Surgical treatment may be advocated as a preferred and cost-effective solution for certain children and adolescents. The role of bariatric surgery in the treatment of obese children or adolescents is controversial. The concerns about surgery to treat obesity in young populations include whether or not surgery is cost effective; how to ensure healthy growth through to adulthood; what support services are needed after surgery; compliance with the postoperative nutrition regimen; and attendance at appointments for long-term follow-up and care. There is very limited evidence available to adequately estimate long-term safety, effectiveness, cost effectiveness or durability of bariatric surgery in growing children. The existing evidence suggests that bariatric surgery in severely obese adolescent results in significant weight loss and improvements in comorbidities and quality of life. Postoperative complications (both physical and psychological), compliance, and follow-up may be more problematic in adolescents than adults, and long-term data on safety, effectiveness, and cost remain largely unavailable.
Pediatric undernutrition is usually the result of inadequatefood supply, access, or utilization; poor access to health andsanitation; and/or inappropriate feeding or child care practices.The greatest risk of undernutrition is in utero through age 2.Various guidelines can be used to classify pediatric malnutrition (Table 30-1). International references are established that allow normalization of anthropometric measures in terms of z scores. Other measurements include height and weight for age,weight for height, BMI, and mid-upper arm circumference. Thegreatest consequence of undernutrition is death, but significantintellectual and physical disability exists in many who survive.
Protein-energy malnutrition (PEM) is a spectrum of conditions caused by varying levels of protein and calorie deficiencies. Primary PEM is caused by social or economic factors that result in a lack of food. Secondary PEM occurs in children with various conditions associated with increased caloric requirements (infection, trauma, cancer) (Fig. 30-1), increased caloric loss (malabsorption), reduced caloric intake (anorexia, cancer, oral intake restriction, social factors), or a combination of these three variables. Protein and calorie malnutrition may
From Grover Z, Ee LC: Protein energy malnutrition, Pediatr Clin North Am 56:1055–1068, 2009 BMI, Body mass index; HFA, height for age; MUAC, mid-upper arm circumference; NCHS, U.S. National Center for Health Statistics; SD, standard deviation;
WFA, weight for age; WFH, weight for height; WHO, World Health Organization.
Severe infection, 35
Figure 30-1 Increased energy needs with stress. (Adapted from Wilmore D: The Metabolic Management of the Critically Ill, New York, 1977, Plenum Publishing. Revised in Walker W, Watkins J, editors: Nutrition in Pediatrics: Basic Science and Clinical Application. Boston, 1985, Little, Brown.) be associated with other nutrient deficiencies, which may be evident on physical examination (Table 30-2).
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Failure to Thrive
Pediatric undernutrition in the United States is often termed failure to thrive and describes circumstances in which a child fails to gain weight appropriately or, in more severe cases, experiences failure in linear growth or head circumference. The terms organic and nonorganic failure to thrive have lost favor in recognition of the frequent interplay between underlying medical conditions that may cause maladaptive behaviors. Similarly, social and behavioral factors that initially may have been associated with feeding problems (see Chapter 21), and poor growth also may be associated with medical problems, including frequent minor acute illnesses.