosclerotic cardiovascular disease r42
      • Bariatric surgery can be considered for patients with severe obesity (ie, class 2 or greater obesity; BMI of 35 kg/m² or higher, or 120% of the 95th percentile for age and sex, whichever is lower) r26r30
        • American Society of Metabolic and Bariatric Surgery guideline indications for adolescent bariatric surgery are widely accepted: r43
          • BMI 35 kg/m² or higher or 120% of the 95th percentile for age and sex (class 2 obesity), with a significant comorbid condition (eg, diabetes, hypertension, obstructive sleep apnea)
          • BMI 40 kg/m² or higher or 140% of the 95th percentile for age and sex (class 3 obesity), whichever is lower
          • Ability to adhere to pre- and postoperative treatments, including nutritional supplementation
          • Developmental delay, autism spectrum, and syndromic obesity are not contraindications, assuming ability to adhere to treatment
          • No minimum age for surgery is specified in society guidelines, although insurance companies may set minimum age limits for coverage; referral to a metabolic and bariatric surgery program is recommended as soon as children are diagnosed with class 2 obesity r43r44
        • Bariatric surgery results in substantial weight loss and improvement in medical comorbidities compared with medical therapy alone r45r46
          • In a study comparing surgical and medical management for severely obese adolescents with type 2 diabetes over 2 years of follow-up, BMI decreased by 29% from baseline and mean hemoglobin A1C concentration decreased by 1.3% in the surgical group, whereas BMI increased by 3.7% from baseline and mean hemoglobin A1C concentration increased by 1.4% in the medical management group r45
          • Weight loss efficacy and improvements in glycemic control, lipids, and blood pressure are durable in adolescents for more than 5 years after surgery r47
        • Sleeve gastrectomy (more than 70%) is the most commonly performed procedure, followed by Roux-en-Y gastric bypass (more than 25%); adjustable gastric banding has fallen into disfavor and is rarely performed r48
        • Sleeve gastrectomy and Roux-en-Y gastric bypass both appear to have excellent surgical outcomes, and there is no consensus on the best procedure; both can be considered standard of care r49
          • In the first large observational study of sleeve gastrectomy and Roux-en-Y gastric bypass in patients younger than 19 years, total weight loss at 3 years was 27% of total body weight; rates between the 2 procedures were similar r46
          • Very high rates of comorbidity remission were reported in the same study, including remission of prediabetes (76%), type 2 diabetes (95%), hypertension (74%), and dyslipidemia (66%)
        • Care should be sought at high-quality multidisciplinary centers with experience in treating adolescents with severe obesity, including performance of bariatric surgery r44
        • Outcomes and safety of bariatric surgery in adolescents are comparable or better than those for adults r49

    Drug therapy

    • Lipase Inhibitor
      • Orlistat c153
        • Orlistat Oral capsule; Children and Adolescents 12 to 17 years: 120 mg PO 3 times daily with each main meal containing fat. May omit dose if a meal is occasionally missed or contains no fat.
    • Adrenergic agonists
      • Phentermine c154
        • 3 times daily dosing (eg, Lomaira or equivalents)
          • Phentermine Hydrochloride Oral tablet; Adolescents 17 years: 4 or 8 mg PO 3 times daily. Usual dose: 8 mg PO 3 times daily.
        • Once daily dosing (eg, Adipex-P or equivalents)
          • Phentermine Hydrochloride Oral tablet; Adolescents 17 years: 15 to 37.5 mg PO once daily or 18.75 mg PO twice daily.
      • Phentermine with topiramate
        • Phentermine Hydrochloride, Topiramate Oral capsule, extended-release; Children and Adolescents 12 to 17 years: 3.75 mg phentermine/23 mg topiramate PO once daily for 14 days, then increase the dose to 7.5 mg phentermine/46 mg topiramate PO once daily. If weight loss is not at least 3% of baseline BMI after 12 weeks, increase the dose to 11.25 mg phentermine/69 mg topiramate PO once daily for 14 days, and then 15 mg phentermine/92 mg topiramate PO once daily. If weight loss is not at least 5% of baseline BMI after another 12 weeks, discontinue therapy. Consider dosage reduction if weight loss exceeds 2 lbs (0.9 kg)/week.
    • Glucagonlike peptide 1 receptor agonists
      • Liraglutide c155
        • Liraglutide Solution for injection [Weight Management]; Children and Adolescents 12 to 17 years: 0.6 mg subcutaneously once daily for 1 week, initially. Then increase the dose by 0.6 mg/week to 3 mg subcutaneously once daily. May lower dose to previous level if a dose increase is not tolerated during dose escalation. If the 2.4 mg dose is not tolerated or weight loss is not at least 1% of baseline BMI after 12 weeks on the maintenance dose, discontinue therapy.
      • Semaglutide
        • Semaglutide Solution for injection [Weight Management]; Children and Adolescents 12 to 17 years: 0.25 mg subcutaneously once weekly for weeks 1 through 4, then 0.5 mg subcutaneously once weekly for weeks 5 through 8, then 1 mg subcutaneously once weekly for weeks 9 through 12, then 1.7 mg subcutaneously once weekly for weeks 13 through 16, and then 2.4 mg subcutaneously once weekly. Consider delaying dose escalation for 4 weeks if a dose increase is not tolerated. May decrease dose to 1.7 mg subcutaneously once weekly if the 2.4 mg dose is not tolerated. Discontinue use if the 1.7 mg dose is not tolerated.

    Nondrug and supportive care c156c157c158c159c160c161c162c163c164c165c166c167c168c169

    Common strategies to recommend r26

    • Limit consumption of sugar-sweetened beverages
    • Follow US Department of Agriculture's recommendations for healthy eating for Americans
      • Broadly recommends a diet low in added sugar, low in concentrated fat, nutrient dense but not calorie dense, within an appropriate calorie range without defined calorie restriction, and with balanced protein and carbohydrate
      • Principles can be adapted to different food cultures
    • Undertake moderate to vigorous physical activity for at least 60 minutes daily
    • Reduce sedentary behavior, specifically screen time
      • American Academy of Pediatrics recommends no media use for children younger than 18 months, a 1-hour limit for ages 2 to 5 years, and a parent-monitored plan for not-excessive media use in older children (with no defined upper limit) r26
    • Avoid skipping breakfast
    • Get an age-appropriate amount of sleep
    Procedures
    Roux-en-Y gastric bypass c170c171c172c173c174c175c176c177c178c179c180c181c182c183c184c185c186c187c188c189c190c191
    General explanation
    • Once the most common and gold standard surgical approach, now mostly overtaken by sleeve gastrectomy r48
    • Performed with minimally invasive surgical techniques
    • Stomach is divided into a small upper pouch and a larger lower remnant pouch, thereby restricting the volume of food that can be consumed
    • Small intestine is reconstructed to enable drainage of both gastric segments, usually by means of a proximal bypass
      • Small intestine is divided distal to the duodenojejunal junction, creating a Y-shaped biliopancreatic limb and a Roux limb
      • Proximal end of the Roux limb is connected to the small upper gastric pouch, and the distal end of the biliopancreatic limb is connected to the Roux limb, creating a bypass effect
    • Results in significant and sustained weight loss r49
    Indication r43
    • BMI 35 kg/m² or higher or 120% of the 95th percentile for age and sex (class 2 obesity), with a significant comorbid condition (eg, diabetes, hypertension, obstructive sleep apnea)
    • BMI 40 kg/m² or higher or 140% of the 95th percentile for age and sex (class 3 obesity), whichever is lower
    • Ability to adhere to pre- and postoperative treatments, including nutritional supplementation
    Contraindications r43
    • Medically reversible cause of obesity
    • Ongoing substance abuse
    • Medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to treatment
    • Current or planned pregnancy within 12 to 18 months of surgery
    Complications
    • Anastomotic stricture
    • Gastrointestinal leak
    • Small bowel obstruction
    • Dumping syndrome
    • Nutritional deficiencies owing to malabsorption
    Vertical sleeve gastrectomy
    General explanation
    • Has overtaken Roux-en-Y gastric bypass and now accounts for more than 70% of adolescent bariatric surgical procedures r48
    • Most of the stomach is removed (including the entire greater curve), resulting in a small gastric sleeve
    • Results in postprandial satiety
    Indication r43
    • BMI 35 kg/m² or higher or 120% of the 95th percentile for age and sex (class 2 obesity), with a significant comorbid condition (eg, diabetes, hypertension, obstructive sleep apnea)
    • BMI 40 kg/m² or higher or 140% of the 95th percentile for age and sex (class 3 obesity), whichever is lower
    • Ability to adhere to pre- and postoperative treatments, including nutritional supplementation
    Contraindications r43
    • Medically reversible cause of obesity
    • Ongoing substance abuse
    • Medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to treatment
    • Current or planned pregnancy within 12 to 18 months of surgery
    Complications r49
    • Staple-line leak
    • Stricture formation
    • Bleeding
    • Nutritional deficiencies

    Special populations

    • Patients younger than 2 years r50
      • WHO growth charts that plot weight for age and weight for length are used in this age group rather than BMI r3
      • Infants and children from birth to 2 years may have abnormal or unhealthy growth if the sex-specific weight for length is greater than the 97.7th percentile (+2 standard deviations above the median) according to WHO growth charts r3
      • Management consists of the following:
        • Encourage exclusive breastfeeding from birth to age 6 months and continued breastfeeding once solid foods are introduced to age 12 months and beyond
        • Avoid sugar-sweetened beverages
        • For toddlers aged 12 to 24 months, use age-appropriate strategies
          • Eat 3 meals per day at table with other family members
          • Provide snacks with water instead of juice
          • Offer frequent opportunities for play
          • Limit television time, with no screens in the bedroom
    • Monogenic obesity
      • Patients with severe obesity associated with POMC (pro-opiomelanocortin), PCSK1 (proprotein convertase subtilisin/kexin type 1), or LEPR (leptin receptor) deficiency are candidates for treatment with the MC4R agonist (melanocortin 4 receptor), setmelanotide r51
      • In small open-label trials, most patients treated with setmelanotide for 1 year achieve more than 10% weight loss and reduced hunger r52

    Monitoring

    • Measure growth parameters, including BMI, at all well-child visits c192c193
    • Frequency of visits depends on intensity and stage of treatment, usually every 1 week to 1 month, to monitor progress
    • Monitor fasting lipid panel and fasting levels of glucose, AST, and ALT in children aged 9 to 18 years with BMI in the 95th percentile or higher or BMI between 85th and 94th percentile with risk factors (eg, elevated blood pressure, family history of obesity-related diseases) r50

    Complications and Prognosis

    Complications

    • Obesity-related conditions affect almost every system r50
      • Obstruction sleep apnea c194
      • Worsening asthma c195
      • Nonalcoholic fatty liver disease c196
      • Gallstones c197
      • Gastroesophageal reflux disease c198
      • Type 2 diabetes c199
      • Polycystic ovary syndrome c200
      • Hypertension c201
      • Dyslipidemia c202
      • Pseudotumor cerebri c203
      • Slipped capital femoral epiphysis c204
      • Blount disease c205
      • Chronic skin inflammation and infections c206c207
      • Depression c208
      • Eating disorders c209
      • Dental caries r53c210

    Prognosis

    • Obesity is often a chronic condition; many children with overweight and obesity become adults with overweight and obesity r54
    • Infant growth rate parameters correlate with overweight, obesity, BMI, waist circumference, and body composition later in childhood r55
    • Children with obesity aged 2 to 5 years with BMI higher than 95th percentile are more than 4 times more likely to become adults with obesity r56
    • Childhood obesity significantly increases atherosclerotic cardiovascular disease and subsequent mortality in adulthood r42
    • Childhood obesity is associated with increased risk of dyslipidemia, hypertension, type 2 diabetes, nonalcoholic steatohepatitis, and polycystic ovarian syndrome r42

    Screening and Prevention

    Screening

    At-risk populations r57

    • Universal screening is recommended
    • US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents aged 6 years or older and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status

    Screening tests r57

    • Calculate BMI and determine BMI percentile using appropriate growth chart at least annually (eg, at well-child visit) c211
    • Assess diet, physical activity, and sedentary behaviors annually c212c213c214

    Prevention

    • Identify children at risk and recommend lifestyle behavior changes to prevent obesity and encourage healthy BMIs
      • Implement prevention interventions when BMI starts to cross percentiles upward, even before they reach the 85th to 95th percentile
      • Target behaviors
        • Encourage exclusive breastfeeding from birth to age 6 months, then supplement with breastfeeding when solid foods are introduced until age 12 months and beyond r58c215c216
          • Avoid high protein intake during complementary feeding
        • Between 12 and 24 months, there is no evidence to recommend reduced-fat cow's milk r58
        • Limit consumption of sugar-sweetened beverages c217
        • Encourage intake of fruits and vegetables c218
        • Limit screen time and avoid use of screen devices during mealtimes r58c219
        • Encourage eating breakfast daily r58c220
        • Limit dining out, especially fast-food restaurants c221c222
        • Encourage family meals r58c223
        • Adjust portion sizes appropriately for age; allow child to self-regulate intake c224c225
        • Encourage diet rich in calcium and high in fiber c226c227
        • Encourage diet with balanced macronutrients c228
        • Limit consumption of energy-dense foods c229
        • Promote moderate to vigorous exercise for at least 60 minutes daily r58c230
        • Ensure adequate sleep duration c231
      • Interventions that include diet combined with physical activity can reduce risk of obesity in children up to age 5 years; interventions that focus only on physical activity do not appear to be effective in children of this age r59
      • Interventions that focus only on physical activity can reduce the risk of obesity in children aged 6 to 12 years or adolescents aged 13 to 18 years; in these age groups, there is no evidence that interventions that focus only on diet are effective r59
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