Improving Access to Child and Adolescent Weight Loss Surgery: A Review of Updated National and International Practice Guidelines

Each month, the OMA Pediatric Committee reviews a pediatric-focused obesity research update to help keep you up to date about the latest findings. This month’s update explores metabolic bariatric surgery (MBS) as an intervention for severe pediatric obesity, highlighting current guidelines, patient eligibility, surgical options, and the role of telehealth in expanding access to care. Learn how evolving recommendations from leading organizations, including the AAP and ASMBS, are shaping the future of obesity treatment for children and adolescents.

Article Summary

Metabolic bariatric surgery (MBS) is an effective intervention for treating pediatric obesity, but access remains limited. This review examines the latest guidelines from the professional organizations including the American Academy of Pediatrics (AAP) and the American Society for Metabolic and Bariatric Surgery, highlighting patient selection, surgical options and the role of telehealth in expanding care for children and adolescents with severe obesity.

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Article Review

The article examines metabolic bariatric surgery (MBS) as an intervention for severe childhood and adolescent obesity. It highlights the growing prevalence of severe pediatric obesity, its associated health risks including Type 2 diabetes and cardiovascular risk, and the limitations of conventional treatment methods such as lifestyle modifications and pharmacological therapy. The authors summarize recent guidelines from the American Academy of Pediatrics (AAP), the American Society for Metabolic and Bariatric Surgery (ASMBS), and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), which aim to improve access to MBS for pediatric patients. Additionally, the article discusses the role of telehealth in addressing barriers to obesity management and MBS referral.

Current Guidelines

American Academy of Pediatrics (AAP) Guidelines (2023)

According to the AAP, bariatric surgery is recommended for youth with a BMI ≥40 or ≥35 with significant obesity-related comorbidities. Evaluation by a multidisciplinary team (including a pediatric or bariatric surgeon, a pediatric gastroenterologist or obesity medicine physician, a mental health specialist, a dietician, and an exercise specialist) and referral to specialized centers is required.

ASMBS and IFSO Guidelines (2022)

These guidelines align closely with the AAP, recommending bariatric surgery for adolescents meeting similar BMI criteria. They emphasize specialized pediatric bariatric surgical training and comprehensive preoperative and postoperative multidisciplinary care.

Historical Context

Historically, pediatric bariatric surgery was reserved as a last resort after exhausting lifestyle and pharmacological interventions. Recent guidelines advocate earlier surgical consideration, reflecting evidence that conservative treatments alone rarely achieve sustained weight loss. European guidelines support surgery for youths with even lower BMIs (30-35 kg/m²) if severe comorbidities like uncontrolled type 2 diabetes are present, due to the ability of bariatric surgery to treat type 2 diabetes more effectively than anti-obesity medications.

Importance of Early Intervention

Childhood obesity frequently persists into adulthood, increasing risks for severe health issues including cardiovascular disease, metabolic syndrome, and mental health disorders. Early intervention with bariatric surgery is crucial to prevent these lifelong complications.

Eligibility and Barriers to Surgery

Contemporary ASMBS guidelines indicate that Tanner staging and linear growth should not limit surgery eligibility for adolescents aged 10-19 with severe obesity. Despite strong evidence of MBS safety and efficacy, barriers persist due to concerns about nutritional deficiencies, limited pediatric management experience, and uncertainty regarding long-term outcomes. As a result, many adolescents are referred late, complicating surgical outcomes.

Surgical Options

Roux-en-Y Gastric Bypass (RYGB)

Historically regarded as the gold standard, RYGB effectively reduces BMI and improves obesity-related comorbidities. Long-term studies like the Adolescent Morbid Obesity Surgery (AMOS) trial report sustained weight loss, though approximately 25% of patients may require additional surgery due to weight regain.

Sleeve Gastrectomy (SG)

Recently, SG has become the preferred procedure due to lower technical complexity and fewer nutritional malabsorption issues. SG typically results in substantial weight loss sustained at five years. However, it has a higher incidence of gastroesophageal reflux disease (GERD) compared to RYGB, necessitating careful preoperative counseling and postoperative monitoring.

Clinical Evidence: Teen-LABS Study

The Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study supports both RYGB and SG efficacy, showing sustained BMI reductions at three years (RYGB 28%, SG 26%). Additionally, bariatric procedures substantially improve obesity-related comorbidities such as hypertension, dyslipidemia, and diabetes.

Barriers to Access

Significant barriers include regional disparities in specialized pediatric obesity care and a shortage of pediatric-trained bariatric surgeons. To address this, organizations such as the American College of Surgeons have introduced rigorous credentialing standards, yet shortages persist, particularly in rural or densely populated areas.

Role of Telehealth

Telehealth has become a valuable tool for pediatric obesity management, facilitating access to care irrespective of geographical and logistical challenges. Telemedicine effectively supports preoperative evaluation, lifestyle counseling, and postoperative care. Despite high patient satisfaction, telehealth cannot entirely replace in-person evaluations and the shortage of trained specialists remains a limitation.

Conclusion

Childhood and adolescent obesity remains a critical public health issue with significant lifelong implications. While lifestyle interventions remain foundational, metabolic and bariatric surgery provides substantial, sustained weight loss and significant comorbidity improvements. Early referral, multidisciplinary management, increased access to specialized pediatric bariatric surgeons, and complementary telehealth services are essential for optimal outcomes. Further research should examine the long-term outcomes of MBS in adolescents, including sustained weight loss, metabolic health, quality of life, psychological outcomes and potential complications.