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Consider using a multidisciplinary approach when treating obese children
Watch for underlying diagnoses that may contribute to obesity, such as growth hormone deficiency.
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Childhood obesity, which has been identified by The World Health Organization as a serious public health concern, should be addressed on an individual basis with pediatric patients, according to a Canadian orthopedist.
Benjamin A. Alman, MD, discussed considerations for orthopedists treating obese children at the American Academy of Orthopaedic Surgeons annual meeting.
Many factors contribute to obesity, and surgeons treating obese children need to use a multidisciplinary program.
“It needs to be individualized to what is causing the problem in that child, this may require dietary as well as activity modification and some underlying endocrine dysregulation may need to be managed,” he said.
Growth plate
Recent research has shown that more than half of obese children have vitamin D levels low enough to create mild bone health effects, Alman said. Other studies have indicated a high rate of thyroid dysregulation.
“Dietary factors [such as] having inappropriate levels of calcium may slow the growth plate,” he said. “Hormones, insufficient vitamin D levels and inappropriate amounts of leptin may also keep the growth plate from growing.”
Several studies have associated slipped capital femoral epiphysis (SCFE) with obesity. Due to reports of failure using single, percutaneous screw fixation in obese patients, some surgeons are advocating two-screw fixation. However, Alman said that a risk/benefit analysis is needed.
“Blount’s disease is also common in obese children, and just the overload of the medial side of the growth plate, associated with tension on the lateral side of the growth plate from the weight, is enough to cause a growth abnormality,” he said.
Bone density
There is conflicting research regarding whether obese children have high or low bone density. Defining the normative values for obese children is difficult because the normative values for nonobese children are unknown and bone density changes throughout childhood.
“Even though the absolute values may be higher than age-matched populations, functionally they have low bone density,” Alman said.
Obese children may often have foot pain or malalignment. Physicians should also be aware of disorders contributing to obesity. Alman cited a study of nearly 1,000 obese patients conducted by Thomas Reinehr, MD, and colleagues which found 13 patients with underlying disorders such as Cushing’s syndrome, Prader-Willi syndrome and growth hormone deficiency.
During the discussion session, Alman noted that surgeons in British Columbia do not get increased reimbursement for cases based on body mass index although Alberta has a modifier for obesity.
Paul Tornetta III, MD, the moderator of the session, said that surgeons in the United States can use a 29 modifier to denote the complexity of a case.
“If you choose to do it with an obese patient, which I did once for a pelvic fracture, I was compensated for it,” he said.
For more information:
- Benjamin A. Alman, MD, can be reached at the Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8, Canada; 416-813-7981; e-mail: benjamin.alman@sickkids.ca. He has no direct financial interest in any products or companies mentioned in this article.
- Paul Tornetta III, MD, can be reached at 850 Harrison Ave., 3rd Floor, Boston, MA 02118; 617-414-5212; Email: ptornetta@pol.net. He is a consultant for, and receives royalties from Smith & Nephew.
References:
- Pediatric orthopedics and obesity. Symposium H: Obesity in North America. Presented at Presented at the American Academy of Orthopaedic Surgeons 76th Annual Meeting. Feb. 25-28, 2009. Las Vegas.
- Reinehr T, Hinney A, de Sousa G, et al. Definable somatic disorders in overweight children and adolescents. J Pediatr. 2007;150(6):618-622.