What is the initial workup for an obese 5-year-old child with excessive hunger?

Initial Workup for an Obese 5-Year-Old with Excessive Hunger

The most critical first step is to plot height and weight on growth charts to determine if height velocity has decreased with weight gain—this single finding distinguishes simple obesity from pathological causes like Cushing's syndrome or growth hormone deficiency that require immediate endocrine evaluation. 1

Immediate Growth Chart Assessment

• Plot all available historical growth data to identify when upward weight crossing began and whether height percentiles are simultaneously declining 1, 2
• Lack of height gain with rapid weight gain is the hallmark of Cushing's syndrome in children and demands urgent workup 1
• Crossing downward across height percentiles while weight trajectory increases upward indicates a pathological condition requiring endocrine referral 1

First-Tier Laboratory Evaluation

If growth charts suggest pathological causes (especially decreased height velocity), obtain:

• TSH and free T4 to exclude hypothyroidism 1
• 24-hour urinary free cortisol or late-night salivary cortisol to screen for Cushing's syndrome 1
• Fasting glucose and insulin to assess for insulin resistance 1
• Lipid profile for cardiovascular risk stratification 1
• Liver function tests to screen for non-alcoholic fatty liver disease 1

Clinical Red Flags Requiring Immediate Endocrine Referral

• Central adiposity with moon facies, buffalo hump, or purple striae suggests Cushing's syndrome 1
• Severe short stature with increased truncal adiposity suggests growth hormone deficiency 1
• Excessive hunger (hyperphagia) with developmental delay may indicate genetic obesity syndromes requiring specialized evaluation 1

Comprehensive Dietary and Behavioral Assessment

For the child with normal height velocity (simple obesity):

• Evaluate portion sizes, meal frequency, and consumption of sugar-sweetened beverages, juice, and fast food 3, 2
• Assess total screen time (should be <2 hours daily) and physical activity levels (goal: 60 minutes moderate-to-vigorous activity daily) 3, 2
• Review parental obesity status, as parental obesity strongly predicts childhood obesity and identifies high-risk families 3

Initial Management Strategy

Initiate intensive family-based lifestyle modification immediately as the prerequisite for all obesity treatments in this age group—do not delay intervention hoping the child will "grow into" their weight. 4, 3, 2

Dietary Interventions (CHILD-1 Recommendations):

• Eliminate all sugar-sweetened beverages and juice 3
• Avoid fast food and energy-dense, nutrient-poor items 3, 2
• Increase whole grains, vegetables, fruits, and lean proteins 3, 2
• Establish regular meal patterns with appropriate portion control 3
• Remove high-calorie foods from the home environment 3

Physical Activity Requirements:

• At least 60 minutes of moderate-to-vigorous physical activity daily (can be accumulated in smaller increments) 3, 2
• Promote unstructured outdoor play for at least 30 minutes daily 3
• Establish routine family physical activities 3

Parental Role Modeling:

• Parents must become active role models by increasing their own physical activity and dietary changes 3
• Family-wide behavioral changes are essential for success 3

Follow-Up Protocol

• Schedule 6-month follow-up to assess BMI percentile trajectory 3, 2
• If BMI percentile continues increasing, intensify registered dietitian counseling, increase physical activity focus, and shorten follow-up to 3 months 3
• Reassess cardiometabolic risk factors (lipids, glucose, blood pressure) annually or more frequently if abnormal 2

Critical Pitfalls to Avoid

• Never assume simple obesity without evaluating growth charts—this is the most common diagnostic error 1
• Never implement caloric restriction or weight-loss diets in young children, as rapid weight loss can delay linear growth and compromise development 3
• Never delay Cushing's workup if height velocity is decreased—immediate cortisol assessment is mandatory 1
• Avoid stigmatizing language when discussing weight, as this harms the parent-child relationship and future health behaviors 3

Realistic Treatment Goals

• Weight maintenance rather than weight loss is the appropriate goal for this growing child, allowing BMI to gradually decrease as height increases 3
• Even a 5-10% reduction in excess weight or stable weight with continued height growth improves cardiovascular risk factors 4, 5
• Success rates at 2 years are modest (<10% achieve BMI reduction >0.25 SD), but metabolic improvements occur even without dramatic BMI changes 5, 2