The American Academy of Pediatrics (AAP) has formally recommended expanding access to bariatric and metabolic surgery for children and adolescents with severe obesity. The organization announced a set of practice- and system-level recommendations in a position statement presented at the 2019 AAP National Conference & Exhibition in New Orleans, Louisiana.1
When lifestyle interventions cannot provide long-term success for obesity treatment, metabolic surgery represents a viable method for patients with severe forms of obesity to achieve significant and sustainable weight loss.2 Roux-en-Y gastric bypass and sleeve gastrectomy have become the most commonly performed procedures, with substantial evidence supporting their safety and efficacy in pediatric patients.3
Based on research that has accumulated over the last decade in children and adolescents, “surgery is safe and effective when performed in high-quality centers,” said Sarah Armstrong, MD, FAAP, lead author of the AAP position statement and executive committee member of the organization’s Section on Obesity.
“Unfortunately, we see significant disparities in which patients have access to bariatric surgery. Surgery needs to be an option for all qualifying patients, regardless of race, ethnicity or income,” she added.1
Barriers to Surgery
Of approximately 4.5 million adolescents in the United States who are candidates for bariatric surgery, very few will undergo surgical treatment for severe obesity.2 One research consortium found that after an initial insurance authorization request, less than half (47%) of qualifying adolescent candidates received insurance coverage compared with 85% of adults who qualified and received authorization.2 Age was the most commonly cited reason for denial. After time-consuming appeals processes, more adolescents in the study were eventually approved for coverage, but this required significant effort from physicians, families, and support staff.3 The AAP therefore outlined recommendations specific to private and public insurance providers for not only the provision of payment for pediatric bariatric procedures, but also for preoperative care to ensure appropriate selection of surgical candidates, as well as for all medications and supplements requisite for optimal surgical outcomes.2
Furthermore, research has found that clinicians are hesitant to refer pediatric patients for metabolic and bariatric surgery. This reluctance may be explained by a combination of factors, including lack of understanding or awareness, bias toward the perception that “weight is a personal responsibility rather than a medical problem,” and concerns about long-term growth and development — although a robust body of research has indicated that bariatric surgery does not impair linear growth.2
Racial, ethnic, and socioeconomic disparities also remain problematic in access to bariatric surgery for younger patients, with inconsistencies particularly associated with socioeconomic status.2
In their position statement, the AAP recommends that clinicians advocate for greater access to high-quality pediatric metabolic and bariatric surgery for all qualifying patients, regardless of race, ethnicity, and socioeconomic background. At the health system level, the AAP recommends adherence to the best practice guidelines outlined in the policy statement, which includes avoidance of unsubstantiated age limits and an increase in the number of and access to pediatric-focused metabolic surgery centers.2
Existing Evidence and Best Practices
The AAP has described pediatric obesity as an “epidemic within an epidemic,” with earlier obesity-related health problems dramatically affecting life expectancy.1 Metabolic and bariatric surgery represents an effective and evidence-based treatment for adolescents with severe obesity and related comorbidities, including dyslipidemia, type 2 diabetes, and hypertension.3 Previous studies have demonstrated that comorbidity resolution rates are higher in younger patients who undergo bariatric surgery when compared with adults.3
With regard to safety, surgical complications are generally infrequent (minor complications, 15%; major perioperative complications, 8%), but patients will need to be monitored for anemia, bone mineral density loss, and micronutrient deficiencies (iron, folate, vitamin B12) after surgery.2,3 Risk-taking behavior and mental health will also need to be monitored.2
Shared decision making involving the patient, family, and medical and surgical providers should be incorporated into treatment planning.2 In patients who qualify for surgery, eligibility must be determined with respect to physiologic, psychologic, and developmental maturity. Consultation with an ethics professional may be necessary in challenging situations.2
AAP Practice-Level Recommendations
- Clinicians should recognize that children and adolescents with severe obesity, defined as a body mass index ≥35 kg/m2 or ≥120% of the 95th percentile for age and sex, are at risk for major health complications and should be referred to available programs at centers that are highly experienced in pediatric obesity care, including bariatric surgery.2
- To best guide medical decision making with families, clinicians should be aware of the efficacy, risks, benefits, and long-term implications of common metabolic and bariatric procedures.2
- Clinicians should identify patients with obesity who meet criteria for metabolic and bariatric surgery and provide referrals to pediatric-focused surgery programs.2
- Coordination of a multidisciplinary care team will be necessary before and after surgery and should involve the patient, family, and anesthesia and surgical teams in addition to the pediatric care providers.2
- Healthcare providers will need to closely monitor patients after surgery for deviations in nutritional status and mental health.2
Overall, changes are needed at the provider, system, and insurer levels to improve access to bariatric surgery for youth with severe obesity. “Recognizing that severe obesity is a serious and worsening public health crisis in children and adolescents, [we are] calling for greater access to metabolic and bariatric surgery, one of the few strategies that has been shown to be effective in treating the most severe forms of the chronic disease,” wrote the AAP in a press release.1
Clinicians can direct parents who are looking for more information on bariatric surgery to HealthyChildren.org.1
1. AAP recommends greater access to surgical treatments for severe obesity [news release]. New Orleans, LA: American Academy of Pediatrics; October 27, 2019. Accessed October 27, 2019.
2. Armstrong SC, Bolling CF, Michalsky MP, Reichard KW; AAP Section on Obesity, Section on Surgery. Pediatric metabolic and bariatric surgery: evidence, barriers, and best practices. Pediatrics. 2019;144(6):e20193223.
3. Bolling CF, Armstrong SC, Reichard KW, Michalsky MP; AAP Section on Obesity, Section on Surgery. Metabolic and bariatric surgery for pediatric patients with severe obesity. 2019;144(6):e20193224.