Archivos para 23 julio 2008

AMA Recommends 4-Stage Approach to Treatment of Childhood Obesity


July 17, 2008 — A 4-stage approach to treatment of childhood obesity is recommended by the American Medical Association (AMA), according to a review for primary care clinicians in the July 1 issue of the American Family Physician. The study authors note that many of these recommendations for treatment and prevention can be carried out by family clinicians.

“Childhood obesity has become so severe that diseases that once affected only adults are now appearing in children,” writes Goutham Rao, MD, from Children’s Hospital of Pittsburgh in Pittsburgh, Pennsylvania. “The long-term implications of this epidemic are extremely serious. Obese children are much more likely than children of healthy weight to become obese adults.”

The statistics are alarming, with “overweight” youth (those with age-adjusted and sex-adjusted body mass index [BMI] above the 95th percentile, which is equivalent to the “obese” classification for adults) consisting of 13.9% of children 2 to 5 years old, 18.8% of children 6 to 11 years old, and 17.4% of adolescents and teenagers 12 to 19 years old.

Although type 2 diabetes in children was rare 2 decades ago, it now accounts for nearly one half of all new cases of diabetes among children in some settings. In adults, correlates of obesity include not only type 2 diabetes but also hypertension, osteoarthritis, gout, dyslipidemia, cardiovascular disease, and biliary tract disease as well as cancers of the colon, breast (in postmenopausal women), endometrium, and esophagus.

Recognizing the scarcity of practical strategies available to primary care clinicians to combat the problem of childhood obesity, the AMA recently convened an expert panel to review evidence about how best to manage and prevent obesity and to write a series of reports.

Specific recommendations of The Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity, and their accompanying level of evidence, are as follows:

  • At least once a year, measure height and weight and calculate BMI plus BMI percentile for all children (level of evidence, C).
  • To achieve or maintain a healthy weight, encourage all children to participate in at least 60 minutes of moderate to vigorous physical activity on most, and preferably all, days of the week (level of evidence, A).
  • Advise children not to drink more than 1 serving per day of sweetened beverages, such as fruit juice, fruit drinks, regular-calorie soft drinks, sports drinks, energy drinks, sweetened or flavored milk, or sweetened iced tea (level of evidence, B).
  • Advise families to limit their children’s television viewing and other screen time to 2 hours per day or less (level of evidence, B).
  • Recommend that children’s fast-food consumption be limited to no more than once per week (level of evidence, C).
  • Advise families with children to eat meals together as often as possible, on most, and preferably all, days of the week (level of evidence, C).


During the annual visit, family clinicians should evaluate key dietary and lifestyle habits, including consumption of sweetened beverages and physical activity; willingness to improve dietary and lifestyle habits; and family history of obesity and related illnesses.

Dietary habits that contribute to obesity include frequent consumption of fast food and large volumes of sweetened beverages, eating large portions, skipping breakfast, eating high-fat snacks or other foods high in energy density, low intake of fruits and vegetables, and irregular meal frequency and snacking patterns.

Physical examination should include measurement of pulse, blood pressure, and evaluation for signs often associated with obesity, such as hepatomegaly from fatty liver disease and acanthosis nigricans, which is associated with insulin resistance. The examination may detect signs of possible reversible causes of obesity, such as deep purple striae and the “buffalo hump” of Cushing’s syndrome.

The degree of obesity and presence of comorbid conditions should determine laboratory testing. A fasting lipid profile is recommended for children with BMI between the 85th and 94th percentiles but with no obesity-related illnesses, Children with BMI between the 85th and 94th percentiles and with obesity-related illnesses should also be tested for alanine transaminase, aspartate transaminase, and fasting blood glucose levels, and children with BMI higher than the 95th percentile should also undergo measurement of serum urea nitrogen and creatinine levels.

Depending on progress, the committee recommends a staged approach of increasing intensity to manage overweight and obese children and adolescents 2 to 19 years old:

  • Stage I (Prevention-Plus Protocol): Make specific dietary and physical activity recommendations, with monthly follow-up. If BMI does not improve in 3 to 6 months, consider stage II.
  • Stage II (Structured Weight Management Protocol). This more structured plan includes a low–energy-dense, balanced diet; structured meals; supervised physical activity of at least 60 minutes daily; limiting television-watching and other screen time to 1 hour per day or less; and use of logs to self-monitor these behaviors. Family clinicians may require assistance from allied care professionals to implement this step, and children should be followed up as often as needed. If BMI does not improve in 3 to 6 months, stage III is appropriate.
  • Stage III (Comprehensive, Multidisciplinary Intervention) and Stage IV (Tertiary-Care Intervention) are more intensive interventions administered by highly trained teams expert in obesity management. Specialized centers can provide effective, intensive counseling programs that promote behavior modification for obese children. Referral is especially indicated for severely obese children and for those with obesity-related comorbidities.
  • “A four-stage approach to treatment of childhood obesity is recommended,” Dr. Rao writes. “Many of these recommendations can be carried out by family physicians for treatment and prevention. These include advising families to limit consumption of sweetened beverages and fast food, limit screen time, engage in physical activity for at least 60 minutes per day, and encourage family meals on most, and preferably all, days of the week.


Dr. Rao has disclosed no relevant financial relationships.

Am Fam Physician. 2008;78:56-63.

Clinical Context

According to the Centers for Disease Control and Prevention, children with age-adjusted and sex-adjusted BMI from the 85th to 94th percentiles are considered “at risk for overweight” and those with BMI at the 95th percentile or greater are considered “overweight.” The prevalence of overweight children is 13.9% for ages 2 to 5 years, 18.8% for ages 6 to 11 years, and 17.4% for ages 12 to 19 years. In the May-June 2005 issue of Ambulatory Pediatrics, Perrin and colleagues found that only 12% of pediatricians self-reported high efficacy in the management of obesity.

This study summarizes the recommendations for the assessment and management of childhood overweight and obesity from the AMA Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity.

Study Highlights

  • Recommendations were based on literature review and expert opinion.
  • The AMA recommends consistent terminology for children and adults: “overweight” (BMI from 85th to 94th percentile), “obese” (BMI at or above 95th percentile), and “severely obese” (BMI above 99th percentile).
  • Assessment includes dietary and lifestyle habits, family history, physical examination, readiness to change, and laboratory tests.
  • Dietary habits linked to obesity are frequent fast-food intake, large volumes of sweetened drinks, large portions, skipping breakfast, high-energy dense foods, few fruits and vegetables, and irregular meals and snacking.
  • Lifestyle habits include environment, social support, barriers to activity, sedentary behavior, and physical activity.
  • Pertinent family history includes obesity, type 2 diabetes, and cardiovascular disease.
  • Physical examination should include height, weight, BMI, pulse, and blood pressure.
  • Physical examination findings associated with obesity are hepatomegaly from fatty liver disease, acanthosis nigricans linked to insulin resistance, and striae and buffalo hump from Cushing’s syndrome.
  • Stages of readiness to change are precontemplation, contemplation, preparation, action, and maintenance.
  • Laboratory testing is guided by BMI and personal or family history of risk factors:
    • BMI from 85th to 94th percentiles and no risk factors: fasting lipid profile
    • BMI from 85th to 94th percentiles and risk factors: add alanine transaminase and aspartate transaminase and fasting blood glucose
    • BMI above 95th percentile: add serum urea nitrogen and creatinine levels
  • Address weight and lifestyle habits once a year with all patients.
  • Treatment for overweight and obese children aged 2 to 19 years includes 4 stages.
  • Stage I consists of specific recommendations, monthly follow-up, and advancement to stage II if BMI does not improve in 3 to 6 months: 5 or more daily servings of fruits and vegetables, television and computer use of no more than 2 hours daily, no television in child’s room, at least 60 minutes of daily moderate to vigorous physical activity, no sugar-sweetened drinks, breakfast daily, meals outside the home limited, family meals at least 5 times a week, and self-regulation of food.
  • Stage II consists of more structured and supervised stage I recommendations, limiting television and computer use to less than 1 hour daily, follow-up as often as needed, help from allied health professionals, and advancement to stage III if BMI does not improve in 3 to 6 months.
  • Stage III involves multidisciplinary intervention.
  • Stage IV involves tertiary care intervention.
  • Referrals are important for children with severe obesity or obesity-related morbidities.
  • Goal is to maintain lifetime healthy behaviors, but guidelines depend on age and obesity level:
    • BMI 85th to 94th percentiles: maintain weight until BMI below 85th percentile or BMI curve decreases
    • BMI at 95th percentile or greater: maintain weight until BMI below 85th percentile or weight loss up to 1 pound per month until BMI below 85th percentile
    • BMI more than 21 or 22 kg/m2 in children aged 2 to 5 years or at 99th percentile or greater: weight loss of 1 to 2 pounds per month until BMI below 85th percentile
  • Obesity prevention for children with BMI between 5th and 84th percentiles should address dietary habits, sedentary behaviors, physical activity, authoritative parenting, family involvement, and school and community support.
  • The National Initiative for Children’s Healthcare Quality published a guide to facilitate implementation.

Pearls for Practice

  • The recommended assessment of childhood obesity includes evaluation of dietary and activity habits, family history of obesity-related illnesses, readiness to change habits, and related physical examination findings. Depending on the severity of obesity and related conditions, laboratory testing might include fasting lipid profile, alanine transaminase, aspartate transaminase, fasting blood glucose, serum urea nitrogen, and creatinine.
  • The recommended 4-stage approach to treatment of childhood obesity includes limiting intake of sweetened drinks and fast food; limiting television and computer use; physical activity for at least 60 minutes daily; family meals; close follow-up; and, if needed, assistance from allied health professionals or weight management center.

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Neonates in Intensive Care Endure Painful Procedures, Mostly Without Analgesia


July 11, 2008 — Over a 2-week period, neonates in intensive care underwent a median of 10 painful procedures per day, 79.2% without analgesia, in a study from Paris.

“The number of painful procedures is so high that the first step to improve procedural pain management must significantly reduce these numbers,” the authors, led by Ricardo Carbajal, MD, from the Hôpital d’enfants Armand Trousseau, in Paris, France, write.

“The knowledge that some vulnerable neonates underwent 153 tracheal aspirations or 95 heel sticks in a 2-week period should elicit a thoughtful and relevant analysis on the necessity and the risk/benefit ratio for our clinical practices,” they observe.

The study is published in the July 2 issue of the Journal of the American Medical Association.

Vulnerable Neonates, Long-Term Consequences From Pain

Compared with older children and adults, neonates are more sensitive to pain, and multiple lines of evidence suggest that repeated and prolonged exposure to pain alters a neonate’s subsequent pain processing, long-term development, and behavior. “It is essential, therefore, to prevent or treat pain in neonates,” the group writes, and there are numerous pharmacological and nonpharmacological treatments that can alleviate procedural pain in these infants.

Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain, they add.

They aimed to report the findings from epidemiologic data on neonatal pain collected from direct bedside observations of neonates in Paris as part of the Epidemiology of Procedural Pain in Neonates study.

This prospective observational study collected around-the-clock bedside data on all painful or stressful procedures performed in 430 neonates admitted to 13 of 14 intensive care units in tertiary care centers in Paris. Data were collected from the first 14 days of admission during a 6-week period.

Painful procedures were considered as those that invaded a neonate’s bodily integrity, and stressful procedures were defined as those that mainly caused physical uneasiness or annoyance.

Nonpharmacologic analgesia included administering sweet solutions or allowing nonnutritive sucking. Pharmacologic analgesia included intravenous opioids and topical drugs.

The average gestational age was 33 weeks, and the average intensive care unit stay was 8.4 days.

The investigators identified 44 painful procedures, of which the 6 most common were nasal aspiration (28.9% of the procedures), tracheal aspiration (23.3%), heel stick (19.8%), adhesive removal (12.7%), gastric tube insertion (2.4%), and venipuncture (1.8%).

Of the 16 identified stressful procedures, the 6 most frequent were nursing care (39.2%), oral aspiration (26.9%), washing the neonate (8.5%), blood pressure measurement (8.5%), radiographs (6.0%), and infant weighing (5.8%).

Average of 16 Painful or Stressful Procedures Each Day

During the study period, neonates experienced 42,413 painful and 18,556 stressful first-attempt procedures and 10,366 painful and 1180 stressful supplemental-attempt procedures.

Each neonate experienced a mean of 16 painful plus stressful procedures each day, and some experienced as many as 62 procedures each day.

Table. Number of Painful and Stressful Procedures in Neonates in ICU*

Procedure In 2 Weeks Per Day
Painful or stressful procedures, n, mean (SD) 141 (107) 16 (9)
Painful procedures, n, mean (SD) 98 (78) 12 (8)
Painful or stressful procedures, n, median (range) 115 (4 – 613) 16 ( 0 – 62)
Painful procedures, n, median (range) 75 (3 – 364) 10 (0 – 51)

*ICU indicates intensive care unit.

Of the 42,413 painful procedures, only 20.8% were carried out with specific analgesia before the procedure: 2.1% were performed with pharmacologic-only therapy, 18.2% with nonpharmacologic therapy, and 0.4% with both.

“Advances in neonatal care in recent decades, with increased survival of immature and sick neonates, have led to an increased number of invasive procedures that may cause pain in these vulnerable neonates,” the group writes. “The prevention of pain in critically ill neonates is not only an ethical obligation, it also averts immediate and long-term consequences,” they add.

Clinical Pain Assessment Correlates With Brain Activity

In another study, changes in brain activity in response to a painful stimulus (a heel prick) were well correlated to facial expression changes in 33 test occasions in 12 infants. In 10 of the 33 test cases, however, the infants showed a cortical response without a change in facial expression, suggesting that pain assessment based on behavioral tools alone may underestimate pain.

These findings, by Rebeccah Slater, PhD, from University College London, in the United Kingdom, and colleagues, are published online June 24 in PLoS Medicine.

Pain in infancy is poorly understood, the group writes. Current assessment tools such as the premature infant pain profile (PIPP) are based on behavioral measures (changes in facial expression) and physiologic measures (changes in heart rate and oxygen saturation).

The ability to use near-infrared spectroscopy to measure changes in oxygenated and deoxygenated hemoglobin concentration in the cortex in response to a noxious stimulus has provided investigators with the first opportunity to evaluate whether pain-assessment tools reflect pain processing in the brain, they add.

The team hypothesized that in infants who received a heel prick, clinical pain scores calculated using the PIPP would correlate with cortical hemodynamic activity.

They studied 12 clinically stable infants in a neonatal unit in a London hospital. The postmenstrual age (gestational age plus postnatal age) of the infants was 25 to 43 weeks, and their postnatal age was 5 to 134 days.

Clinical pain scores — facial expression (eye squeeze, brow bulge, and nasolabial furrow), heart rate, and oxygen saturation — and cortical hemodynamic activity were assessed during 33 clinically required heel pricks.

Behavioral Tools May Underestimate Pain Response

Clinical pain scores, especially facial expression, correlated well with cortical hemodynamic activity, but in some cases, infants did not show changes in facial expression but did show cortical responses to pain.

“While painful stimulation generally evokes parallel cortical and behavioral responses in infants . . . pain assessment based on behavioral tools alone should be interpreted with caution, as they could underestimate the total pain response,” the researchers write.

In an accompanying Editors’ Summary, A. David Edwards, MD, also from Imperial College London, writes that attention-deficit disorders, learning disorders, and behavioral problems in later childhood may be linked to repetitive pain in the preterm infant.

Concurring with the study authors’ conclusions, he notes: “The results of this study raise further awareness of the ability of infants to experience pain and highlight the possibility that pain based on behavioral tools alone may underestimate the pain response in infants.”

The Journal of the American Medical Association article was supported by funds from the Fondation CNP and the Fondation de France, in France. Lead author Dr. Carbajal is affiliated with the Centre National de Ressources de lutte contre la Douleur. A complete list of disclosures is available in the original article. The PLoS Medicine article was funded by the Wellcome Trust, the Medical Research Council, and SPARKS. The study authors have disclosed no relevant financial relationships.

JAMA. 2008;300:60-70.

PLoS Med. 2008;5:e129.

Clinical Context

In the November 2006 issue of Pediatrics, Batton and colleagues reported the recommendation from the American Academy of Pediatrics to minimize painful interventions in neonates. In the 1998 issue of Biology of the Neonate, Amand noted that neonates have greater pain sensitivity than other individuals. In the December 1997 issue of the Clinical Journal of Pain, a multicenter chart review by Johnston and colleagues found that each neonate underwent an average of 2 procedures per day during a 1-week period.

This prospective study uses direct bedside observation to report data on painful or stressful procedures and analgesic therapy in neonates admitted to the intensive care unit.

Study Highlights

  • 430 neonates, including preterm neonates younger than 45 postconceptional weeks and term neonates younger than 28 days, admitted to 8 neonatal intensive care units and 5 pediatric intensive care units in 1 region in France were enrolled.
  • There were no exclusion criteria.
  • Subjects included 309 neonates (71.9%) in neonatal intensive care units and 121 (28.1%) in pediatric intensive care units.
  • Mean gestational age at birth was 33 weeks (range, 24 – 42 weeks).
  • Mean birth weight was 1962 g (range, 490 – 4760 g).
  • 237 (55.1%) were boys.
  • 303 (70.5%) required mechanical tracheal ventilation.
  • Data collection on pain, stress, discomfort, and analgesic therapy occurred for the first 14 days of admission.
  • Mean duration of stay was 8.4 days.
  • 24 (5.6%) died during the study period.
  • No modifications were made in each institution’s pain management protocol.
  • Pharmacologic therapy included intravenous opioids, topical eutectic mixture of lidocaine and prilocaine, or other drugs.
  • Nonpharmacologic therapy included sweet solution, nonnutritive sucking, and skin-to-skin maternal contact.
  • Nursing and medical staff recorded bedside procedures, defined as medical, nursing, surgical, diagnostic, or therapeutic activity performed in the unit.
  • Procedures did not include continuous therapy.
  • Painful procedures were defined either by invasion of the bodily integrity, causing skin or mucosal injury from introducing or removing foreign material into the airway, digestive, or urinary tract, or by clinician assessment.
  • A group of 15 nurses and physicians in the neonatal intensive care unit assigned final classification of painful procedures, defined by a mean score of more than 40 on a 100-point scale.
  • Stressful procedures were defined by physical uneasiness or annoyance or by disturbance of equilibrium between the neonate and the environment.
  • A research assistant verified documentation of procedures up to 3 times per week in each site.
  • 60,969 first-attempt procedures included 42,413 (69.6%) painful and 18,556 (30.4%) stressful procedures.
  • 11,546 supplemental attempts at procedures included 10,366 (89.8%) attempts at painful procedures and 1,180 (10.2%) attempts at stressful procedures.
  • Each neonate underwent an average of 141 procedures (range, 4 – 613 procedures) and 16 procedures per day (range, 0 – 62 procedures).
  • Each neonate underwent an average of 98 painful procedures (range, 3 – 364 procedures) and 10 painful procedures per day (range, 0 – 51 procedures).
  • The most common painful procedures were nasal aspiration (28.9%) and tracheal aspiration (23.3%).
  • The most common stressful procedures were nursing care (39.2%) and oral aspiration (26.9%).
  • Analgesic therapy specifically for painful procedures included pharmacologic-only in 907 (2.1%), nonpharmacologic-only in 7734 (18.2%), both pharmacologic and nonpharmacologic in 164 (0.4%), and none in 33,608 (79.2%).
  • Nonspecific analgesia was received during 14,495 (34.2%) painful procedures.
  • Analgesic therapy specifically for stressful procedures included pharmacologic-only in 136 (0.7%), nonpharmacologic-only in 1077 (5.8%), both pharmacologic and nonpharmacologic in 6 (< 0.1%), and no treatment in 17,337 (93.4%).
  • Nonspecific analgesia was received during 3144 (16.9%) stressful procedures.
  • Factors associated with greater use of specific analgesia included prematurity, parental presence, surgery, daytime (7 AM to 6 PM), category of procedure, and hospitalization days 2 to 14.
  • Factors associated with less use of specific analgesia included mechanical ventilation, noninvasive ventilation, nonspecific analgesia, and higher Clinical Risk Index for Babies score.

Pearls for Practice

  • In the first 14 days of admission to the intensive care unit, each neonate undergoes an average of 16 painful or stressful procedures per day and an average of 12 painful procedures per day.
  • Neonates who undergo painful procedures in the intensive care unit receive specific pharmacologic or nonpharmacologic analgesia in 20% of cases.

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