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CAN AN ANAESTHETIC PREOPERATIVE EXCESS WEIGHT PATHWAY IMPROVE OUTCOMES FOR CHILDREN LIVING WITH SEVERE OBESITY?
Z. A. Burton, N. Aswani, L. Cronin, J. Reynolds, N. Marshall, V. Hodgetts
Sheffield Children's NHS Foundation Trust, UK
Background
In 2019 1 in 4 UK children undergoing general anaesthesia were living with overweight and obesity (OAO)(1), figures exacerbated by Covid-19. Childhood obesity leads to a five-fold increased likelihood of adulthood obesity, associated chronic conditions and reduced life expectancy(2). The current estimated UK cost of OAO is £98 billion. Lifestyle interventions can help reduce this burden.
Problem
Children with OAO undergo more surgical procedures, have increased anaesthetic risk and poorer perioperative outcomes. Nationally, there is no robust preoperative screening process to risk-assess or consent for obesity related outcomes, representing a missed opportunity for both risk reduction and health promotion(1).
Strategy for change
In March 2021 a weekly preoperative excess weight clinic was initiated at Sheffield Children’s Hospital for severely obese children (>99.6th BMI centile), involving face-to-face appointments with an anaesthetic consultant trained in motivational interviewing. Anaesthetic risk and comorbidities were evaluated, and individualised age-appropriate lifestyle goals agreed, tailored to biopsychosocial needs. Appropriate referrals were made to paediatricians, Tier 2 programmes and an Exercise and Physical Activity Therapist.
Since 2021, major iterative improvements included: Relocation to the Advanced Wellbeing Research Centre with gym access; Sleep Nurse Specialist referral pathway; close collaborative working and referral to Tier 3 clinics; introducing an app-based digital patient information repository, national guidance on consent and risk discussions(3), Nurse Practitioner-led excess weight clinics and a combined oral health promotion clinic.
Measure of improvement
The natural trajectory is for severely obese children to continue gaining weight into adulthood. Significant improvement in body composition and cardiometabolic risk are evident following BMI standard deviation score (BMI SDS) reductions >0.25, with greater benefits >0.5 BMI SDS(4). The clinic database includes 304 children (41.1% female; mean age 10.4 years, SD 4.01), of which 173 (56.9%) have undergone surgery. 72.3% (n=125) reduced their BMI SDS preoperatively (mean -0.28; SD 0.26); 27.7% (n=48) and 13.3% (n=23) reduced >0.25 and >0.5 BMI SDS respectively. In several cases, obesity reduced sufficiently to reduce at least one weight category (22.0%, n=38), no longer be classified “severely obese” (12.7%, n=22), no longer have insulin resistance or liver dysfunction, require CPAP for OSA or post-operative HDU beds.
Lessons learnt
Over half of children were in the lowest two deciles of deprivation (Figure 1). Families value being listened to in a non-judgemental face-to-face setting with an individualised multidisciplinary approach. Outcomes from lifestyle intervention in this setting have superseded expectations; families facing imminent increased perioperative risks may be more motivated to adopt positive behavioural change.
Message for others
As health professionals, everyone has a role in health promotion and ensuring sustainability. This initiative has shown that by capitalising on this “teachable moment”, significant perioperative risk-modification and health benefits are feasible, with potential for longer term health and socioeconomic effects.
References:
- Burton ZA, Lewis R, Bennett T, McLernon DJ; Paediatric Anaesthesia Trainee Research Network; Engelhardt T, Brooks PB, Edwards MR. Prevalence of PErioperAtive CHildhood obesitY in children undergoing general anaesthesia in the UK: a prospective, multicentre, observational cohort study. Br J Anaesth. 2021 Dec;127(6):953-961.
- Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016 Feb;17(2):95-107.
- Burton ZA, Saddington F, Russell K and the Society for Obesity and Bariatric Anaesthesia, 2023. Anaesthesia consent for children and young people living with obesity. https://www.sobauk.co.uk/guidelines-1 (Accessed 1st February 2024)
- Reinehr T, Lass N, Toschke C, Rothermel J, Lanzinger S, Holl RW. Which amount of BMI-SDS reduction is necessary to improve cardiovascular risk factors in overweight children? J Clin Endocrinol Metab (2016) 101.