AAP Releases Guidelines on the Management of Obesity in Children and Adolescents

The American Academy of Pediatrics (AAP) released clinical practice guidelines for the evaluation and treatment of obesity in children and adolescents. The recommendations were published in Pediatrics.

Approximately 14.4 million children and adolescents are affected by obesity, which has been noted as the most common pediatric chronic disease.

The AAP identified pediatricians and researchers who formed a subcommittee that conducted an evidence review of studies including data on obesity treatment and obesity-related comorbidities. The review was designed to answer 2 key overarching questions.

1. What are effective clinically based treatments for pediatric obesity?
2. What is the risk for comorbidities among children with obesity?

The subcommittee reviewed interventional studies that included assessments of obesity prevention among children with any weight or those with overweight and obesity, and  comorbidity studies that compared comorbidities in individuals with and without obesity or based on obesity severity.

Key Action Statements

The key action statements in the guidelines were based on evidence from randomized controlled trials, comparative effectiveness trials, and high-quality longitudinal and epidemiologic studies. Each key action statement includes statements on the benefits, risks, role of patient preferences, and strength of recommendations.

• Clinicians should conduct a comprehensive patient history, mental and behavioral health screening, social determinants of health evaluation, physical examination, and diagnostic studies in children 2 years and older with overweight (BMI ≥85th percentile to <95th percentile) or obesity (BMI ≥95th percentile).
• The subcommittee recommends that lipid abnormalities, abnormal glucose metabolism, and abnormal liver function be evaluated in children and adolescents 10 years and older with obesity; lipid abnormalities alone should be evaluated in children and adolescents with overweight.
• Children 10 years and older with overweight and obesity, as well as those aged between 2 and 9 years with obesity, should be evaluated for dyslipidemia.
• Children and adolescents with overweight and obesity should also be evaluated for prediabetes and diabetes, using fasting plasma glucose, 2-hour plasma glucose after a 75-g oral glucose tolerance test, or glycosylated hemoglobin.
• In children and adolescents who are 3 years and older with overweight and obesity, clinicians must monitor for hypertension by taking blood pressure measurements at every visit.
• Intensive health behavior and lifestyle treatment should be provided for children 6 years and older and those 2 through 5 years of age with overweight and obesity.

The subcommittee also drafted key statements for pharmacotherapy and surgery.

• Adolescents who are 12 years and older with obesity should be provided with guidance on weight loss pharmacotherapy (eg, glucagon-like peptide-1 receptor agonists, metformin, orlistat, and topiramate), as an adjunct to health behavior and lifestyle treatment.
• The subcommittee also recommends that adolescents who are 13 years and older with severe obesity (BMI ≥35 or 120% of the 95th percentile for age and sex) be referred to pediatric centers for evaluation for metabolic and bariatric surgery.

Expert Consensus Recommendations

The consensus recommendations were based on expert opinion and supported by AAP-endorsed guidelines, clinical guidelines, and/or position statements from professional societies, as well as extensive literature reviews.

• Health care providers must individualize and tailor treatment of overweight and obesity among children and adolescents, based on the initial and longitudinal evaluation of individual, structural, and contextual risk factors.
• The subcommittee recommends evaluation for obstructive sleep apnea in children and adolescents with obesity.
• Clinicians can consider performing a polysomnogram in children and adolescents with obesity and at least 1 symptom of disordered breathing. 
• The risk for polycystic ovarian syndrome in adolescent girls with obesity may be assessed by evaluating menstrual irregularities and signs of hyperandrogenism.
• In adolescents 12 years and older, clinicians should monitor for symptoms of depression in children and adolescents with obesity and perform an annual evaluation for depression using a formal self-report tool.
• The AAP subcommittee recommends maintaining a high index of suspicion for idiopathic intracranial hypertension in patients, particularly girls, with new-onset or progressive headaches in the setting of significant weight gain. 
• Clinicians may also offer weight loss pharmacotherapy, as an adjunct to health behavior and lifestyle treatment, to children with obesity aged between 8 and 11 years.

The guideline authors concluded, “It is hoped that pediatricians and other [pediatric health care providers], health systems, community partners, payers, and policy makers will recognize the significance and urgency outlined by this [clinical practice guideline] to advance the equitable and universal provision of treatment of the chronic disease of obesity in children and adolescents.”