Pediatric Primary Care Case Studies (27 page)

Culture has a significant impact on attitudes about foods, food choices, and eating practices and must be addressed as part of the management plan (Lumeng, 2008). The goal is to work within the culture to adopt culturally-appropriate healthier eating habits. Because the obese child is part of a family unit with other members who typically also have weight management issues, changes to more healthful nutrition and physical activity practices should focus on both the child and the family; family meals and healthier eating practices should be emphasized for all members of the unit. Likewise, physical activities should be encouraged for all members of the family, with physical activities scheduled as a family unit together whenever possible.

A Staged Treatment for Obesity

Using an evidence-based approach to the management of childhood obesity provides guidance to help children, adolescents, and their family to return to healthier nutrition and physical activity practices. In addition, the treatment of secondary complications (e.g., type 2 diabetes and obstructive sleep apnea) that are now more commonly found in younger obese children and adolescents also
becomes an area that requires attention in order to avoid resulting negative personal and societal consequences. The AAP Expert Committee (Barlow & Expert Committee, 2007) recommends a four-stage approach for the prevention and management of overweight. Highlights of these stages are identified by Gottesman et al. (2010):

•   
Stage 1: Prevention Plus:
The goal of this stage is to move the child’s BMI to the 85th percentile; it will take 3–6 months for a noticeable change in BMI. Key concepts are to encourage family meals, eating at the table, adding more daily servings of fruits and vegetables, daily breakfast, and no sweetened beverages. Vigorous physical activity daily for ≥ 60 minutes needs to be planned with ≤ 2 hours of daily screen time per day allowed for the child. The provider should see the patient every 3 to 6 months. The goal of this stage is to increase physical activity, decrease physical inactivity, and improve the nutrition quality of the child’s meals and snacks and develop better eating practices (e.g., not eating in front of television or grazing on food throughout the day).

•   
Stage 2: Structured Weight Management:
Stage 2 includes all components of stage 1 with the addition of behavioral counseling. The key components of healthy eating in this stage are to emphasize foods with low calorie density, structured meals with one to two healthy snacks, and no sweetened beverages. The child should have 60 minutes of planned and supervised daily physical activity, and screen time should be limited to ≤ 60 minutes daily. A daily recording of physical activity and TV time, with a 3-day food log between visits, should be submitted for review. The parent or child should identify and use planned reinforcements which are not food related for desired behaviors. Schedule monthly visits to the PCP, and use of the services of multidisciplinary team members should be considered including referrals to family counseling, dietitian, physical therapy, and/or exercise therapist.

•   
Stage 3: Comprehensive, Multidisciplinary Intervention:
The strategies for stage 3 include those listed in stages 1 and 2 plus a diet and daily physical activity plan to achieve a negative energy balance for weight loss. A multidisciplinary team approach is essential for both the child and family. More frequent follow-up visits are needed, with visits scheduled every 2 to 3 weeks. If comorbid medical issues are present, they must be monitored closely.

•   
Stage 4: Tertiary Care Intervention:
Older children and adolescents who are severely obese and have failed stage 3 need to be referred to a pediatric obesity expert for stage 4 intervention. Management strategies may include very low calorie meal and snack plans, pharmacotherapy (e.g., Sibutramine or Orlistat), and/or bariatric surgery. A multidisciplinary team approach is essential.

Prevention

Prevention of overweight and obesity is of paramount importance, and every pediatric health supervision visit beginning at birth should provide anticipatory guidance about healthful nutrition practice, a healthy weight, and the promotion of age-appropriate physical activities and goals. When a child is found to be at risk for overweight or is obese, management of this problem and secondary complications, if present, become the focus of treatment to get the child “back on track.” Once obesity is established it is difficult to reverse. Therefore, the prevention of childhood overweight must focus on health promotion and anticipatory guidance activities that emphasize healthful nutrition and optimal feeding and eating behaviors. The National Association of Pediatric Nurse Practitioners in their Healthy Eating and Activity Together (HEAT) Initiative developed clinical practice guidelines entitled
Identifying and Preventing Overweight in Childhood;
these can be accessed via the National Guideline Clearinghouse at
http://www.guideline.gov
. They are an excellent resource for PCPs.

Strengthening Parenting Skills and Family Motivation for Change

Strengthening parenting skills and family motivation to embrace healthful nutrition practices and inclusion of physical activity into a daily life plan are strategies the PCP must employ for both the prevention and treatment of obesity. The tenets of motivational interviewing techniques stress the need for self-management of healthcare problems and/or a return to healthier lifestyles and choices. The steps of motivational interviewing include assessing the importance, confidence (using a scale of 0–10 to rate confidence in the ability to change), and readiness for change; exploring the importance of making a behavior change; building confidence in the ability to change; and planning for change. For children, motivational interviewing requires the healthcare provider to work with the child and/or parents, who are the ones who determine what practices and interventions for change can be implemented in their lives. The emphasis is on patient values and preferences rather than telling the child or parent exactly what they “must do” (Gance-Cleveland, 2007). Information about motivational interviewing can be found at
http://www.motivationalinterview.org
.

Therapeutic Plan: What will you do therapeutically to manage this child?

Maria’s BMI is at the 97th percentile, which requires stage 1 weight management—prevention plus—as identified for this category. Reducing Maria’s sedentary activities by decreasing her daily screen time, increasing her daily physical activities through increased opportunities for active play, and providing more healthful meals and snacks with appropriate portions as identified in
http://Mypyramid.gov/KIDS/
are the three areas to address with Mrs. Smith. Because Maria has been teased about her weight by her preschool
friends, you address the problem of negative self-esteem, which could become an issue for her. Furthermore, Mrs. Smith has indicated a readiness for change regarding nutrition and physical activity for her whole family. Building Mrs. Smith’s confidence that she can identify changes that will work considering her family’s lifestyle and personal preferences is essential.

Mrs. Smith identified the following plan for Maria. She will be allowed only 2 hours of screen time per day, and they will walk to preschool and the grandparents’ home rather than going in the car. She will encourage more play time. Mrs. Smith is going to talk with the grandparents about providing Maria with more nutritious snacks and will also discuss with her husband ways they can increase the entire family’s physical activity time together. Mrs. Smith says that she is going to try to reduce the number of times Maria has fast foods and will reduce Maria’s soda drinking to two half-cans per week. She is also going to talk with Maria about her schoolmates calling her “fatso” and how best to respond to them.

Caries

A dental referral is initiated for Maria, and you provide her mother with pamphlets and teaching about healthy dental practices including daily brushing, fluoride sealants, and dental visits.

Skin Issues

You recommend a topical over-the-counter barrier cream to be applied twice a day.

When do you want to see this patient back again?

You want to initially see Maria back in a month to 6 weeks. You will review the laboratory studies that were ordered, discuss the effectiveness of the treatment plan, and support the family in the new treatment management at this time. As the family develops self-care skills, further appointments can be spread further apart.

How should you close today’s visit?

You end by saying that Maria will be scheduled for a follow-up visit in 6 weeks to check her weight and review how Maria and her family are doing with the increased emphasis on healthy food choices and practices and increasing their daily activity. You ask Mrs. Smith to tell you how comfortable she is with implementing some of the suggestions that either you have given her or she has identified on her own to increase Maria’s daily physical activity and to promote more healthful nutrition practices for her daughter. You write the plan down in Maria’s chart and identify that, on a scale of 1 to 10, Mrs. Smith is a 5 in her comfort level that this plan will help both Maria and her family. You praise Mrs. Smith for her willingness to address the family’s issue of being overweight and provide Mrs. Smith with a list of local community recreational programs that focus on increasing physical activities for young children and their parents.

The Follow-Up Visit

Maria and her mother return in 6 weeks for a weight recheck and follow-up counseling regarding nutrition and physical activity. Her weight is a ½ pound lower and she has seen the dentist and begun dental treatment for her multiple caries. You review her laboratory results. Her fasting blood glucose is 90 mg/dL (normal) and her thyroid and lipid panels are also within normal limits for age. Mrs. Smith is pleased with Maria’s normal laboratory results.

Mrs. Smith says that the entire family is walking twice every day for a total of 30 to 45 minutes. The grandparents have also been receptive to reducing the portion sizes they give Maria when they provide her meals and are giving her healthier food choices by providing more fruits and vegetables. Maria still asks for candy rewards but Mrs. Smith is limiting this to only once a week as compared to five or six times, which she had done in the past.

You decide to wait to order polysomnography based on the data that Maria’s loud snoring has not worsened and she remains awake and cheerful during the day.

Key Points from the Case