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    Apr.26.2022

    Obesity in Children

    Synopsis

    Key Points

    • Obesity refers to an excess of body fat; estimated clinically 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 and 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 under 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
    • Work-up 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
    • Intensity of intervention should increase in a stepwise fashion and is tailored to motivation of the family and degree of obesity; pharmacologic therapy and bariatric surgery are options for severely obese adolescents who have failed to respond to behavioral approaches
    • Obese children are at risk for multiple complications, including type 2 diabetes mellitus, 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 2 years and above and use WHO growth charts from birth up to 2 years

    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 2 years and 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 r1
      • 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 r1
    • Infants and children aged from birth up to 2 years with sex-specific weight for length greater than 2 standard deviations above the median (above the 97.7th percentile) according to World Health Organization growth charts may have unhealthy or abnormal growth r2r3
      • 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 r4
    • Rates of overweight, obesity, and severe obesity in children and adolescents have been rising around the world in recent decades r5r6

    Classification

    • By severity r7
      • 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 r4
    • By etiology
      • Primary (exogenous) obesity
        • 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
        • 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
        • Affects a minority of obese children
        • Alteration in single gene leads to early onset severe obesity
        • Most common is MC4R mutation; other forms include leptin deficiency, leptin receptor mutations, and POMC deficiency
        • May be associated with malformation syndromes such as Prader-Willi or Bardet-Biedl syndromes
        • 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:
      • Nutrition
        • Food choices
        • Fast food
        • Caloric intake
        • Family meals
        • Snacking
        • Beverage intake (especially soda, sugared drinks, and alcohol)
        • Frequency of dining out
      • Physical activity
        • Involvement in sports
        • Time spent outside
        • Duration, intensity, and frequency of activity
        • Mode of transportation used to get to school
      • Sedentary activities c4
        • 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 c5
        • Glucocorticoids c6
    • Inquire about risk factors for pediatric obesity
      • Maternal diabetes mellitus c7
      • Small for gestational age c8
      • Large for gestational age c9
      • Parental obesity (particularly maternal) c10c11
      • Breastfeeding duration c12
      • Weight of siblings c13
    • Other history may indicate comorbidities/associated findings in obesity
      • Developmental delay may be sign of a genetic syndrome c14
      • Early failure to thrive and hypotonia with later weight gain and voracious appetite may be signs of Prader-Willi syndrome c15c16c17c18
      • Snoring or disrupted sleep with daytime drowsiness may be sign of sleep apnea c19c20c21
      • Headaches may indicate hypertension or sleep apnea c22c23
      • Joint pain may be result of excess weight and may indicate slipped capital femoral epiphysis or Blount disease c24c25c26
      • Menstrual irregularity may result from obesity and may be sign of polycystic ovary syndrome when accompanied by acne or hirsutism c27c28
      • Polyuria and polydipsia may be signs of type 2 diabetes c29c30
      • Fatigue with dry skin, poor appetite, and cold intolerance may be signs of hypothyroidism c31c32c33c34
      • Social isolation and lack of interest in activities may be signs of depression c35c36

    Physical examination

    • Height and weight
      • Calculate BMI from weight and height
        • BMI = weight in kilograms / (height in meters)²
        • Plot BMI on appropriate CDC growth chart for children aged 2 years and above; use WHO growth charts from birth up to 2 yearsr8
      • Compare weight gain with height gain r3
        • Height and height velocity are usually normal or increased in exogenous obesity c37c38
        • Short stature and decreased height velocity suggest possible endocrine cause such as hypothyroidism or growth hormone deficiencies c39c40c41c42c43c44
    • Waist circumference at level of iliac crest
      • Limited pediatric references for these measurements
    • Weight distribution: central obesity versus generalized obesity c45
      • Central obesity more commonly seen in Cushing syndrome
    • Vital signs
    • Skin findings
      • Violaceous striae may be sign of Cushing syndrome c46
      • Acanthosis nigricans and skin tags may indicate insulin resistance c47c48
      • Severe acne and hirsutism in pubertal girls suggest polycystic ovary disease c49c50
    • Signs associated with syndromic obesity, for example:
      • Neurodevelopmental delay c51
      • Dysmorphic facial features characteristic of Prader-Willi syndrome or Down syndrome c52c53
      • Small hands and feet c54c55
      • Polydactyly c56
      • Short stature c57
      • Tall stature and rapid growth c58c59
      • Hypotonia c60
    • Signs associated with underlying causes or complications of obesity, for example:
      • Abnormal gait; hip, knee, or foot tenderness; or limited range of motion in hip c61c62c63c64c65
      • Hepatomegaly or right upper quadrant tenderness c66c67
      • Goiter c68
      • Premature appearance of secondary sexual characteristics c69

    Causes and Risk Factors

    Causes

    • Primary (exogenous) obesity is caused by complex relationships between genetics, nutrition, physical activity, and environmental factors c70
    • Obesity may be secondary to a variety of disease states, including:
      • Endocrine conditions c71
        • Hypothyroidism c72
        • Cushing syndrome c73
        • Growth hormone deficiency c74
        • Pseudohypoparathyroidism c75
        • Neonatal hyperinsulinemia c76
      • Hypothalamic dysfunction c77
        • Resection of brain tumors, such as craniopharyngioma c78c79
      • Medications
        • Antipsychotic drugs c80
        • Glucocorticoids c81
    • Obesity may accompany several genetic syndromes or single gene defects c82c83

    Risk factors and/or associations

    Age
    • Prevalence of obesity in US children aged 2 to 19 years (2017-2018) r4
      • Preschool-aged children: 13.4% c84
      • School-aged children: 20.3% c85
      • Adolescents: 21.2% c86
      • Overall: 19.3%
    • Increasing prevalence rate of obesity with increasing age is observed worldwide r5
    Sex
    • Higher incidence in males in all age groups in the United States r4c87c88
    Genetics
    • Monogenic obesity
      • Mutation of MC4R (melanocortin 4 receptor) is associated with severe early onset obesity, tall stature, and hyperphagia; it is the most common monogenic risk factorc89c90c91c92
      • Leptin deficiency and leptin receptor mutations are associated with severe early onset obesity and hypogonadotropic hypogonadism c93c94c95c96
      • Deficiency of POMC (pro-opiomelanocortin) is associated with severe early onset obesity, low plasma cortisol level, and skin and hair abnormalities c97c98c99c100
      • Deficiency of PCSK1 (prohormone convertase 1) is associated with severe early onset obesity and low insulin and cortisol levels c101c102c103
      • Abnormalities in genes associated with hypothalamic development (eg, SIM1, BDNF, NTRK2) have been associated with obesity in a small number of cases c104c105c106
    • Syndromic obesity
      • Several genetic syndromes are associated with obesity and neurodevelopmental abnormalities
        • Prader-Willi syndrome c107d1
        • Bardet-Biedl syndrome c108
        • Alström syndrome c109
        • Wolfram syndrome c110
        • Beckwith-Wiedemann syndrome c111d2
        • WAGRO syndrome c112
        • Carpenter syndrome c113
        • Cohen syndrome c114
        • Down syndrome c115d3
        • MEHMO syndrome c116
        • MOMO syndrome c117
        • Smith-Magenis syndrome c118
        • Wilson-Turner syndrome c119
        • Börjeson-Forssman-Lehmann syndrome c120
    • Primary obesity
      • 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
    Ethnicity/race
    • Prevalence of obesity in US children aged 2 to 19 years (2017-2018) r4
      • Non-Hispanic Asian youth: 8.7% c121
      • Non-Hispanic White youth: 16.1% c122
      • Non-Hispanic Black youth: 24.2% c123
      • Hispanic youth: 25.6% c124
    • Prevalence of obesity in children worldwide varies significantly between countries and across world regions; highest in high-income Western countries (around 15%) and lowest in sub-Saharan Africa and South Asia (below 3%) r5
    Other risk factors/associations
    • Prenatal risk factors
      • Parental obesity c125
      • Maternal gestational diabetes c126
      • Maternal smoking during pregnancy c127
    • Childhood risk factors
      • Never breastfed c128
      • Rapid infant weight gain c129
      • Short sleep duration c130
      • Depression c131
      • Presence of disability c132
    • Other factors
      • Excess intake of sugar-sweetened beverages c133
      • Skipping breakfast c134
      • Dining out, particularly at fast-food restaurants c135
      • Low intake of fruits and vegetables c136c137
      • Physical inactivity c138
      • Television viewing c139
    • Prevalence of childhood obesity is lowest in wealthier socioeconomic groups c140c141

    Diagnostic Procedures

    Primary diagnostic tools

    • Measure height and weight at least annually (eg, well-child visit) in order to calculate BMI and determine corresponding normalized percentile using appropriate growth chart c142c143
      • Use CDC growth charts for children and adolescents 2 years and older and WHO growth charts from birth up to 2 yearsr2r8
    • Diagnose obesity in children aged 2 years and older with BMI at or above the 95th percentile for age and sex r1
      • BMI at or above 120% of the 95th percentile for age and sex is considered severe obesity r4
      • BMI at or above the 85th percentile and below the 95th percentile for age and sex is considered overweight r1
    • For infants and children from birth up 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 r2r3
    • Include history, systems review, and physical examination in initial work-up to assess for weight-related comorbidities and complications
    • While not strictly required for diagnosis, additional evaluations are based on age of child, BMI, and clinical findings
      • Obtain fasting lipid panel in children aged 2 to 8 years with BMI in the 95th percentile or greater, or BMI between 85th and 94th percentile and family history of dyslipidemia or other high-risk condition
      • Obtain fasting lipid panel in children aged 9 to 18 years with BMI between 85th and 94th percentile and no risk factors; alternatively screen with nonfasting non-HDL cholesterol and follow-up with fasting lipid panel if results are abnormal
      • Obtain 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 (elevated blood pressure, family history of obesity-related diseases)
      • Endocrine evaluation is indicated if specific endocrine causes of obesity are suspected
      • Additional investigations may be indicated for evaluation of specific comorbidities or complications, including:
        • Glucose tolerance test if diabetes is suspected
        • Radiologic evaluation for certain orthopedic complications
        • Polysomnography if sleep apnea is suspected
        • Abdominal ultrasonography for nonalcoholic fatty liver disease or polycystic ovary disease
        • Genetic testing for specific syndromes associated with obesity

    Laboratory c144c145c146c147c148c149c150c151c152c153c154c155c156c157c158c159c160

    Imaging c161c162c163c164

    Differential Diagnosis

    Most common

    • Secondary obesity c165
      • 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 c166
      • 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 c167
      • 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 demonstrating 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 mellitus is diagnosed
    • Refer to appropriate specialist based on complications and suspected causes (eg, orthopedic surgeon, geneticist, psychologist)
    • Refer to multidisciplinary obesity clinic if obesity is severe and does not improve after initial treatment stages

    Treatment Options

    A staged approach to treatment has been recommended for all children and adolescents 2 years and older with BMI greater than 85th percentile r9

    • Consists of age-appropriate intensive lifestyle modification (ie, diet, physical activity, behavior) for child and family
    • Intensity of interventions increases with each stage and is tailored to motivation of the family and degree of obesity
      • If the child and family have attempted modifications for 3 to 6 months without lowering BMI, then they should progress in intensity to the next stage
    • Stage 1: prevention plus (primary care setting)
      • Families focus on basic healthy eating and activity habits to improve BMI
        • Eat at least 5 servings of fruits and vegetables each day
        • Minimize sugar-sweetened drinks
        • Limit screen time to less than 2 hours per day
        • Be physically active at least 1 hour each day
        • Prepare more meals at home
        • Eat together as a family 5 to 6 days per week
        • Eat a healthy breakfast every day
        • Involve entire family in lifestyle changes
        • Allow child to self-regulate amounts during meals
      • Need to consider behaviors to target depending on current behaviors, families' cultural values, schedule, and motivation
    • Stage 2: structured weight management (primary care setting)
      • Specific eating and activity goals supplement the goals in stage 1
        • Planned diet with balanced macronutrients
        • Structured daily meals and planned snack
        • Further reduction of screen time to less than 1 hour per day
        • Planned physical activity for 1 hour each day
        • Monitor behavior with logs
        • Reinforce achieving targets
      • Eating plan requires input of dietitian
      • Some families need counseling to help with parenting skills or motivation
      • Best implemented with monthly visits
    • Stage 3: comprehensive multidisciplinary intervention (pediatric weight management setting)
      • Intensity of this stage usually requires multidisciplinary weight management clinic
        • Structured behavior modification program with food and activity goal setting
        • Parental participation, especially for children younger than 12 years
        • Parent education about improving home environment
        • Multidisciplinary team approach
        • Systematic measurement of body measurements, diet, and physical activity
        • Frequent office visits with weekly and later, monthly, visits
        • Group therapy may be helpful
    • Stage 4: tertiary care intervention
      • Intense interventions for severely obese teens that have attempted weight control in stage 3 program
        • Pharmacologic therapy
          • Three agents are FDA-approved for treatment of obesity in adolescents:
            • Orlistat
              • Approved for weight loss in people aged 12 years and older
              • Reversible pancreatic and gastric lipase inhibitor that limits absorption of dietary fat
              • May be considered in conjunction with lifestyle modifications in adolescents with BMI 30 kg/m² or greater or BMI of 27 kg/m² or greater with comorbidities (eg, hypertension, hyperlipidemia, diabetes) r10
              • Results in modest additional lowering of BMI when combined with diet and exercise in obese adolescents versus lifestyle modifications alone r10
              • Gastrointestinal adverse effects may limit use
              • 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 r10
            • Phentermine
              • Approved for short-term use (a few weeks) for weight loss in people aged 17 years and older r11
              • Sympathomimetic; results in appetite suppression r11
              • May be considered in conjunction with lifestyle modifications in adolescents with BMI 30 kg/m² or greater or BMI of 27 kg/m² or greater with comorbidities (eg, hypertension, hyperlipidemia, diabetes) r11
              • Results in modest additional lowering of BMI when combined with diet and exercise in obese adolescents versus lifestyle modifications alone r12
            • Liraglutide
              • Approved for weight loss in people aged 12 years and older
              • Glucagonlike peptide 1 (GLP-1) receptor agonist
              • May be considered in patients with body weight above 60 kg and BMI of 30 kg/m² or greater r13
              • Results in modest additional lowering of BMI when combined with diet and exercise in obese adolescents versus lifestyle modifications alone r14
              • Administered by subcutaneous injection r13
              • Gastrointestinal adverse effects may limit use r14
          • Other agents with putative weight loss benefits include metformin, exenatide, and topiramate
            • Further studies are needed to establish role in management of obesity in pediatric patients; none are approved for use for this specific indication
        • Bariatric surgery
          • American Society of Metabolic and Bariatric Surgery guideline indications for adolescent bariatric surgery are widely accepted: r15
            • BMI equal to or greater than 35 kg/m², or 120% of the 95th percentile for age and sex (class II obesity), with a significant comorbid condition (eg, diabetes, hypertension, obstructive sleep apnea)
            • BMI equal to or greater than 40 kg/m², or 140% of the 95th percentile for age and sex (class III 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 II obesity r15r16
          • Bariatric surgery results in substantial weight loss and improvement in medical comorbidities compared to medical therapy alone r17r18
            • 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, while BMI increased by 3.7% from baseline and mean hemoglobin A1C concentration increased by 1.4% in the medical management group r17
          • 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 r19
          • 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 r20
            • 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 r18
            • 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 r16
          • Outcomes and safety of bariatric surgery in adolescents are comparable or better than for adults r20
    • Investigational approaches
      • Some new treatment modalities that show some initial promise in facilitating weight loss include:
        • Mindfulness r21
        • Internet-based interventions r22

    Drug therapy

    • Orlistat c168
      • 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.
    • Phentermine
      • Phentermine Hydrochloride Oral tablet; Adolescents 17 years: 4 or 8 mg PO 3 times daily. Usual dose: 8 mg PO 3 times daily.
    • Liraglutide
      • Liraglutide Solution for injection [Weight Management]; Children and Adolescents 12 to 17 years: 0.6 mg subcutaneously once daily for 1 week, then increase dose by 0.6 mg/week to 3 mg subcutaneously once daily. May lower dose to previous level if patient does not tolerate a dose increase during dose escalation; dose escalation may take up to 8 weeks. May reduce target dose to 2.4 mg/dose if 3 mg/dose is not tolerated. Discontinue use if patient cannot tolerate 2.4 mg/dose. Discontinue use if the patient has not had a reduction in BMI of at least 1% from baseline after 12 weeks on maintenance dose.

    Nondrug and supportive care c169c170c171c172c173c174c175c176c177c178c179c180c181c182

    Procedures
    Roux-en-Y gastric bypass c183c184c185c186c187c188c189c190c191c192c193c194c195c196c197c198c199c200c201c202c203c204
    General explanation
    • Once the most common and gold standard surgical approach, now mostly overtaken by sleeve gastrectomy r19
    • 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 r20
    Indication
    • BMI equal to or greater than 35 kg/m², or 120% of the 95th percentile for age and sex (class 2 obesity), with a significant comorbid condition (eg, diabetes, hypertension, obstructive sleep apnea) r15
    • BMI equal to or greater than 40 kg/m², or 140% of the 95th percentile for age and sex (class 3 obesity), whichever is lower r15
    • Ability to adhere to pre- and postoperative treatments, including nutritional supplementation r15
    Contraindications
    • Medically reversible cause of obesity r15
    • Ongoing substance abuse r15
    • Medical, psychiatric, psychosocial, or cognitive condition that prevents adherence with treatment r15
    • Current or planned pregnancy within 12 to 18 months of surgery r15
    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 over 70% of adolescent bariatric surgery procedures r19
    • Most of the stomach is removed (including the entire greater curve), resulting in a small gastric sleeve
    • Results in postprandial satiety
    Indication
    • BMI equal to or greater than 35 kg/m², or 120% of the 95th percentile for age and sex (class 2 obesity), with a significant comorbid condition (eg, diabetes, hypertension, obstructive sleep apnea) r15
    • BMI equal to or greater than 40 kg/m², or 140% of the 95th percentile for age and sex (class 3 obesity), whichever is lower r15
    • Ability to adhere to pre- and postoperative treatments, including nutritional supplementation r15
    Contraindications
    • Medically reversible cause of obesity r15
    • Ongoing substance abuse r15
    • Medical, psychiatric, psychosocial, or cognitive condition that prevents adherence with treatment r15
    • Current or planned pregnancy within 12 to 18 months of surgery r15
    Complications
    • Staple-line leak r20
    • Stricture formation r20
    • Bleeding r20
    • Nutritional deficiencies r20

    Comorbidities c205

    Special populations

    • Patients younger than 2 years
      • WHO growth charts that plot weight for age and weight for length are used in this age group rather than BMI r2
      • Infants and children from birth up 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 r2
      • 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 pro-opiomelanocortin (POMC), proprotein convertase subtilisin/kexin type 1 (PCSK1) or leptin receptor (LEPR) deficiency are candidates for treatment with the melanocortin 4 receptor (MC4R) agonist, setmelanotide r23
      • In small open label trials, most patients treated with setmelanotide for 1 year achieve more than 10% weight loss and reduced hunger r24

    Monitoring

    • Measure growth parameters, including BMI, at all well-child visits c206c207
    • 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)

    Complications and Prognosis

    Complications

    • Obesity-related conditions affect almost every system
      • Obstruction sleep apnea c208
      • Worsening asthma c209
      • Nonalcoholic fatty liver disease c210
      • Gallstones c211
      • Gastroesophageal reflux disease c212
      • Type 2 diabetes c213
      • Polycystic ovary syndrome c214
      • Hypertension c215
      • Dyslipidemia c216
      • Pseudotumor cerebri c217
      • Slipped capital femoral epiphysis c218
      • Blount disease c219
      • Chronic skin inflammation and infections c220c221
      • Depression c222
      • Eating disorders c223
      • Dental caries r25

    Prognosis

    • Obesity is often a chronic condition; many overweight and obese children become overweight and obese adults
    • Infant growth rate parameters correlate with overweight, obesity, BMI, waist circumference, and body composition later in childhood r26
    • Obese children aged 2 to 5 years with BMI higher than 95th percentile are more than 4 times more likely to become obese adults

    Screening and Prevention

    Screening

    At-risk populations

    • Universal screening is recommended r27
    • US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents aged 6 years and older and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status r27

    Screening tests

    • Calculate BMI and determine BMI percentile using appropriate growth chart at least annually (eg, at well-child visit) r27c224
    • Assess diet, physical activity, and sedentary behaviors annually r27c225c226c227

    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 c228c229
        • Limit consumption of sugar-sweetened beverages c230
        • Encourage intake of fruits and vegetables c231
        • Limit screen time to 2 hours; avoid all screen time in children younger than 2 years c232
        • Encourage eating breakfast daily c233
        • Limit dining out, especially fast food restaurants c234c235
        • Encourage family meals c236
        • Adjust portion sizes appropriately for age; allow child to self-regulate intake c237c238
        • Encourage diet rich in calcium and high in fiber c239c240
        • Encourage diet with balanced macronutrients c241
        • Limit consumption of energy dense foods c242
        • Promote moderate to vigorous exercise for at least 60 minutes daily c243
        • Ensure adequate sleep duration c244
      • Interventions that include diet combined with physical activity interventions 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
      • Interventions that only focus on physical activity can reduce the risk of obesity in children aged 6 to 12 years and adolescents aged 13 to 18 years; in these age groups, there is no evidence that interventions that only focus on diet are effective
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