AAP Bariatric Surgery Recommendations

A recent policy statement (SC Armstrong et al. Pediatrics 2019; 144 (6): e20193223) outlines current evidence regarding adolescent bariatric surgery and makes recommendations for practitioners & policymakers.  There is also an accompanying technical report which provides more detail and supporting evidence.  Thanks to Ben Gold for this reference.

Full PDF Link: Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices

This policy statement uses “adolescent” to refer to a person from age 13 years to age 18 years.

Background: “Although nearly 4.5 million US adolescents have severe obesity, current estimates suggest that only a small faction undergo metabolic and bariatric surgery…Many providers prefer a “watchful waiting” approach, or long-term lifestyle management.50 However, current evidence suggests that pediatric patients with severe obesity are unlikely to achieve a clinically significant and sustained weight reduction in lifestyle-based weight management programs53 and that watchful waiting may lead to higher BMI and more comorbid conditions…In addition, comparative data examining
postoperative outcomes along the severely obese BMI spectrum (low, middle, and high) suggest that adolescents within a lower BMI range (BMI <55) at the time of bariatric
surgery have a higher probability of achieving nonobese status when compared with individuals with a higher starting BMI (BMI ≥55).”

From Table 2 -Indications for Bariatric Surgery:

  1. Class 2 obesity, BMI ≥35, or 120% of the 95th percentile for age and sex, whichever is lower  along with clinically significant disease, including obstructive sleep apnea (AHI .5), T2DM, IIH, NASH, Blount disease, SCFE, GERD, and hypertension
  2. Class 3 obesity, BMI ≥40, or 140% of the 95th percentile for age and sex, whichever is lower. Clinically significant disease is not required but commonly present

Recommendations for practitioners:

  • Seek high-quality multidisciplinary centers that are experienced in assessing risks and benefits of various treatments for youth with severe obesity, including bariatric surgery, and provide referrals to where such programs are available.
  • Identify pediatric patients with severe obesity who meet criteria for surgery and provide
    timely referrals to comprehensive, multidisciplinary, pediatric-focused metabolic and bariatric surgery programs.
  • Monitor patients postoperatively for micronutrient deficiencies and consider providing iron, folate, and vitamin B12 supplementation as needed.
  • Monitor patients postoperatively for risk-taking behavior and mental health problems.

SYSTEM-LEVEL RECOMMENDATIONS:

  • Advocate for increased access for pediatric patients of all racial, ethnic, and socioeconomic backgrounds to multidisciplinary programs
  • Consider best practice guidelines, including avoidance of unsubstantiated lower age limits, in the context of potential health care benefits and individualized patient-centered care.
  • For insurers: Provide payment for care (pre-operative, operative & post-operative). Reduce barriers to pediatric metabolic and bariatric surgery (including inadequate payment, limited access, unsubstantiated exclusion criteria, and bureaucratic
    delays in approval requiring unnecessary and often numerous appeals) for patients who meet careful selection criteria.

My take: These recommendations are in general agreement with previous guidelines.  I think having the stamp of approval from the AAP is likely to help in getting coverage and may shift attitudes.

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