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Associated Comorbidities of Pediatric Obesity

Associated Comorbidities of Pediatric Obesity . Sandra G Hassink, MD, FAAP Director Weight Management Program A I duPont Hospital for Children Wilmington, DE. Severe Obesity Related Emergencies. Hyperglycemic Hyperosmolar state DKA Pulmonary emboli Cardiomyopathy of obesity

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Associated Comorbidities of Pediatric Obesity

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  1. Associated Comorbidities of Pediatric Obesity Sandra G Hassink, MD, FAAP Director Weight Management Program A I duPont Hospital for Children Wilmington, DE

  2. Severe Obesity Related Emergencies • Hyperglycemic Hyperosmolar state • DKA • Pulmonary emboli • Cardiomyopathy of obesity • Complications of Bariatric Surgery

  3. Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, et al. CMAJ. 2003 Apr 1;168(7):859-66.

  4. Hyperglycemic Hyperosmolar State “Death caused by hyperglycemic Hyperosmolar state at the onset of type 2 diabetes."Morales AE, Rosenbloom AL.J Pediatric 2004 Feb 144 (2) 270-3. • “Seven obese African American youth were considered to have died from diabetic ketoacidosis.”

  5. Hyperglycemic Hyperosmolar State • “Despite meeting the criteria for Hyperglycemic Hyperosmolar state and not for DKA.” • “All had previously unrecognized type 2 diabetes, and death may have been prevented with earlier diagnosis or treatment.”

  6. Hyperglycemic Hyperosmolar State • Patients presented to medical care with symptoms which were not linked to presentation of type 2 diabetes. • Vomiting. • Abdominal Pain. • Dizziness. • Weakness. • Polyuria/Polydipsia. • Weight loss. • Diarrhea.

  7. Hyperglycemic Hyperosmolar State • HHS- diagnostic criteria • plasma glucose > 600mg/dl • Arterial pH >7.3 • serum bicarbonate > 15 mmol/l • Serum ketones none-trace • Urine ketones none-trace • effective serum osmolality >320 mOsm/kg • stupor or coma • Rubin HM J Pediatr 1969:74:`77-86 • Morales A J Pediatr 2004 Feb, 270-273 • Chiasson JLCMAJ. 2003 Apr 1;168(7):859-66.

  8. Pulmonary Embolism • Classic Symptoms • Dyspnea • Chest pain • Decreased O2 • Hemoptysis • Other Signs/Symptoms: • Back, shoulder, upper abdominal pain • Painful respiration • Cyanosis • Syncope • Cardia Arrhythmia • New onset of wheezing • Obstructive Sleep Apnea and Coagulation disorders increase risk • Most common complication of gastric bypass/banding in adults, has been reported in adolesents after surgery • Sugerman HJ, Sugerman EL, DeMaria EJ, et al Gastrointest Surg. 2003 Jan: 7(1):102-07

  9. Cardiomyopathy of Obesity • Cardiac steatosis • Left ventricular dysfunction. • dilation • increased left ventricular wall stress • compensatory (eccentric) left ventricular hypertrophy • left ventricular diastolic dysfunction • Right Ventricular dysfunction • Exacerbated by pulmonary hypertension due to UAO • Alpert, MA Am J Med Sci 2001 Apr, 321(4);225-36.

  10. Roux-en-Y Gastric Bypass-Early Complications • Bleeding • Bowel Perforation • DVT/PE • Dehydration • Dysphagia • Nausea/Vomiting • Small Bowel Obstruction • Anastomotic Leak • Peritonitis

  11. Roux-en-Y Gastric Bypass-Late Complications • Cholecystitis • Dysphagia • GERD • Incisional Hernia • Malnutrition • Pancreatitis • Ulcers • Renal Calculi • Strictures • Internal Hernia • Small Bowel Obstruction

  12. Lap-Band Adverse Events • Intra operative • Iatrogenic gastrostomy • Early Post-operative • Hemorrhage • Port infection • Stomal obstruction • Perforation • Late complications • Mechanical dysfunction • Erosion • Slippages Ponce, et al., 2005

  13. Post Bariatric Surgery Mediation Considerations • No aspirin or aspirin containing products • No non steroidal anti inflammatory agents • All medications should be crushed (no extended release or enteric coated products)

  14. Potential Metabolic Complications from Bariatric Surgery • Anemia • Fe, B12, copper, vitamins A and E, deficiency or an imbalance in zinc intake • Neurologic Complications - Related to Vitamin B12 deficiency • Ophthalmoplegia • Nystagmus • Ataxia • Peripheral Neuropathy • Impaired memory • Gallstone Formation von Drygalski A, Andris DA. Nutr Clin Pract. 2009 Apr-May;24(2):217-26

  15. Potential Metabolic Complications from Bariatric Surgery • Hyperparathyroidism –Ca and vitamin D def • Aches/pains • Depression • Abdominal pain, Nausea/Vomiting • Excessive urination • Confusion • Muscle Weakness, Fatigue • Protein deficiency • Hair loss • Edema • Hypoalbuminemia • Anemia • Extreme Fatigue • Inability to walk

  16. Co-morbidity's Requiring Immediate Attention • Pseudotumor Cerebri • Slipped Capital Femoral Epiphysis • Blount’s Disease • Sleep Apnea • Non alcoholic hepatosteatosis • Cholelithiasis

  17. John A Moran Eye Center, Salt Lake City UT

  18. Pseudotumor Cerebri • Definition. • Raised intracranial pressure with papilledema and a normal cerebrospinal fluid in the absence of ventricular enlargement. • Risk • Obesity occurs in 30%-80% of affected children. • Scott Am J Opth 1997; 124:253-255 • In a series of case-controlled studies in adolescents and adults, obesity and recent weight gain were the only factors found significantly more often in pseudotumor cerebri patients than control patients. • Lessell S. SurgOphthalmol 1992;37(3):155-66.

  19. Pseudotumor Cerebri • Diagnosis • May present with headaches, vomiting, blurred vision or diplopia. • Neck, shoulder, and back pain have also been reported. • Lessell S. Surv Ophthalmol 1992;37(3):155-66. • Loss of peripheral visual fields and reduction in visual acuity may be present at diagnosis • Baker RS, Carter D, Hendrick EB, Buncic JR. Arch Ophthalmol 1985;103(11):1681-6. • Increased intracranial pressure may lead to visual impairment or blindness. • Treatment • Acetazolamide • Lumboperitoneal shunt (in severe cases), • Weight loss • Newborg B. Arch Intern Med 1974;133(5):802-7.

  20. Pseudotumor Cerebri - Associated Conditions • Mastoiditis and lateral sinus thrombosis • Hypoparathyroidism, Pseudohypoparathyroidism • Steroid treatment and withdrawal • Thyroid replacement • SLE • Green M. Pediatr Clin North Am 1967;14(4):819-30.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.Walker AE, Adamkiewicz JJ. JAMA 1964;188:779-84.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.DelGiudice GC, Scher CA, Athreya BH, Diamond GR.. J Rheumatol 1986;13(4):748-52. • Medication associated with no clear does-response relationship • Nalidixic acid • Ciprofloxacin • Tetracycline • Lessell S. Surv Ophthalmol 1992;37(3):155-66. • Vitamin A and isoretinoin therapy are established causes of pseudotumor cerebri. • Morrice G Jr, Havener WH, Kapetansky F. JAMA 1960;173:1802-5. • Roytman M, Frumkin A, Bohn TG. Cutis 1988;42(5):399-400.

  21. Points to Remember • A fundiscopic examination should be a routine part of the examination of the obese child • Children may not complain of visual field disturbances. When suspicious – test • Pseudotumor cerebri is essentially a diagnosis of exclusion after other causes of increased intracranial pressure are eliminated.

  22. Slipped Capital Femoral Epiphysis • Diagnosis • Suspect and immediately evaluate in an obese patient who presents with limp. • 50%-70% patients with SCFE are obese. • Wilcox J Pediatr Orthop 1988:8:196-200. • Can also present with complaints of groin, thigh, or knee pain referred by obturator nerve

  23. Slipped Capital Femoral Epiphysis • Diagnosis • Motion of the hip in abduction and internal rotation is limited on examination. • X- ray • Anteroposterior view of the pelvis and frog leg that includes both hips. • Comparison of the hips • Bilateral disease occurs in up to 20% of patients. • Intervention • Requires surgical correction and weight loss.

  24. SCFE-Pathology • Medial and posterior displacement of the femoral epiphysis through the growth plate relative to the femoral neck • Busch MT, Morrissy RT. Orthop Clin North Am 1987;18(4):637-47. • The preferential site of slipping within the epiphysis is a zone of hypertrophic cartilage cells under the influence of both gonadal hormones and growth hormone • Kempers MJ, Noordam C, Rouwe CW, Otten BJ. CanJ Pediatr Endocrinol Metab 2001;14(6):729-34. • .

  25. SCFE - Associated Causes • Continued weight gain. • Renal failure • History of radiation therapy • Primary hypothyroidism. • Loder RT, Greenfield ML.. J Pediatr Orthop . 2001;21(4):481-7. • Gonadotropin-releasing hormone agonists • Growth hormone therapy • Kempers MJ, Noordam C, Rouwe CW, Otten BJ. J Pediatr Endocrinol Metab 2001;14(6):729-34. • Grumbach MM, Bin-Abbas BS, Kaplan SL. Horm Res 1998;49(Suppl 2);41-57.

  26. Blount’s disease Bowing of tibia and femur either unilateral or bilateral. • 2/3 of patients with Blount’s • disease may be obese. • Dietz J Pediatr 1982:101:735-737.

  27. Blounts Disease

  28. Blount’s Disease - Obesity Related Orthopedic Morbidity • Etiology • Injury to the growth plate, fissuring and clefts in the physis as well as fibrovascular and cartilaginous repair tissue at the physeal-metaphyseal junction. • .Wenger DR, Mickelson M, Maynard JA.J Pediatr Orthop. 1984 Jan;4(1):78-88. • Results from overgrowth of the medial aspect of the proximal tibial metaphysis. • Treatment • Requires evaluation and correction by orthopedic surgeon. • Weight loss

  29. Blount’s disease

  30. Points to Remember • A careful hip and knee examination should be a routine part of the evaluation and follow-up of every obese child. • An obese child complaining of or presenting with hip, knee, groin, or thigh pain should have a complete and thorough examination of his/her hips, including radiological studies. • In an obese child, an unusual or abnormal gait should not be attributed to “excess weight” but should be thoroughly investigated with a careful hip and knee examination.

  31. 2.bp.blogspot.com/.../GCODtaW6Av4/s320/bipap.jpg /www.airecoremedicalservices.com/pic02.jpg

  32. Upper Airway Obstructive Sleep Apnea Syndrome • Structure • Adipose tissue in upper airway contributes to Upper Airway Obstruction • Shelton KE, et al Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis. 1993;148(2):462–466 • Abdominal adiposity maycompromise respiratory excursion • Kessler R et al The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases. Chest. 2001;120(2):369–376. • Function • Infiltration of adipocytes into diaphragmatic muscles may alter respiratory mechanics • Fadell E et al. Fatty infiltration of the respiratory muscles in the Pickwickian syndrome. N Engl J Med. 1962;266(17):861–863.

  33. Obstructive Sleep Apnea • OSAS in children is defined as a disorder of breathing during sleep characterized by. • prolonged partial upper airway obstruction. • and/or intermittent complete obstruction (obstructive apnea). • that disrupts normal ventilation during sleep and normal sleep patterns. • Schechter MS. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):e69-79.

  34. Airway Mechanics: • Dynamic relationship: • Negative intra-thoracic pressure during inspiration: • Always a closing pressure • Airway size and shape: • This may favor airway opening or closure • Airway tone: • Tissue rigidity • Neuromuscular: • Too much: Airway constriction • Too little: Airway collapse Fricke, BL et al: Korean J Radiol 8(6), December 2007 Courtesy of Dr. Aaron Chidikel

  35. Obstructive Sleep Apnea Effects • Cognitive • Decreases in learning and memory. • Rhodes J Pediatr 1995;127:741-744. • Deficits in attention, motor efficiency and graphomotor ability. • Greenberg GD, Watson RK, Deptula D.. Sleep 1987;10(3):254-62. • Cardiopulmonary • Pulmonary hypertension,systemic hypertension, right heart failure. • Tal A, Leiberman A, Margulis G, Sofer S. Pediatr Pulmonol 1988;4(3):139-43. • Marcus CL, Greene MG, Carroll JL. Am J Respir Crit Care Med 1998;157(4 Pt 1):1098-103. • Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis Chest 1969;55(2):110-4. • Sleep disturbance • Weight >200% above ideal had oxygen saturation <90% for half to total sleep time. • 40% of severely obese children demonstrated central hypoventilation. • Silvesti Pediar Pulmonol 1993;16:124-139.

  36. Evaluation- History • Nighttime symptoms Daytime symptoms • Snoring Morning headache • Restless sleeping Daytime tiredness • Heavy or noisy breathing Napping • Orthopnea Poor school function • Frequent night awakening Inattentiveness • Enuresis Short term memory • Observed apnea deficit • Diaphoresis Irritability • Cyanosis Elevated blood pressure

  37. OSAS-diagnosis • Symptom checklists in research settings • Chervin RD et Sleep Med. 2000;1(1):21–32 • History, audio and video taping, and overnight oximetry and daytime nap polysomnography are poor predictors of OSAS. • The definitive diagnosis of OSAS is made by nighttime polysomnography. • Clinical practice guideline: Pediatrics 2002;109(4):704-12. • Severity of obstruction may not correlate with either degree of obesity or severity of sleep symptoms.

  38. Treatment • Definitive treatment is weight loss • Willi SM et al Pediatrics. 1998;101(1 Pt 1):61–67. • Tonsil/Adenoidectomy-temporizing • CPAP/BIPAP-Titrated in sleep lab • Marcus CL et al.J Pediatr. 1995;127(1)(((3):88–94. • Extreme cases unresponsive to weight loss/BiPap/CPAP uvulopharyngopalatoplasty, craniofacial surgery, and, in severe cases, tracheostomy • Section on Pediatric Pulmonology, Pediatrics. 2002;109(4):704–712. • Gastric Bypass/Banding in adults

  39. Points to Remember • Ask specifically about sleep disturbances, snoring, and sleep position. Families will often disregard these symptoms. • Obstructive sleep apnea syndrome should be especially considered in obese children with poor school performance and concentration difficulties. • Sleep symptoms can evolve over time. Keep asking about sleep disturbance as you follow these children. Weight gain, intercurrent upper respiratory infections, and Tonsillar enlargement can provoke symptoms.

  40. Asthma Classic example of an obstructive lung disorder Airway obstruction: Inflammation Bronchospasm Mucus plugging Airway reactivity: Response to triggers Reversible airflow obstruction Obesity Classic example of a restrictive lung disorder Chest wall restriction: Body mass Abdominal fat Decreased breathing movements Lung compression Tissue deposition of fat: Airway narrowing Fixed airflow obstruction Asthma and obesity:Respiratory physiology Courtesy of Dr. Aaron Chidikel

  41. Pulmonary - Asthma • Pulmonary mechanics change with obesity • Decreased lung volumes and thoracic distensibility • Fung KP, et al. Arch Dis Child. 1990;65(5):512–515. • Breathing pattern: Higher frequency, lower tidal volume. • Weiss S, et al.Obesity and Asthma Direction for Research NHLBI Workshop. Am J Respir Crit Care Med. 2004;169;963–968 • Obesity may contribute to severity of asthma • Obese asthmatic children have more missed school days, receive more medication and have lower peak expiratory flow rates than non obese asthmatic children. • Luder E, et al. J Pediatr. 1998;132(4):699–703. • Increase cough, wheeze and dyspnea. • del Rio-Navaro B, et al. Allergol Immunopathol (Madr). 2000;28(1):5–11.

  42. Pulmonary- Asthma • Bronchial hyperreponsiveness increases in obesity • Szilagyi PG et al. Pediatr Ann. 1999;28(1):43–52 • Weight reduction in obese patients reduces asthma symptoms. • Weiss S, Shore S. Am J Respir Crit Care Med. 2004;169;963–968 • Gastroesophageal reflux is increased in obesity • Leptin is increased in obese children and in normal weight asthmatic boys vs. non asthmatic boys. • Inflammatory cytokines may exacerbate asthma. • Guler N et al. J Allergy Clin Immunol. 2004;114(2):254–259.

  43. Asthma- Evaluation and Treatment • Obese children, if inactive may not report symptoms unless specifically asked. • Altered activity patterns • Dropping out of sports • Slowing down • Losing interest • As exercise increases during treatment of obesity, symptoms of exercise induced asthma may emerge • It is important to optimize asthma treatment in every obese, asthmatic child

  44. NAFLD to NASH Obesity Fatty Liver/Steatosis Genetic Predisposition 2nd “Hit” Inflammation Fibrosis Cirrhosis • Day CP, James OF. Gastroenterology 1998;114(4):842-5. • Harrison SA, Diehl AM. Semin Gastrointest Dis 2002;13(1): 3-16.

  45. Non Alcoholic Steatohepatitis - Obesity • Diagnosis • Increased liver enzymes and fatty liver on ultrasound in the absence of other causes of liver disease. • Rule out other causes of fatty liver • Liver Biopsy • Etiology • 20%-25% obese children have evidence of steatohepatitis. • Tazawa Acta Paeditr 1997;86:238-241. • Obesity and type 2 diabetes are the strongest predictors of progression of fibrosis • Age is also a risk factor for cirrhosis which may reflect increased duration of risk for the “second hit” thought to initiate fibrosis. • Angulo P, Keach JC, Batts KP, Lindor KD. Hepatology 1999;30(6):1356-62.

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