CLIPP case 4. 8yo well-child visit (obesity, DM, ADHD) Flashcards
Overweight and obesity def
Overweight: BMI > 85%ile
Obese: BMI > 95%ile
Weight and Height “age”
Age at which the child would plot at the 50%ile. Does not take the other into account.
ADHD diagnosis, prevalence, treatment
- inattentiveness, hyperactivity, impulsivity
- 8-10% prevalence in the U.S.
- 80% respond to tx with stimulant like methylphenidate. No increased risk of substance abuse.
Stimulant medication traits
- May cause decreased appetite (most common. minor wt loss), insomnia, decreased growth velocity, and tics (<1%)
- BBW of CV risk rejected. CV risks (1) primarily limited to children with known heart disease, (2) higher for adults (who account for about 10% of stimulant usage)
Obesity risk factors
High birth weight, GDM; obese parent; low socio-economic status; Prader-Willi, Bardet-Biedl, and Cohen syndromes; early menarche; shorter breastfeeding
Obesity sequelae
- HTN
- Dyslipidemia
- OSA (15 sec), Pickwickian syndrome
- Early puberty and advanced bone age
- T2DM (19% of DM in kids; 25% have ketonuria at presentation)
- Steatohepatitis, gallbladder disease
- Slipped capital femoral epiphysis (see internal rotation), Blount dz (bow-legged)
- Restrictive lung disease
- Increased incidence of RAD is not thought to be causal
Diabetes diagnosis
A1c >/= 6.5%
Fasting BG > 126 (preferred)
BG > 200, 2hr after 75g oral glucose tolerance
Random BG > 200
Pediatric screening for T2DM
At 10yo or puberty, then every 2 years, if BMI > 85%ile or Weight-for-height >85%ile with 2 of the following:
- FHx of T2DM in first or second degree
- Native, African-Amer, Latino, Asian, Pac
- Acanthosis nigricans / polycystic ovary syndrome / hypertension / dyslipidemia
- During gestation, GDM or maternal DM
BP in kids
Based on age, gender, ht, wt: Normal < 90th Prehypertension 90th to 95th Stage 1 hypertension 95th to 99th + 5 mmHg Stage 2 hypertension > 99th + 5 mmHg
HTN in kids
*Screeen yearly starting at age 3
*Most is primary, often obese kids, so no further w/u (if 6yo or older)
*Unless suspicion of renal parenchymal disease or coarctation of the aorta (>99%ile, young, no FHx)
*Other causes: Umbilical line as neonate -> renal vascular disease; UTI -> renal scarring;
CA excess (pheo or neuroblastoma)
2ndary HTN in kids
- Umbilical vein or artery access perinatally may predispose to renal vascular disease
- UTI causing renal scarring is one of leading causes of HTN later in life
- CA excess (pheo or neuroblastoma)
- FHx renal disease: ask if family members have ever needed dialysis
- Coarctation of the aorta: may not present until school age. Check femoral and LE pulses
8yo boy with obesity, HTN, and ADHD is doing poorly in school
DDx for school failure:
- Sensory impairment
- Sleep disorder
- Mood disorder
- Learning disability
- Conduct disorder
- ODD/CD is the psychiatric condition with the highest comorbidity rates with ADHD
Childhood obesity epidemiology
- Prevalence of childhood overweight and obesity in U.S. has doubled in past 20 years
- 15% of 6 to 19-year-olds are obese > 95th percentile for BMI
- Higher rates among minority and economically disadvantaged children
- Probability of childhood obesity persisting into adulthood: 20% at age 4 years, 80% at adolescence. s obesity
- Comorbidities will likely persist into adulthood
BMI
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
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:
- Max 1 lb/month in kids
- Max 1 lb/week in teens
- Use BMI as a visual aid has been shown to be an effective motivator for changing eating, drinking, and exercise habits
