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S: Subjective
Reason for visit: Annual well-child visit for a 10-year-old boy, accompanied by his mother.
History: His mother is worried about his weight, which has increased since he started spending more time on screens during the school year. He eats school breakfast and lunch, drinks two or three cans of soda a day, and plays outside on weekends only. He snores at night but has no pauses in breathing that his mother has noticed. No headaches, abdominal pain, knee or hip pain, or increased thirst or urination. He says other children at school sometimes tease him.
Family history: Father has type 2 diabetes; maternal grandmother has hypertension.
O: Objective
- Growth: height at the 60th percentile; weight above the 97th percentile; BMI at the 97th percentile for age and sex.
- Vital signs: blood pressure 112/70 (below the 90th percentile for age, sex and height), heart rate 84.
- Skin: velvety darkening at the back of the neck (acanthosis nigricans).
- HEENT: tonsils 2+, no exudate.
- Abdomen: soft, nontender; liver edge not palpable.
- Musculoskeletal: normal gait; full, painless hip range of motion.
- Development and mood: doing well in school; screen for low mood is negative.
A: Assessment
- Obesity (BMI at or above the 95th percentile), without severe obesity.
- Acanthosis nigricans, suggesting insulin resistance.
- Snoring, with a risk of obstructive sleep apnea to explore.
- Weight-related teasing.
P: Plan
Following the American Academy of Pediatrics clinical practice guideline (Hampl et al., 2023):
- Evaluate for related conditions. The guideline recommends evaluating children aged 10 and older with obesity for lipid abnormalities, abnormal glucose metabolism and nonalcoholic fatty liver disease. Order a lipid panel, an HbA1c or fasting glucose, and an ALT.
- Intensive health behavior and lifestyle treatment. The guideline recommends family-centered, multicomponent treatment of at least 26 hours of contact over 3 to 12 months. Refer the family to the area's pediatric weight management program, which meets these criteria.
- Motivational interviewing today. Explore the family's priorities. They choose two goals: replacing soda with water or milk, and a family walk after dinner three times a week.
- No watchful waiting. The guideline advises against delaying treatment in the hope that a child will grow out of obesity.
- Medication and surgery. Not indicated at his age; the guideline addresses pharmacotherapy for adolescents aged 12 and older and surgical evaluation for adolescents aged 13 and older with severe obesity.
- Snoring. Ask about daytime sleepiness and school performance; consider a sleep study if symptoms continue.
- Teasing. Use person-first, nonjudgmental language, talk with him about how he's coping, and offer a school counselor referral.
- Follow-up: review lab results by phone and see him in 1 month.
Reference
Hampl, S. E., Hassink, S. G., Skinner, A. C., Armstrong, S. C., Barlow, S. E., Bolling, C. F., Avila Edwards, K. C., Eneli, I., Hamre, R., Joseph, M. M., Lunsford, D., Mendonca, E., Michalsky, M. P., Mirza, N., Ochoa, E. R., Sharifi, M., Staiano, A. E., Weedn, A. E., Flinn, S. K., . . . Okechukwu, K. (2023). Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics, 151(2), Article e2022060640. https://doi.org/10.1542/peds.2022-060640
