Obesity (pediatrics): Clinical sciences

Obesity refers to excessive fat accumulation in the body that is strongly associated with dyslipidemia, diabetes mellitus type 2, nonalcoholic fatty liver disease, and cardiovascular conditions. Now, when assessing overweight and obesity, in children under two years of age, you should use weight-for-length classification, and in children above two years of age, you should use body mass index.

If your patient is presenting with chief concerns suggestive of obesity, obtain a comprehensive history and physical examination, including measurements of weight and height. If the child is under 2 years of age, measure their length, not height. The patient’s prenatal and perinatal history may reveal risk factors, like gestational diabetes or fetal macrosomia, while family history might reveal parental obesity.

Obesity is often associated with type 2 diabetes mellitus, so always ask about the presence of polydipsia, polyphagia, and polyuria! In some cases, history might reveal a limp and pain in the hip, groin, thigh, or knee, which is suggestive of slipped capital femoral epiphysis.

Biological female adolescents could also report irregular menstrual cycles and heavy menstrual bleedings in combination with hair loss, which is suggestive of polycystic ovary syndrome.

History might also reveal frequent snoring during sleep, which could be a sign of obstructive sleep apnea, as well as the use of medications associated with obesity, such as corticosteroids, anti-seizure medications, and antidepressants.

Next, ask for symptoms of mental health and behavioral conditions that can increase the risk of obesity, such as depression, anxiety, and disordered eating.

History could also reveal psychosocial stressors or adverse childhood experiences, like bullying, which can trigger physiologic changes that can result in weight gain. Finally, look for social determinants that can increase the risk of obesity. For example, in under-resourced communities, children often lack access to fresh produce or safe spaces for physical activity, and those living in households with food insecurity are more likely to develop obesity.

Family and household factors that increase a child’s risk of being obese include authoritarian or permissive parenting styles, consumption of sweetened beverages and snacks, sedentary behaviors, and inadequate sleep.

Now, here’s a clinical pearl! Some children might present with an underlying genetic condition that predisposes them to obesity, such as Prader-Willi syndrome, or endocrine conditions, like hypothyroidism and Cushing syndrome!

On the physical exam, your patients will typically present with increased waist circumference, excess adiposity, and a prominent suprapubic fat pad. Some patients might have elevated blood pressure, which is suggestive of obesity-related hypertension.

Next, be sure to examine the patient’s skin! Check for abdominal stretch marks, which are also known as abdominal striae. In obesity, stretch marks are typically narrow and pale pink to white, in contrast to Cushing syndrome, which is associated with wide purple stretch marks! Next, examine the skin folds since local skin friction and moisture can result in superficial skin inflammation called intertrigo.

Also, look for acanthosis nigricans on the nape of the neck or in the axillae, which is suggestive of diabetes mellitus, as well as acne and hirsutism, which is suggestive of polycystic ovary syndrome.

Next, palpate the abdomen and check for liver enlargement since hepatomegaly is often associated with non-alcoholic fatty liver disease or NAFLD. If history reveals a limp, always check for hip tenderness, which could be a sign of slipped capital femoral epiphysis.

Finally, in biologically male individuals, excessive adipose tissue converts more testosterone to estradiol, which promotes the enlargement of glandular breast tissue, so these patients might present with gynecomastia. At this point, you should suspect obesity, so your next step is to assess the patient’s age.