Pediatric Obesity: The Widening Waistline

It is a usual scenario in my practise when the parents describe their obese child like ‘She has been healthy like this since beginning’. Even we doctors use the word ‘healthy’ very loosely to describe fattiness. It is not right to discriminate obese children in the society, but in medical practise, a line between healthy and fatty needs to be drawn. To do so, we must understand that obese is ‘not healthy’.

 

The prevalence of over-weight and obesity has been increasing exponentially over the last decade. Various cities in our countries are coming up with pediatric obesity prevalence figures between 6-22%. Obesity, just like type 2 diabetes, is no longer a disease of the rich. The prevalence in increasing in economically challenged as well.

 What is Obesity and Overweight in pediatric age group?

We do not follow absolute BMI values in pediatric age group. A BMI of 20 is normal for a 14 year old; but it is high for a 5 year old child. For given age and sex, if the body mass index falls between 85^th to 95^th percentiles, the child is said to be overweight. If it is above 95^th percentile, the child is obese. In simple terms, when the weight percentile is much above the height percentile on a growth chart, the child is probably obese.

What are the usual culprits in Pediatric Obesity?

Most of the pediatric obesity is exogenous and lifestyle related. Reduced outdoor play, increased consumption of calorie dense foods, increased screen time [TV, computers, PS3s etc] are the common causes. Media plays a direct and indirect role in causing pediatric obesity by promoting fast food culture and reducing calorie expenditure due to inactivity.

Endocrinal causes like Cushing’s [exogenous/endogenous] and pseudohypoparathyroidism are rare. Obesity in operated CNS tumors like craniopharyngioma can be due to excess steroid replacement or Growth hormone deficiency. Physiological doses of steroid replacement [9-12mg/m² of hydrocortisone] usually do not cause obesity.

Hypothyroidism does not cause obesity; it causes edema and mild weight gain. Most of the obesity associated with mild hypothyroid is actually lifestyle related and hypothyroid is only the tip of the iceberg of weight gain. That is the reason such children do not lose weight even after starting thyroid supplementation.

Genetic causes such as MC4R mutation, Prader Willi, Laurence Moon Biedl, ACTH deficiency, Leptin deficiency are rare causes of hypothalamic obesity. They cause rapid weight gain during infancy and early childhood due to problem in the energy homeostasis.

Why Obesity is bad for children?

Pediatric obesity is associated with co-morbidities like metabolic syndrome, Polycystic Ovary syndrome, Type 2 diabetes [T2DM], Non Alcoholic Steato-Hepatitis, Gall stones, and increased risk for cardiovascular disease. Prevalence of T2DM in children is rapidly increasing in India due to obesity. Skeletal problems like Slipped capital femoral epiphysis, Blount’s disease and osteoarthritis are seen in obese children. Obese children are likely to get psychosocial problems in the school. Obstructive Sleep Apnea can cause day time sleepiness, headaches and poor concentration in studies. These children are ten times more likely to get glomerulonephritis.

What is the minimum that a family physician can do?

We can ask the parents to monitor the intake of their child. Starving is a bad choice for weight reduction. A child needs 3 meals [Breakfast, lunch and dinner] and 2 snacks in a day; however, grazing in between the meals needs to be avoided. Buffalo milk can be substituted by either ‘low fat’ or cow’s milk. Sensitize the mother about keeping an eye on the monthly oil consumption; that way the dietician will get realistic figures. 

Plotting a child’s weight and height during each visit is the least we can do.  This helps in ruling out or considering many hormonal disorders like Cushing’s syndrome. Motivating the family towards lifestyle modification is a continuous process, beginning with the family physician. Identify the risk factors such as Acanthosis Nigricans [thick blackish skin over nape of neck, axillae and groins], high blood pressure, history of menstrual irregularity, family history of T2DM/cardiovascular disease/hyperlipidemia.

Which patient needs a referral to endocrinologist?

In the age of specialization, the role of family physicians is crucial in screening patients and identifying the need for referral.  A child, who is short and obese, definitely warrants urgent evaluation by a pediatric endocrinologist.  Sudden onset rapidly progressive obesity, obesity during infancy, obesity with delayed milestones or mental retardation, family history of hyperlipidemia/ type 2 diabetes/ sudden cardiac death, signs and symptoms of Cushing’s syndrome, early or delayed puberty are the scenarios which need detailed evaluation by a team of endocrinologist, dietician and a counselor.

What an endocrinologist does for an obese child?

The purpose of endocrinologist referral is not just ruling out endocrinological/genetic causes, but also to stratify the risk of getting endocrinal manifestations secondary to obesity. Lipid profile, liver enzymes and blood sugars are the minimum tests required for co-morbidities, along with multiple blood pressure recordings. Endocrine work-up is needed in selected cases.

Individual child is given weight targets and diet plan for short interval of time. Pharmacotherapy in pediatric obesity has a limited role and needs to be accompanied by intensive lifestyle modification. Drugs like metformin and orlistat have statistically significant, yet modest role in weight reduction in children beyond 8 and 12 years of age. These are given when the lifestyle modification alone is not helping or there are associated significant co-morbidities or risk factors. Other drugs are not licensed. Repeated assessment of the compliance and response is essential is a successful and sustainable weight control.

The initial approach in any obese child is to identify the treatable causes and modifiable factors in the lifestyle. A frequent follow up at 3-6 months for assessment is needed. Weight loss is recommended only for moderate to severe obesity or when the simple lifestyle changes have failed. Bariatric surgery is reserved for morbid obesity associated with co-morbidities and non-responsive to standard management. Such surgeries are not done until the skeletal and sexual growth is complete.

Finally, the management of pediatric obesity is a team-work. Successful and sustainable weight control needs continuous support from the family. Family members need to take part in the treatment by changing the diet for the entire family, sacrificing on their television hours and setting examples by promoting healthy lifestyle.

-Dr.Tushar R Godbole

MBBS, DCH, DNB, PDCC, MNAMS

Consultant Pediatric and Adolescent Endocrinologist,

Lecturer in Pediatrics, Dr.Vasant Pawar Medical College Nashik

Consultant at Six Sigma Hospital, Nashik and Niramay Pediatric Superspeciality Hospital, Aurangabad.

Early Puberty: Hitting the panic Button!

Precocious Puberty can occur in girls as well as boys. If not detected and treated early, such children can have serious physical  and psychological problems.

Arpita [name changed] came to my clinic with her mother. She was eight and a half year old and clearly in distress. Her parents were panicked as Arpita had her first periods at such a tender age. Precocious Puberty is a hormonal disorder in children where the pubertal changes happen early. As per the definition, the puberty is called precocious [early] if the pubertal changes [breast development] in girls starts before 8 years or the testis/penis enlarges in boys before 9 years of age. It may be accompanied by development of pubic/ body hair and change in the body odour.

Normal Puberty:

Puberty, is caused by sex steroids that are produced in the gonads [Ovaries in girls and testis in the boys]. The timing of puberty is largely determined by genes and the environment. The signal for producing these steroids originates from the hypothalamus [a part of brain]. Hypothalamus and gonads are active at birth, but it goes off to sleep for almost 10-12 years till the right time for puberty is there. Hypothalamus receives cues from environment and the body fat; and when the time is right, between 10-13 years it starts producing weak signals. These signals stimulate pituitary gland to produce hormones. These hormones become more active as the signal goes from weak to strong with time. Gonads [Testes/ Ovaries] respond to these hormones and start producing sex steroids [Testosterone/ Estrogen]. Sex steroids act on sex organs. In girls, the usual pattern is enlargement of breasts, followed by appearance of pubic hair and in the last, menses. Boys have enlargement of testes, followed by enlargement of penis, appearance of pubic hair and sperm production. Both boys and girls grow rapidly during the pubertal age and gain almost 25 percent of their final height during puberty. Girls have their puberty earlier and stop growing earlier than boys.

Precocious Puberty: Causes

Puberty can start early when either the brain signals early or the gonads become active even without the signal. Adrenal gland may cause early development of underarm/pubic hair.

In girls, most of the times, the cause for early puberty is not found. Such condition is called as ‘Idiopathic’. Where in boys, most of the cases have underlying brain, testicular or adrenal problem. Various disorders of brain [Tumour/ Infection/ Trauma/ Radiation/ Surgery] can make this signal appear early. Exposure to various medicines, skin creams or pesticides may also cause pubertal changes in children. Sometimes the pubertal changes start early but do not progress to full-blown puberty. Early puberty may run in families.

What are the dangers of early puberty?

As the puberty starts, the bones grow and mature faster. During early puberty, these kids appear taller than their peers as the peers have not yet entered puberty. But as the puberty advances, the bones stop growing early and the final height of such children is often severely compromised. Such children end up being short. There is also psychological impact on the children such as school absenteeism and feeling embarrassed. Such children are at high risk for getting sexual exposure and abuse due to their physical maturity. The underlying causes such as brain tumour need urgent attention and treatment.

Can early puberty be treated?

It is necessary to investigate the cause of this early puberty. Some blood tests help in knowing if the puberty has started from the brain, adrenals or the gonads. An X-ray of the wrist tells us about the accelerated growth and the potential for final height. Only a rough prediction can be made about the final height in such cases by looking at wrist x-ray.

Most of the cases in girls are treatable with monthly/ three monthly injections of Leuprolide. Boys may need further investigations like MRI brain and adrenal hormone testing. Treatment in boys mainly depends on the underlying cause. The puberty is usually delayed by the medications till the child is old and mature enough to handle the pubertal changes. The treatment halts the puberty and allows bones to grow for more time, thus helping to grow to a normal height.

Is it safe to halt the puberty by medications in such cases?

The medications [Leuprolide] are temporarily delaying the puberty. Puberty usually re-starts within 6-18 months of stopping the treatment. Occasionally some patients may have allergy/ pain, otherwise the drug is safe. Rarely patients can have abscess at the injection site. Patients on treatment need to consume calcium [Milk, Ragi, Lentils] as the bone keep growing for longer periods at slow pace.

Summary:

Puberty is said to be early if it starts in girls below 8 and boys below 9 years of age. Early puberty may have psychologic effects on children. These children are tall in early stages but their bones stop growing early and they remain short as Adults. Problems in the brain, pituitary, adrenals, gonads [testes/ovary] and some drugs/chemicals can cause this problem. Most of these problems are treatable. The purpose of treatment is to achieve normal height and to delay the puberty till the child is mature enough to manage it.

Dr.Tushar Godbole

Pediatric Endocrinolgist

How tall is tall enough? Optimizing your child's height.

 Growth is a fundamental right of children. With India still following the secular trend for height, we expect the subsequent generations to be slightly taller than their parents. Many factors like genetic potential [height of the biological parents], birth weight and nutrition decide the final height of a child. Any kind of prolonged stress due to physical illness has a negative effect on the child's final height. Many hormonal deficiencies/excess can lead to growth failure.

How much a child should grow normally?
Growth rate varies with age. During infancy and toddler-hood, the height gain is very rapid, which slows down during mid-childhood. Once the puberty starts, the height gain also picks up, to fall again after the puberty is achieved [earlier in females]. The best way to know if the child is growing normally, is to keep a height record. There are many formulas to roughly calculate the average height for given age, but using a growth chart is simpler and ideal. Plotting the serial heights on a growth chart gives a fair idea about a child's growth.

Image courtesy: www.cdc.gov.in

Is my child short?
In the given population, not all persons are of same height. Generally speaking, there is a normal range for height. Being short, by definition, means having a height below the lower margin of normal range or 5th percentile for the reference population range. For those who are familiar with statistics, this 5th percentile roughly corresponds to - 2 standard deviations.On a growth chart, this height will fall below the lowest line.
A child will also be called short, if his predicted height is less as compared to his parents, this is particularly true for tall parents.
There are reference data available for Indian pediatric population.

Why is my child short?
There are many reasons for a sapling for not thriving. There can be problems in the sapling, the water or the soil. Similarly, there can be problems in the child, the nutrition and emotional environment. Various medical conditions slow down or halt the growth. Deficiency of Growth Hormone or Thyroid hormone may lead to severe degree of short stature. More commonly, there are children who are 'late bloomers'. These children start their pubertal growth spurt late and continue to grow beyond the normal periods, thus compensating for the earlier loss.

What are growth charts?

Indian Growth Chart

These are graphical representations of heights of healthy children with percentile lines drawn. The charts are different for boys and girls. Plotting the height of child on this chart gives a comparative idea as to on what percentile the child is lying. A normally growing child has all his plots within the normal area  [usually depicted in white colour on the chart] [Click here for growth chart for Boys and Girls] and going parallel to the percentile lines. There are various growth charts available, it doesn't matter which one is being used for practical purposes, unless the child has condition like Down's/Turner's syndrome, where there are specific charts available.

How frequently do I need to check my child's Height?
It is recommended that the height should be recorded during each health visit. During first two years of life, the length is recorded instead of height. Frequent recordings are needed during this period as the child grows rapidly. After two years of age, at least 2 to 3 times a year. A period of at least 3 to 6 months is required to know the speed at which the child is growing, hence there is no point in measuring the height before 3 months interval.

Can You predict how much shall my child grow?
As there are many variables in a child's growth. exact height prediction is not possible. There are, however, methods to make rough predictions using parent's heights [Mid-parental height*]. There are ways to predict the final height based on the 'bone-age' of the child using a left hand x-ray. Girls beyond bone-age of 14 and boys beyond bone-age 16 generally do not grow much.

Shall I take off label medicines for optimizing my child's growth?
The market is flooded with useless and many a times harmful health supplements. Brands like 'Hightex', 'Step up', 'Speed Height', 'Body-plus' and 'Health-plus' falsely promise an exuberant height gain, these are nothing but hoax. None of these medicines is approved by Drug Controller General of India [DCGI]. Every medicine has side effects, and shouldn't be consumed unless required and prescribed by a qualified physician.

What is growth Hormone Therapy?
Growth hormone is a hormone produced by the master gland - pituitary. It is the major driving force for the growing bones and it acts well when all the other hormones like thyroid hormone are normal and the child is getting proper nutrition. In Growth hormone therapy, daily growth hormone injections are given to those patients, who have the deficiency of this hormone. It can also be given to short children with certain syndromes like Turner's, Prader-Willi or Russel-Silver syndrome, to improve the height. Growth hormone therapy is costly and has its own side effects, hence should not be given except when medically indicated.

What can I do to increase my child's height?
Ensuring proper nutritional intake that includes proteins, iron and calcium, is the minimum that parents can do to optimize their child's growth. Growing bones, especially during puberty, need calcium and vitamin D. Vitamin D needs to be supplemented if your children are not getting enough of sunlight. Milk is a rich source of calcium and at least half a liter milk is needed to meet the recommended daily intake of calcium during this growing period. Vegetarian diet has low quality protein, but the quality can be improved by combining different pulses and legumes [Mix Daal]. Eggs and meat have good-quality proteins. Green leafy vegetables are rich sources of iron. Health supplements are costly and are not required for normal growth. Regular exercise stimulates bone growth, but hanging on a bar [as shown in various misleading advertisements including Complan] doesn't help in increasing the height.

Consult your pediatrician / pediatric endocrinologist if you have any doubts or concerns about your child's growth or pubertal status.

*Mid-parental height/Target height is calculated using the formula:
For Boys: [Father's height+Mother's height + 13] / 2 in centimeters.
For Girls: [Father's height+Mother's height -13] / 2 in centimeters.
If father's height is 170cm and mother's height of 155cm, the target height for their boy will be 169cm [±5cm], and for their girl will be 156 [±5cm].

Febrile seizure? Time to cool off your child

What is a Febrile Seizure:

Febrile seizures, or commonly know as fever fits, are common. Up to 4 % of children throw fits during a febrile episode. Febrile seizures are commonly seen in age group 6 months to 6 years of age. It is a very frightening experience for any parent to witness his little one seizing. But most febrile seizures are harmless.

Febrile seizure is not same as epilepsy. Epilepsy [Seizure disorder, also called as Mirgi or Apasmar in India] is repeated seizures, that are unrelated to fever. Epilepsy is treatable, though it requires medications for a prolonged duration.

The exact cause for fever fits is unknown, but they are known to run in families. Fever is usually triggered by any infection like common cold or a diarrhea, and the child can throw a seizure at the height of fever. This seizure is usually self limiting, subsides within a few seconds/ minutes [usually less than 10 min] and child regains consciousness soon after.


Do these seizures tend to recur?

In up to 30-50% chances, these seizures may recur with fever. A positive family history, younger age [less than a year] makes a child prone for recurrent febrile seizure. Usually children out grow their febrile seizure by the age of 5-6 years. In rare instances, if there are more than one febrile seizure in a day, or the fits occur only in some one part of the body, there is a risk of developing epilepsy.

Do they have any effect on child's brain?

In most instances, these febrile seizures last for a few seconds, do not recur within 24hrs. Such simple febrile seizures are benign in nature, and these children do not develop epilepsy or have any long term effects on their brain development.

What is meningitis?

Meningitis is a serious condition. Its the infection of brain and its surroundings. Meningitis can also present with fever and seizures, just like febrile seizure, but children with meningitis are usually sicker and have other symptoms like poor feeding, lethargy and vomiting.
In case of fever and seizure you need to rush hospital immediately if:

• Your child is less than 6 months of age
• Not feeding properly
• Excessively sleepy
• Headache/ neck pain
• Purple rash anywhere on the skin
• first time fever with seizure

What is the treatment for febrile seizure?

Before starting treatment, many a times treating physicians may have to perform certain blood tests and lumbar puncture to confirm that the child is not suffering from meningitis, as both conditions can present in similar fashion. Lumbar puncture, when performed under expert hands, is a safe procedure, and does not have any effect on child's spine/ walking.

Febrile seizure usually does not need any extra treatment other that control of fever. An anti-seizure medication [eg. Frisium] may be prescribed for a short duration of 3-5 days, but there is usually no need for long term anti-seizure medications. Antibiotics are usually given if the cause of fever is bacterial throat/ ear/ urinary infection.

What the parents can do at home:

In a known case of febrile seizure, parents can start with fever medications as soon as the child gets a fever anytime above 100.4*F [38*C]. The temperature can be measured in the armpit and not necessarily in the mouth. One should avoid using the mercury thermometer in mouth as there is risk of biting & breaking the thermometer. It is a good idea to have a prescription of paracetamol [same as Crocin / Calpol/ PCM] with the dosage written from your pediatrician. Paracetamol is a safe drug and can be safely given up to 4-5 times in a day for the control of fever. Various drugs like Aspirin/ Nimesulide are harmful in children, and are best avoided. Wet sponging the whole body [not just forehead] is sometimes helpful in bringing down the fever, if its too high.

Despite adequate control of fever, child may throw a seizure. In such case, place the child on a safe place to avoid injury. Remove any tight clothing/ jewelery around the neck and place the child in lateral position. Make sure the airway is open, do not splash water on face [a common but dangerous custom in India]. A rectal suppository [soft tablet to be inserted in to the anus] or nasal spray of anti-seizure medications are available on prescription, and can be used during such episode to control the seizures. Consult your pediatrician and keep this medications handy, stored in refrigerator. After the fits have subsided, do not immediately feed the child.

Always visit your pediatrician after any episode of fever with seizure to make sure it isn't something other than a febrile seizure.

Pediatric Second Opinion: Knowing your child's disease better

Pediatric Second Opinion: Knowing your child's disease better: "Many times parents are unaware of the health condition of these child. Especially in country like India, a proper communication between pare..."

A hole in the heart.

Many times parents are unaware of the health condition of these child. Especially in country like India, a proper communication between parents and treating physician is lacking. This may be due to lack of time or lack of a proper rapport with the doctor. Too much of information or use of lots of technical terms can sometimes leaves parents confused. Parents need to get the right information, not only because its there right,  but because it helps them to get an idea about the severity, progress and the likely outcome of the disease.

In this blog, We are trying to deliver the right information in simple words,so that parents from all educational backgrounds can understand their child's condition.

Stating this  blog with a common heart condition diagnosed in children.

A hole in the heart: congenital heart disease.

Yesterday I saw my colleague nurse saddened and worried about her nephew. Apparently her nephew was diagnosed to have "a hole in the heart". She broke into tears while mentioning about the parents getting worried and quite concerned about their kid. What amazed me was, the parents knew nothing except that there was "a hole in the heart" of their child.

The heart, while developing inside a fetus, is made up of tiny tubes. These tubes are made up of muscle fibres, and after a series of events, finally develop into 4 chambers, 2 atria [pleural for atrium]and 2 ventricles. There is a hole in the heart in all of our hearts at some point of development. These holes are present in the partition between the two chambers of the heart[between two atria or ventricles]. Some of these holes disappear early in fetal life while others get closed soon after birth. If the hole continues to be there after birth, its called as a septal defect.

These defects allow shunting of blood between the chambers up to a variable extent, depending upon the size and pressures. A smaller defect doesn't allow much of a shunting but creates loud noise, which is heard on the chest as a "murmur". A large defect causes a lot of shunting and mixing of blood, thus can lead to increased pressure in the lungs.

Many of these defects are innocent, get detected on general check-ups and need no treatment except for wait-and-watch for spontaneous closure, which usually happens by 3-4 years of age.

If it fails to get closed or the size is moderate, child can be operated electively with almost 100% success rate.

In case the defect is large, child may suffer from repeated chest infections and fails to grow properly. These children need medical therapy to prevent the heart from failing. The medical management is usually a time-buyer, till the definitive surgery is planned. Most of the large defects are correctable after surgery, and these children can lead a normal healthy life after surgery.

There are few forms of septal defects associated with bluishness of lips and nails. These are complex heart diseases, called as cyanotic congenital heart diseases. In such diseases, the septal defects are actually helpful for the survival of the child as they allow mixing and keep some oxygen rich blood flowing to the vital organs like brain.

If you are the parent with a child diagnosed with a "hole in heart", don't get unduly alarmed or depressed. Find an opportunity to discuss with doctor the nature and the size of the defect. Discuss the treatment options medical and surgical. Its a good idea to discuss the tentative timing and expenses of the surgery so that you can plan your things accordingly. Doctor may not be able to give you exact percentage but always discuss the quality of life the child will have after a corrective surgery, especially if he/she has other ailments along with heart disease, for example a stroke or neurological impairment. Its very important to protect such children from common infections by observing hygienic measures. Ensuring adequate diet, iron supplements in the prescribed doses and additional vaccines to prevent infections are the minimum that you should do for your child.

Never lose hope if your child is detected to have a "hole in the heart", as most of them are curable.

Post your queries and we will try to solve them

Hello,

This blog is dedicated to those parents whose children are sick and undergoing medical treatment.
Such parents could post their queries regarding their child's health condition or the treatment options.

We are practicing doctors from India, trying to help parents from India and abroad who want an expert second opinion on their child's health condition.