Referral Guidelines are peer reviewed guidelines developed to assist referring providers in their approach to a patient presenting with common signs or symptoms suggestive of an endocrine condition, and when to refer to Pediatric Endocrinology.
Symptoms/Signs:
- Overweight (BMI > 85 %ile for age and sex) or obese (BMI > 95th %ile for age and sex)
- Normal/tall stature
- Normotensive/ hypertensive
- Acanthosis nigricans, striae
- Joint tenderness
- Early pubarche, gynecomastia in boys, hirsutism in girls
Past history:
- History of low birth weight
- abnormal weight gain for many years
- Irregular dietary habits -skipping major meals, snacking, binge eating, stress eating, eating out
- Consumption of sugar sweetened beverages
- Decreased physical activity/ increased screen time.
Family history:
- Obesity
- bariatric surgery in other family members
Refer to Differential Diagnosis section
Blood tests:
- Fasting blood glucose
- Complete metabolic panel including liver function tests
- Fasting lipid panel
Other tests to consider:
- Hemoglobin A1c and two-hour oral glucose tolerance test (OGTT) if diabetes is suspected
TSH and T4 only if there are other signs/symptoms of thyroid disease (irregular menses, poor linear growth, etc)
Routine:
May be referred to a specialized weight management center if there is no improvement in z-BMI/ weight after 3- 6 months of healthy eating and increased exercise (family based counseling).
Patient may be referred as needed for comorbidities:
- Hyperglycemia/Impaired glucose tolerance test
- Menstrual irregularity
- Cushing disease/syndrome
- Thyroid disorder
- Previous growth data/growth charts
- Pertinent medical records
- Recent laboratory and radiologic studies
- Exogenous obesity: associated with normal growth and tall stature.
- Endocrine disorders: Cushing disease, hypothyroidism, Pseudohypoparathyroidism: associated with short stature/slow growth velocity
- Genetic disorders: Melanocortin-4 receptor mutation, Prader-Willi syndrome, Bardet-Biedl syndrome, other monogenic obesity syndromes
Additional History:
- Abnormal weight gain along with normal height gain (tall stature or taller than expected stature for family)
· Irregular dietary habits -skipping major meals, snacking, binge eating, stress eating, eating out
· Consumption of sugar sweetened beverages
· Decreased physical activity/ increased screen time.
Associated problems:
· Joint pain
· Shortness of breath, snoring at night
· Daytime sleepiness, headache
· Vision changes
· Acanthosis
· Menstrual irregularity
· Poor self-esteem, depression, history of bullying
Laboratory Abnormalities:
· Pre-diabetes is defined as fasting blood glucose: 100-125 mg/ dl, or 2 hours post prandial glucose: 140-200 mg/dl after glucose load of 1 gm/ kg (maximum dose: 75 gm), or HbA1c 5.7-6.5%.
· Liver enzymes may be abnormal (secondary to fatty liver or Non-alcoholic steato-hepatitis (NASH))
· Fasting lipid panel may show multiple abnormalities: elevation of triglycerides and LDL cholesterol and decreased HDL cholesterol concentrations.
· 24 hour urinary free cortisol or midnight salivary cortisol if Cushing disease suspected
· Polysomnogram if obstructive sleep apnea (OSA) is suspected.
Management of obesity and metabolic syndrome: A family based lifestyle modification is the cornerstone of management. It involves:
Nutritional therapy
· Decreasing/eliminating sugar-sweetened beverages, regular meals daily, including breakfast, controlling portion size, consumption of 5 servings of fruits and vegetables per day, limiting consumption of fast-food intake and “eating out”, removing junk food from the household, having healthy food readily available.
Physical activity/ avoidance of inactivity:
· Encouraging >60 min of moderate to vigorous physical activity/day to be incorporated in the daily routine.
· Limiting screen viewing, including computer use and video games to <2 h per day removal of TV from the bedrooms.
Treatment for comorbidities if present
· Hyperlipidemia: Lifestyle modification, statins as needed based on LDL level and level of risk factors.
· NASH: Life style modification, metformin and thiazolidinediones, consider referral to gastroenterologist.
· Sleep apnea: Referral to sleep specialist/ENT. Tonsillectomy and adenoidectomy and use of CPAP device.
· Hypertension: Lifestyle modifications, DASH diet and antihypertensive medication as needed, consider referral to cardiologist/nephrologist.
· Menstrual irregularity/ polycystic ovarian syndrome: Metformin, Oral contraceptive pills.
· Joint pain: Appropriate x-rays, consider referral to orthopedic specialist.
· Depression: Referral to mental health provider.
Bariatric surgery: Indicated in very select patients who have been followed at a multidisciplinary weight management center and have BMI > 35 with severe comorbidities or BMI > 40 with less severe comorbidities.
National Heart Lung and Blood Institute: Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents- 2011. Available from: http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm.
Styne DM, Arslanian SA, Connor EL, Farooqi IS et al. Pediatric Obesity—Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline. JCEM. 2017; 102(3):709-757 https://doi.org/10.1210/jc.2016-2573
Cook S, Auinger P, Li C, Ford ES. Metabolic syndrome rates in United States adolescents, from the National Health and Nutrition Examination Survey, 1999-2002. J Pediatr. 2008;152(2):165-70. Epub 2008/01/22. doi: 10.1016/j.jpeds.2007.06.004. PubMed PMID: 18206683.
Pratt JS, Lenders CM, Dionne EA, Hoppin AG, Hsu GL, Inge TH, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring, Md). 2009;17(5):901-10. Epub 2009/04/28. doi: 10.1038/oby.2008.577. PubMed PMID: 19396070; PubMed Central PMCID: PMC3235623.
Authors: Indrajit Majumdar and Teresa Quattrin
Updated 12/2022 by Michelle Knoll