Tuesday, 19 January 2016

8 out of 10 mothers - what do front line clinicians need to know about childhood obesity?

Childhood obesity is frequently in the news.  The proportion of children who are overweight or obese in countries such as the UK has risen considerably in the past few decades.  Most overweight children will go onto be overweight adults with all the implied risks.  It is often perceived that health issues in later life are the main reason for concern but many children have significant health problems and psychosocial problems (1) during childhood as a result of their weight.  Tackling the problem is made extremely difficult by a number of factors.  As front line clinicians, what are supposed to be doing about it when we see a child who is overweight?

The first problem is recognition.  How often are children brought to a GP surgery by a parent who is concerned that their child is overweight?  Last month, Archives of Disease in Childhood published a study with an outcome that will surprise few of us. It showed that only 18% of mothers of obese children perceived their child to be moderately overweight. (2) That means that if we take an opportunistic approach, four times out of five we have to break news as well as take the problem forward.  Like I said, not a surprising statistic but a sobering one.

The next problem is the identification of obesity.  Definitions vary and there is disagreement about the best method of determining if a child is obese.  The majority seems to rest with BMI being the least worst measure but then you need a weight, a height, a calculator and a paediatric BMI centile chart.

If you feel defeated already, wait for the punchline: the evidence for the effectiveness of interventions is poor or non-existent.  This is one of the reasons that there are currently no commissioned services specialising in childhood obesity in the UK.  Bariatric surgery aside, there are no interventions that have both a significant impact and a good evidence base, so should we even bother?

I think that the answer is yes, but you can choose your reason.  You may, for example, choose to embrace the idea of making every contact count.  Ideally we all address things like obesity opportunistically.  I can’t pretend to succeed there very often.  One of the problems is the feeling that people don't see it as a problem in the same way that clinicians do.

Alternatively you may wish to know what really needs to be referred to secondary care according to those who specialise in this group of patients.  In 2012, in the absence of guidance from a national body (that would mandate the provision of a clinical service) the Obesity Services for Children and Adolescents (OSCA) group of paediatricians produced a consensus statement (3).  These were the indications for referral according to that statement:

Possible underlying cause to obesity suggested by
  • Short stature
  • Dysmorphism
  • Learning difficulties

Comorbidities suggested by
  • Hypertension
  • Symptoms of sleep apnoea
  • Acanthosis Nigricans
  • Evidence of Polycystic Ovary Syndrome
  • Psychological morbidities
  • Safeguarding concerns
  • Impaired glucose intolerance, dyslipidaemia or liver dysfunction
  • Family history of Type 2 diabetes before the age of 40 or cardiovascular disease before the age of 60 in a close relative

Acanthosis Nigricans (thickened and pigmented patches of skin in the neck and axillae) in children is often associated with insulin insensitivity.  (picture taken from commons.wikimedia)

I can’t argue with any of those as they all seem quite reasonable.  Essentially the experts are saying that children who might have a medical cause or effect of their obesity should be referred. 

The difficulty with this list is that it rather brings me full circle.  In order to know whether a child’s obesity might be secondary to something or might be causing another problem, I need to examine them and ask a few questions.  I can’t really do this without making the diagnosis of obesity.  For this I need to mention that the child might be overweight so I need to do a few measurements.  I should probably explain why I suddenly have an acute interest in the young person's armpits.  Even if I do explain myself, 8 out of 10 mothers will probably be a little surprised.

Edward Snelson
Counting every contact

  1. Strauss RS, Social marginalization of overweight children, Arch Pediatr Adolesc Med. 2003 Aug;157(8):746-52.
  2. Dowd et al, The association between maternal perceptions of own weight status and weight status of her child: results from a national cohort studyArch Dis Child 2016;101:28-32 doi:10.1136/archdischild-2015-308721
  3. Vine et al, Assessment of childhood obesity in secondary care: OSCA consensus statement: Arch Dis Child Educ Pract Ed 2012;97:98-105 doi:10.1136/edpract-2011-301426

Thursday, 7 January 2016

The Trouble with Training (Easter egg - when to do a Chest X-ray in children in the ED or General Practice)

I remember well how difficult it is to stay up to date across the thousands of clinical scenarios that face the General Practitioner.  When I was faced by something not in the top 100 weekly problems, I usually had to think back to my training.  That works well as long as what I recalled was accurate, and was best practice at the time and remained so.  What are the chances of all three being true even five years post-training?

Accurate recall (keep taking that thiamine) aside, the first issue is whether one's training involved the demonstration of standard care.  I was recently pulled into a twitter conversation about whether children with pneumonia required a chest X-ray (CXR).  The person facilitating the discussion was one of the local GP trainers who had himself been asked by one of the GP trainees here in Sheffield.  The trainee felt that they were getting mixed messages and wanted to know the right answer.  Of course a complete answer doesn't fit in a tweet.  Also, tweets are transient unless they are the kind that get you fired.  So a GPpaedsTips post seems to me to be the best place for a proper answer.  Since the question was about acute paediatrics, I can legitimately put a foot outside of the Primary Care remit of this site, but it seems the ideal opportunity to also address the question of when a CXR might be indicated for a child in a General Practice setting.

Continuing with the theme of see one do one, lets start with children with pneumonia in a secondary care setting in the UK.  The British Thoracic Society guidelines for community acquired pneumonia in children are, in my opinion, very good.  Their recommendation that "Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia" is based on the old principle of 'if it doesn't change your management don't do it.'  Putting that into practice requires a little step back and for us to ask the question, 'what is a CXR for?'  I used to think it was needed to diagnose pneumonia.  That is a fallacy, since X-ray changes will have a time lag and a CXR can be a false negative.  So, is it to show the severity, or what kind of pneumonia it is?  No, the severity is a clinical assessment and the type of chest infection is determined by a combination of the clues in the assessment and the response to treatment.  According to the BTS guidelines, CXR in the ED or paediatric assessment unit should mainly be used for the cases which are a little bit different from the routine LRTI.  This might be repeated LRTI, a child who is severely unwell or a number of other reasons.  That doesn't mean find a reason.  It means find a good reason.  In particular, if you think the child is well enough to treat as an outpatient, BTS recommends never doing a CXR.  Never is a strong word but it's a good place to start and puts the GP CXR question in context.

Adults, with their risk of lung cancer, are different.  In children, signs and symptoms are usually all you need when making decisions about treatment or referral when it comes to children's respiratory problems.  In my opinion, doing a CXR for a child in primary care should be for a situation where the X-ray could give information that allows treatment to be given or a referral to be avoided.  I can't think of any situations where the CXR would do that but a history and examination would not.

I understand that one reason that CXRs are done for children in Primary Care is to reassure parents or clinicians.  I would be very wary of that plan.  CXRs often have findings on them, especially when a child has a viral illness.  A finding is not the same thing as a clinically significant abnormality, but it is not very reassuring either.

Then there is the possibility that a CXR might be done in the belief that one would be done for the same patient in a hospital setting.  That is also tricky since practices change.  The trouble is that they may change slowly and inconsistently.  I believe that the safest approach is to avoid second guessing what tests someone else will want.  I either ask them or leave them to request their own investigations.

So then there is the challenge of being up to date.  I would like to use this opportunity to tell all my secondary care colleagues how stupidly easy we have it in this regard.  The environment we work in continually provides us with updates and learning (if you are surrounded by the kind of clever yet pragmatic clinicians I work with).  I remember how General Practice is a relatively isolated learning environment and how difficult it is to keep abreast of changes in so very many areas.

That's the trouble with training and keeping up to date: these things have the tendency to look fun and manageable but actually have the tendency to expand exponentially and take over.  Meanwhile, we all have a ship to run. The solution: Cling on, outsource your troubles and let FOAMed give you the answers.

Snelson out

Disclaimer: I need reassurance too. I'm just not sure where to find it any more.

BTS guideline for Community Acquired Pneumonia in Children