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Sixty-seven percent of Americans are considered overweight, and 40% are obese-as defined by a body mass index (BMI) of 30 or greater. The prevalence of obesity among all Americans has tripled since the 1960s, increased by 50% from 1986 to 1998, and continues to climb at a dramatic rate.1
Although obesity is a major concern for many adults, it's thought to be the most common health problem facing U.S. children today.2
Overweight and obesity are serious chronic conditions associated with a wide range of physically and emotionally devastating conditions. Both patient safety and caregiver injury are fast becoming serious considerations in managing care of children who are obese.
Obesity simply refers to the condition of having too much body fat. It's different from being overweight, which refers to weighing too much.3 Both terms mean that the child's weight is greater than what's generally considered healthy for height and age. Children grow at different rates, so determining whether a child is obese or overweight is often difficult. However, most researchers agree that more than 12.5 million U.S. children and teens are overweight or obese.4 Over the past 20 years, the proportion of overweight children ages 6 through 11 has more than doubled and the rate for adolescents ages 12 through 19 has tripled.5
Results from the 2003-2004 National Health and Nutrition Examination Survey (NHANES), using measured height and weight, indicate that an estimated 17% of children and adolescents ages 2 to 19 years are overweight, and more specifically, 13.9% of 2- to 5-year-olds were found overweight in 2004, as were 19% of 6- to 11-year-olds. Among 12- to 19-year-olds, 17% were considered overweight.6 Studies suggest that obese adolescents are up to 80% as likely to become obese adults. Approximately 25% to 30% of adult cases begin with childhood obesity.7
A history of excess weight in childhood that persists into adulthood is associated with more severe obesity-related complications later in life. Obese children can develop serious health problems, such as diabetes and heart disease, often carrying these conditions into an obese adulthood. Overweight children are at higher risk for developing a number of conditions such as type 2 diabetes mellitus, metabolic syndrome, hypertension, asthma, obstructive sleep apnea, nonalcoholic liver disease, early puberty or menstruation, anorexia, bulimia or preoccupation with food, intertrigo, and more.8 Children who suffer with weight issues tend to have more depression, low self-esteem and anxiety. Some children act out or are disruptive in social settings, while others withdraw socially.9 Stress and anxiety also interfere with learning. Some depressed children are known to hide their sadness and appear emotionally flat or overly cheerful. Research suggests children of all ages are accessing medical care for these conditions and medication administration for chronic conditions among children is on the rise.10
The challenge to nurses is finding better ways to understand weight regulation and then seeking strategies to promote safe nursing care and policies and programs that promote health and healthy behaviors. Additionally, nurses best serve children by recognizing the threat a preoccupation with food poses throughout life. Overweight children are at risk for low self-esteem because of the social emphasis on appearance and the widespread bias against those of size.11 Keep in mind the goal of health and fitness as compared to physical appearance and body weight.
Obesity holds financial consequences to the family, community, and society in general. For example, the economic burden of obesity is significant with estimates of the total economic costs associated with the disease reaching 5.5% to 7.8% of all national healthcare expenditures.12,13
Obesity is found to be associated with a 36% increase in inpatient and outpatient spending.14 Obesity-related issues cost Americans nearly $150 billion annually; $117 billion is spent on health and health-related issues, and another $33 billion is spent on the largely unsuccessful weight loss industry. The economic impact on family could be measured directly and indirectly, and must be recognized when counseling children and their families regardless of practice setting.
Although genetics undeniably play a role in the obesity epidemic, the environment unlocks the child's genetic predisposition to obesity. For example, studies suggest that on average, children spend between 2 and 4 hours/day using electronic media.15 As electronic media usage increases, so does the overall BMI among children.16
Today, nearly 9 out of 10 school-aged students are driven to school. Compare this to a generation ago, when approximately half of all school age children walked or biked to school. There are fewer opportunities for activity throughout the day, with less than 4% of elementary schools reportedly providing physical education. All the while eating habits are changing. Children are eating more and in larger portions.17 Parents are reluctant to allow children to play in areas previously thought to be safe, further restricting opportunities for activity.18 Together, these factors set the foundation for a lifelong struggle with weight that begins early in life.
The goal of hospital-based nursing care is essentially twofold: prevent caregiver injury and provide physically and emotionally safe patient care. When an obese child accesses nursing care, physical size can complicate even the most basic intervention. One of the first steps to consider is various stages of physical development and evolving mental capacity unique to each child, irrespective of physical size. The next step is the physical challenges of care. At the heart of success is anticipating issues such as skin breakdown, intravenous access, respiratory function, basic resuscitation measures, altered drug absorption, pain management, and mobility-and addressing those issues in a size-sensitive manner.
Further, clinicians who treat obese pediatric patients need to have proper training and expertise. Many healthcare providers receive only basic training in pediatric care and little to no additional training in managing a child with issues of excessive adiposity and size. For example, a highly skilled pulmonologist may know very little about obstructive sleep apnea among children whose clinicians have problems fitting equipment or calming a child's fears. It's important to understand healthcare providers' skill levels and provide necessary training. Consultation, team conferences, and transfer are options when facility staff feels ill-equipped to manage the child's needs.
Obese children face skin challenges similar to obese adults, but assessment can be more challenging. Children may not fully understand the purpose of a comprehensive skin assessment, which may seem unnecessarily invasive. Communication is at the heart of understanding and is best achieved when based on both age and developmental stage. Age-specific communication competencies can help the nurse present information in a way that enables the child to understand what he'll experience, as well as how to prepare for any unfamiliar assessment, treatment, or procedure. The amount of information and the time spent will vary according to age and development level. However, regardless of age, developing a relationship with the child can improve his willingness to allow more invasive procedures, such as a comprehensive skin assessment. Keep in mind that skin within skin folds is sufficient to cause skin breakdown. Tubes and catheters can burrow into soft tissue. To further prevent skin erosion, reposition tubes and catheters-and the child-at least every 2 hours. This is especially difficult for children who are reluctant to move around or aren't comfortable because of their physical appearance or the care environment's physical restrictions.
Wound healing is problematic because blood supply to adipose tissue is usually compromised, which diminishes oxygen and nutrients necessary to prevent breakdown and promote healing. Elevated intra-abdominal pressure, which is seldom seen among pediatric patients and therefore may be unfamiliar to pediatric nurses, can increase tension on wound edges, especially when the child moves. Elevated intra-abdominal pressure occurs when fatty tissue accumulates in the abdominal area to the extent that the added pressure leads to clinical manifestations such as pressure on the cardiopulmonary system, lymphatics, and more. Each of these circumstances are exacerbated if the child lacks protein, vitamin, and mineral stores or has a wound within a skin fold where excess bacterial, fungal or viral contamination and moisture can accumulate. Some obese children might have a history of inadequate nutritional intake-sound nutritional intake. Consider adequate nutritional assessment, which includes physical exam, medical and social history, and lab values such as albumin, prealbumin, serum transferrin and lymphocyte count. Keep the dietitian involved to incorporate the latest input and resources.
Many obese children present with pulmonary issues, two in particular: obesity hypoventilation syndrome (OHS) and certain types of sleep apnea. The child with OHS often sleeps better in the semi-Fowler's position because abdominal fat is diverted from the thoracic cavity, as happens in the supine position. A number of children at home use continuous positive airway pressure. It's essential that those managing the needs of the child are aware of any home treatment. Further, depending on policy, your facility may request the child bring his breathing equipment for evaluation or even use, when appropriate. Resources such as a sleep study consultation can be very helpful to the child. Critical care intervention can be frightening for the child, parents, and siblings. Storytelling for younger children and developmentally appropriate explanations for older teens can be helpful in calming the frightened, dependent patient.
If long-term ventilator support becomes necessary, doing a tracheostomy can be problematic if the trachea is buried deep within fatty tissue. Surgeons may end up creating a large wound accessing the trachea. This poses the risk of postoperative complication that may not occur with thinner children, such as bleeding, infection, and erosion of the surrounding skin. To complicate matters, standard-sized tracheostomy tubes often aren't long enough for an obese child's neck. Involve the purchasing agent or consider using an endotracheal tube; tap the expertise of the pulmonologist or pulmonary clinical nurse specialist in managing this special situation. Further, make sure tracheostomy tube ties are wider and longer to accommodate the child's larger, thicker neck. Take care to avoid allowing the tracheostomy tube ties from burrowing into a skin fold in the back of the neck, as this could lead to unexpected and avoidable skin breakdown and infection.
Regarding vital signs, a task as simple as taking BP can pose a challenge. A BP cuff sufficient to fit the child comfortably is essential. A thigh cuff may actually work best. Using a cuff that's too small or taping the cuff edges together to attempt to make it fit will lead to an inaccurate reading. It best serves the child to have the cuff in a designated area so the nurse has easy access when the equipment is needed-the same with other critical equipment, especially if an emergency occurs. If CPR is necessary, a Doppler measurement may be necessary to hear blood flow through the carotid artery. Placing a backboard under the patient is a challenge-and keep in mind that once resuscitation efforts are successfully complete, the board must be removed or serious skin consequences can occur. If the child is on a low air loss surface with a CPR-quick release, the surface can be deflated, with the bed frame serving as a backboard. Most bariatric bed frames can adjust to a narrower width, allowing easier, safer patient access. A narrower bed frame also provides the ability to transfer the patient from the pediatric unit to critical care while on the bariatric bed-thus avoiding a lateral transfer into a gurney in a critical situation. Reviewing features of specialized equipment with the vendor before an emergency makes good sense from a risk management perspective.
Excess body fat can alter drug absorption, depending on the medication. Dosage of some medication is calculated using the child's actual body weight, while others are based on ideal body weight. Trying to remember which drug falls into which category is nearly impossible. Include the service of the clinical pharmacist on your team in making critical decisions for obese children. Further, consider the length of needles used for intramuscular injections, as standard 1- to 1.5-inch needles may not be able penetrate past adipose tissue in a patient with a thick layer of fatty tissue. A longer needle may be necessary.
I.V. access can be just as challenging. If it takes more than two attempts to start a peripheral I.V., and there's no other reason not to consider using a peripherally inserted central catheter or midline catheter, this may be the best option. Both can stay in place for weeks to months, thereby eliminating frequent attempts.
Pain and pain management can present differently for the child and certainly different yet for the child with a high degree of adiposity. Keep in mind the special concerns of children who don't fully understand the unfamiliar procedures and treatments they experience.19 Physical pain can lead to emotional issues and create a circularity of fear and distrust. Age-specific communication skills are also important for the assessment of pain and proper pain control. Consider a child life specialist to assist in this area.
When hospitalized, overweight children are at risk for certain hazards of immobility. Common immobility-related complications could include skin breakdown, muscle weakness, urinary stasis, constipation, pain management challenges, and depression. Immobility also contributes to pulmonary complications such as atelectasis or pneumonia. The obese child is more inclined to develop complications resulting from a long hospitalization. An aggressive interdisciplinary team that meets regularly to discuss issues is essential to identify nursing concerns in a timely appropriate manner with the goal of preventing the common, predictable, and preventable complications associated with hospitalization. The team can also serve as a resource to consider some of the safe patient handling challenges in addressing the movement needs of heavier children and the nurses who care for them.
Preventing nursing injuries is an essential component of all patient care, including pediatric nursing care. As more children of all ages are heavier, pediatric nurses must be aware of the inherent risks. Issues of caregiver injury are gaining global, national, and statewide recognition. Research indicates that on any one day, 17% of nurses report experiencing back pain.20 Fifty percent of nurses report the thought of leaving nursing within the next 12 months because of working conditions, which include fear of injury.21
As of January 2009, eight states have legislated safe patient handling bills, nine have bills pending, and a national bill is in consideration. Caregiver safety is a serious nursing issue. Because of the nature of pediatric nursing, nurses in this patient care area may not be as prepared to address issues of caregiver injury as other units within acute care hospitals. Additionally, special training and equipment may not have been made available simply by virtue of the nature of the patient.
A safe patient handling effort is best composed of (1) changes in the physical environment, (2) equipment, (3) resources, and (4) organizational policies. Adapting the physical environment with wider doorways, floor-mounted toilets, ease of access in hallways and corridors, and attention to floor covering is an important first step.22 Equipment specially designed for overweight children can promote independence and prevent nursing injury.23 A weight-rated, air-displacement, lateral transfer product allows a safe, confident transfer. Physical and occupational therapists, ergonomists, safety officers, and clinical staff members-including nurses and nurse consultants-are often responsible for making recommendations for equipment, and serve as clinical experts or resources for nurses providing direct patient care or planning for care.
Wide, front-wheeled walkers; wide wheelchairs; oversized stretchers; abdominal binders; bedside commodes; wider room chairs; specialty bed frames; wide, heavy-duty beds that lower close to the floor; gowns large enough to cover the patient entirely; bed-frame trapeze; reclining wheelchairs; lift and transfer systems; lifting bands; and ceiling lifts are just a few items that serve the needs of the nurse caring for the larger child. Criteria-based protocols or preplanning for use of equipment and specially training is the final piece of a successful comprehensive care plan.
Nurses in outpatient, primary care, home health, school, and other community-based settings are well aware of the challenges in encouraging health promoting strategies among children whose weight interferes with health. BMI is used to indicate if the child is overweight for age and height. Growth charts, established by the CDC, help identify overweight and obese children, with overweight delineated as BMI-for-age between 85th and 94th percentiles, and obesity as BMI-for-age 95th percentile or above.
When considering the individual child, keep in mind that BMI doesn't account for unique differences such as an excessively muscular or pregnant teen; therefore, other factors such as growth and development are considered in the overall assessment. Consider the child's overall health, rather than looking at a number, to make a decision as important as weight regulation. Family history, eating habits, calorie intake, activity, and the child's overall emotional and physical health are essential to a comprehensive assessment.
Assessment-based intervention targets the child's age and criteria discussed above, including any health conditions. Intervention could include medically supervised nutritional and activity changes, behavioral counseling, medications, or weight loss surgery. For children under age 7 who have no other health concerns, the goal of intervention may comprise weight maintenance rather than weight loss. This recognizes that as the child adds inches but not pounds, the BMI-for-age will decrease over time to a healthier range. On the other hand, weight loss is typically recommended for children over 7 or for younger children who have weight-related health concerns.
The methods for maintaining weight or losing weight are the same: the child needs to consume a nutritious diet and increase physical activity. Success depends largely on commitment to helping the child make these lifelong behavioral changes. Small changes can make a big difference in the child's perception of health and healthy living. For example, even very young children recognize food choices made by parents and emulate these behaviors when given the opportunity.24 Remind parents that they're in control of purchasing, preparing, and deciding where food is consumed, so they have the most influence over these changes in the home. Discourage "dining in front of a screen," as this leads to fast and mindless eating. Limit restaurant eating because many of the menu options are high in fat and calories. Never use food as a reward or punishment.
A critical component of weight loss, especially for children, is physical activity. It not only burns calories but promotes overall health. Such habits established in childhood help adolescents maintain healthy weight despite hormonal changes, rapid growth, and social influences that often lead to overeating. Active children are more likely to become fit adults. Strive to increase the child's activity levels by finding creative ways to concurrently limit the number of hours spent on sedentary activities. Emphasize activity, not exercise. The child's activity doesn't have to be a structured exercise program-the object is just to get him moving.
Two prescription weight regulation pharmaceutical medications are available for adolescents: sibutramine and orlistat. Sibutramine, which is approved for adolescents older than 16, alters the brain's chemistry to improve satiety more quickly. Orlistat, which is approved for adolescents older than 12, prevents the absorption of fat in the intestines. An emerging theme concerning obese individuals of all ages is to consider combination therapies directed toward several targets. By using combination therapies, it's anticipated that greater weight loss will be achieved compared with a single approach.25 Regardless, the risks of long-term medication administration is still unclear, and long-term outcome data on weight loss and weight maintenance for adolescents is still a debated issue. And, clearly, weight loss drugs aren't a substitute for a healthy lifestyle of nutrition and activity.
Weight loss surgery (WLS) has been a very successful weight loss strategy for certain adults, and therefore has been explored for some severely obese adolescents who have been unable to lose weight using other medically supervised weight loss strategies.26 However, as with any type of surgery, there are potential risks and long-term complications. Also, the long-term effects of weight loss surgery on a child's future growth and development are still not fully understood.
Although performed across the United States, WLS in adolescents is still a relatively uncommon procedure. However, surgeons performing WLS on adolescents ensure the teen meets strict selection criteria, clearances, preoperative educations (including exams and contracts), and informed consent. Most surgeons require attendance at support groups and information sessions, all with the goal that the teen fully understands, to the extent he is able, the impact of the surgery. Informed consent is especially challenging among those under 18 years of age. Informed consent, while important for patients of all ages, is an extremely important and potentially complex process in pediatric care. Pediatric nurses should recognize policies that support the informed consent process in their particular facility.
Whether the child is overweight or simply at risk, family-based programs can work to address weight and health issues that cling to some children for a lifetime. Nurses are in a position to help parents understand the threat food-related power struggles with the child pose to long-term success. Parents must recognize the resource or barrier that they pose, and be aware of the example they set for their child.
The goal of nursing, whether in the hospital or community setting, is to seek ways to serve children and their families by encouraging and emphasizing a positive lifestyle.
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