For the first time, the American Academy of Pediatrics has issued clinical practice guidelines for medication or bariatric surgery to treat severely obese children starting at 12 and 13 years old.

Kaiser Permanente Northern California has been preparing for the guidelines since the academy issued similar policy statements in 2019, said Elizabeth Shaw, DO, who is The Permanente Medical Group regional director of pediatric medical specialties.

Dr. Shaw stressed that the new guidelines are about potentially life-saving health interventions in children and teens with certain levels of obesity and current obesity related complications. Nineteen percent of American children are currently affected by obesity, according to the academy, and if trends continue, that could grow to 57% by 2050.

“Some children with obesity go on to develop obesity related complications that have huge impacts on their lives that could shorten their lifespans,” said Dr. Shaw. “In some cases we can reverse or greatly improve obstructive sleep apnea and type 2 diabetes with bariatric surgery.”

Services to determine eligibility

Dr. Shaw said even though the new guidelines are not a surprise in the medical world, the news is just beginning to settle on families nationwide whose children struggle with obesity.

“For some families, they would ask, ‘Why would I ever want to do that for my child?’” said Dr. Shaw. “And others say, ‘I have family members who have had success with those interventions.’”

In addition to obstructive sleep apnea and diabetes, obesity in children can cause high blood pressure, fatty liver disease, back pain, and foot problems.

Dr. Shaw said Kaiser Permanente Northern California anticipated the academy’s guidelines with the creation in 2020 of a working group and a consulting service to help pediatricians and family medicine doctors determine if a child could be eligible for consideration for surgery. Referrals for surgery often require multiple specialists and a psychologist, she added.

The new guidelines are encouraging but should not be viewed as an easy and quick fix, said Mary Blair-Rogers, MD, a pediatrician who runs the Fit4Life program at the Kaiser Permanente South Sacramento Medical Center.

“On the one hand, lifestyle change such as eating better and exercising more is not getting us where we need to be, so paring medication with a lifestyle change could work very well for some of these kids,” said Dr. Blair-Rogers. “On the other hand, you don’t want to give people the idea that it’s a quick fix, because it’s not. If the medication helps you get to a good weight, and you discontinue it, you might go right back up.”

Many factors causing condition

According to the pediatric academy, obesity is no longer seen as a failure of willpower to eat less and exercise more, but the outcome of a complex series of environmental and biological influences. In the recent paper accompanying the new recommendations, the academy details 40 individual influencers of childhood obesity.

Those influences on obesity range from snack behavior and meal size to maternal smoking and early use of antibiotics. Children of parents who have lower levels of education and income, children who have less access to healthy food options and physical activity opportunities, and children who have high levels of adverse childhood experiences are more likely to be obese.

Dr. Blair-Rogers said pediatricians are likely to move with great care before recommending medication or surgery for severely obese children. With surgery, for example, those with depression or other psychosocial concerns would need screening and support prior to the surgery to avoid adverse outcomes.   

“This would be a serious intervention, but at the same time, we can no longer just tell you to eat less and exercise more,” Dr. Blair-Rogers said. “We have to do something more aggressive, and if these interventions are considered, we have to really follow these kids closely. But I am very hopeful they could work for certain people.”

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