Guideline sources The following summarized guidelines for the evaluation and management of childhood obesity are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2023), the American Diabetes Association (ADA 2023), the Endocrine Society (ES 2017), the U.S. Preventive Services Task Force (USPSTF 2017), and the American College of Endocrinology (ACE/OS/AACE 2013). 1 2 3 4 5 Guidelines 1. Screening and diagnosis Indications for screening: As per AAP 2023 guidelines, measure height and weight, calculate BMI, and assess BMI percentile using age- and sex-specific growth charts or growth charts for children with severe https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 1/8 6/29/23, 3:51 AM Childhood obesity Pathway obesity at least annually to screen for overweight, obesity, and severe obesity in all 2-18 years old children. B As per USPSTF 2017 guidelines, screen 6 years old children and adolescents for obesity. B Diagnosis: As per AAP 2023 guidelines, diagnose overweight and obesity in 2-18 years old patients as follows, based on BMI and BMI percentiles using age- and sex-specific growth charts: Situation Guidance BMI 85th to < 95th percentile Overweight BMI 95th percentile Obesity BMI 120% of the 95th percentile for age and sex. B Severe obesity As per ES 2017 guidelines, calculate the BMI and use normative BMI percentiles for the diagnosis of overweight or obesity in 2 years old pediatric and adolescent patients. B 2. Diagnostic investigations Evaluation for comorbidities: As per AAP 2023 guidelines: Elicit a comprehensive patient history, obtain mental and behavioral health screening, evaluation of social determinants of health, physical examination, and the following diagnostic studies to evaluate for obesity-related comorbidities in 2-18 years old patients with overweight or obesity: B Situation Guidance Obtain a fasting lipid panel to evaluate for dyslipidemia in 10 years old pediatric and adolescent patients with obesity or overweight B . Consider evaluating for lipid abnormalities also in patients aged 2-9 years with obesity. B Dyslipidemia Obtain a fasting plasma glucose, 2-hour plasma glucose after 75-g oral glucose tolerance test, or HbA1c to evaluate for abnormal glucose metabolism in 10 years old pediatric and adolescent patients with obesity B or with overweight in the Diabetes https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 2/8 6/29/23, 3:51 AM Childhood obesity Pathway presence of risk factors for T2DM or nonalcoholic fatty liver disease. B Obtain an alanine transaminase measurement B to evaluate for abnormal liver function in 10 years old pediatric and adolescent patients with obesity B or with overweight in the presence of risk factors for T2DM or nonalcoholic fatty liver disease. B Nonalcoholic fatty liver disease Measure BP at every visit starting at 3 years of age to evaluate for hypertension in pediatric and adolescent patients with overweight and obesity. B Hypertension Assess for symptoms and signs of the following comorbidities in pediatric and adolescent patients with obesity: Situation Guidance Elicit a sleep history, including symptoms of snoring, daytime somnolence, nocturnal enuresis, morning headaches, and inattention, to to evaluate for obstructive sleep apnea in pediatric and adolescent patients with obesity. Obtain polysomnography in case of at least one symptom of disordered breathing Obstructive sleep apnea Assess for menstrual irregularities and signs of hyperandrogenism (hirsutism, acne) to assess the risk for PCOS in female adolescent patients with obesity PCOS Monitor for symptoms of depression in pediatric and adolescent patients with obesity. Obtain annual evaluation for depression with a formal self-report tool in 12 years old adolescent patients Depression Obtain a musculoskeletal review of systems and perform a physical examination (internal hip rotation in growing child, gait) as part of obesity evaluation. Instruct immediate and complete activity restriction, non-weight- Slipped capital femoral epiphysis https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 3/8 6/29/23, 3:51 AM Childhood obesity Pathway bearing with use of crutches and refer to an orthopedic surgeon for emergent evaluation in patients with suspected slipped capital femoral epiphysis. Consider referring the patient to an emergency department if an orthopedic surgeon is not available Maintain a high index of suspicion for idiopathic intracranial hypertension with new-onset or progressive headaches in the context of significant wt gain, especially in females. E Idiopathic intracranial hypertension As per ES 2017 guidelines, obtain evaluation for potential comorbidities (including diabetes mellitus or prediabetes, dyslipidemia, hypertension or prehypertension, nonalcoholic fatty liver disease, PCOS, obstructive sleep apnea, psychiatric comorbidities) in pediatric or adolescent patients with a BMI of 85th. B Show 2 more Evaluation for underlying etiologies: Do not obtain routine laboratory evaluations for endocrine etiologies in pediatric patients with obesity unless the patient's stature and/or height velocity are attenuated (assessed in relationship to genetic/familial potential and pubertal stage). D Consider obtaining genetic testing in patients with extreme early-onset obesity (< 5 years of age) and having have clinical features of genetic obesity syndromes (in particular, extreme hyperphagia) and/or a family history of extreme obesity. C 3. Medical management General principles: manage pediatric and adolescent patients with overweight or obesity following the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach acknowledging obesity's biologic, social, and structural drivers. B Show 4 more Weight loss medications: As per AAP 2023 guidelines, offer weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment in 12 years old adolescent patients with obesity. B Consider offering weight loss pharmacotherapy also in patients aged 8-11 years. E As per ES 2017 guidelines, consider offering pharmacotherapy in pediatric or adolescent patients with obesity only after a formal program of intensive lifestyle modification has failed to limit weight gain or to ameliorate comorbidities. C Do not use obesity medications in < 16 years old patients with overweight, except in the context of clinical trials. B https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 4/8 6/29/23, 3:51 AM Childhood obesity Pathway Show 2 more 4. Nonpharmacologic interventions Behavioral lifestyle interventions: As per AAP 2023 guidelines: Offer intensive health behavior and lifestyle treatment in 6 years old patients with overweight or obesity. B Consider offering this treatment also in patients aged 2-5 years. B Offer greater contact hours ( 26 hours of face-to-face, family-based, multicomponent treatment over a 3-12-month period) of health behavior and lifestyle treatment for better results. B As per ES 2017 guidelines, offer intensive, age-appropriate, culturally sensitive, family-centered lifestyle modifications (dietary, physical activity, behavioral) to promote a decrease in BMI. B Show 5 more As per USPSTF 2017 guidelines, offer comprehensive, intensive behavioral interventions to promote improvements in weight status in 6 years old pediatric and adolescent patients with obesity. B 5. Surgical interventions Bariatric surgery: As per AAP 2023 guidelines, refer 13 years old adolescent patients with severe obesity (BMI 120% of the 95th percentile for age and sex) to a local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery center for evaluation for metabolic and bariatric surgery. B As per ES 2017 guidelines: Consider offering bariatric surgery only under the following conditions: the patient has attained Tanner 4 or 5 pubertal development and final or near-final adult height, the patient has a BMI of > 40 kg/m or has a BMI of > 35 kg/m and significant, extreme comorbidities extreme obesity and comorbidities persist despite compliance with a formal program of lifestyle modification, with or without pharmacotherapy psychological evaluation confirms the stability and competence of the family unit (psychological distress due to impaired quality of live from obesity may be present, but the patient does not have an underlying untreated psychiatric illness) the patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits there is access to an experienced surgeon in a pediatric bariatric surgery center of excellence providing the necessary infrastructure for patient care, including a team capable of long-term follow-up of the metabolic and psychosocial needs of the patient and family. C https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 5/8 6/29/23, 3:51 AM Childhood obesity Pathway Avoid offering bariatric surgery in the following patients: pre-adolescent patients pregnant or breastfeeding adolescent patients, or planning to become pregnant within 2 years of surgery patients not mastered the principles of healthy dietary and activity habits patients with an unresolved substance abuse, eating disorder, or untreated psychiatric disorder. D 6. Specific circumstances Patients with diabetes mellitus: Consider offering metabolic surgery for the treatment of adolescent patients with T2DM with severe obesity (BMI > 35 kg/m ) and having elevated HbA1c and/or serious comorbidities despite lifestyle and pharmacologic interventions. B Perform metabolic surgery only by an experienced surgeon working as part of a well-organized and engaged multidisciplinary team, including a surgeon, endocrinologist, dietitian nutritionist, behavioral health specialist, and nurse. A 7. Preventative measures Healthy lifestyle: As per ES 2017 guidelines, promote and participate in the ongoing healthy dietary and activity education of children and adolescents, parents, and communities, and encourage schools to provide adequate education about healthy eating. B Show 9 more As per AACE 2013 guidelines, counsel parents to include their children in healthy eating behavior changes as adult feeding behavior is solidly rooted from childhood. B Clinical findings Symptoms Past medical history Anxiety Bardet-biedel syndrome Arthralgia Cushing's syndrome Low self-esteem Depression Myalgia Diabetes mellitus Sleeping disorder Dyslipidemia Weight gain Eating disorder Fragile X syndrome Social history GH deficiency High birth weight https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 6/8 6/29/23, 3:51 AM Childhood obesity Pathway Consumption of sugar- sweetened beverages Hypertension Hypothyroidism Excessive screen time Leptin deficiency Physical inactivity Metabolic syndrome Skipping breakfast Nonalcoholic fatty liver disease Obstructive sleep apnea Genetic testing PCOS Prader-willi syndrome Mc4r gene mutation Prediabetes Pomc gene mutation Radiation therapy to the head area Slipped capital femoral epiphysis TBI Turner syndrome Vitamin B12 deficiency Vitamin D deficiency Anthropomorphic exam BMI waist circumference Studies 2022 VI-0521 in Obese Adolescents (mid-dose) In adolescents with obesity, mid-dose phentermine/topiramate was superior to placebo with respect to reduction in BMI at week 56. Aaron S Kelly et al. NEJM Evid. 2022 Jun. 2022 VI-0521 in Obese Adolescents (top-dose) In adolescents with obesity, top-dose phentermine/topiramate was superior to placebo with respect to reduction in BMI at week 56. Aaron S Kelly et al. NEJM Evid. 2022 Jun. References 1. Sarah E Hampl, Sandra G Hassink, Asheley C Skinner et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023 Feb 1;151 2):e2022060640. Open 2. Dennis M Styne, Silva A Arslanian, Ellen L Connor et al. Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017 Mar 1;102 3 709 757. Open https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 7/8 6/29/23, 3:51 AM Childhood obesity Pathway 3. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 4. US Preventive Services Task Force, Grossman DC, Bibbins-Domingo K et al. Screening USPSTF for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Jun 20;317 23 2417 2426. Open 5. Gonzalez-Campoy JM, St Jeor ST, Castorino K et al. Clinical practice guidelines for healthy eating for the prevention and treatment of metabolic and endocrine diseases in adults: cosponsored by the American Association of Clinical Endocrinologists/the American College of Endocrinology and the Obesity Society. Endocr Pract. 2013 Sep-Oct;19 Suppl 3 1 82. Open https://web.pathway.md/diseases/recOvKX5JND0yp3SJ 8/8