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April 1, 2022

Pediatric Research Update | April 2022

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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 addresses pediatric obesity and bariatric procedures.

Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices

Article Summary

The AAP published its first policy statement regarding metabolic-bariatric surgery just before the COVID-19 pandemic. The pandemic demonstrated how dangerous a COVID-19 infection is to adults and children with obesity. This statement is a powerful tool in efforts to improve care for pediatric patients with obesity.

Article Review

Dr. Armstrong and her co-authors, working with the AAP Section on Obesity and the AAP Surgical Section, review evidence, barriers, best practices, and recommendations regarding pediatric metabolic bariatric surgery (MBS). This is the first such document from a pediatric organization.

First, they review the evidence regarding MBS and children with the disease of obesity, including data quality and data sources; the Teen-Labs and FAB5+ studies from the United States and The AMOS study from Sweden are briefly reviewed. Outcomes, including weight loss and, most importantly, resolution of the complications of obesity, show better results than comparable adult studies. The complications of MBS are less frequent than in comparable adult studies, and there were no perioperative deaths or deaths out to 8 years post-op directly attributable to the patient’s MBS.

They go over indications and eligibility. Indications include pediatric patients with 1) a BMI over 35 or over 120% of the 95th %tile (whichever is lower) if they have a complication of obesity or 2) a BMI over 40 or over 140% of the 95th %tile (whichever is lower) if they have no complications of obesity. They note that disabilities warrant additional considerations and do not necessarily disqualify the patient. Under eligibility, they stress that there is “no evidence to support the application of age-based eligibility limits.”

MBS remains infrequent in the pediatric age group, and they discuss the many barriers children with obesity and their families face. Studies have shown that access is skewed by race, ethnic group, and socio-economic status. Insurance coverage for the pediatric age group is worse than that for adults despite growing evidence of the medical necessity for effective control of the disease of obesity.

Provider concerns remain a barrier to MBS. They noted that this stems from a lack of knowledge of the biology of the disease, the surgical procedures themselves, the risks of MBS, and the follow-up of MBS. There is also a concern for abnormal growth and development after MBS, for which no evidence exists. Recent studies have shown that providers also frequently demonstrate bias explicitly or implicitly despite the increasing understanding that the disease of obesity has a physiological basis and is not purely a behavioral problem. They also point out the irony that lifestyle therapy and counseling are infrequently durable and effective for pediatric patients with severe obesity but that lifestyle therapy and counseling are an important part of interdisciplinary pediatric weight management. They address cost-effectiveness by noting the adult studies that show a positive return on investment compared to patients who do not get MBS at about five years after the MBS.

Under best practices, the authors stress a multidisciplinary care model before and after MBS. They note the availability of MBSAQIP (Metabolic Bariatric Surgical Accreditation and Quality Improvement Program) certification from the American College of Surgeons and The Association of Metabolic Bariatric Surgery for surgical programs that choose to serve patients from the pediatric age group. They stress the necessity for age-appropriate care to be delivered by all disciplines involved in the care of children with obesity.

Then, they go on to make recommendations to pediatric healthcare providers. They suggest pediatric healthcare providers recognize the risks of severe obesity in children. They need to seek out high-quality multidisciplinary centers to help them with their patients with obesity. They need to understand MBS's efficacy, risks, benefits, and long-term health implications. They need to identify patients who meet the criteria for MBS and provide referrals. They must coordinate pre- and post-op care and monitor patients for micronutrient deficiencies.

Finally, they make some system-level recommendations. Pediatric healthcare providers need to advocate for increased access to multidisciplinary pediatric weight management programs. Medical centers need to recognize and use best practice guidelines. They need to consider potential healthcare benefits. They need to use individualized patient-centered care, and they need to increase the number of multidisciplinary pediatric weight management clinics as well as increase access to those clinics. Public and private payors need to provide payment for pediatric multidisciplinary weight management teams to work with the children and their families preoperatively and postoperatively. They need to provide compensation for MBS and reduce barriers to MBS.

Dr. Armstrong and her co-authors have provided pediatric care providers with guidance when faced with the problem of a patient with the disease of obesity. They have also challenged the healthcare system to provide better, more accessible, and more equitable care for children with the condition of obesity and their families.

Armstrong SC, Bolling CF, Michalsky MP, et al. AAP SECTION ON OBESITY, SECTION ON SURGERY. Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices. Pediatrics. 2019;144(6):e20193223