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Childhood obesity

Key sources
The following summarized guidelines for the evaluation and management of childhood obesity are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2023), the American Diabetes Association (ADA 2023), the Endocrine Society (ES 2017), the U.S. Preventive Services Task Force (USPSTF 2017), and the American College of Endocrinology (ACE/OS/AACE 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per AAP 2023 guidelines, measure height and weight, calculate BMI, and assess BMI percentile using age- and sex-specific growth charts or growth charts for children with severe obesity at least annually to screen for overweight, obesity, and severe obesity in all 2-18 years old children.
B
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  • Diagnosis

2.Diagnostic investigations

Evaluation for comorbidities
As per AAP 2023 guidelines:
Elicit a comprehensive patient history, obtain mental and behavioral health screening, evaluation of social determinants of health, physical examination, and the following diagnostic studies to evaluate for obesity-related comorbidities in 2-18 years old patients with overweight or obesity:
B
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Guidance
Dyslipidemia
Obtain a fasting lipid panel to evaluate for dyslipidemia in ≥ 10 years old pediatric and adolescent patients with obesity or overweight
B
. Consider evaluating for lipid abnormalities also in patients aged 2-9 years with obesity.
B
Diabetes
Obtain fasting plasma glucose, 2-hour plasma glucose after 75-g oral glucose tolerance test, or HbA1c to evaluate for abnormal glucose metabolism in ≥ 10 years old pediatric and adolescent patients with obesity
B
or with overweight in the presence of risk factors for T2DM or NAFLD.
B
NAFLD
Obtain an alanine transaminase measurement
B
to evaluate for abnormal liver function in ≥ 10 years old pediatric and adolescent patients with obesity
B
or with overweight in the presence of risk factors for T2DM or NAFLD.
B
Hypertension
Measure BP at every visit starting at 3 years of age to evaluate for hypertension in pediatric and adolescent patients with overweight and obesity
B
Assess for symptoms and signs of the following comorbidities in pediatric and adolescent patients with obesity:
Situation
Guidance
Obstructive sleep apnea
Elicit a sleep history, including symptoms of snoring, daytime somnolence, nocturnal enuresis, morning headaches, and inattention, to evaluate for obstructive sleep apnea in pediatric and adolescent patients with obesity. Obtain polysomnography in case of at least one symptom of disordered breathing
PCOS
Assess for menstrual irregularities and signs of hyperandrogenism (hirsutism, acne) to assess the risk for PCOS in female adolescent patients with obesity
Depression
Monitor for symptoms of depression in pediatric and adolescent patients with obesity. Obtain annual evaluation for depression with a formal self-report tool in ≥ 12 years old adolescent patients
Slipped capital femoral epiphysis
Obtain a musculoskeletal review of systems and perform a physical examination (internal hip rotation in a growing child, gait) as part of obesity evaluation. Instruct immediate and complete activity restriction, non-weight-bearing with the use of crutches, and refer to an orthopedic surgeon for emergent evaluation in patients with suspected slipped capital femoral epiphysis. Consider referring the patient to an emergency department if an orthopedic surgeon is not available
Idiopathic intracranial hypertension
Maintain a high index of suspicion for idiopathic intracranial hypertension with new-onset or progressive headaches in the context of significant wt gain, especially in females
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  • Evaluation for underlying etiologies

3.Medical management

General principles: manage pediatric and adolescent patients with overweight or obesity following the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach acknowledging obesity's biologic, social, and structural drivers.
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  • Weight loss medications

4.Nonpharmacologic interventions

Behavioral lifestyle interventions
As per AAP 2023 guidelines:
Offer intensive health behavior and lifestyle treatment in ≥ 6 years old patients with overweight or obesity.
B
Consider offering this treatment also in patients aged 2-5 years.
B
Offer greater contact hours (≥ 26 hours of face-to-face, family-based, multicomponent treatment over a 3-12-month period) of health behavior and lifestyle treatment for better results.
B

5.Surgical interventions

Bariatric surgery: as per AAP 2023 guidelines, refer ≥ 13 years old adolescent patients with severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) to a local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery center for evaluation for metabolic and bariatric surgery.
B

6.Specific circumstances

Patients with diabetes mellitus
Consider offering metabolic surgery for the treatment of adolescent patients with T2DM with severe obesity (BMI > 35 kg/m²) and having elevated HbA1c and/or serious comorbidities despite lifestyle and pharmacologic interventions.
B
Perform metabolic surgery only by an experienced surgeon working as part of a well-organized and engaged multidisciplinary team, including a surgeon, endocrinologist, dietitian nutritionist, behavioral health specialist, and nurse.
A

7.Preventative measures

Healthy lifestyle: as per ES 2017 guidelines, promote and participate in the ongoing healthy dietary and activity education of children and adolescents, parents, and communities, and encourage schools to provide adequate education about healthy eating.
B
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