How young for bariatric surgery in children?

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Obesity affects 50% of adults and 18% of children in the USA. It has wide-ranging comorbidities with clinical, psychosocial, and economic ramifications. Obesity refers to a condition of excess body fat. The basis for weight gain is a fundamental imbalance between caloric intake and output, but individual variation based on genetics, metabolism, and diverse environmental triggers is seen. Although modifications to our obesogenic society and education about the risks in our environment may lead to a decrease in the incidence of obesity through prevention, treatment for those already obese is critically important. In adults, the most successful treatment programs for obesity include a surgical procedure. This article discusses the problems obesity presents to children and their families, highlights the unique aspects of treating obesity in children, reviews the currently utilized bariatric surgical procedures, and introduces those bariatric procedures that are under development. When considering whether to use bariatric surgical procedures in a multidisciplinary weight management program for children, the special needs and characteristics of children with a severe weight problem must be considered. Development of bariatric surgical techniques and devices and implementation of these tools in multidisciplinary weight management programs need greater attention. This will require the combined efforts of the pediatric health care providers from many specialties and partnerships with industry to facilitate discovery and implementation.

Section snippets

The problem

Currently, there is considerable debate around who, at any age, has obesity, when obesity becomes a true health problem, how much of a problem obesity presents, and how much risk to take with treatment. Recent guidelines from the American Academy of Pediatrics (AAP) emphasize the identification and treatment of obesity at various ages.1 Children ages 2-18 years old with a basal metabolic index (BMI) between the 85th and 95th percentile for their age and gender are at risk of obesity and should

Unique challenges of children

Children present a number of unique challenges for weight management. The first challenge is that children have a family with siblings, parents, and other care providers. The family will of necessity be involved in any weight management plan. Participation in a weight management program is time-consuming for the whole family. Food availability and nutritional education will affect the whole family. Physical activity routines are best established on a family basis. Much of the weight management

Opportunities to individualize treatment

Recommendations regarding bariatric procedures in children have included behavioral screening and family screening to “qualify” the patient and family for a bariatric procedure. To justify surgical intervention, children should be extremely obese and should have some identifiable consequence of the obesity on their medical or psychosocial status. They should understand the nature of the surgical treatment of obesity, understand the important role they will play in their own success (or

Bariatric procedures

Bariatric procedures must be part of a multidisciplinary weight management program that the patient uses long term. Currently, we hypothesize that the best results with bariatric procedures will be achieved only when performed as part of a multidisciplinary long-term weight management program.47 The program optimally includes family nutritional education, physical activity education, and behavioral support. Bariatric procedures are not a cure for obesity and need to be considered as one

New procedures

A number of concepts/procedures are in development as bariatric procedures. These include the intragastric balloon, vagal stimulator, gastric stimulator, endosleeve duodenojejunal bypass, and endoscopic gastroplasty techniques. They can be divided into temporary and semipermanent procedures.

The FDA and bariatric procedures

Bariatric procedures can be divided into those with devices and those without devices. Those procedures that involve implanted devices come under the control of the FDA. The AGB, the endosleeve, the gastric stimulators, and the vagal blocker all fall into this category. They will be studied for safety and efficacy before they are FDA-approved.

Typically, medical devices are developed and studied in adults before they are approved for use in human beings by the FDA. For approval in children,

Conclusions

Children with obesity are ill with a chronic, incurable disease that threatens their physical health, their psychosocial well being, and the economic future of society. The question is not how young to treat them, but which aggressive, effective treatments can be most safely used to affect a heathy weight. The current generation of children with obesity needs treatment now. The best that medicine has to offer currently for patients with obesity is a surgical procedure combined with a

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