Children's Hospital Association consensus statements for comorbidities of childhood obesity

Abstract

Background: Childhood obesity and overweight affect approximately 30% of US children. Many of these children have obesity-related comorbidities, such as hypertension, dyslipidemia, fatty liver disease, diabetes, polycystic ovary syndrome (PCOS), sleep apnea, psychosocial problems, and others. These children need routine screening and, in many cases, treatment for these conditions. However, because primary care pediatric providers (PCPs) often are underequipped to deal with these comorbidities, they frequently refer these patients to subspecialists. However, as a result of the US pediatric subspecialist shortage and considering that 12.5 million children are obese, access to care by subspecialists is limited. The aim of this article is to provide accessible, user-friendly clinical consensus statements to facilitate the screening, interpretation of results, and early treatment for some of the most common childhood obesity comorbidities.

Methods: Members of the Children's Hospital Association (formerly NACHRI) FOCUS on a Fitter Future II (FFFII), a collaboration of 25 US pediatric obesity centers, used a combination of the best available evidence and collective clinical experience to develop consensus statements for pediatric obesity-related comorbidities. FFFII also surveyed the participating pediatric obesity centers regarding their current practices.

Results: The work group developed consensus statements for use in the evaluation and treatment of lipids, liver enzymes, and blood pressure abnormalities and PCOS in the child with overweight and obesity. The results of the FFFII survey illustrated the variability in the approach for initial evaluation and treatment as well as pattern of referrals to subspecialists among programs.

Conclusions: The consensus statements presented in this article can be a useful tool for PCPs in the management and overall care of children with overweight and obesity.

Figure 1.

Initial evaluation of the obese child: Current recommendation and practice variability among stage III pediatric obesity centers participating in FFFII. *Obtained generally for research purposes or to monitor progress in specialized weight management programs. LDL, low-density lipoprotein cholesterol; HDL, high-density lipoprotein cholesterol; AST, aspartate aminotransferase; ALT, alanine transaminase; TSH, thyroid-stimulating hormone; free T4, free thyroxine. Color image is available online at www.liebertpub.com/chi

Figure 2.

Lipid management in children and adolescents with overweight or obesity (for nonobese children, refer to the American Academy of Pediatrics guidelines). ^*Non-HDL-c=total cholesterol−HDL-c. ^†Risk factors described in Table 1. ^‡Children with LDL-c ≥130 PLUS 0–1 risk factors fall between moderate and high risk. LDL-c, low-density lipoprotein cholesterol; HDL-c, high-density lipoprotein cholesterol. Color image is available online at www.liebertpub.com/chi

Figure 3.

LDL-c management in children and adolescents with overweight or obesity with “high-risk” lipid profile (see Fig. 2). *Non-HDL-c=total cholesterol−HDL-c. ^†Risk factors (see Table 1). ^‡Statin therapy (see Table 2). LDL-c, low-density lipoprotein cholesterol; HDL-c, high-density lipoprotein cholesterol. Color image is available online at www.liebertpub.com/chi

Figure 4.

Triglyceride treatment (children ≥8 years) based on fasting triglyceride levels. *Before treatment with Lovaza: rule out alcohol use by patient or family history of bleeding disorders; discontinue aspirin-containing products; and note that comparably concentrated preparations are increasingly available without prescription. LDL-c, low-density lipoprotein cholesterol; HDL-c, high-density lipoprotein cholesterol. Color image is available online at www.liebertpub.com/chi

Figure 5.

Evaluation of abnormal liver enzymes in children with obesity. ALT, alanine transaminase; ANA, antinuclear antibody; Ab, antibody; IgA, immunoglobulin A; GGT, gamma-glutamyl transpeptidase; GI, gastrointestinal. Color image is available online at www.liebertpub.com/chi

Figure 6.

Evaluation and treatment of hypertension in children with overweight or obesity. BUN, blood urea nitrogen; CBC, complete blood count. Color image is available online at www.liebertpub.com/chi

Figure 7.

Management of polycystic ovary syndrome (PCOS) in adolescents with obesity. DHEAS, dehydroepiandrosterone; LH, luteinizing hormone; FSH, follicle-stimulating hormone; TSH, thyroid-stimulating hormone; free T4, free thyroxine; CAH, congenital adrenal hyperplasia; MRI, magnetic resonance imaging. Color image is available online at www.liebertpub.com/chi

Figure 8.

Treatment of polycystic ovary syndrome (PCOS) in adolescents with obesity. *Consider combination therapy of oral contraceptives and metformin. Consider referral to endocrine, adolescent medicine, gynecology, or dermatology according to your institutional resources and policies. Color image is available online at www.liebertpub.com/chi