Tina Simpson, MD, MPH; Jean Ivey, DSN, CRNP

Author Information

Abstract and Introduction

Abstract

This is a Pediatric Management Problem (PMP) designed to test your problem-solving and decision-making abilities.
Instructions: Read the PMP below. Then outline how you would assess and manage the problem. Finally, compare your rationale and decision to that listed in the shaded area.

Introduction

Ana is a 15-year-old Hispanic female who presented to the clinic for evaluation of a rash. She first noticed the rash about 3 months ago. It is located on the back of her neck. She reports that it is not pruritic. She had no new exposures, such as lotions, detergents, or soap prior to the onset of this rash. Her mother has told her on several occasions that her neck looks "dirty."

Medical History

She has no chronic medical problems. She has never been hospitalized nor had any surgeries. She has used several over-the-counter creams for this rash but with no improvement. She has no known allergies. Menarche was at age 11, and her periods have been regular.

Family Medical History

Her family history is significant for hypertension in her father and Type II diabetes in her maternal grandmother.

Ana lives with her parents and two siblings, ages 2 years and 6 years. She is in the 10th grade and is a "straight A" student. She is involved in choir and enjoys talking on the phone with friends. She is not involved in sports.

Physical Examination

General: Alert, no acute distress

Vital signs: Temperature = 98.9; Pulse = 90; BP = 115/70; RR = 16; Weight = 75.2 kg ; Height = 157.5 cm; BMI = 30.3

HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Tympanic membranes normal. Mucous membranes moist.

Neck: Supple. No thyromegaly.

Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs.

Lungs: Clear to auscultation bilaterally.

Abdomen: Soft, nondistended, nontender. Normal active bowel sounds.

Extremities: No club, cyanosis, or edema. Brisk capillary refill.

Neurologic: No focal deficits.

Skin: Hyperpigmented velvety hyperkeratotic plaques on the posterior neck and bilateral axillae

What is Your Assessment?

Ana's skin findings are consistent with acanthosis nigricans, which may be seen in obese patients and represent insulin resistance. Ana's body mass index (BMI) of 30.3 is above the 95th percentile for age and gender.

Use of BMI to Classify Children and Adolescents as Overweight or Obese

BMI is defined as the ratio of weight (kilograms) to height squared (m[2]). BMI is often used to define overweight and obesity because it utilizes commonly available data that correlate well with body fatness measurements (American Academy of Pediatrics, 2003). Growth charts are available from The Centers for Disease Control (CDC) for determining BMI percentiles for age and gender.
The Childhood Obesity Action Network Expert Committee (2007) recommends that healthcare providers at least annually assess and plot the height, weight, and BMI of children and adolescents. Addition ally, this committee defines an individual (ages 2-18 years) with a BMI for age and gender between the 85th and 95th percentile as overweight and greater than the 95th percentile as obese.

Childhood Obesity

The prevalence of childhood overweight and obesity has continually increased over time. According to data from the National Health and Nutrition Examination Surveys (NHANES), the prevalence of obesity in the last 20 years for children up to age 11 years has doubled and has tripled for adolescents ages 12-19 years (Singhal, Schwenk, & Kumar, 2007).
Childhood obesity represents a significant risk for childhood morbidity. Potential consequences of childhood obesity include Type II diabetes, hypertension, dyslipidemia, metabolic syndrome, sleep disorders, fatty liver disease, and psychosocial impairment (Doak, Visscher, Renders, & Seidell, 2006).

Evaluation of the Overweight/ Obese Child or Adolescent

The majority of childhood obesity is exogenous and represents increasing caloric intake and decreasing physical activity (Singhal et al., 2007). According to the 2005 Youth Risk Behavior Survey, only 36% of high school students met the recommendations for physical activity of at least 60 minutes per day on 5 or more days. Only 20% of students ate the recommended 5 fruits and vegetables per day (CDC, 2006).
The Childhood Obesity Action Network Expert Committee (2007) recommends that healthcare providers qualitatively assess the dietary patterns of all pediatric patients. The committee specifically addresses inquiring about sweetened-beverage consumption, fruit and vegetable consumption, frequency of eating out and family meals, consumption of excessive portion sizes, and daily breakfast consumption. The committee also recommends that providers assess whether pediatric patients are meeting the recommended 60 minutes of moderate physical activity daily and limiting sedentary activities like TV watching, computer use, and playing stationary video games to no more than 2 hours per day. Importantly, providers are also encouraged to assess patients' readiness to change both dietary and physical activity behaviors.
Laboratory tests to be considered in the evaluation of the overweight or obese pediatric patient include: fasting glucose, insulin, lipid panel, transaminase, BUN, and creatinine (Childhood Obesity Action Network, 2007; Singhal et al., 2007).

Treatment of the Overweight/ Obese Child or Adolescent

The Childhood Obesity Action Network Expert Committee (2007) recommends a staged approach for the treatment of the pediatric patient with a BMI of greater than the 85th percentile. Activities in the treatment protocol should include a structured behavioral modification plan with well-defined physical activity and nutritional goals and monitoring of behavior. Treatment plans should allow for close follow-up with health providers.
Patients with BMIs of greater than the 95th percentile and significant co-morbidities who have not been successful with staged behavioral modification treatment plans should be referred to pediatric tertiary weight management centers (Childhood Obesity Action Network, 2007). Additional treatment options for these patients include very-low calorie diets, use of medications (such as orlistat, sibutramine, and metformin), and bariatric surgery (Childhood Obesity Action Network, 2007; Singhal et al., 2007).
In this scenario, Ana would be classified as obese and her physical finding of acanthosis nigricans is suggestive of insulin resistance. Ana's provider obtained baseline labs, started her on structured nutritional and physical activity modification plan, and arranged for close follow-up.