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AAP guidelines promote access to pediatric metabolic, bariatric surgery

NEW ORLEANS — A new AAP policy statement offered ways for pediatricians to improve access to metabolic and bariatric surgery for pediatric and adolescent patients who qualify for the procedures.

The AAP also suggested steps that could be taken by government, health and academic medical centers, as well as public and private insurers.

According to Sarah Armstrong, MD, FAAP, lead author of the policy statement and member of the executive committee of the AAP Section on Obesity, the predominant treatment method for obesity involved watchful waiting with a focus on nutrition and activity.

“We are not recommending no watchful waiting; we are just cautioning against excessive periods of watchful waiting, particularly for those who have severe obesity and serious medical complications,” she told Infectious Diseases in Children.

Armstrong explained that bariatric surgery appears to have a fixed reduction effect on BMI and patients may benefit more from surgical intervention when their BMI is lower.

“If you have a child with a BMI of 45 and you do bariatric surgery, your chances are to get to a BMI of 35,” she said. “Then, the hope is that they would sustain that BMI throughout adulthood. That is still officially in the obese range, but it is much less severe.”

Photo of doctors in hospital performing surgery surrounded by health monitors 
Source: Adobe Stock

The AAP also urged pediatricians to advocate for increased access to metabolic and bariatric surgery for all qualified patients, regardless of racial, ethnic or socioeconomic backgrounds.

According to the authors, contraindications for surgery include medically correctable causes of obesity; current untreated or poorly controlled substance abuse or substance abuse within the preceding year; the presence of medical, psychiatric, psychosocial or cognitive conditions that could affect adherence to postoperative dietary and medication plans; and current pregnancy or pregnancy planned for 12 to 18 months following the procedure.

According to Armstrong and colleagues, medical centers should use best practices related to metabolic and bariatric surgery, including multidisciplinary, age-tailored care that aligns with the family’s values and preferences, to ensure safe and effective care. No lower age limits have been made for the procedure, so the authors suggested that these centers consider the potential health benefits and individualized care for patients and families. Further, they recommended that centers increase the number of multidisciplinary centers focused on metabolic and bariatric surgery, ensuring access to these centers for all teens who meet criteria for the procedure.

Armstrong explained that if that same child were to wait for surgery and do watchful waiting, and their BMI is 55 at age 18 years, they will likely have a BMI of 45 for the rest of their life

The recommendations focused on improving provider knowledge about indications for the procedure — including having a BMI of 35 or higher or having a weight that is 120% or higher of the 95th percentile for age and sex — the importance of assisting families with decision-making based on risks, and benefits of the intervention and collaboration with a multidisciplinary team to identify the best treatment options and optimize pre- and post-surgery care.

The AAP also urged pediatricians to advocate for increased access to metabolic and bariatric surgery for all qualified patients, regardless of racial, ethnic or socioeconomic backgrounds.

“If we had a new medication to treat asthma, we would all learn the indications, make sure we understood the dosing and we’d be prescribing it,” Armstrong said. “I think we have to be a little bit mindful that weight loss surgery has some bias and stigma that come along with it, and we have to be careful that this bias isn’t limiting our ability to help kids get the treatment they need.”

According to the authors, contraindications for surgery include medically correctable causes of obesity; current untreated or poorly controlled substance abuse or substance abuse within the preceding year; the presence of medical, psychiatric, psychosocial or cognitive conditions that could affect adherence to postoperative dietary and medication plans; and current pregnancy or pregnancy planned for 12 to 18 months following the procedure.

Armstrong and colleagues stressed that medical centers should use best practices related to metabolic and bariatric surgery, including multidisciplinary, age-tailored care that aligns with the family’s values and preferences, to ensure safe and effective care. No lower age limits have been made for the procedure, so the authors suggested that these centers consider the potential health benefits and individualized care for patients and families. Further, they recommended that centers increase the number of multidisciplinary centers focused on metabolic and bariatric surgery, ensuring access to these centers for all teens who meet criteria for the procedure.

The AAP suggested that private and public insurers pay for multidisciplinary pre- and post-operative care, the surgery itself and ongoing care for patients who meet criteria for metabolic and bariatric surgery. Barriers to surgery, such as inadequate payment, limited access, unsubstantiated exclusion criteria and bureaucratic delays in approval for surgery, should also be reduced.

The policy statement was accompanied by a technical report that provided details and supporting evidence.

“The release of these policy guidelines is the beginning,” Armstrong said. “We don’t expect that all pediatricians will suddenly know how to take care of patients presurgery, will know exactly what procedures to discuss with them, or how to manage them long term after surgery. We know that there’s going to be a learning curve associated with that.”

Armstrong said she hopes the policy guidelines could lead to clinical practice guidelines and further implementation strategies. – by Katherine Bortz

References:

Armstrong SC, et al. Pediatrics. 2019;doi:10.1542/peds.2019-3223.

Bolling CF, et al. Pediatrics. 2019;doi:10.1542/peds.2019-3224.

Disclosures: Armstrong reports a research relationship with AstraZeneca. All other authors report no relevant financial disclosures.

NEW ORLEANS — A new AAP policy statement offered ways for pediatricians to improve access to metabolic and bariatric surgery for pediatric and adolescent patients who qualify for the procedures.

The AAP also suggested steps that could be taken by government, health and academic medical centers, as well as public and private insurers.

According to Sarah Armstrong, MD, FAAP, lead author of the policy statement and member of the executive committee of the AAP Section on Obesity, the predominant treatment method for obesity involved watchful waiting with a focus on nutrition and activity.

“We are not recommending no watchful waiting; we are just cautioning against excessive periods of watchful waiting, particularly for those who have severe obesity and serious medical complications,” she told Infectious Diseases in Children.

Armstrong explained that bariatric surgery appears to have a fixed reduction effect on BMI and patients may benefit more from surgical intervention when their BMI is lower.

“If you have a child with a BMI of 45 and you do bariatric surgery, your chances are to get to a BMI of 35,” she said. “Then, the hope is that they would sustain that BMI throughout adulthood. That is still officially in the obese range, but it is much less severe.”

Photo of doctors in hospital performing surgery surrounded by health monitors 
Source: Adobe Stock

The AAP also urged pediatricians to advocate for increased access to metabolic and bariatric surgery for all qualified patients, regardless of racial, ethnic or socioeconomic backgrounds.

According to the authors, contraindications for surgery include medically correctable causes of obesity; current untreated or poorly controlled substance abuse or substance abuse within the preceding year; the presence of medical, psychiatric, psychosocial or cognitive conditions that could affect adherence to postoperative dietary and medication plans; and current pregnancy or pregnancy planned for 12 to 18 months following the procedure.

According to Armstrong and colleagues, medical centers should use best practices related to metabolic and bariatric surgery, including multidisciplinary, age-tailored care that aligns with the family’s values and preferences, to ensure safe and effective care. No lower age limits have been made for the procedure, so the authors suggested that these centers consider the potential health benefits and individualized care for patients and families. Further, they recommended that centers increase the number of multidisciplinary centers focused on metabolic and bariatric surgery, ensuring access to these centers for all teens who meet criteria for the procedure.

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Armstrong explained that if that same child were to wait for surgery and do watchful waiting, and their BMI is 55 at age 18 years, they will likely have a BMI of 45 for the rest of their life

The recommendations focused on improving provider knowledge about indications for the procedure — including having a BMI of 35 or higher or having a weight that is 120% or higher of the 95th percentile for age and sex — the importance of assisting families with decision-making based on risks, and benefits of the intervention and collaboration with a multidisciplinary team to identify the best treatment options and optimize pre- and post-surgery care.

The AAP also urged pediatricians to advocate for increased access to metabolic and bariatric surgery for all qualified patients, regardless of racial, ethnic or socioeconomic backgrounds.

“If we had a new medication to treat asthma, we would all learn the indications, make sure we understood the dosing and we’d be prescribing it,” Armstrong said. “I think we have to be a little bit mindful that weight loss surgery has some bias and stigma that come along with it, and we have to be careful that this bias isn’t limiting our ability to help kids get the treatment they need.”

According to the authors, contraindications for surgery include medically correctable causes of obesity; current untreated or poorly controlled substance abuse or substance abuse within the preceding year; the presence of medical, psychiatric, psychosocial or cognitive conditions that could affect adherence to postoperative dietary and medication plans; and current pregnancy or pregnancy planned for 12 to 18 months following the procedure.

Armstrong and colleagues stressed that medical centers should use best practices related to metabolic and bariatric surgery, including multidisciplinary, age-tailored care that aligns with the family’s values and preferences, to ensure safe and effective care. No lower age limits have been made for the procedure, so the authors suggested that these centers consider the potential health benefits and individualized care for patients and families. Further, they recommended that centers increase the number of multidisciplinary centers focused on metabolic and bariatric surgery, ensuring access to these centers for all teens who meet criteria for the procedure.

The AAP suggested that private and public insurers pay for multidisciplinary pre- and post-operative care, the surgery itself and ongoing care for patients who meet criteria for metabolic and bariatric surgery. Barriers to surgery, such as inadequate payment, limited access, unsubstantiated exclusion criteria and bureaucratic delays in approval for surgery, should also be reduced.

The policy statement was accompanied by a technical report that provided details and supporting evidence.

“The release of these policy guidelines is the beginning,” Armstrong said. “We don’t expect that all pediatricians will suddenly know how to take care of patients presurgery, will know exactly what procedures to discuss with them, or how to manage them long term after surgery. We know that there’s going to be a learning curve associated with that.”

Armstrong said she hopes the policy guidelines could lead to clinical practice guidelines and further implementation strategies. – by Katherine Bortz

References:

Armstrong SC, et al. Pediatrics. 2019;doi:10.1542/peds.2019-3223.

Bolling CF, et al. Pediatrics. 2019;doi:10.1542/peds.2019-3224.

Disclosures: Armstrong reports a research relationship with AstraZeneca. All other authors report no relevant financial disclosures.

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