COMORBIDITES OF COMORBIDITES OF PEDIATRIC OBESITYPEDIATRIC OBESITY

William J. Cochran, MD, FAAPWilliam J. Cochran, MD, FAAP

Geisinger ClinicGeisinger Clinic

WHY WORR ABOUT WHY WORR ABOUT PEDIDATRIC PEDIDATRIC OBESITY?OBESITY?

INTRODUCTIONINTRODUCTION

Pediatric obesity is of epidemic Pediatric obesity is of epidemic proportionproportion

Pediatric obesity is the most Pediatric obesity is the most common chronic disease of common chronic disease of childhoodchildhood

Figure IV: Percent of Figure IV: Percent of obese children and obese children and adolescentsadolescents

0

2

4

6

8

10

12

14

16

1963-70

1971-74

1976-80

1988-94

1999-02

6-11 years12-19 years

IS PEDIATRIC OBESITY A IS PEDIATRIC OBESITY A REAL HEALTH ISSUE OR REAL HEALTH ISSUE OR JUST A COSMETIC JUST A COSMETIC PROBLEM?PROBLEM?

ADULT OBESITYADULT OBESITY

Type II DiabetesType II Diabetes Coronary Heart DiseaseCoronary Heart Disease HypertensionHypertension CancerCancer Joint DiseaseJoint Disease Gallbladder DiseaseGallbladder Disease Pulmonary DiseasePulmonary Disease

RISK OF CHILDHOOD RISK OF CHILDHOOD OBESITY PERSISTING OBESITY PERSISTING INTO ADULTHOODINTO ADULTHOOD Guo 1999Guo 1999

– 20% at 4 years of age20% at 4 years of age– 80% in adolescence80% in adolescence

IMPACT OF CHILDHOOD IMPACT OF CHILDHOOD OBESITY ON ADULT OBESITY ON ADULT HEALTHHEALTH Childhood obesity has significant Childhood obesity has significant

impact on health in adulthoodimpact on health in adulthood Hoffmans 1998Hoffmans 1998

– Dutch adolescent males followed for Dutch adolescent males followed for 32 years32 years

– Increased mortality in obese vs. leanIncreased mortality in obese vs. lean

IMPACT OF CHILDHOOD IMPACT OF CHILDHOOD OBESITY ON ADULT OBESITY ON ADULT HEALTHHEALTH Mossberg 1989Mossberg 1989

– Swedish adolescents studied after Swedish adolescents studied after 40 years40 years

– Increased mortality in obese vs. non-Increased mortality in obese vs. non-obese obese

IMPACT OF CHILDHOOD IMPACT OF CHILDHOOD OBESITY ON ADULT OBESITY ON ADULT HEALTHHEALTH Must, 1992:Harvard growth studyMust, 1992:Harvard growth study 13-18 year old adolescents13-18 year old adolescents 1922-1935, evaluated 19881922-1935, evaluated 1988 Obesity: BMI >75% on at least Obesity: BMI >75% on at least

two occasions during adolescencetwo occasions during adolescence

IMPACT OF CHILDHOOD IMPACT OF CHILDHOOD OBESITY ON ADULT OBESITY ON ADULT HEALTHHEALTH Increased all cause mortality in males Increased all cause mortality in males

and femalesand females Increased mortality from CAD in malesIncreased mortality from CAD in males Increased morbidity from CAD in males Increased morbidity from CAD in males

and femalesand females Increased risk of colon cancer in malesIncreased risk of colon cancer in males Increased risk of arthritis in femalesIncreased risk of arthritis in females

IMPACT OF CHILDHOOD IMPACT OF CHILDHOOD OBESITY ON ADULT OBESITY ON ADULT HEALTHHEALTH Obesity in childhood was a more Obesity in childhood was a more

powerful predictor of these risks powerful predictor of these risks than obesity in adulthood!than obesity in adulthood!

CHILDHOOD CHILDHOOD COMPLICATIONS OF COMPLICATIONS OF PEDIATRIC OBESITYPEDIATRIC OBESITY

PSYCHOSOCIALPSYCHOSOCIAL

Most common complication of Most common complication of childhood obesitychildhood obesity

SelfSelf– Increased rates of depressionIncreased rates of depression– Poor self esteemPoor self esteem

May carry over into adulthoodMay carry over into adulthood

– Children are sensitized to obesity at Children are sensitized to obesity at young ageyoung age

PSYCHOSOCIALPSYCHOSOCIAL

SelfSelf– Mellbin, 1989Mellbin, 1989

Increased rates of behavior and learning Increased rates of behavior and learning problems in those gaining weight problems in those gaining weight rapidlyrapidly

Etiology uncertain, ? Sleep apneaEtiology uncertain, ? Sleep apnea

PEER RELATIONSHIPSPEER RELATIONSHIPS

Richardson, 1961Richardson, 1961– 10-11 year old children prefer friends 10-11 year old children prefer friends

with various handicaps vs. obesewith various handicaps vs. obese Staffieri, 1967Staffieri, 1967

– Children 6-10 years of age associate Children 6-10 years of age associate obesity with lazinessobesity with laziness

Obese children may choose Obese children may choose younger friends, less judgmentalyounger friends, less judgmental

PSYCHOSOCIALPSYCHOSOCIAL

Adult Relationships Adult Relationships – May have false expectations of child May have false expectations of child

based on their sizebased on their size

SOCIETAL SOCIETAL DISCRIMINATIONDISCRIMINATION

Canning, 1966Canning, 1966– Acceptance rates at college lower for Acceptance rates at college lower for

obese than non-obese females with the obese than non-obese females with the same credentialssame credentials

National Longitudinal Survey of Youth National Longitudinal Survey of Youth 19931993– Obese adolescent females as young adults Obese adolescent females as young adults

had less education, less income, higher had less education, less income, higher poverty rate, and decreased rates of poverty rate, and decreased rates of marriagemarriage

ENDOCRINE ENDOCRINE COMPLICATIONSCOMPLICATIONS Non-insulin-dependent diabetes Non-insulin-dependent diabetes

mellitusmellitus– Pinhas-Hamiel 1994Pinhas-Hamiel 1994

The incidence of NIDDM has increased 10 The incidence of NIDDM has increased 10 foldfold

One third of new diabetic children 10-19 One third of new diabetic children 10-19 years of age had Type II DMyears of age had Type II DM

92% of these had a BMI >90%92% of these had a BMI >90%

– Geisinger weight management Geisinger weight management programprogram

– 1-2% have type II DM1-2% have type II DM

ENDOCRINE ENDOCRINE COMPLICATIONSCOMPLICATIONS Insulin resistanceInsulin resistance

– Elevated fasting insulin levels with Elevated fasting insulin levels with normal Hgb A1Cnormal Hgb A1C

– Ratio of fasting insulin to glucose Ratio of fasting insulin to glucose Adult female: normal <1:4Adult female: normal <1:4 Normal for children not establishedNormal for children not established

– First step towards developing Type II First step towards developing Type II DMDM

Insulin Resistance

Obesity

Metabolic Syndrome SyndromeType 2DM

NASH

PCOSDyslipidemia

Hypertension

ENDOCRINE ENDOCRINE COMPLICATIONSCOMPLICATIONS Geisinger weight management Geisinger weight management

programprogram– 60% have insulin resistance60% have insulin resistance– 10% have fasting insulin level > 100 10% have fasting insulin level > 100

(Nl <17)(Nl <17)

ENDOCRINE ENDOCRINE COMPLICATIONSCOMPLICATIONS Acanthosis nigricansAcanthosis nigricans

– Velvety, hyperpigmented, thickened Velvety, hyperpigmented, thickened skinskin

– Associated with obesity and insulin Associated with obesity and insulin resistanceresistance Not sensitive for insulin resistanceNot sensitive for insulin resistance

– Resolves with weight lossResolves with weight loss

ENDOCRINE ENDOCRINE COMPLICATIONSCOMPLICATIONS Increased linear growth initiallyIncreased linear growth initially

– Growth plates may close earlierGrowth plates may close earlier Advanced bone ageAdvanced bone age Earlier onset of pubertyEarlier onset of puberty

POLYCYSTIC OVARY POLYCYSTIC OVARY SYNDROMESYNDROMEHyperandrogenism Hyperandrogenism Ovarian dysfunctionOvarian dysfunction

– OligomenorrheaOligomenorrhea– AmenorrheaAmenorrhea– 55% of adolescent females have polycystic 55% of adolescent females have polycystic

ovaries on USovaries on US Cutaneous manifestationsCutaneous manifestations

– HirsuitismHirsuitism– AcneAcne– Acanthosis nigricansAcanthosis nigricans

POLYCYSTIC OVARY POLYCYSTIC OVARY SYNDROMESYNDROME Insulin resistanceInsulin resistance HyperlipidemiaHyperlipidemia InfertilityInfertility Premature adrenarchePremature adrenarche Bacha F, Arslanian S. Enod Trends Bacha F, Arslanian S. Enod Trends

11(1)200411(1)2004

HYPERTENSIONHYPERTENSION

HypertensionHypertension– Primary hypertension uncommon in Primary hypertension uncommon in

childhoodchildhood– 60% of children with persistently 60% of children with persistently

elevated blood pressure had weight elevated blood pressure had weight >120% IBW >120% IBW

Lauer J Pediatr 1975;86:697-706.Lauer J Pediatr 1975;86:697-706.

– Use pediatric standardsUse pediatric standards– Geisinger weight management program Geisinger weight management program

45% have hypertension45% have hypertension

HYPERTENSIONHYPERTENSION

RiskRisk– Overweight adolescents have 8.5 Overweight adolescents have 8.5

fold risk of hypertension as adults.fold risk of hypertension as adults. Srinivasan Metab 1996;45:235-240.Srinivasan Metab 1996;45:235-240.

– Cardiac hypertrophy/LVH on Cardiac hypertrophy/LVH on ultrasound. ultrasound.

– Long term risk of CVD and strokeLong term risk of CVD and stroke

DYLIPIDEMIADYLIPIDEMIA

The atherosclerotic process The atherosclerotic process beings in childhood (Bogalusa beings in childhood (Bogalusa Heart Study)Heart Study)

Lipid levels tend to track with ageLipid levels tend to track with age

DYLIPIDEMIADYLIPIDEMIA

Overweight during adolescence Overweight during adolescence associated with associated with – 2.4 fold increase in prevalence of 2.4 fold increase in prevalence of

cholesterol >240mg/dl cholesterol >240mg/dl – 3 fold increase in LDL values 3 fold increase in LDL values

>160mg/dl >160mg/dl – 8 fold increase in HDL values<35 8 fold increase in HDL values<35

mg/dl in adults 27-31 yearsmg/dl in adults 27-31 years– Srinivasan Metab 1996;45:235-240.Srinivasan Metab 1996;45:235-240.

DYLIPIDEMIADYLIPIDEMIA

Geisinger weight management programGeisinger weight management program– 45% have hypercholesterolemia45% have hypercholesterolemia– Range of abnormal cholesterol: 175-338Range of abnormal cholesterol: 175-338

Freeman 1999Freeman 1999– 65% of obese 5-10 year old children have at 65% of obese 5-10 year old children have at

least one cardiovascular disease risk factorleast one cardiovascular disease risk factor– 25% of obese 5-10 year old children have 2 25% of obese 5-10 year old children have 2

or more risk factorsor more risk factors

NON-ALCOHOLIC NON-ALCOHOLIC FATTY LIVER DISEASEFATTY LIVER DISEASE Hepatic steatosisHepatic steatosis

– Increased fat in the liverIncreased fat in the liver– Steatohepatitis associated with liver Steatohepatitis associated with liver

inflammation and elevated liver inflammation and elevated liver enzymesenzymes

– 20%-25% obese children have 20%-25% obese children have evidence of steatohepatitisevidence of steatohepatitis

Tazawa Acta Paeditr 1997;86:238-241Tazawa Acta Paeditr 1997;86:238-241

INSULIN RESISTANCE INSULIN RESISTANCE AND FAT DEPOSITIONAND FAT DEPOSITION

Insulin resistance

Free Fatty AcidsInsulin resistance

Insulin resistance

insulin

Liver

Muscle

NON-ALCOHOLIC NON-ALCOHOLIC FATTY LIVER DISEASEFATTY LIVER DISEASE Liver disease can progress to fibrosis Liver disease can progress to fibrosis

or frank cirrhosisor frank cirrhosis Obesity and type 2 diabetes are the Obesity and type 2 diabetes are the

strongest predictors of progression of strongest predictors of progression of fibrosis fibrosis

Age is also a risk factor for cirrhosis Age is also a risk factor for cirrhosis which may reflect increased duration which may reflect increased duration of risk for the “second hit” thought to of risk for the “second hit” thought to initiate fibrosis. initiate fibrosis.

Angulo P, Keach JC, Batts KP, Lindor KD. Hepatology Angulo P, Keach JC, Batts KP, Lindor KD. Hepatology 1999;30(6):1356-621999;30(6):1356-62

NON-ALCOHOLIC NON-ALCOHOLIC FATTY LIVER DISEASEFATTY LIVER DISEASE RashidRashid

– 83% of children with steatohepatitis 83% of children with steatohepatitis were obesewere obese

– 75% had fibrosis-cirrhosis75% had fibrosis-cirrhosis Geisinger weight management Geisinger weight management

programprogram– 50 % have hepatomegaly50 % have hepatomegaly– 15% have elevated liver enzymes15% have elevated liver enzymes

CHOLELITHIASISCHOLELITHIASIS

Uncommon in children Uncommon in children – Increased risk in those with hemolytic Increased risk in those with hemolytic

disordersdisorders Obesity accounts for 8%-33% of Obesity accounts for 8%-33% of

gallstones in childrengallstones in children– Friesen Clin Pediatr 1989.7:294Friesen Clin Pediatr 1989.7:294

May be associated with weight lossMay be associated with weight loss– Crichlow Dig Dis. 1972;17:68-72Crichlow Dig Dis. 1972;17:68-72

CHOLELITHIASISCHOLELITHIASIS

Relative risk of gallstones in Relative risk of gallstones in adolescent girls with obesity is adolescent girls with obesity is 4.24.2– Honore Arch Surg 1980;115:62-64Honore Arch Surg 1980;115:62-64

50% of cholecystitis in 50% of cholecystitis in adolescents associated with adolescents associated with obesity obesity – Crichlow Dig Dis. 1972;17:68-72Crichlow Dig Dis. 1972;17:68-72

SLIPPED CAPITAL SLIPPED CAPITAL FEMORAL EPIPHYSISFEMORAL EPIPHYSIS

50%-70% patients with SCFE are obese.50%-70% patients with SCFE are obese.– Wilcox J Pediatr Orthop 1988:8:196-200Wilcox J Pediatr Orthop 1988:8:196-200

Suspect and immediately evaluate in an Suspect and immediately evaluate in an obese patient who presents with limp.obese patient who presents with limp.

Can also present with complaints of Can also present with complaints of groin, thigh, or knee paingroin, thigh, or knee pain

SLIPPED CAPITAL SLIPPED CAPITAL FEMORAL EPIPHYSISFEMORAL EPIPHYSIS

DiagnosisDiagnosis– Physical examinationPhysical examination

Motion of the hip in abduction and internal rotation is Motion of the hip in abduction and internal rotation is limited on examination.limited on examination.

– XrayXray AP view of pelvis to include both hips AP view of pelvis to include both hips Bilateral disease occurs in up to 20% of patientsBilateral disease occurs in up to 20% of patients Medial and posterior displacement of the femoral Medial and posterior displacement of the femoral

epiphysis through the growth plate relative to the epiphysis through the growth plate relative to the femoral neckfemoral neck

Busch MT. Orthop Clin North Am 1987;18(4):637-47Busch MT. Orthop Clin North Am 1987;18(4):637-47

BLOUNT’S DISEASEBLOUNT’S DISEASE

DiagnosisDiagnosis– Bowing of tibia and femur either unilateral Bowing of tibia and femur either unilateral

or bilateral.or bilateral. EtiologyEtiology

– Results from overgrowth of the medial Results from overgrowth of the medial aspect of the proximal tibial metaphysisaspect of the proximal tibial metaphysis

– 2/3 of patients with Blount’s disease are 2/3 of patients with Blount’s disease are obeseobese

Dietz J Pediatr 1982:101:735-737Dietz J Pediatr 1982:101:735-737

TreatmentTreatment– Surgery associated with weight lossSurgery associated with weight loss

OBSTRUCTIVE SLEEP OBSTRUCTIVE SLEEP APNEAAPNEA

OSAS in children is defined as a disorder of OSAS in children is defined as a disorder of breathing during sleep characterized by:breathing during sleep characterized by:– prolonged partial upper airway prolonged partial upper airway

obstructionobstruction– and/or intermittent complete obstruction and/or intermittent complete obstruction

(obstructive apnea)(obstructive apnea)– that disrupts normal ventilation during sleep that disrupts normal ventilation during sleep

and normal sleep patternsand normal sleep patterns Schechter MS. Technical report: diagnosis and management Schechter MS. Technical report: diagnosis and management

of childhood obstructive sleep apnea syndrome. Pediatrics of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):e69-79.2002;109(4):e69-79.

OBSTRUCTIVE SLEEP OBSTRUCTIVE SLEEP APNEAAPNEA 40% of severely obese children 40% of severely obese children

demonstrated central demonstrated central hypoventilationhypoventilation– Silvesti Pediatr Pulmonol 1993;16:124-Silvesti Pediatr Pulmonol 1993;16:124-

139139 Abnormal sleep patterns reported in Abnormal sleep patterns reported in

94% of obese children studied94% of obese children studied– Kahn A, Mozin MJ, Rebuffat E, Sottiaux Kahn A, Mozin MJ, Rebuffat E, Sottiaux

M, Burniat W, Shepherd S, et al. Sleep M, Burniat W, Shepherd S, et al. Sleep 1989;12(5):430-8.1989;12(5):430-8.

OBSTRUCTIVE SLEEP OBSTRUCTIVE SLEEP APNEAAPNEA Symptoms of sleep apnea Symptoms of sleep apnea

– Nighttime awakening / restless sleepNighttime awakening / restless sleep– Excessive snoring / apneaExcessive snoring / apnea– Difficulty awaking in the morningDifficulty awaking in the morning– Daytime somnolenceDaytime somnolence– Nocturnal enuresisNocturnal enuresis– Decreased ability to concentrateDecreased ability to concentrate

Poor school performance.Poor school performance. Gozal D. Sleep-disordered breathing and school Gozal D. Sleep-disordered breathing and school

performance in children. Pediatrics 1998;102(3 performance in children. Pediatrics 1998;102(3 Pt 1):616-20.Pt 1):616-20.

OSAS - ETIOLOGYOSAS - ETIOLOGY

Increased fat mass in pharynx, Increased fat mass in pharynx, neck, chest and diaphragmneck, chest and diaphragm

Increased muscle relaxation Increased muscle relaxation during sleepduring sleep

Enlarged tonsils and adenoidsEnlarged tonsils and adenoids– Silvestri JM, Weese-Mayer DE, Bass Silvestri JM, Weese-Mayer DE, Bass

MT, Kenny AS, Hauptman SA, Pearsall MT, Kenny AS, Hauptman SA, Pearsall SM. Pediatr Pulmonol 1993;16(2):124-SM. Pediatr Pulmonol 1993;16(2):124-99

OSAS-DIAGNOSISOSAS-DIAGNOSIS

History, audio and video taping, and History, audio and video taping, and overnight oximetry are poor predictors overnight oximetry are poor predictors

The definitive diagnosis of OSAS is The definitive diagnosis of OSAS is made by nighttime polysomnographymade by nighttime polysomnography– Clinical practice guideline: diagnosis and Clinical practice guideline: diagnosis and

management of childhood obstructive sleep management of childhood obstructive sleep apnea syndrome. [No authors listed.] apnea syndrome. [No authors listed.] Pediatrics 2002;109(4):704-12Pediatrics 2002;109(4):704-12

Severity of obstruction may not Severity of obstruction may not correlate with either degree of obesity correlate with either degree of obesity or severity of sleep symptomsor severity of sleep symptoms

OBSTRUCTIVE SLEEP OBSTRUCTIVE SLEEP APNEAAPNEA

Children with sleep apnea demonstrate Children with sleep apnea demonstrate significant decreases in learning, significant decreases in learning, attention span and memoryattention span and memory

– Rhodes J Pediatr 1995;127:741-744.Rhodes J Pediatr 1995;127:741-744.– Greenberg GD, Watson RK, Deptula D.. Greenberg GD, Watson RK, Deptula D..

Sleep 1987;10(3):254-62.Sleep 1987;10(3):254-62.

OBSTRUCTIVE SLEEP OBSTRUCTIVE SLEEP APNEAAPNEA Pulmonary hypertension,systemic Pulmonary hypertension,systemic

hypertension, right heart failurehypertension, right heart failure– .Tal A, Leiberman A, Margulis G, Sofer .Tal A, Leiberman A, Margulis G, Sofer

S. Pediatr Pulmonol 1988;4(3):139-43S. Pediatr Pulmonol 1988;4(3):139-43– Marcus CL, Greene MG, Carroll JL. Am J Marcus CL, Greene MG, Carroll JL. Am J

Respir Crit Care Med 1998;157(4 Pt Respir Crit Care Med 1998;157(4 Pt 1):1098-1031):1098-103

– Massumi RA, Sarin RK, Pooya M,Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis Chest Reichelderfer Dis Chest 1969;55(2):110-41969;55(2):110-4

OSAS - TREATMENTOSAS - TREATMENT

Weight loss Weight loss – Willi SM, Oexmann MJ, Wright NM, Willi SM, Oexmann MJ, Wright NM,

Collop NA, Key LL Jr. Pediatrics Collop NA, Key LL Jr. Pediatrics 1998;101(1 Pt 1):61-71998;101(1 Pt 1):61-7

Continuous positive airway Continuous positive airway pressure (CPAP) or bilevel positive pressure (CPAP) or bilevel positive airway pressure (BPAP)airway pressure (BPAP)

TonsilladenoidectomyTonsilladenoidectomy

PSUEDOTUMOR PSUEDOTUMOR CEREBRICEREBRI DefinitionDefinition

– Raised intracranial pressure with Raised intracranial pressure with papilledema and a normal papilledema and a normal cerebrospinal fluid in the absence cerebrospinal fluid in the absence of ventricular enlargementof ventricular enlargement

Obesity occurs in 30%-80% of Obesity occurs in 30%-80% of children with psuedotumor cerebrichildren with psuedotumor cerebri– Scott Am J Opth 1997; 124:253-255Scott Am J Opth 1997; 124:253-255

PSUEDOTUMOR PSUEDOTUMOR CEREBRICEREBRI May present with headaches, May present with headaches,

vomiting, blurred vision or vomiting, blurred vision or diplopiadiplopia

Neck, shoulder, and back pain Neck, shoulder, and back pain have also been reportedhave also been reported– Lessell S. Surv Ophthalmol Lessell S. Surv Ophthalmol

1992;37(3):155-661992;37(3):155-66 Papilledema is part of pathology Papilledema is part of pathology

but may not occur at presentationbut may not occur at presentation

John A Moran Eye Center, Salt Lake City UT

PSUEDOTUMOR PSUEDOTUMOR CEREBRICEREBRI Loss of peripheral visual fields Loss of peripheral visual fields

and reduction in visual acuity and reduction in visual acuity may be present at diagnosismay be present at diagnosis– Baker RS, Carter D, Hendrick EB, Buncic Baker RS, Carter D, Hendrick EB, Buncic

JR. Arch Ophthalmol 1985;103(11):1681-6.JR. Arch Ophthalmol 1985;103(11):1681-6.

Increased intracranial pressure Increased intracranial pressure may lead to visual impairment or may lead to visual impairment or blindness.blindness.

PSUEDOTUMOR PSUEDOTUMOR CEREBRICEREBRI Weight lossWeight loss

– Newborg B. Arch Intern Med Newborg B. Arch Intern Med 1974;133(5):802-71974;133(5):802-7

AcetazolamideAcetazolamide Lumboperitoneal shunt in severe Lumboperitoneal shunt in severe

casescases

CONCLUSIONS CONCLUSIONS REGARDING REGARDING PEDIATRIC OBESITYPEDIATRIC OBESITY

PEDIATRIC OBESITY PEDIATRIC OBESITY IS NOT JUST A IS NOT JUST A COSMETIC COSMETIC PROBLEM!PROBLEM!

COMPLICATIONS ARE COMPLICATIONS ARE COMMON IN PEDITRIC COMMON IN PEDITRIC OBESITYOBESITY All children with BMI> 95% should All children with BMI> 95% should

be evaluated for associated co-be evaluated for associated co-morbiditiesmorbidities– Physical examinationPhysical examination

BPBP Fundiscopic examFundiscopic exam Hip and knee examinationHip and knee examination Acanthosis nigricansAcanthosis nigricans Hirsutism / acneHirsutism / acne HepatomegalyHepatomegaly

COMPLICATIONS ARE COMPLICATIONS ARE COMMON IN PEDITRIC COMMON IN PEDITRIC OBESITYOBESITY Laboratory evaluationLaboratory evaluation

– Fasting lipid profileFasting lipid profile– Liver panelLiver panel– Fasting insulin and glucoseFasting insulin and glucose– Hgb A1CHgb A1C

To be consideredTo be considered– PolysomnogramPolysomnogram– Abdominal USAbdominal US

THANK YOU!THANK YOU!

SCFE: ASSOCIATED SCFE: ASSOCIATED CAUSESCAUSES Continued weight gainContinued weight gain Renal failureRenal failure History of radiation therapyHistory of radiation therapy Primary hypothyroidismPrimary hypothyroidism

– Loder RT, Greenfield ML.. J Pediatr Orthop . Loder RT, Greenfield ML.. J Pediatr Orthop . 2001;21(4):481-72001;21(4):481-7

Gonadotropin-releasing hormone agonistsGonadotropin-releasing hormone agonists Growth hormone therapyGrowth hormone therapy

– Kempers MJ, Noordam C, Rouwe CW, Otten Kempers MJ, Noordam C, Rouwe CW, Otten BJ. J Pediatr Endocrinol Metab BJ. J Pediatr Endocrinol Metab 2001;14(6):729-342001;14(6):729-34

Pseudotumor Cerebri - Pseudotumor Cerebri - Associated ConditionsAssociated Conditions

Mastoiditis.Mastoiditis. Lateral sinus thrombosis.Lateral sinus thrombosis. Hypoparathyroidism,Hypoparathyroidism, Steroid treatment and withdrawal.Steroid treatment and withdrawal. Thyroid replacement,Thyroid replacement, SLE.SLE.

Green M. Pediatr Clin North Am 1967;14(4):819-30.Green M. Pediatr Clin North Am 1967;14(4):819-30. Palmer RF, Searles HH, Boldrey EB.. J Neurosurg 1959;16(4):378-84.Palmer RF, Searles HH, Boldrey EB.. J Neurosurg 1959;16(4):378-84. Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol 1989;5(1):5-11.Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol 1989;5(1):5-11. Walker AE, Adamkiewicz JJ. JAMA 1964;188:779-84.Walker AE, Adamkiewicz JJ. JAMA 1964;188:779-84. Neville BG, Wilson J.. Br Med J 1970;3(722):554-6.Neville BG, Wilson J.. Br Med J 1970;3(722):554-6. Huseman CA, Torkelson RD.. Am J Dis Child 1984;138(10):927-31.Huseman CA, Torkelson RD.. Am J Dis Child 1984;138(10):927-31. DelGiudice GC, Scher CA, Athreya BH, Diamond GR.. J Rheumatol 1986;13(4):748-DelGiudice GC, Scher CA, Athreya BH, Diamond GR.. J Rheumatol 1986;13(4):748-

52.52.

Drugs Associated With Drugs Associated With Pseudotumor Pseudotumor CerebriCerebri

Growth hormone therapyGrowth hormone therapy Nalidixic acid,Ciprofloxacin,Tetracycline therapy Nalidixic acid,Ciprofloxacin,Tetracycline therapy

– No clear dose-response relationship No clear dose-response relationship Lessell S. Surv Ophthalmol 1992;37(3):155-66.Lessell S. Surv Ophthalmol 1992;37(3):155-66.

Vitamin A and isoretinoin therapy are Vitamin A and isoretinoin therapy are established causes of pseudotumor cerebriestablished causes of pseudotumor cerebri..

Morrice G Jr, Havener WH, Kapetansky F. JAMA Morrice G Jr, Havener WH, Kapetansky F. JAMA 1960;173:1802-5.1960;173:1802-5.

Roytman M, Frumkin A, Bohn TG. Cutis 1988;42(5):399-400.Roytman M, Frumkin A, Bohn TG. Cutis 1988;42(5):399-400.