AAP Recommends Bariatric Surgery for Severely Obese Kids

Fran Lowry

October 29, 2019

NEW ORLEANS — With some 4.5 million children and adolescents in the US with severe obesity, the American Academy of Pediatrics (AAP) has issued a new policy statement calling for greater access to bariatric surgery, one of the few strategies shown to be effective in treating severe obesity in children.

The policy statement, entitled "Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices," describes the current prevalence of severe obesity (BMI ≥ 35 kg/m2 or 120% of the 95th percentile for age and gender) and forecasts a dramatically shortened life expectancy for much of today's generation compared with their parents.

"We see an ongoing epidemic of obesity. There are currently 12 million US children with obesity, but there is also this 'epidemic within an epidemic' of 4.5 million with severe or very severe obesity," lead author Sarah C. Armstrong, MD, professor of pediatrics, Duke University, Durham, North Carolina, told Medscape Medical News.

The prevalence of severe obesity increases with age, note the authors. Recent data from the National Health and Nutrition Examination Survey (NHANES) report the prevalence of severe obesity in youth at 7.9%. Among 12 to 15 year olds the prevalence is 9.7%, and among 16 to 19 year olds, it is 14% — roughly double the prevalence two decades ago.

"Those children have significantly higher weights, but also very serious health problems like diabetes, high blood pressure, and sleep apnea. The purpose of this report is to provide a summary of the evidence and recommendations for decisions about when surgical options should be considered for those children," Armstrong said.

The policy statement, along with an accompanying technical report, "Metabolic and Bariatric Surgery for Pediatric Patients with Severe Obesity," were discussed during a special session this past weekend at the American Academy of Pediatrics (AAP) 2019 National Conference.

"Just to be clear, the Academy absolutely continues to support efforts to improve healthy food access and physical activity for all children. Weight loss surgery is never and was never intended to be a public health strategy," Armstrong stressed.

"But, we have found that children with severe obesity are very unlikely to reverse their obesity by adulthood through traditional behavioral and lifestyle changes," she explained.

Surgery Underused in Severely Obese Kids for Many Reasons

The technical report details the different surgical options available and provides evidence of their safety and efficacy in children.

It also outlines best practice guidelines for pediatricians and other clinicians who may want to consider surgical weight management for their patients.

Metabolic and surgical treatments for severe obesity in patients younger than age 18 are not only safe and effective, but sustain weight loss and reverse associated cardiometabolic conditions, according to studies that have followed patients for 3 to 10 years, Armstrong said.

Yet despite their safety and efficacy, surgery is underused in severely obese pediatric patients for a variety of reasons, she noted.

One, pediatricians may be unaware that surgery is an option, or may doubt its efficacy.

"The under-referral by physicians at this point in time is understandable in that...this is really the first time the Academy has issued guidance to pediatricians, so we really haven't had much information on who to refer, how to prepare, where to send patients, and how to follow up, until this report and statement," she noted.

Second, lack of insurance and poor socioeconomic status, which often go together, are other barriers to care.

"There are striking disparities in who gets surgery. We know the obesity epidemic itself is disproportionately affecting racial and ethnic minorities and children who are living in poverty," Armstrong said.

"Yet, what we found was that surgery is mostly done in middle and upper income white children. And yet, there's no evidence to suggest that children of color and those from low income backgrounds would have any worse outcomes," she noted.

Look for Centers With Expertise in the Field

When considering surgery, it is important to search out comprehensive care centers with expertise in this patient population, Armstrong stressed.

"This is a big qualification. We really want to make sure people understand that it's not just a matter of having the procedure. It's safe and effective when done in comprehensive care centers, where you have surgeons who are familiar with working with adolescents and families."

And these centers also have "pediatricians who have training and expertise in identifying patients who are a good fit for surgery and who are willing to work with them for months ahead of time to prepare them and afterwards to help follow through," she noted.

Clinicians should look for centers that have met pediatric-specific metabolic and bariatric surgery accreditation standards, as established by the American Society of Metabolic and Bariatric Surgery and the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

"The MBSAQIP provide an online list of programs that have met the criteria for patient preparation, follow through, and the provision of adequate support for patients and their families. Pediatricians can look up programs that are geographically close to them when they make referrals," she explained.

"No Line in the Sand" When it Comes to Age Cut-Off or BMI

And there is no "line in the sand" when it comes to age cut-offs, Armstrong noted.

"Can we send 4 year olds for surgery? Of course not. That's not the intention. Proper selection of pediatric patients for weight loss surgery is based on physiologic and psychologic maturity, family support, and other factors that need to be discussed with the healthcare team."

Although weight loss surgery tends to be done in older teenagers, "there is no evidence to say that it shouldn't be done before age 14 or 15."

Indeed, the AAP recommends avoiding arbitrary age limits; rather, the procedure should be considered for any patient with severe obesity who meets the criteria for surgery, and candidates should be selected on a case-by-case basis.

"The decision to have metabolic and bariatric surgery should be based on the health and needs of the individual patient," stressed pediatric surgeon Marc Michalsky, MD, another author of the policy statement.

"This should be a thoughtful, collaborative decision made between the patient, their parents, and their medical and surgical team based on their BMI, other health conditions, and quality of life," he said in an AAP press release.

There is also evidence to suggest surgery is safer and more effective when done at a lower BMI, Armstrong told Medscape Medical News.

"This argues against an extended period of watchful waiting," she said.

"While we want to be sure that we give families all the resources to support healthy behavior changes and reduce weight that way, we don't want to have such extensive periods of watchful waiting that children become irreversibly sick," she concluded.

The policy statement and technical report were presented during a session on bariatric surgery on June 27, 2019, at the AAP National Conference and Exhibition in New Orleans.

Pediatrics. 2019;144:e20193223, e20193224. Policy Statement, Technical Report

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