TECHNICAL REPORT

Metabolic and Bariatric Surgery forPediatric Patients With Severe ObesityChristopher F. Bolling, MD, FAAP,a Sarah C. Armstrong, MD, FAAP,b Kirk W. Reichard, MD, MBA, FAAP,c

Marc P. Michalsky, MD, FACS, FAAP, FASMBS,d SECTION ON OBESITY, SECTION ON SURGERY

abstractSevere obesity affects the health and well-being of millions of children andadolescents in the United States and is widely considered to be an “epidemicwithin an epidemic” that poses a major public health crisis. Currently, feweffective treatments for severe obesity exist. Metabolic and bariatric surgeryare existing but underuse treatment options for pediatric patients with severeobesity. Roux-en-Y gastric bypass and vertical sleeve gastrectomy are the mostcommonly performed metabolic and bariatric procedures in the United Statesand have been shown to result in sustained short-, mid-, and long-term weightloss, with associated resolution of multiple obesity-related comorbid diseases.Substantial evidence supports the safety and effectiveness of surgical weightloss for children and adolescents, and robust best practice guidelines forthese procedures exist.

DEFINITION OF SEVERE OBESITY AND EPIDEMIOLOGY

This technical report uses the term “pediatric” in reference to a personunder 18 years of age. Although the term “adolescent” may be defineddifferently in various studies and clinical settings, this technical reportuses “adolescent” to refer to a person aged 13 to 18 years. Although BMIpercentile for age and sex is widely used to define weight status in thepediatric population regarding underweight, normal weight, overweight,and obesity, the BMI percentile, BMI z score, and several other establishedmethods of measurement have significant limitations when applied topopulations at the highest and lowest ends of the obesity spectrum. Inaddition, these measures often do not change greatly even whensignificant weight loss occurs. For these reasons, the preferred method ofreporting weight status in severe obesity is as a percentage over the 95thBMI percentile for age and sex.1

Although adults with class 2 obesity have an absolute BMI of 35 or higher,direct correlation within the pediatric population requires some additionalconsideration. Specifically, because BMI values increase over time fromage 2 to 18 years, the use of absolute BMI is generally not considered an

aDepartment of Pediatrics, College of Medicine, University of Cincinnatiand Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;bDepartments of Pediatrics and Population Health Sciences, DukeCenter for Childhood Obesity Research, and Duke Clinical ResearchInstitute, Duke University, Durham, North Carolina; cDivision ofPediatric Surgery, Nemours/Alfred I. duPont Hospital for Children,Wilmington, Delaware; and dDepartment of Pediatric Surgery, Collegeof Medicine, The Ohio State University and Nationwide Children’sHospital, Columbus, Ohio

Technical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, technical reports from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

Dr Armstrong conceptualized and contributed to the content for theinitial manuscript, contributed the clinical perspective of therecommendations, and contributed to revisions and critical edits ofthe entire manuscript; Dr Bolling conceptualized and contributed tothe content for the initial manuscript, was responsible for the initialdrafting of the manuscript, contributed the clinical perspective of therecommendations, and contributed to revisions and critical edits ofthe entire manuscript; Drs Michalsky and Reichard conceptualized andcontributed to the content for the initial manuscript, contributed thesurgical perspective and the enrollment criteria table, and contributedto revisions and critical edits of the entire manuscript; and all authorsapproved the final manuscript as submitted and agree to beaccountable for all aspects of the work.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

To cite: Bolling CF, Armstrong SC, Reichard KW, et al. AAPSECTION ON OBESITY, SECTION ON SURGERY. Metabolic andBariatric Surgery for Pediatric Patients With SevereObesity. Pediatrics. 2019;144(6):e20193224

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accurate surrogate for adiposity andmay either over- or underestimateassociated health risks. Forexample, among younger children,a BMI at 120% of the 95thpercentile (severe obesity) will stillbe well below an absolute BMI of 35.In addition, adolescents, who areoften near adult heights, can havea BMI of 35, thereby meeting theadult definition of class 2 obesity,but this BMI may be below 120%of the 95th percentile. As a result,severe obesity in children andadolescents is defined as havinga BMI $35 or a BMI that is $120%of the 95th percentile for age and sex,whichever is lower. This definitionof “severe obesity,” per theAmerican Heart Association, isan appropriate point of referencefor use in children and adolescents2 years and older.1,2 Cut points todefine severe obesity are meant toidentify patients at greatest risk fordeveloping chronic and progressivedisease states (ie, hypertension,impaired glucose metabolism,dyslipidemia, etc) because of theirweight status.1 The World HealthOrganization’s classification ofobesity in adults, which is helpful indiscussing the likelihood ofcomorbidities, has prompted theuse of obesity classifications inyouth. Class 2 obesity is defined ashaving a BMI $120% of the 95thpercentile or BMI $35, and class 3obesity is defined as having a BMI$140% of the 95th percentile orBMI $40. As with many illnesses,patient populations of racial orethnic minorities or with limitedresources experience the majorityof disease burden. African Americanand Hispanic populations havebeen shown to have 1.5 to 2 timesthe prevalence of severe obesitywhen compared with age-matchedwhite counterparts.1 AmericanIndian youth are also at increasedrisk for severe obesity andespecially weight-related type 2diabetes mellitus.3 In addition,when controlling for race and

ethnicity, lower socioeconomicstatus is associated with higherprevalence of severe obesity; thiseffect is most pronounced in girlsand is present across all age groups.4

Prevalence of obesity remains wellabove historic norms andcontinues to increase in low-incomepopulations and in certain racialand ethnic populations.5 In addition,the prevalence of severe obesity isincreasing at a greater rate amongall groups and most significantlyamong adolescents.2 Data from2014 reveal that nearly 10% ofadolescents were identified ashaving class 2 obesity (BMI $120%of the 95th percentile or BMI $35)and that 5% were identified ashaving class 3 obesity (BMI $140%of the 95th percentile or BMI $40).These results represent a dramaticincrease from the estimated rate ofclass 2 obesity or higher in 1999 as1.3%.6 When combined with thehigh probability of correspondingobesity in adulthood7 and theanticipated cumulative impact ofrelated comorbid diseases, theprevalence of severe obesity hasbeen appropriately described asan “epidemic within an epidemic.”

The increase of severe obesity and itsassociated illnesses has resulted ina treatment crisis. Althoughbehavioral and lifestyle interventionswill be successful for certainindividuals, the overall outcomes ofbehavioral and lifestyle interventionsare discouraging when viewed asa solution for a larger number ofpatients with severe obesity.8–12

Youth with severe obesity requireeffective intervention to preventa lifetime of illness and poor qualityof life.

CONSIDERATIONS FOR PURSUINGMETABOLIC AND BARIATRIC SURGERY

Patient age as well as multiplevariables related to developmentalmaturity factor into the decisionand optimal timing for metabolic

and bariatric surgery. Recent datafrom the Teen-LongitudinalAssessment of Bariatric Surgery(Teen-LABS) study reveal thatpatients undergoing a weight lossprocedure (ages 12–28 years, witha mean age of 17 years)demonstrate a direct correlationbetween increasing preoperativeBMI and a higher probability ofpresenting with multiple comorbidconditions and/or associatedcardiovascular risk factors.13,14

Furthermore, evidence suggests thatindividuals who present with thehighest BMI levels at the time ofsurgical intervention (ie, BMI .50)are less likely to achievea nonobesity state (ie, BMI ,30)after a successful operation.15,16

Correspondingly, recent data fromthe Teen-LABS consortium haverevealed that increased weight lossafter bariatric surgery, female sex,and younger age at the time ofsurgical intervention serve toindependently predict anincreased likelihood ofimprovement in a number ofcardiovascular risk factors (ie,elevated blood pressure,dyslipidemia, and abnormallyelevated levels of high-sensitivityC-reactive protein).14 Additionally,resolution of comorbid diseaseoccurs before a normal weight isachieved. Collectively, such resultssuggest that optimal timing ofmetabolic and bariatric surgeryfor children and adolescents,designed to maximize long-termhealth benefits, warrants furtherresearch, clinical consideration,and potential refinements.

Barriers to insurance coverageoccur for more than half ofadolescents seeking treatment,which delay care.17 These barriersare especially acute for patientsfrom racial and ethnic minorities.18,19

These barriers seem most relatedto economic disadvantage.20 Fora patient who meets criteriaand whose family wishes to pursue

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surgical treatment, the processwould ideally begin as soon aspossible. Clinicians can balance thechild’s psychological anddevelopmental understanding ofthe procedure and the likelihoodof successful weight loss throughbehavioral modifications withpotential benefits for health andquality of life with surgicalintervention.

Preparing a patient for metabolicand bariatric surgery starts witha realistic discussion of theavailable treatment options (ie,choosing a specific weight lossprocedure) and likely expectedoutcomes with the patient andfamily. At present time, payersoften require documentation ofprevious weight loss attempts andfrequently require documentation ofother related medical andbehavioral evaluations. Althoughsuccess rates are low, some youthwith severe obesity will respond tobehavioral interventions.Documentation of theseinterventions, even whenunsuccessful, can assist inpreparing a patient for surgicalintervention. Understandingvarious payer-specific mandates forapproval of insurance coverage ofsurgical weight loss can be bothconfusing and time consuming forhealth care providers and patientsand their families. An equallyimportant part of the initialconversation with a patient andfamily is the identification ofa local or regional tertiary carefacility that is equipped to provideongoing bariatric surgical care tothe pediatric population.

Ideally, early communicationwith a local or regional centermay serve to streamline theprocess by establishing the needfor various mandatory componentsof the preoperative evaluation.Although most centers rely oncomprehensive multidisciplinaryresources to conduct the necessary

preoperative evaluation, thedevelopment of a focusedcollaboration between a pediatricweight loss center and a pediatricor other primary care practice canserve to expedite the process.Whether conducted entirely by thereferring practice, by the weightloss treatment center, or as anestablished collaborative effort, thepreoperative evaluation mayinclude evidence of regular visitswith the multidisciplinary weightloss team and evidence thatcomorbid conditions have beenscreened for and appropriatelymanaged. Additionally,a multidisciplinary weight lossteam can screen for and treatgenetic disorders (eg, Bardet-Biedlsyndrome and Prader-Willisyndrome) and selectivehormonal abnormalities (eg,proopiomelanocortin mutations andleptin deficiency) that can bemedically managed. Acomprehensive evaluation bya behavioral health clinician isessential early in the process todocument the child’s psychologicalwell-being or to document aneffective treatment plan, ifindicated, for behavioral healthconcerns. In addition, a pediatricmental health clinician who hasexperience with obesity is able todocument that the child has thenecessary social and emotionalsupport to follow through withrequired postoperativelifestyle modifications.

The patient’s primary carepediatrician plays an important rolein the perioperative period bymonitoring progress andrecognizing and reportingsymptoms to the surgical program.Long-term follow-up requiresmonitoring the patient’s progress,including weight regain andnutritional status. Adolescent girlsundergoing metabolic and bariatricsurgery have a higher risk forpregnancy than peers,21 and

pediatricians can discuss this riskand develop a family-planningapproach before surgery.Specific discussions related toreproductive health and variousoptions for appropriatecontraception can be a shareddecision between the providerand patient as well as the family,as desired by the patient.

Studies reveal a small risk foranemia and bone mineral densityloss among adolescents aftermetabolic and bariatric surgery.22

Evidence on specific pre- andpostoperative laboratory studies islacking. Pediatricians or surgeonsmay obtain routine laboratory testresults as indicated by theprocedure and patient. Particularattention should be focused on theneed to monitor and addresspotential long-term micronutrientdeficiencies in the postoperativeperiod. Although psychosocialfunctioning and health-relatedquality of life usually improve aftermetabolic and bariatric surgery,10

pediatric patients with preexistingemotional concerns may requireadditional and ongoing evaluationpostoperatively. In addition,adolescents may develop risk-taking behaviors, includingincreased use of alcohol,increased sexual activity, andsuicide ideation, after surgery.21,23–25

COMMON WEIGHT LOSS PROCEDURESAND THEIR OUTCOMES

Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB)has been considered the goldstandard for the surgicalmanagement of severe obesity inadults26–28 and adolescents.29–31

Like all contemporary weight lossoperations, RYGB is performed byusing minimally invasive surgicaltechniques (ie, laparoscopic surgery)and results in significant andsustained weight loss fromalterations in appetite, satiety, and

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regulation of energy balance.32

RYGB requires the creation a smallproximal gastric pouch incombination with an accompanyingroux limb of jejunum, whicheffectively excludes the remainingstomach (ie, gastric remnant), andproximal small bowel from thestream of ingested enteral content.The resulting anatomy createsa direct conduit between thenewly established gastric pouchand jejunum, resulting ina “downstream” exposure ofenteral content to the importantbiliopancreatic enzymes.

Vertical Sleeve Gastrectomy

Vertical sleeve gastrectomy (VSG)emerged as an alternative weightloss procedure in both adults andyouth in the mid-2000s and iscurrently the most common bariatricoperation performed in the UnitedStates.27,33 Current evidencesuggests that altered gastricemptying and neurohormonalmechanisms may also be involved inachieving weight loss.34 The VSGinvolves removal of ∼80% of thestomach (consisting of the entiregreater curve), resulting in a gastricsleeve (60–100 mL capacity).Creation of a uniformly fashionedsleeve is typically accomplished byusing surgical dilators as a guide thatrange in size from 36F to 44Fcatheter diameter. Because thepylorus and distal antrum areanatomically preserved, gastric fillingand emptying remain largely intact,resulting in enhanced postprandialsatiety while avoiding the intestinal“dumping syndrome” that can occurafter RYGB. Because VSG does notinclude creation ofa gastrojejunostomy (ie, intestinalbypass), malabsorption and thecomplications stemming from morecomplex surgical anatomy are lessfrequent.35 As is the case in adults,26

major complications in adolescentsafter VSG are less common than afterRYGB and include staple-line leak,stricture formation, and bleeding.36

Nutritional complications are alsoless common with VSG than withRYGB and include iron deficiencyand vitamin B12 deficiency,presumably related to decreasedproduction of intrinsic factorresulting from the loss of thegastric fundus.36

Laparoscopic Adjustable GastricBand

The laparoscopic adjustable gastricband (LAGB) is an implantable deviceconsisting of a silastic belt lined bya soft, low-pressure, adjustableballoon that is placed around theproximal portion of the stomach ina circumferential fashion (ie,immediately beneath thegastroesophageal junction). Thecreation of a “pseudo-pouch” at theproximal end of the stomach limitsfood intake and promotes earlysatiety because of its restrictiveproperties. The balloon is connectedto a small subcutaneous fluidreservoir positioned on theabdominal wall. In an outpatientsetting, the volume of the balloonlining the band may be adjusted bypercutaneous infusion or aspirationof sterile water from thesubcutaneous port. The ability tomodulate the narrowness of the bandlimits food intake but does not affectphysiologic pathways regulatingenergy balance, appetite, or satiety. asin RYGB or VSG. Although initiallybelieved to be a desirable option forthe adolescent population on thebasis of several short-term safety andefficacy reports,27 a relative paucityof longitudinal outcomes incombination with reports of weightregain and high device-explant ratesin both adult37 and adolescent38

populations have dampenedenthusiasm for this procedure.Complications associated with LAGBinclude port and catheter disruption,proximal gastric pouch dilatation,gastric erosion, and esophagealdysfunction. Explant rates mayexceed 20%, and those proceduresare associated with increased

morbidity.39 To date, use of theadjustable gastric band has beenrestricted to individuals 18 yearsand older by the US Food andDrug Administration.

Complications and Outcomes

Surgical complications afterbariatric surgery in adolescents areinfrequent, with the majority beingdefined as minor (15%) andoccurring in the early postoperativeperiod (eg, postoperative nauseaand dehydration).35,36,40 Majorperioperative complications (30 days)occurred in 8% of Teen-LABSparticipants. In addition, reoperationbefore hospital discharge wasrequired in 2.7%, which is similar torecent outcomes reported in a largeadult series.41 Micronutrientdeficiencies are common after bothRYGB (iron, 66%; vitamin B12, 8%;folate, 6%) and VSG (iron, 32%;folate, 10%).36 Vitamin D deficiencyis common preoperatively amongteenagers with obesity and does notchange significantly after surgery.36

Folate deficiency is a concern forfemale patients of childbearing age.36

However, most longitudinal studies ofadolescent metabolic and bariatricsurgery do not assess nutrientdeficiency or follow a patientthrough subsequent pregnancy toassess for related complications.40

In addition, although data related topsychosocial complications afterweight loss surgery in adolescentsare relatively sparse, recent dataciting an increased risk of poormental health in the postoperativetime period among individuals withhigher levels of anxiety, depression,and poor mental health highlightsthe need for long-term follow-up.25

Although no perioperative deathswere reported in the Teen-LABS,Adolescent Morbid Obesity Surgery(AMOS), or Follow-up of AdolescentBariatric Surgery at 5 Plus Years(FABS-51) cohorts, 3 deaths (0.3%)occurred postoperatively at 9 months(related to infectious colitis),16

3.3 years (related to hypoglycemic

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complications in a patient with type 1diabetes),36 and 6 years (unrelated),respectively, collectively representinga recently reported 0.3% mortalityrate.40

Several recent prospective multi-institutional studies have helped todefine weight loss and comorbidityoutcomes for bariatric surgicalprocedures in adolescents. The Teen-LABS study consortium has published3-year outcomes from the first large(242 subjects), prospective,observational study in patientsyounger than 19 years undergoingRYGB and VSG, with an overall follow-up rate of 89%.36 Although the studywas not specifically designed todetect between-group differences,total weight loss at 3 years was 27%in all patients and was similar forboth procedures. Comorbidityresolution rates, including type 2diabetes mellitus (95%),hypertension (80%), anddyslipidemia (66%), exceeded thosereported in similar adult cohorts.25 Ina more recent analysis, researchersexamined changes in overallprevalence of baseline cardiovasculardisease risk factors in the samecohort as well as predictors of suchchange. There was an 85% reductionin the overall multiplicity ofassociated risk factors, whereby one-third (33%) of study participants had$3 risk factors at baseline(preoperatively), with only 5%demonstrating a similar degree by3 years.14 Improvements in certainvariables (ie, dyslipidemia, elevatedblood pressure, impaired glucosemetabolism, and systemicinflammation) in association withincreasing weight loss were notunexpected. Investigators alsoobserved in postanalysis studies thatafter surgery, younger participantswere more likely to experienceimprovements in dyslipidemia andelevated high-sensitivity C-reactiveprotein levels compared with olderpatients and that female patientswere more likely than male patients

to experience significantimprovements in blood pressure.These results are novel and offer newinsights into long-term outcomes andsupport ongoing refinement in theevolving selection criteria andoptimal timing of bariatric surgery inthis age group.14

In the AMOS study, a prospective,controlled, and nonrandomizedinterventional study, researcherscompared 80 adolescentsundergoing RYGB with a matchedcohort of adults of a parallel studyafter metabolic and bariatricsurgery as well as a matched controlgroup of adolescents undergoingconventional medical treatment ofobesity in Sweden.42 Recentlyreported outcomes from thiscomparative analysis revealeda significant reduction in both weightand BMI at 5 years amongadolescents that was strikinglysimilar to results observed among theparallel adult subjects. In addition,the study authors reportedsubstantial improvements in severalcomorbidities and cardiovascular riskfactors. These results comparedfavorably with those of the adolescentnonsurgical control group.Furthermore, the AMOS studyrevealed a 92% resolution in elevatedliver transaminase levels in patientsafter surgery versus an 18%resolution rate in control patients.39

To date, the FABS-51 study is thelongest prospective longitudinalanalysis of subjects undergoingadolescent metabolic and bariatricsurgery, consisting of 58 adolescentpatients undergoing RYGB (mean age,17.1 years), with a mean follow-up of8.0 years (range, 5.4–12.5 years). TheFABS-51 study revealed a 29% long-term reduction in preoperative BMIas well as a significant reduction inelevated blood pressure, type 2diabetes mellitus, and dyslipidemia.16

The effect on type 2 diabetes mellitusis especially striking. Surgicalintervention results in betteroutcomes than medical management

in youth with severe obesity and type2 diabetes mellitus.43,44

In no prospective studies is theefficacy of the various weight losssurgery procedures in pediatricpatients directly compared, buta recent meta-analysis revealed that1-year outcomes favored laparoscopicRYGB over LAGB, with intermediateresults achieved in a small group ofpatients who underwent laparoscopicVSG.45 In 1 single institutionalretrospective comparison,adolescents undergoing laparoscopicVSG lost twice as much weight asthose undergoing LAGB at 24months.46 Two smaller retrospectivestudies suggest similar weight loss inadults and adolescents afterlaparoscopic VSG (1 and 2 years) andLAGB (1 year).27 Finally, in a single-institution longitudinal-outcomestudy of adolescents undergoinglaparoscopic RYGB, the total weightloss percentage (37%) wasindependent of the baseline BMI, andpatients with lower baseline BMIswere more likely to achieve normalweight at 1 year.15 The results of thisanalysis raise the possibility ofa therapeutic “ceiling effect” and may,if confirmed, support the need forchanges in current referral patternsso that potential candidates maybenefit from surgical consultationbefore reaching extremely high BMIlevels (ie, $50).

Clear evidence pointing to “the best”or most appropriate weight lossprocedure for pediatric patients withsevere obesity remains elusive. RYGBwas, by far, the most common weightloss surgical procedure used amongadolescents in the early 2000s,47 withLAGB gaining popularity later in thedecade,48 only to be followed quicklyby the emergence of the VSG asa primary operation. Although ananalysis of weight loss surgicalprocedural prevalence in the UnitedStates from the early 2010s revealsan equal proportion of VSGs andRYGBs, more recent data havesuggested that VSG has become the

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most commonly performed weightloss operation among adolescents,reflecting a pattern similar to the oneobserved in the adult population.33 Asin the adult population, the use of theLAGB in adolescents has dramaticallydeclined in frequency.33,35 Despite thepresence of comparative resultsbetween RYGB and VSG that suggestsimilar surgical outcomes, there isstill a need for prospective studies,controlling for confounding variablesand potential selection bias.

THE CURRENT CLIMATE FOR PEDIATRICMETABOLIC AND BARIATRIC SURGERY

Access to Care

No unified reporting system tracksthe overall procedural prevalence ofpediatric metabolic and bariatricsurgery in the United States. Thispaucity of data prevents theestablishment of an accurateassessment of current access tobariatric surgical care. According torecent cross-sectional data,approximately 4 million adolescentshave severe obesity.6 In a recentanalysis of discharge data obtainedfrom the Healthcare Cost andUtilization Project Kids’ InpatientDatabase, Kelleher et al49 showed anincrease in procedural prevalencefrom 0.8 per 100 000 adolescents in2000 to 2.3 per 100 000 in 2003,resulting in approximately 1000 casesper year. However, the investigatorsreported no subsequent change in theannual rate of adolescent weight lossprocedures between 2003 and2009.49 In an additional report,Zwintscher et al48 identified as manyas 1600 adolescent patients from thesame database, suggesting thatprocedural prevalence has likelycontinued to increase, albeitrepresenting a fraction of the overallprocedural prevalence whencompared with the adult population.Low rates of metabolic and bariatricsurgery in the adolescent populationare likely to be multifactorial.Availability of surgical options,

physician attitudes regarding surgery,and individual assessment of likelypatient outcome from surgery allappear to influence whether patientsare referred for surgicalevaluation.50,51

For example, recent reports fromboth the United States and the UnitedKingdom highlight the potentialimpact of differing attitudes towardthe use of metabolic and bariatricsurgery in the pediatric population(including the potential differences inassociated referral patterns) amongmedical versus surgical health careproviders.50,52 In addition, recentdata used to examine insurancecoverage for adolescent metabolicand bariatric surgery in the UnitedStates reveal reduced approvals incomparison with those for adultsseeking similar coverage.17 In thismulti-institutional review, Inge et al17

showed that payers initially approvedmetabolic and bariatric surgery forless than half of adolescents who metthe requirements. In contrast, payersinitially approved 80% to 85% ofadults who met similar criteria.Ultimately, 80% of adolescentsreceived insurance approval, but itrequired patients, physicians,families, and support staff to engagein complex and time-consumingappeals processes. Adolescentsseeking metabolic and bariatricsurgery were required to appealunfavorable coverage decisions asmany as 5 times before obtaining therequired authorization. Theimplications of such disparity inaccess to specialized health carecompared with adults with severeobesity undergoing bariatric surgery,commonly during the fifth or sixthgeneration of life, becomes even morecompelling considering thecumulative impact of numerousobesity-related disorders potentiallyleading to reduced quality of life andearly mortality in younger patients.Limited studies indicate that theimprovement in comorbidities mayenhance the cost-effectiveness of

adolescent metabolic and bariatricsurgery.53,54

Best Practice Guidelines andNational Accreditation Standards

Metabolic and bariatric surgery in thetreatment of severe obesity was firstdescribed in the late 1950s and early1960s in the adult population and ledto the establishment of formalizedclinical guidelines in the 1990s withthe release of the National Institutesof Health consensus guidelinesstatement.55 A correspondingframework for clinical eligibility inthe pediatric population, however, hasonly emerged within the past 2decades. Initial consensus-drivenrecommendations were predicated onthe previously established adultclinical guidelines, including anoverall assessment of relatedcomorbid diseases in combinationwith the use of anthropomorphiccriteria (ie, minimal BMI).56 Incontrast to the adult model, theseinitial recommendations called fora more conservative approachregarding minimal eligibility criteria(ie, BMI $40 in the presence ofsevere obesity-related comorbiditiesor BMI $50 with or without severecomorbid disease). The most recentlyupdated guidelines from theAmerican Society of Metabolic andBariatric Surgery (ASMBS) followevidence from several ongoingstudies revealing favorableresults.57–59 In these updatedguidelines, absolute age limits areeliminated, the World HealthOrganization weight classification isadopted, and the weight andcomorbidity guidelines are broughtinto alignment with adultrecommendations. Unlike clinicalsituations in which competingguidelines confuse care, therecommendations for weight losssurgery in children and adolescentsare aligned and evidence based, yetthey are not uniformly applied,creating barriers to accessingrecommended care.

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Consensus recommendations relatedto clinical criteria will likelycontinue to evolve in the decades tocome. Best practice guidelinespublished by the ASMBS andpediatric-specific metabolic andbariatric surgery accreditationstandards established by the jointASMBS and American College ofSurgeons Metabolic and BariatricSurgery Quality ImprovementProgram establish a robustframework for the safe delivery ofsurgical weight management in thecontext of a multidisciplinary caremodel.60 Clinical programs seekingpediatric accreditation within theMetabolic and Bariatric SurgeryQuality Improvement Program arerequired to demonstrate access tochild- and adolescent-specificclinical care resources designed todeliver optimal age-appropriatecare. Such resources includeincorporation of pediatric healthcare providers with expertise ingeneral pediatric medicine,nutrition, anesthesia, andbehavioral disciplines (www.mbsaqip.org).

Multidisciplinary Care Model

With recent interest in metabolic andbariatric surgery as safe and effectivetreatments of severe pediatricobesity, several important age-specific considerations have led to thedevelopment of child- andadolescent-specific clinical standardsfor perioperative evaluation,corresponding surgical care, andlong-term follow-up. In expertrecommendations established duringthe 2011 Children’s HospitalAssociation multidisciplinarycollaborative panel, FOCUS on a FitterFuture, which was commissioned toestablish and disseminate expertrecommendations pertaining to allaspects of childhood obesityprevention and treatment strategies,Michalsky et al61 presenteda consensus-driven road map forinstitutional development of age-appropriate weight loss surgical care.

As a primary goal of the expert panelreport, the authors highlighted theimportance of multidisciplinary care,which maximizes child- andadolescent-specific health careresources to deliver optimal care. Thereport emphasized the need for aninstitutional commitment to a cultureof clinical excellence and safetyduring the delivery of age-appropriate weight loss surgical care.The report also offered a point-by-point set of recommendations,including establishment of a “medicalhome” (ie, including the need toestablish routine communicationamong members of themultidisciplinary weight loss teamand the patient’s primary careprovider). Key components of themedical home for pediatric patientswith severe obesity include theestablishment of a “medical leader,”a qualified pediatric medical providerwith experience in the screening andtreatment of common obesity-relatedcomorbid conditions. The team ofmedical home providers may alsoinclude an adolescent-specificbehavioral health specialist,a dedicated registered dietitianfamiliar with the management ofindividuals undergoing metabolic andbariatric surgery, a licensed socialworker, and medical subspecialistsrequired on a case-by-case basis (ie,cardiology, nephrology,gastroenterology and hepatology,endocrinology, etc).

The ASMBS has published bestpractice guidelines that includecontemporary and consensus-drivenclinical inclusion criteria.57 A jointASMBS–American College of Surgeonsnational accreditation standardrecommendation details specificrequirements for the delivery ofweight loss surgical care forindividuals younger than 18 years. Allgroups strongly support thethoughtful delivery of complex care foran emerging and vulnerablepopulation. The Teen-LABSconsortium has also published

contemporary examples forimplementation of this generalframework for institutions consideringthe establishment of pediatric surgicalweight management programs.62

These works, along with theaccompanying policy statement,“Pediatric Metabolic and BariatricSurgery: Evidence, Barriers, and BestPractices,”63 provide a coordinatedand reinforcing view of the role ofmetabolic and bariatric surgery foryouth with severe obesity.

CONCLUSIONS

Severe obesity in children andadolescents is a worsening healthcrisis in the United States.Unfortunately, severe obesity has feweffective treatments. The applicationof metabolic and bariatric surgery inthe pediatric population providesevidence-based effective treatment ofsevere obesity and related comorbiddiseases.14,16,36,42 Improved access tometabolic and bariatric surgery forpediatric patients with severe obesityis urgently needed. American Academyof Pediatrics policy recommendationsregarding metabolic and bariatricsurgery in pediatric patients can befound in the accompanying policystatement, “Pediatric Metabolic andBariatric Surgery: Evidence, Barriers,and Best Practices.”63

LEAD AUTHORS

Christopher F. Bolling, MD, FAAPSarah C. Armstrong, MD, FAAPKirk W. Reichard, MD, MBA, FAAPMarc P. Michalsky, MD, FACS, FAAP, FASMBS

SECTION ON OBESITY EXECUTIVECOMMITTEE, 2017–2018

Christopher F. Bolling, MD, FAAP,ChairpersonSarah C. Armstrong, MD, FAAPMatthew Allen Haemer, MD, MPH, FAAPNatalie Digate Muth, MD, MPH, RD, FAAPJohn Conrad Rausch, MD, MPH, FAAPVictoria Weeks Rogers, MD, FAAP

LIAISON

Marc P. Michalsky, MD, FACS, FAAP, FASMBS

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CONSULTANT

Stephanie Walsh, MD, FAAP

STAFF

Mala Thapar, MPH

SECTION ON SURGERY EXECUTIVECOMMITTEE, 2017–2018

Kurt F. Heiss, MD, FAAP, ChairpersonGail Ellen Besner, MD, FAAPCynthia D. Downard, MD, FAAPMary Elizabeth Fallat, MD, FAAPKenneth William Gow, MD FACS, FAAP

STAFF

Vivian Baldassari Thorne

ABBREVIATIONS

AMOS: Adolescent Morbid ObesitySurgery

ASMBS: American Society ofMetabolic and BariatricSurgery

FABS-51: Follow-up of AdolescentBariatric Surgery at 5Plus Years

LAGB: laparoscopic adjustablegastricband

RYGB: Roux-en-Y gastric bypassTeen-LABS: Teen-Longitudinal

Assessment ofBariatric Surgery

VSG: vertical sleeve gastrectomy

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements

with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of

Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

DOI: https://doi.org/10.1542/peds.2019-3224

Address correspondence to Christopher F. Bolling, MD, FAAP. E-mail: bolling.cf@gmail.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Armstrong disclosed that she has a research relationship with AstraZeneca. Drs Bolling, Michalsky, and Reichard have indicated they

have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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63. Armstrong SC, Bolling CF, Michalsky MP,Reichard KW; American Academy ofPediatrics, Section on Obesity andSection on Surgery. Pediatric metabolicand bariatric surgery: evidence,barriers, and best practices. Pediatrics.2019;144(6):e20193223

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