Childhood obesity as a safeguarding issue: positive experiences with the "new home" environment as a treatment for weight management

OBJECTIVES

Childhood obesity can lead to acute and chronic comorbidities and adult obesity, highlighting the need for prompt intervention. Families and caregivers play a vital role in treatment and when primary interventions fail, this may become a child protection issue.

CASE PRESENTATION

We present two cases of severe childhood obesity where targeted lifestyle interventions failed to impact weight status. Both cases feature child welfare involvement with patients coming into the care of the local authority (under s20 of the Children Act 1989). Foster placement resulted in significant weight loss and improved BMI achieved through reduced portions, healthier choices, restricted calories to recommended daily intake for age and increased activity. Physical and emotional wellbeing benefits were observed and improvements in obesity related comorbidities.

CONCLUSIONS

Failure to reduce a child's weight alone does not constitute a child protection issue. In severe cases, where maximum intervention has failed and when the child has obesity related comorbidites or at a higher risk of developing them, home environment change should be considered in the child's best interest as a treatment for severe childhood obesity.

Prevalence of severe childhood obesity in Wales UK

BACKGROUND

In Wales, approximately one in eight children is obese (aged 4-5 years). The aim of this prevalence study was to examine the trends in severe childhood obesity and investigate any relationship with socioeconomic deprivation.

METHODS

Data for all children included as part of the Wales Childhood Measurement Programme (2013/14-2017/18) were utilized. Data on the number who had a body mass index above the 99.6th centile indicating severe obesity were calculated over time by sex and in relation to deprivation.

RESULTS

Of the 162 208 children measured between 2013/14 and 2017/18 (mean age 5.06 years, standard deviation 0.35 years), the overall prevalence of severe obesity was 3.1% (95% confidence interval [CI] 3.0-3.2%). This varies from 1.9% (95% CI 1.7-2.1%) in the least deprived areas to 3.9% (95% CI 3.7-4.0%) in the most deprived areas. Boys have higher prevalence of severe obesity than girls: 3.6% (95% CI 3.4-3.9%) of boys (n = 598) and 3.0% (95% CI 2.7-3.2%) of girls (n = 467) were categorized as severely obese in reception year in Wales in 2017/18. Prevalence has increased over time but this is not statistically significant.

CONCLUSION

This study found significantly higher levels of severe obesity in areas of socioeconomic deprivation. Levels of severe obesity were significantly higher in boys than in girls.

Neglected children with severe obesity have a right to health: Is foster home an alternative?-A qualitative study

OBJECTIVE

To explore key person's perspectives of foster home placement or notification of risk of harm to Social Services of children with severe obesity.

METHODS

This case study research was performed in the southwest of Sweden and based on interviews with nine informants: a foster home youth, two foster parents, a social worker, two hospital social workers, a pediatric physician, a pediatric nurse, and a psychologist. Content analysis was used for narrative evaluations, within- and cross case analyses and displays.

RESULTS

Positive health outcomes of the foster home placement were described as a healthy and normalized weight status, a physically and socially active life, and an optimistic outlook on the future. The foster parents made no major changes in their family routines, but applied an authoritative parenting style regarding limit setting about sweets and food portions and supporting physical activity. The professionals described children with severe obesity as having suffered parental as well as societal neglect. Their biological parents lacked the ability to undertake necessary lifestyle changes. Neglected investigations into learning disabilities and neuropsychiatric disorders were seen in the school and healthcare sector, and better collaboration with the Social Services after a report of harm might be a potential for future improvements. Rival discourses were underlying the (in) decision regarding foster home placement.

CONCLUSION

A child's right to health was a strong discourse for acting when a child was at risk for harm, but parental rights are strong when relocation to a foster home is judged to be necessary.

Medical neglect at a tertiary paediatric hospital

Medical neglect is under-researched and the extent of the problem in Australia is unknown. We conducted a review of the referrals for medical neglect to the Child Protection Unit (CPU) at a tertiary children's hospital in Sydney over a 5 years period, from 2011 to 2016, to determine what medical conditions are being referred, the reason for the medical neglect concern and whether cases are managed in line with American Academy of Pediatrics (AAP) guideline on medical neglect. 61 cases of medical neglect were identified, constituting 4.1% of all referrals to the Child Protection Unit for physical abuse and neglect. There was a wide variety of medical conditions. Most were chronic medical conditions (87%). The top two medical conditions were chronic and complex multi-system disorders (37.7%) and endocrine disorders (18%). The majority of medical neglect were related to concerns that the caregivers were unwilling to follow medical advice (45.9%) or unable to provide necessary medical care (26.2%). In line with the AAP guideline on medical neglect, all cases were managed by addressing communication difficulties (100%) and resource issues were addressed in 80% of cases. A report to statutory child protection agencies was made in 50% of cases. Directly observed therapy and medical contracts were used in 30% and 26% of cases. We conclude that children with chronic medical conditions may be at risk of medical neglect. Communication difficulties were a factor in all cases. Statutory agency intervention is often required.

Considerations in identifying pediatric dental neglect and the legal obligation to report

BACKGROUND

Dental health care professionals play an important role as mandated advocates when health care neglect is suspected in children; however, there is some confusion around what constitutes child neglect.

METHODS

The authors reviewed the dental literature for descriptors and definitions of neglect. They studied the individual state statutes to learn the protection afforded for both victims of neglect and for health care providers acting on behalf of such children. They also reviewed methods of action to address suspected neglect.

RESULTS

The authors found confusion around what is or is not child neglect. Yet, dental professionals are tasked by the law, and by a moral code, to protect children from neglect. The authors offer a definition of neglect and suggested practice guidelines to assist the practitioner acting as a child's advocate.

CONCLUSIONS

Clinicians can use strategies to address the problem of child neglect. A digital data treatment registry may provide additional views of a child's health status.

PRACTICAL IMPLICATIONS

With a better understanding of the definition of neglect, strategies can be implemented for use by the dental team to address this problem of neglect and reduce its incidence.

Medical neglect

Medical neglect occurs when children are harmed or placed at significant risk of harm by gaps in their medical care. This is most likely to occur and to be recognized when families lack resources, commonly due to poverty, and when medical demands are high, such as with complex, severe, and chronic illness. A systematic evaluation of the probabilities for harm from gaps in care versus benefits from improved care will define medical neglect. A broad consideration of child, family, community, and medical system contributions to identified gaps will guide management. Special circumstances, such as lapsed immunizations, unremitting obesity, and medically motivated alterations in care, are often challenging for medical providers. Guidance for these specific situations is available from the American Academy of Pediatrics, and from the medical literature.

Bariatric surgery for obese children and adolescents: a review of the moral challenges

BACKGROUND

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

DISCUSSION

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

SUMMARY

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.

Evidence, ethics, and values: a framework for health promotion

We propose a new approach to guide health promotion practice. Health promotion should draw on 2 related systems of reasoning: an evidential system and an ethical system. Further, there are concepts, values, and procedures inherent in both health promotion evidence and ethics, and these should be made explicit. We illustrate our approach with the exemplar of intervention in weight, and use a specific mass-media campaign to show the real-world dangers of intervening with insufficient attention to ethics and evidence. Both researchers and health promotion practitioners should work to build the capacities required for evidential and ethical deliberation in the health promotion profession.

Associations between abdominal fat and body mass index on vitamin D status in a group of Spanish schoolchildren

BACKGROUND/OBJECTIVES

To analyze the association between different anthropometric variables and vitamin D status in a group of Spanish schoolchildren.

SUBJECTS/METHODS

Study subjects were 102 children aged 9-13 years. Records were made of their height, body weight, body mass index (BMI), waist and hip measurements (to determine the quantity of visceral or abdominal fat), and the thickness of the tricipital and bicipital skinfold (to determine the quantity of subcutaneous fat). Diets were analyzed using a 3-day weighed food record and vitamin D intakes compared with those recommended. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were measured using chemiluminescent assay.

RESULTS

The mean serum 25(OH)D concentration was 49.6+/-15.9 nmol/l. The mean serum 25(OH)D in the ID subjects (that is, those with insufficient vitamin D levels, 25(OH)D of <70 nmol/l) was 46.6+/-13.4 nmol/l and in the AD subjects (that is, those with adequate vitamin D levels, 25(OH)D of > or =70 nmol/l) was 77.5+/-8.4 nmol/l (P<0.001). No significant difference was observed between both groups in vitamin D intake. However, the ID subjects had higher body weight, BMI, waist measurement and waist/height ratio than the AD subjects. Using a multiple linear regression analysis, only weight and BMI were found to independently influence 25(OH)D values. Children with a body weight, BMI, bicipital skinfold thickness, waist measurement and waist/height ratio above the 50th percentile for each variable were at a greater risk of having a low serum 25(OH)D concentration (<70 nmol/l).

CONCLUSIONS

BMI and abdominal obesity influence the appearance of vitamin D insufficiency in children.