Dr.Venkatesh Kumar.M, Dr.C.Jayakumar,Dr.Praveena, Dr.Navya George,
AIMS-Kochi.
8 years old girl with global developmental delay with history of
increased weight gain ,decreased physical activity and hyperphagia over
the past 2 years with 2 admissions in the past for speech delay and
seizures.Physically she had large size head,almond shaped eyes,narrow
palpebral fissure with chub cheeks,acanthosis nigricans,apple shaped
abdomen and dry skin.Auxology revealed weight for age, BMI above
95th percentile and Height for age between 50th and 75th
centile.Systemic examination was unremarkable.
Differentials considered were:
1 . Endocrine-Hypothyroidism,Pseudohypoparathyroidism,Cushing’s
syndrome,GH deficiency
2 . Monogenic disorders
3 . Syndromes-Prader Willi
4 . Neurological or Hypothalamic
causes(craniopharyngioma,hamartoma,glioma)
5 . Drug induced(Glucocorticoids,Antiepileptics)
6 . Psychological(Depression,Binge eating disorder)
Labs:
Thyroid profile:T4-1.32 ng/dl,TSH-4.12 IU/ml
Lipid profile: Total cholesterol-108.4 mg/dl,LDL -54.4 mg/dl,HDL -45.5
mg/dl,VLDL – 12.8 mg/dl,Plasma triglycerides-63.8 mg/dl.
Plasma glucose(fasting):83.8 mg/dl , HBA1C : 5.2%
Chest Xray: Increased bronchovascular markings
Xray wrist: Bone age corresponds to 8 years(i.e,chronological age).
USG Abdomen:Hepatosplenomegaly with mild fatty infiltration.
MRI Brain with contrast : Anterior pituitary gland is hypoplastic with
abnormal morphology,Normal posterior pituitary bright spot,small
sized sella,no focal lesions,no ectopic posterior pituitary.
Karyotyping: 46 XX
FISH: Negative for Prader Willi Syndrome
WES: Negative
Total serum cortisol(measured at 8 am): 9.67 mcg/dl( 3-21 mcg/dl)
Diagnosis:Morbid Obesity with Global Developmental
delay(?Endocrinal/Syndromic)
The child was started on T.Metformin and was asked to follow up later.
Discussion:Childhood obesity has become an important public health
problem in India as well as other countries.
Etiology: 1 )Exogenous or Primary obesity(>90%)- due to
parental,prenatal,lifestyle,dietary,environmental factors.
2 )Endogenous or Secondary obesity(<10%)-
- Endocrine:Hypothyroidism,Cushing’s syndrome,GH
deficiency,Pseudohypoparathyroidism - Monogenic disorders: Melanocortin-4 receptor
haploinsufficiency,Leptin or leptin receptor insufficiency. - Syndromes-Prader Willi, Bardet-Biedl, Alstrom, Cohen
- Neurological or Hypothalamic:
Cranipharyngioma,Hamartoma,Histiocytosis,infective causes. - Drug induced: Glucocorticoids, Antiepileptics, Antipsychotics,
Sulfonylureas. - Psychological: Depression,Binge eating disorders.
Red flags for Pathological Obesity: - Early onset obesity- Very rapid gain in weight in first few years
- Short stature for age
- Hyperphagia- non discriminatory
- Dysmorphism
- Associated features- Developmental delay, visual abnormalities,
behavioural problems - History of steroid intake
- Hypogonadism
BMI should be assessed and plotted in IAP2015 BMI charts which is
useful for diagnosing overweight and obesity.Waist circumference is an
important predictor of Visceral obesity.
Lab evaluation: - Exogenous obesity: Fasting lipid profile, alanine aminotransferase
(ALT), renal function tests, fasting blood glucose, oral glucose
tolerance test, glycosylated hemoglobin (if indicated) - Hypothyroidism: TSH, free thyroxine
- Cushing syndrome: Serum or salivary cortisol (11 PM),
dexamethasone suppression test, 24-hour urine-free cortisol test - Growth hormone deficiency: Bone age, Insulin-like growth
factor1, Insulin-like growth factor binding protein-3, growth
hormone stimulation test - Pseudohypoparathyroidism: Calcium, phosphorus, parathyroid
hormone, X-ray hand - Genetic or monogenic obesity: Specific genetic test (advised a
specialist) - Hypothalamic and pituitary disease: Magnetic resonance imaging
(MRI) of brain
Management:The initial management of pediatric obesity is lifestyle
modification at primary HCP level.If this afils,then it is transferred to
multimodal approach including parents,family and
school,pediatricians,specialists for comorbidities like
Endocrinologists,Pulmonolgists,psychologists,counsellors and dieticians
in the prevention ,management and follow up care of overweight and
obese children. - Dietary management
- Physical activity/exercise/reduction in screen time
- Pharmacological management:GLP-1 analogues
- Surgical management: Roux-en-Y gastric pass and sleeve
gastrectomy.
Risks associated with Childhood obesity: - Neurological:Pseudotumor cerebri
- Cardiovascular:Dyslipidemia,Hypertension,coagulopathy,endothel
ial dysfunction - Endocrine:Type-2 DM,Precocius puberty,Polycystic Ovarian
syndrome,Hypogonadism - Pulmonary:Sleep apnea,asthma,exercise intolerance
- GIT:Gallstones,Steatohepatitis.
- Renal:Glomerulosclerosis
- Psychological:Poor self esteem,depression,eating disorders.
Take Home Message:Pediatricians should recognise and treat pediatric
obesity as a chronic disease characterised excess or dysfunctional
body fat(adiposity) which impairs the health leading to long term
morbidity and even mortality.
He should explain the risk associated with the obesity clearly to the
child and motivate the family to follow a healthy diet and lifestyle.