When is it appropriate to refer a pediatric patient with obesity to endocrinology?

When to Refer Pediatric Patients with Obesity to Endocrinology

Pediatric patients with obesity should be referred to endocrinology when they have severe obesity (BMI ≥99th percentile) with comorbidities, suspected endocrine causes of obesity, or when they have failed intensive lifestyle interventions. 1

Assessment and Staging of Pediatric Obesity

Before considering referral, pediatric obesity should be properly assessed and staged:

1. BMI Classification:

   • Overweight: BMI 85th-95th percentile
   • Obesity: BMI ≥95th percentile
   • Severe obesity: BMI ≥99th percentile or ≥120% of the 95th percentile

2. Edmonton Obesity Staging System for Pediatrics (EOSS-P) should be used to evaluate the four domains (4 "M"s) 1:

   • Metabolic complications: Insulin resistance, prediabetes, type 2 diabetes, dyslipidemia
   • Mechanical complications: Sleep apnea, musculoskeletal issues
   • Mental health issues: Depression, anxiety, body image concerns, binge eating
   • Social Milieu: Family dynamics, school environment, bullying

Specific Indications for Endocrinology Referral

1. Suspected Endocrine Causes

Refer when there are signs of potential endocrine disorders 1, 2:

• Attenuated growth patterns (short stature) with obesity
• Rapid weight gain with no clear lifestyle cause
• Cushingoid features (buffalo hump, striae, moon facies)
• Signs of hypothyroidism
• Early or delayed puberty

2. Severe Obesity with Comorbidities

Refer when severe obesity (BMI ≥99th percentile) is accompanied by 1, 3:

• Type 2 diabetes or prediabetes
• Dyslipidemia unresponsive to initial management
• Hypertension despite lifestyle intervention
• Non-alcoholic fatty liver disease (NAFLD)
• Polycystic ovary syndrome (PCOS)

3. Failed Lifestyle Intervention

Refer when 1, 2:

• No improvement in BMI or comorbidities after 6 months of intensive lifestyle intervention
• Need for consideration of pharmacotherapy (for children ≥10 years)

Initial Management Before Referral

Primary care providers should initiate the following before referral:

1. Comprehensive Assessment:

   • Calculate and plot BMI on CDC growth charts
   • Document weight trajectory over time
   • Screen for comorbidities: blood pressure, fasting glucose, lipid profile, liver enzymes 1

2. Family-Based Lifestyle Intervention 1:

   • Dietary modifications
   • Increased physical activity
   • Behavioral strategies
   • Family involvement

What to Expect from Endocrinology Referral

Endocrinology consultation typically provides:

1. Specialized Evaluation:

   • Rule out rare endocrine causes of obesity
   • Advanced metabolic testing
   • Detailed assessment of comorbidities

2. Advanced Treatment Options:

   • Consideration of pharmacotherapy in appropriate candidates
   • Metformin may be considered for children ≥10 years with insulin resistance or prediabetes 4, 5
   • Coordination with multidisciplinary team

3. Management of Specific Endocrine Comorbidities:

   • Insulin resistance
   • Prediabetes/Type 2 diabetes
   • PCOS in adolescent girls

Common Pitfalls to Avoid

• Delayed Referral: Don't wait until severe complications develop before referring
• Overreliance on BMI alone: Consider the presence of comorbidities and the EOSS-P staging
• Inadequate initial workup: Complete appropriate screening tests before referral
• Failure to initiate lifestyle intervention: Family-based lifestyle modification should be started immediately and continued even after referral 1
• Inappropriate expectations: Pharmacotherapy for pediatric obesity is limited, with only orlistat FDA-approved for children ≥12 years 5

Conclusion

The decision to refer a pediatric patient with obesity to endocrinology should be based on severity of obesity, presence of comorbidities, suspicion of endocrine etiology, and response to initial lifestyle interventions. Early referral is warranted for children with severe obesity and comorbidities to prevent long-term health complications and improve quality of life.