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The lowest figures were in the Leicestershire district of Harborough, with just 0.

Pediatric Obesity Algorithm: A Practical Approach to Obesity Diagnosis and Management

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Thank you for your support. For infants up to the age of 2, BMI is not assessed. Instead, the infants' weight percentile is compared to length percentile. There are two options for the use of growth charts in infants up to the age of 2 years: Center for Disease Control CDC charts which are based on a cohort of mostly Caucasian American infants who were mostly bottle fed or WHO charts which are based on infants from multiple areas of the planet with diverse racial and ethnic backgrounds who were mostly breastfed. Body mass index charts are used for children between the ages of 2—20 years.

These charts were developed using five cross sectional nationally representative health surveys taken between the years of — An additional BMI chart has been developed for children aged 2—20 years with severe obesity This decrease or dip and subsequent rise in the BMI curve is referred to as adiposity rebound.

If a child's BMI either has no decrease or prematurely rises between the ages of 2 and 6 years, the child is at risk or has obesity. This phenomenon is called early adiposity rebound. In June the American Medical Association declared obesity a disease. Children, like adults, suffer from the manifestations of obesity on most aspects of their physical and psychological health.

Adiposopathy is a term used to describe endocrine and immune responses to increased adipose tissue while fat mass disease describes the physical response to increased adipose tissue 13 , A careful history that includes family history, prenatal, birth and postnatal care, followed by any medical complications in childhood and medications used both for the management of comorbid conditions and the management of obesity should be obtained.

The quality of life of children with obesity may be poor. They are at increased risk for isolation from peers, they are subject to bullying, they are at increased risk for anxiety and depression, and they are at increased risk for eating disorders, especially binge eating disorder, night eating disorder, and bulimia 15 — Social history includes not only a dietary recall, but also a history of breast or bottle feeding, the timing of introduction of complementary foods and parenting style.


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In addition, an assessment of the child's activity level including access to safe areas to exercise and support for a high level of activity is important. Finally, the clinician needs to assess sedentary time and non-academic screen time. The differential diagnosis of children with obesity starts with an assessment of linear growth. Linear growth proceeds in children until fusion of growth plates. Children with obesity due to nutritional, also referred to as endogenous, obesity have consistent or accelerated growth. These children are at risk for early development of secondary sexual characteristics and may have bone age development that exceeds their chronological age by more than 2 standard deviations.

Preventing childhood obesity

In contrast, a child with obesity who has an underlying endocrinopathy will typically have decreased linear growth. It is in the children with a deceleration in growth that testing for thyroid hormones is indicated. If there is clinical suspicion of Cushing's syndrome, a dexamethasone suppression test or 24 h urinary free cortisol level is indicated 1 , 2 , Genetic causes of obesity should be considered in children with severe obesity before the age of 5 years.

These young children may present with developmental delay, short stature, dysmorphic facies, or hyperphagia. However, many other genetic causes of obesity not associated with known syndromes no doubt contribute as well 18 — Children with special needs are at increased risk of developing obesity Some of these children are at increased risk due to associated difficulties with movement or coordination. Developmentally delayed or special needs children can present with decreased or normal growth.

Presentation is highly variable and the practitioner should take a careful family history and consider a referral to a geneticist. Clinical evaluation of the child with obesity includes a focused review of systems. The diagnostic work up of a child with obesity is driven by a careful history of prenatal factors, family history, feeding history, sleep duration and issues, exercise, family and cultural expectations, screen time, location and timing of meals, bullying or social isolation, motivation and ability to make modifications of the family, and finally financial constraints.

In addition, there are many other complications of obesity that require further investigation, some of which are discussed in the section on comorbidities. The physical exam is both important and challenging in children with obesity.

Background

While increased adiposity is usually apparent, children may go to considerable effort to conceal problems, for example removal of excess hair. Children with obesity commonly present wearing more clothing than called for by climatic conditions and may be wearing spandex or other restraining garments under their loose outerwear.

The practitioner should take particular care to preserve the child or adolescent with obesity's need to cover up while still examining the patient. Instead of asking the child or adolescent to fully unclothe, the practitioner can examine the patient sequentially, taking care to reclothe the body parts that are exposed before moving on to the next body part.

A thorough discussion of all of the physical findings that can be associated with obesity does not follow, however we highlight a few areas that should be assessed in every child. Acanthosis nigricans is a cutaneous marker associated with hyperinsulinemia which is frequently perceived by the parents or the child as being due to dirt or eczema, not melanin. An explanation of the cause can be reassuring to the child and the parent and provide opportunity for education of the physiology of glucose metabolism and underlying process of insulin resistance.

Pubertal or tanner staging helps the clinician determine growth potential as well as address the issue of premature thelarche in females or gynecomastia in males. These findings are exacerbated by excess adiposity. Pubertal status also informs laboratory results as some normal values change as puberty progresses.


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The clinician should be aware of the skeletal problems that occur in children with obesity. A radiologic diagnosis is necessary. Slipped capital femoral epiphysis can present as knee or hip pain or without pain resulting in the diagnosis being missed. Prompt assessment and referral to an orthopedic surgeon if the diagnosis is made is necessary. Scoliosis is harder to detect due to adiposity despite occurring in children with obesity at as great or greater a frequency than in normal weight children 25 — The practitioner should have a high index of suspicion for physical abnormalities and should carefully examine the child.

Children with obesity are frequently poorly evaluated by the medical community until symptoms become severe. A careful examination of the entire body for intertrigo, especially if this complaint is inhibiting the child's activity level should be performed. A sensitive examination of the status of excess hair in females should occur. Other findings from the review of systems may determine the examination: for example a history of snoring should prompt a thorough exam of the tonsillar pillars as well as neck circumference.

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In considering how to modify the food intake of a child with obesity, there is no universally accepted approach. An understanding of appropriate intake for a normal weight child is necessary as a starting point. Managing a child with obesity is age dependent. In the first 6 months of life, exclusive breast feeding is the nutrition of choice. Complementary foods should ideally be delayed until 6 months of age.

Increased BMI in childhood and adolescence is associated with early introduction of complementary foods.

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Infants with obesity should not be given any sugar sweetened beverages, nor any fast food or desserts. Infants already struggling to maintain their weight should have age appropriate amounts of formula, and should not be given juice in their bottles. Infants should not be watching TV or any screen of any kind for the first two years of life.

Normal infants may need to sleep up to 18 h a day, and should sleep at least 12 h a day. A toddler age 2—4 years with obesity should have three meals plus 1—2 snacks every day.

They should not be offered sugar sweetened beverages, nor any fast food. Portion sizes should be age appropriate and they should be praised for trying new foods. Parents should model the eating behavior they want their child to have. Toddlers should have a routine sleep pattern.

A Parent's Guide to Childhood Obesity : Sandra Hassink :

Snoring in this age group is frequently associated with tonsillar hypertrophy. If the tonsils cause significant obstruction, removal may be indicated. Up to the age of 2 years, no screen time is recommended. Between the ages of 2 and 4, screen time should be kept to a minimum. Obesity is directly correlated with screen time in this age group. The family should adopt good meal hygiene to include meals at the table, no media while eating, no food rewards, no over controlling behaviors toward consumption of meals, and family based meals.

Obesogenic medications may be a factor for the young child with obesity aged 5—9 years. The use of second generation antipsychotics should be minimized and asthma should be managed with controller medications instead of systemic steroids if clinically possible. Children at this age may also develop hypertension as a complication of their obesity, however etiologies other than obesity must be considered.

Parents are strong role models for children at this age and involvement of the family in the care of the child with obesity is highly recommended.