Managing Childhood Obesity In The Emergency Department

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal Of The Literature
5. Epidemiology
6. Causes Of Obesity
7. Differential Diagnosis
8. Emergency Department Evaluation
9. Childhood Obesity Comorbidities And Their Impact On Emergency Medicine
   1. Asthma
   2. Airway Management
   3. Drug Dosing During Resuscitation
   4. Abdominal Pathology
   5. Orthopedic Challenges
   6. Hypertension
   7. Pseudotumor Cerebri Or Idiopathic Intracranial Hypertension
   8. Psychological Challenges In Childhood Obesity
10. Treatment
11. Controversies And Cutting Edge
12. Summary
13. Risk Management Pitfalls For Obesity In The Emergency Department
14. Tables and Figures
    1. Table 1. Body Mass Index Percentile For Age And Weight Status
15. References

Abstract

Childhood obesity is a chronic medical problem that has become a worldwide epidemic. From 1980 to 2008, the rate of obesity tripled among American children. The National Center for Health Statistics estimates that 16.9% of children and adolescents 2 to 19 years of age can be classified by body mass index percentile as “obese.” This review identifies the causes of pediatric obesity and addresses the comorbidities of pediatric obesity in the emergency department, including impairments in patients’ physical and emotional quality of life. The United States medical system’s response for screening for childhood obesity and early identification and treatment, including lifestyle counseling, has gained momentum slowly. The need for hospitals to adopt standard body mass index recording practices as a required first step in addressing childhood obesity is emphasized. As emergency clinicians treat more children with obesity, they should be aware of the potential associated medical complications and recognize the opportunity to encourage at-risk patients to adopt healthy eating and exercise habits.

Case Presentations

A 4-year-old boy presents to your ED with the chief complaint of wheezing. His past medical history is significant for asthma, with multiple ED visits. On your exam, you notice he is obese and drinking a large sippy cup filled with juice. When you review his vital signs, you note that he weighs 31 kg and has gained 1 kg since his last ED visit 2 weeks ago, which was for a similar complaint.

A 14-year-old girl in ninth grade presents to the ED. She appears obese, with a history of overeating, and reports that she does not participate in any physical activity. She develops shortness of breath when walking up stairs between classes and feels embarrassed to go to a gym or to participate in group sports even though she would like to lose weight. She has tried to diet, but her diets have not lasted more than a week. She has a family history of type II diabetes. Her family and friends often eat at fast-food restaurants, and she usually goes with them and eats unhealthy meals.

How should you approach treating these children’s weight?

Introduction

Childhood obesity is an epidemic. Today’s obese youth are heavier than in previous decades.^1-5 The dramatic increases in childhood overweight and obesity in the United States since 1980 are an important public health concern. The National Center for Health Statistics estimates that 16.9% of children and adolescents 2 to 19 years of age are obese.⁶ The incidence of obesity in the adolescent population, as defined by the Centers for Disease Control and Prevention (CDC), approaches 18%.⁶ An estimated 1% to 2% of United States adolescents are considered morbidly obese, with a body mass index (BMI) > 40.^7,8 In this group, the likelihood of becoming a morbidly obese adult is approximately 80%.⁹ From 1980 to 2008, the rate of obesity tripled among American children 6 to 11 years of age (6.5% to 19.6%) and adolescents 12 to 19 years of age (5.0% to 18.1%).^1,2 Overweight children are at a higher risk of remaining overweight if parents are overweight and if they are overweight as adolescents. Obesity has become a worldwide public health problem.

Critical Appraisal Of The Literature

Obesity and overweight are terms that are used interchangeably in describing excessive weight. According to the CDC’s 2000 growth charts for patients who are ≥ 2 years of age, obesity is defined as a BMI ≥ 95^th percentile for age and gender. For children < 2 years of age, weight-for-length growth charts should be used.¹⁰ Data from the CDC indicate that obesity is a health issue from infancy that may be well established by the time most children enter school.¹¹ Treatment of obesity in children is more effective than treatment of adult obesity; thus, addressing childhood obesity is of utmost importance.¹²

Obesity is a chronic medical problem. Excessive weight in childhood has long-term consequences for the physical and mental health of affected individuals, and it impacts future healthcare costs, productivity, and longevity.13 Some documented effects of obesity include the following:

• Obese youth are at a significantly higher risk for developing obesity-related medical comorbidities and some of the most severe and global impairments in physical, social, and emotional quality of life.¹⁴ Obese children, especially the 4% of the population who are severely obese, can suffer from obesity-related conditions that require inpatient treatment.¹⁵
• Obese children may have needs for specialized medical equipment that is not normally supplied for patients at children’s hospitals.
• Overweight children may have decreased self esteem, and their overweight parents may have similar psychosocial problems. In children 4 to 5 years of age, a higher BMI was positively related to poorer peer relationships and teacher-reported emotional problems in these same children at 8 to 9 years of age.¹⁶
• Patients diagnosed with obesity use more resources, so there is a financial need to identify these patients to contain costs and a need to help them with their weight to decrease their risk for comorbid conditions.^17-20 A 2009 study by the California Center for Public Health Advocacy estimated that, in 2006, physical inactivity and obesity cost California $41.2 billion in direct and indirect costs.²¹ In a retrospective study by Wang and Dietz, asthma and mental disorders were the most common principal diagnoses, with obesity listed as a secondary diagnosis.¹⁸

There is an urgent need to address the childhood obesity epidemic. In 2010, 3 events occurred at a national level: the "Let’s Move" campaign, the Patient Protection and Affordable Care Act (HR 3590), and the White House Task Force on Childhood Obesity report.²²

Risk Management Pitfalls For Obesity In The Emergency Department

1. “I recommended dieting and exercise in that preschool child with a history of infantile hypotonia with poor suck and poor weight gain, mild short stature, developmental delay, hyperphagia, tantrums, and compulsive behaviors.” While poor diet and lack of exercise are the usual culprits for childhood obesity, a small, but significant, number of children have an underlying predisposing disorder that may be genetic, endocrinologic, metabolic, or psychological. Several genetic syndromes include childhood-onset obesity as a symptom. The most common are Prader-Willi syndrome, Fragile X syndrome, and Bardet-Biedl syndrome. Prader-Willi syndrome includes early childhood-onset obesity following infantile hypotonia with poor suck and poor weight gain. Mild short stature, hypogonadism, characteristic facial appearance, developmental delay, hyperphagia, tantrums, and compulsive behaviors are also characteristic of Prader-Willi syndrome. A better recommendation for this patient is evaluation by a geneticist.
2. “I didn’t need further studies to evaluate that child with a rapid alteration in the rate of weight gain and poor linear growth.”

   The majority of overweight children do not have an underlying secondary cause. Studies to rule out secondary causes are not needed unless there has been a rapid alteration in the rate of weight gain, poor linear growth, or presence of syndromic features. Evaluation of growth charts, histories, and physical examinations may give clues as to the need to further evaluate endocrine (eg, hypothyroid or Cushing syndrome) or genetic disorders (Prader-Willi syndrome, Fragile X syndrome, or Bardet-Biedl syndrome). Cushing syndrome presents with onset of rapid weight gain, increase in BMI percentiles, and central obesity. Normal linear growth rules out endocrine disorders, but a family history of endocrine disorders increases a child’s risk. Free thyroxine and thyroid-stimulating hormone levels are used to screen for hypothyroidism. A 24-hour urinary free cortisol level is used to evaluate for hypercortisolism or Cushing syndrome. Genetic disorders are associated with dysmorphic features, developmental delay, vision or hearing abnormality, or poor linear growth. Evaluation by a geneticist in early-onset obesity may be helpful, but the emergency clinician may consider obtaining leptin levels.

3. “I didn’t need further studies to evaluate that child with a family history of endocrine disorders.”

   Studies to rule out secondary causes are not needed unless there has been a rapid alteration in the rate of weight gain or poor linear growth. A family history of endocrine disorders increases a child’s risk of being overweight. For example, a family history of type 2 diabetes, a high-risk ethnicity (ie, African American, Hispanic, Native American), and central adiposity increase the risk of hyperinsulinism or type 2 diabetes. Patients with type 2 diabetes present with polyuria, nocturia, polydipsia, and unexplained rapid weight loss. Consider further testing in overweight patients with a family history of endocrine disorders.

4. “An obese child presented to the ED with a displaced fracture that required reduction. Since the reduction for the displaced fracture couldn’t be done without sedation, I performed procedural sedation in the ED.”

   Children with obesity experience more-frequent complications in airway management. They are more difficult to bag-valve mask ventilate and can be a challenge to intubate. Obese children suffer more frequently from obstructive sleep apnea and have been noted to desaturate during the preoperative and perioperative period. In addition, obese children tend to experience bronchospasm more frequently. The decision to perform procedural sedation in an obese child should not be undertaken lightly. Emergency clinicians should assess whether the patient has a history of obstructive sleep apnea, asthma, or other comorbidities.

5. “The parents rushed their 6-year-old obese (44 kg) son, who was in status epilepticus, to the ED. No medications were given prior to arrival.

   I obtained IV access and asked the nurse to draw up 4 mg of lorazepam.”

   Dosing medications in obese children presents several challenges because no definitive studies on appropriate dosing have been performed. Furthermore, studies on Broselow^® Tape dosing indicate that obese children are frequently underdosed with medications during CPR. With regard to benzodiazepines, medication dosing should be based on ideal body weight and then titrated up as needed.

6. “An obese 10-year-old female with knee pain for 2 days presented to the ED. She stated she fell while climbing the stairs. The examination was unremarkable for swelling, ecchymosis, or deformity, so I discharged her home without further imaging.”

   Obese children—particularly those ages 11 to 15—are at increased risk for slipped capital femoral epiphysis. Slipped capital femoral epiphysis can often present with knee pain in the absence of hip pain. This patient should have had bilateral frog-leg views of the hips prior to discharge.

7. “An overweight 9-year-old male presented to the ED with right lower quadrant abdominal pain and fever. I was concerned about appendicitis, and given his weight, I felt that a CT scan would be a better initial imaging modality.”

   While ultrasound is not as accurate an imaging tool for appendicitis in obese children (as compared to normal-weight children), multiple studies indicate that obese children with a high pretest probability of appendicitis are almost as likely to have a positive ultrasound for appendicitis as normal-weight children. Based on ALARA guidelines, ultrasound should be the first-line imaging choice in children with abdominal pain where appendicitis is suspected, regardless of weight.

8. “I didn’t think I had to evaluate for suicide when the obese adolescent patient complained of abdominal pain that resolved after an hour.”

   Obese adolescents are more likely to be socially isolated, compared to healthy-weight peers. Adolescents with obesity are vulnerable. With regard to suicide behavior, higher BMI and obesity have been shown to place adolescents at heightened risk for suicidal ideation and serious attempts. Ask about suicidal thoughts and consider social work or psychiatric consultation.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available.

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