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Selections from Journal Watch Pediatrics and Adolescent Medicine Copyright © 2005 Massachusetts Medical Society. All rights reserved.

When all else fails: bariatric surgery for severely obese adolescents ▸

A consensus conference of pediatricians and pediatric surgeons experienced in the area of obesity offers guidelines on evaluating adolescent candidates for bariatric surgery.

Beyond anthropometric measurement and comorbidity assessment, factors unique to youth must be addressed—specifically, adolescent growth and development, patient capacity for decision making, family structure, and likelihood of adherence. Bariatric surgery is warranted only for adolescents who meet defined criteria and have not succeeded in more than 6 months of organized attempts at weight loss. Candidates should be very severely obese (body mass index >40), have attained most of their skeletal maturity (generally, age >13 for girls and >15 for boys), and have related comorbidities that durable weight loss might remedy.

Candidates should be referred to centers with multidisciplinary weight management teams that have expertise with this age group. Surgery should be performed in institutions that meet the tertiary care needs of severely obese youth and collect long-term data on their clinical outcomes.

Comment ▸

Despite our promotion of more exercise and fewer calories, excessive weight remains a problem in pediatric and adolescent patients. Parents and patients alike often ask about surgical options. This report by specialists outlines criteria for recommending Roux-en-Y gastric bypass or adjustable gastric banding for adolescents. The specialists recommend that surgery be carefully deliberated and performed in centers of excellence, with assured long-term follow-up. Patients and families must realize that bariatric surgery is not a panacea but a mechanism for weight loss, to be undertaken in conjunction with dietary and exercise regimens. The risks and adverse effects associated with this surgery should reenergize pediatricians to keep advocating more exercise, less TV and computer time, and smaller portions for their young charges.

Susan Jay, MD

Published in Journal Watch Pediatrics and Adolescent Medicine October 12, 2004

The family that eats together … builds a strong teen ▸

The pressures of modern life often prevent families from having meals together. In this study, the authors investigated the association between the frequency of family meals taken together and indicators of adolescent psychosocial well-being.

The data were derived from a 1998–1999 school-based survey of 4746 adolescents from ethnically and socially diverse communities in the Minneapolis area. Approximately one quarter of the responding students reported having had seven or more meals with their families within the last week; almost a third had had two or fewer family meals. After researchers controlled for family connectedness and socioeconomic factors, they found that adolescents who shared more meals with their family had lower incidences of tobacco, alcohol, and marijuana use; higher grade point averages; fewer depressive symptoms and less suicidal ideation; and, among girls, better self-esteem and fewer suicide attempts.

Comment ▸

We often ask families about their children’s nutrition, focusing on food quality and quantity. We should expand the discussion to include the importance of having meals together as a family. Family reports can help us gauge their organization around meal times and assess our patients’ parent-supervised time.

Elizabeth R. McAnarney, MD

Published in Journal Watch Pediatrics and Adolescent Medicine October 12, 2004

Being too small is not good ▸

Many questions about the neurodevelopmental outcome of small-for-gestational-age term (SGAT) infants remain unanswered. For example, the effects of socioeconomic status (SES) and patterns of growth restriction are unknown. To assess these influences, these authors analyzed data from the National Collaborative Perinatal Project. From January 2, 1959, until December 31, 1966, 58,760 mother-infant pairs were enrolled; 33,291 singleton term births were included in this review. Of these births, 12,060 occurred in low-SES and 21,231 in high-SES families. Evaluations occurred at 8 months and at 4 years of age.

Of 1605 low-SES SGAT infants, 836 had asymmetric undergrowth, 693 had symmetric undergrowth, and 76 could not be characterized. Of 2317 high-SES SGAT infants, 1198 had asymmetric undergrowth, 991 had symmetric undergrowth, and 128 could not be characterized.

The SGAT infants were at greater risk for neurodevelopmental difficulties at 4 months and at 8 years than were normal-sized infants. Differences in intellectual functioning were apparent at 4 years: SGAT children had a greater risk for borderline-to-profound mental retardation (MR) (24.3% vs. 16.3% of low SES, and 10.3% vs. 6.6% of high SES). Few differences were associated with patterns of growth restriction, but SGAT children of high SES with asymmetric growth had more risk for borderline MR at 4 years than their symmetric-growth peers (7.5% vs. 4.2%). The SGAT infants remained lower in weight and smaller in head circumference than normal-growth peers; the difference was more pronounced among symmetric-growth SGAT children.

Comment ▸

SGAT children did less well than normal-growth peers on tests of development and intellect at 4 years of age. It may surprise some of us that growth-restriction patterns did not affect outcomes. I would caution that these population-based data do not take into account specific diagnoses in individual patients. In matters of restricted growth as in other health outcomes, the poor are disadvantaged.

William P. Kanto, Jr., MD

Published in Journal Watch Pediatrics and Adolescent Medicine October 12, 2004

Steroids for mild croup ▸

Although steroids are clearly beneficial for children with moderate-to-severe croup, their role in mild disease remains controversial. In a randomized trial in four Canadian pediatric emergency departments, investigators enrolled 708 children with mild croup (onset within 72 hours and score of ⩽2 points on a validated 17-point measure). The children received a single oral dose of dexamethasone (0.6 mg/kg) or placebo.

Children in the steroid group were significantly less likely to return for care within 7 days than were placebo recipients (7.3% vs. 15.3%). Clinical scores, as assessed by telephone interview, were significantly lower in the steroid group than in the placebo group on days 1 and 2 of follow-up; however, by day 3, scores were similar in both groups. Children in the steroid group lost significantly less sleep than did those in the placebo group (2.9 vs. 4.2 hours). Both health care costs and family costs were significantly lower in the steroid group.

Comment ▸

Steroids win again. These findings extend steroids’ indication in the treatment of croup to mild disease. As an editorialist notes, the benefits of steroid treatment are small but important for children with mild croup and their families. However, I do remain concerned that this will become the “steroid generation” for many diseases.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine October 12, 2004

Talking about death with dying children ▸

Should parents talk to a dying child about death? Seeking answers to this question, Swedish investigators surveyed the parents of children who had died from a malignancy during the previous 10 years.

None of 147 parents who had discussed death with their child expressed any regret. In contrast, 69 of 258 parents (27%) who did not have such a talk expressed regret. Two factors that significantly affected whether parents discussed death were the child’s age and the child’s awareness of imminent death. For example, 50% of parents of children aged 9 to 15 spoke to them about death, compared with 36% of parents of children aged 5 to 8 and just 16% of parents of children aged 4 and younger. Parents who regretted not talking with their children about death, particularly women, reported significantly higher levels of anxiety and depression.

Comment ▸

These data are very informative, although they were collected retrospectively from a unique group of parents. (In other cultures, people might deal differently with death.) Parents often ask for our guidance about what to say to a dying child. Clinicians should let parents know that those who have not discussed death with their dying child later regret it but those who have such discussions express no regret. Ultimately, of course, the decision is theirs.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine November 8, 2004

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