Case 4 (Jimmy): WCC at 8 years with ADHD, obesity, and HTN

Question 1

Obesity in children: Epidemiology

Answer 1

• Prevalence of childhood overweight and obesity in U.S. has doubled in past 20 years
• Currently, approximately 15% of 6 to 19-year-olds are > 95th percentile for BMI on standard growth charts based on reference data from the 1970s; higher rates among minority and economically disadvantaged children.
• Probability of childhood obesity persisting into adulthood:
  20% at age 4 years
  Approximately 80% in adolescence
• Comorbidities will likely persist into adulthood.

Question 2

Obesity in children: Risk factors

Answer 2

Genetic conditions, including:

• Prader-Willi syndrome
• Bardet-Biedl syndrome
• Cohen syndrome

Birth history:

• High birth weight
• Maternal diabetes.

Family history of obesity:

• For young children, if one parent is obese, odds ratio is about 3 that child will be obese in adulthood.
• If both parents are obese, odds ratio is > 10.
• Before age 3 years, parental obesity is a stronger predictor of obesity in adulthood than child’s own weight status.

Critical periods of excessive weight gain:

• Infancy: Extent and duration of breastfeeding inversely associated with risk of obesity in later childhood (possibly due to physiologic factors in human milk, feeding/parenting patterns)
• Adolescence: Normal tendency during early puberty for insulin resistance; early menarche; risk of obesity persisting into adulthood higher among obese adolescents than among younger children.

Environmental:

• Family/parental dynamics
• Lack of safe places for physical activity
• Inconsistent access to healthful food choices
• Low cognitive stimulation in home
• Low socioeconomic status

Question 3

Obesity in children: Sequelae

Answer 3

Hypertension:

• Found to occur up to nine times more frequently in overweight children
• Approximately 1/3 of children with a BMI > 95th percentile are hypertensive.

Obstructive sleep apnea

Pickwickian syndrome

Morbid obesity may directly cause restrictive lung disease, but is not causally linked with reactive airway disease (RAD). (Conversely, poorly controlled RAD, which in turn impairs exercise tolerance, may contribute to obesity.)

Endocrine:

• Insulin resistance (may correlate with acanthosis nigricans on exam)
• Hyperinsulinism
• Type 2 DM
• Obesity typically advances bone age and leads to early puberty

Gastrointestinal:

• Nonalcoholic steatohepatitis
• Gallbladder disease

Orthopedic:
- Blount disease
- Slipped capital femoral epiphysis (SCFE):
Involves displacement of femoral head from femoral neck through physeal plate.
Most commonly occurs at the onset of puberty in obese patients with delayed sexual maturation.
Typical symptoms include an antalgic gait due to pain referred to the hip, thigh, and/or knee, with limited range of motion (especially internal rotation) on examination of the hip.
SCFE can be diagnosed on plain X-rays of the pelvis, which shows widening of the physis.

Question 4

ADHD in children: Diagnosis

Answer 4

There is no laboratory test. Diagnosis of ADHD is based on a set of characteristic clinical findings. Core symptoms:

• Inattention
• Hyperactivity
• Impulsivity

Question 5

ADHD in children: Epidemiology

Answer 5

• Estimated prevalence in the U.S. is about 8–10%, making ADHD the most common neurobehavioral disorder of childhood and among the most common chronic health conditions in school-aged children.
• Not all children with ADHD have obvious behavioral problems, especially those with predominantly inattentive—not hyperactive—type.
• Girls, who more often have the inattentive type, may be significantly impaired socially and academically, yet go unrecognized.

Question 6

Diabetes in children: Etiology

Answer 6

• Type 1 DM is characterized by insulin deficiency, typically due to autoimmune destruction of pancreatic beta cells.
• Type 2 DM is more heterogeneous, but typically involves insulin resistance.

Question 7

Diabetes in children: Presentation

Answer 7

• Patients with Type 2 DM typically have a more indolent presentation than patients with Type 1 DM.
• In Type 2 DM, weight loss is less common, and diabetic ketoacidosis (DKA) is rare, although 25% of patients with Type 2 DM will have ketonuria at diagnosis.
• “Accidental” diagnosis by routine laboratory screening, especially urinalysis, occurs in up to one third of patients with Type 2 DM; this presentation is rare in Type 1 DM.

Question 8

Diabetes in children: Epidemiology

Answer 8

• Type 1 DM is more likely to present in early childhood.
• Age is not generally helpful in differentiating between Type 1 and Type 2 DM in adolescence.
• The Centers for Disease Control (CDC) reports that type 2 DM (previously “non–insulin dependent” or “adult-onset” DM) represented 19% of all DM cases in children between 2002 and 2005. Though most of these patients are adolescents, rare cases have been reported in children as young as 5 years old. The trend is clearly rising.

Question 9

Diabetes in children: Diagnosis

Answer 9

• Symptoms of DM (polyuria, polydipsia, polyphagia or weight loss), plus random blood glucose level > 200 mg/dL (> 11.1 mmol/L) Or,
• Fasting serum glucose > 126 mg/dL (> 7.0 mmol/L) Or,
• 2-hour serum glucose > 200 mg/dL (> 11.1 mmol/L) during oral glucose tolerance test

Question 10

American Diabetes Association Guidelines for Testing for Type 2 DM in Children and Adolescents (criteria, risk factors, timing, frequency, preferred test)

Answer 10

Criteria:
- Overweight
- BMI > 85th percentile
- Weight:height > 85th percentile
- Weight > 120% ideal for height plus any two of following risk factors:
Family history of type 2 DM in first- or second-degree relative
Race/ethnicity (American Indian, African-American, Hispanic, Asian/Pacific Islander)
Signs of insulin resistance (acanthosis nigricans, polycystic ovary syndrome, hypertension, dyslipidemia)

Timing:
- Start screening at age 10 years or at onset of puberty, whichever earlier

Frequency:
- Every 2 years

Preferred test:
- Fasting serum glucose

Question 11

Hypertension in children: When to start measuring

Answer 11

Measure blood pressure (BP) yearly starting at age 3 years as part of routine health maintenance visits.

Question 12

Hypertension in children: Classification

Answer 12

Classification: Systolic and diastolic BP percentile
(based on age, gender, height, and weight)

• Normal: < 90th
• Prehypertension: 90th to 95th
• Stage 1 hypertension: 95th to 99th—plus 5 mmHg
• Stage 2 hypertension: > 99th—plus 5 mmHg

Question 13

Hypertension in children: Etiology (Primary vs. Secondary)

Answer 13

Most blood pressure elevation in children > age 6 years and in adolescents is due to primary hypertension, for which obesity has been found to be an important correlate.

Secondary causes of hypertension, such as renal parenchymal disease and coarctation of the aorta, are more important to consider in young patients who have substantial elevation of blood pressure (often above the 99th percentile) and have little family history of hypertension, but they can also occur in older children and adolescents. Secondary causes also include:

• Placement of umbilical arterial or venous line as neonate might predispose to renal vascular disease.
• Renal scarring due to childhood urinary tract infections
• Catecholamine excess (e.g., pheochromocytoma or neuroblastoma)

Question 14

Review of Immunization Record

Answer 14

Ensure that childhood vaccine series are complete.

Influenza vaccine(s) if patient is being seen in flu season:
- The first year of immunization with either the killed injected or live intranasal vaccine, children < 9 years need two doses one month apart. Thereafter, an annual single dose of vaccine.

Hepatitis A vaccine:

• Recommended for children > than 23 months who live in areas where vaccination programs target older children, who are at increased risk for infection, or for whom immunity against hepatitis A is desired.
• Now routinely recommended at 12 and 18 months.

Question 15

Important factors to consider while taking a history of an obese child:

Answer 15

• Reproductive system (menstrual irregularity). Early menarche, not delayed puberty, has been associated with a BMI > 85th percentile.
• Psychiatric concerns (depression, low self-esteem)

Question 16

Physical Exam (weight assessment, weight classification, measuring blood pressure)

Answer 16

Weight assessment

• Weight age = Age at which weight plots at 50th percentile (Pro: Useful visual tool. Con: Does not take child’s height into account.)
• BMI = (weight in kg)/(height in meters)^2
• BMI better reflects the amount of body fat compared with weight from muscle or bone than weight-for-height measurements.

Classification

• BMI > 95th percentile for age = “Obese”
• BMI 85–95th percentile for age = “Overweight”

Measuring blood pressure

• A cuff that is too large will give a falsely low BP measurement; conversely, a cuff that is too small may give a falsely elevated BP.
• A BP cuff should cover 2/3 of the upper arm, and the internal bladder should encircle 80–100% of the arm circumference.
• “White coat” hypertension is a common cause of elevated BP measurements. Taking several BP readings in succession may reveal a steady decline in the BP toward the normal range in such cases.
• A school nurse may be a valuable asset in obtaining serial BP readings over time in a less threatening environment.
• Positioning may influence BP readings. Patient should be seated, in a relaxed state, with arm held at heart level. Holding the arm down at the side may elevate the systolic BP as much as 20–30 mm Hg in an adolescent.

Question 17

Motivational interviewing

Answer 17

A technique used to discover the patient’s motivation for changing his/her behavior:

• Ask patient and/or caregiver to state their reasons for wanting to change. This sets the tone that this is something they are working on because they want to, not just because you said so.
• Set an attainable goal. Make sure that you and the patient agree upon the goal. Your patient may have the best sense of what is attainable at this time.
• Use external motivators. (Star charts or other reward programs may be especially important motivation for young children who have a limited understanding of more esoteric goals such as good health.)
• Empower patient and family to manage change themselves.

Question 18

Differential Dx: Signs and Sx that mimic ADHD behaviors

Answer 18

1. Sensory impairment: Hearing or vision impairment can mimic inattention.
2. Sleep problems: Inadequate sleep—due to obstructive sleep apnea, narcolepsy, or poor sleep hygiene—may adversely affect school performance. Patients with ADHD often have poor sleep hygiene, but typically do not seem overtired.
3. Mood disorder: The prevalence of mood disorders increases with age. Depression affects an estimated 1–2% of elementary school age children and 5% of adolescents. Depressive symptoms may mimic inattention. Childhood depression has high rate of conversion to bipolar disorder, which may look like hyperactivity. Children with ADHD have a higher rate of mood disorders than control populations. These disorders may mimic or accompany ADHD.
4. Learning disability: A disorder of cognition that manifests itself as a problem involving academic skills. Most states require documentation of a discrepancy between intelligence quotient (IQ) and academic achievement for the diagnosis of a learning disability. Learning disabilities clearly impair academic performance, but may also lead to behavioral and attention problems, particularly at school. Poor school performance frequently prompts the evaluation for ADHD. Inattention may stem from an inappropriate classroom assignment (applies to gifted students as well). Comorbidity between learning disabilities and ADHD is common; many experts feel that one diagnosis should not be made without evaluating for
   the other. An educational assessment should be part of the evaluation for any child with behavioral problems and poor school performance.
5. Oppositional defiant disorder (ODD): Characterized by a pattern of negativistic, hostile, and defiant behavior. Conduct disorder (CD) is a more severe disorder of habitual rule-breaking, characterized by a pattern of aggression, destruction, lying, stealing, and/or truancy. ODD and CD have high comorbidity rates with ADHD.

Question 19

Differential Dx: HTN

Answer 19

Most blood pressure elevation in children over 6 years is due to primary hypertension, and obesity is an important correlate.

Consider secondary causes of hypertension such as renal parenchymal disease and coarctation of the aorta in young patients with substantial blood pressure elevation and with little family history of hypertension.

Question 20

Studies to consider for investigation for comorbidities of obesity:

Answer 20

Hypercholesterolemia, hypertriglyceridemia
- Hypertriglyceridemia and low HDL cholesterol are strongly correlated with metabolic syndrome, which occurs almost exclusively as a consequence of obesity. Several studies have shown that dyslipidemia may improve with weight reduction.

Hyperinsulinism
- 85–95th percentile and no risk factors:
Obtain fasting lipid profile.
- 85–95th percentile with risk factors (family history or physical):
Obtain above plus hepatic transaminases and fasting glucose.
- > 95th percentile (with or without risk factors):
Obtain above plus blood urea nitrogen (BUN) and creatinine.

Question 21

Management: Overweight or obese

Answer 21

1. Weight management goals
   - 85–95th percentile: Weight maintenance or slowing of weight gain until BMI < 85th percentile
   - > 95th percentile: Weight maintenance or gradual weight loss until BMI 85th percentile:
   Not more than one pound per month in pre-teens
   Not more than one pound per week in teens.
   - Assess patient/family readiness for change prior to making treatment plan:
   Inquiring whether weight is a concern for the parent or the child and talking about immediate effects (with patient) and long-term effects (with parent) are effective strategies.
   Using BMI as a visual aid to demonstrate that the child is overweight by national standards has been shown to be an effective motivator for changing eating, drinking, and exercise habits.
   Family must be engaged if any health behaviors are to be
   altered.
   - Follow up every three to six months.
   - Treatment plans may start with general recommendations for dietary changes and physical activity; if not meeting goals, may escalate therapy to include structured diet and exercise programs, with or without direct supervision of multidisciplinary team.
2. Dietary assessment and recommendations
   - No sugar-sweetened beverages (e.g., soda, juice drinks, sports drinks).
   - Limit meals outside the home (especially fast-food restaurants).
   - Eat breakfast daily.
   - Five or more daily servings of fruits and vegetables.
   - Limit consumption of energy-dense foods.
   - Eat diet with balanced macronutrients (fat, protein, carbohydrates).
3. Physical activity assessment and recommendations
   - Limit sedentary activities (“screen time,” such as TV, video games, computer) to less than two hours a day.
   - At least 60 minutes of moderate physical activity daily.

Question 22

Management: Prehypertension

Answer 22

• Implement therapeutic lifestyle changes.
• Ask school nurse to record weekly BP check.
• Follow up BP in office in 6 months.
• Reserve treatment with pharmacological agents for children:
  Whose BP is consistently very high
  With evidence of target-organ effects, such as left ventricular hypertrophy.
• Because development of obesity in childhood and adolescence is strongly related to hypertension in adult life, encourage patients to control their weight and pursue fitness.
• Weight loss and improved cardiovascular conditioning have been demonstrated to lower blood pressure in hypertensive adolescents.
• Many experts recommend beginning a lower sodium diet as a way to reduce blood pressure.

Question 23

Management: ADHD (medication, adverse effects, additional recs)

Answer 23

Medication

• 80% of children with ADHD respond to stimulant medication. (Example regimen: Sustained-release methylphenidate [Concerta] 18 mg by mouth once daily in the morning, Monday through Friday.)
• Patients treated with stimulant medication are at no higher risk for substance abuse than their peers. In fact, some data suggest that a positive response to stimulant medication may reduce a patient’s likelihood of substance abuse, as well as other high-risk behaviors.

Adverse effects:

• Appetite suppressionis most common adverse effect associated with stimulant use. Weight loss, if any, is typically minor.
• Less than 1% of children treated with stimulant medication develop tic disorders. In most cases, the tics resolve when the medication is discontinued.
• Insomniais a common, dose-related side effect. It is typically worse on the first days of medication.
• Studies have shown a slight decrease in growth velocity in children on stimulant medications for ADHD, and growth should be closely monitored for children on these medications. This effect appears to resolve when medications are stopped.
• In 2006 an advisory committee recommended a black box warning (the strongest warning that the Food and Drug Administration [FDA] issues) be placed on stimulant medications regarding cardiovascular risks; the FDA rejected this recommendation, at least for children, issuing a highlighted warning. The cardiovascular risks of these medications seems to be
  (1) primarily limited to children with known heart disease, and
  (2) higher for adults (who account for about 10% of stimulant usage) than children.

Additional recommendations

• Consider educational achievement testing.
• Ask parents to observe child for possible side effects of medication: Poor appetite, difficulty sleeping, facial twitching.
• Recommend website/reading material on ADHD to parents.