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09/24/2013

How Young is Too Young: Bariatric Surgery in Toddlers

by Craig Klugman, Ph.D.

The Oxford American Dictionary defines the term “outrageous” as “shockingly bad or excessive.” Case in point, a recent publication in the International Journal of Surgery Case Reports about a two-and-a-half year old boy in Saudi Arabia who two years ago underwent laparoscopic sleeve gastrectomy (LSG). The toddler is the youngest patient to ever receive this therapy.

In LSG surgery, the surgeon reduces the stomach’s volume by 80 percent. Because of the smaller area, the patient ingests less and eventually with proper diet and exercise, loses weight. Proper nutrition is essential because the person will be consuming far fewer quantities of food.

This case begins with a child experiencing rapid weight gain at age 6 months “when the parents noticed he was looking chubby and overweight.” At 8 months they talked to their doctor. By 14 months, he had a BMI of 29. The child experienced severe sleep apnea and had “bowing of legs.” The article reports that dieting was tried twice, but compliance with the diet could not ascertained “due to the different socio cultural habits and the absence of the practice of calculating the calorific value of the diet.” In other words, the physicians have no idea if changing diet and exercise were ever actually attempted.

Quickly dismissing the child’s diet, the authors explain that they conducted a family history, brain scan, as well as hormonal and genetic testing of the child to ascertain if there was an underlying condition. All tests came up negative. Of course the next logical step was to perform surgery (Sarcasm strongly intended, if that’s not clear). Two years after surgery, the child has a BMI of 24. No report is made as to whether any other aspects of his growth and development are affected.

This surgery is not side effect free. In the short term, there are risks from anesthesia, and dangers of bleeding. Among the reported concerns in adults are weight regain 2 to 3 years after the surgery, gastro-esophageal reflux, dumping syndromes, nutritional deficiencies (iron, vitamin B12, folate, calcium and Vitamin D), protein and selenium deficiencies, absorption problems, increased oxalate absorption, and increased risk of gallstones. In an adult, these can be problematic. In a growing and developing child who needs protein, vitamins, and other chemicals to support brain and body development, such deficiencies may be devastating. The point is, no one knows.

Are the parents insane or simply selfish? Parents owe their children an environment that is geared toward human flourishing. This includes protection from harm, appropriate stimulation both physical and mental, education, love, and attempts to ensure good health (and when that is lacking, good medical treatment).  According to the United Nations Convention on the Rights of the Child, a parent should always have the best interests of the child.  In case you were wondering, Saudi Arabia is a signatory, though that nation has been sanctioned because of juvenile sentencing practices.

As a college professor in Illinois, I am required under the Abused and Neglected Child Reporting Act to inform the Department of Children and Family Services if I suspect child abuse, even if it occurred in the past. In what way are the actions of these parents and doctors not child abuse?  Infants and toddlers don’t eat of their own accord. Someone chooses and prepares food for them. Someone feeds that food to the child. The child does not drive to the supermarket and load up on high caloric food with which to stuff himself. It is the rare two-year-old who one can stop from running around but exercise does not seem to have been tried. Who was enabling this child to eat a weight gaining diet? The only voice from the parents is that diet did not work.

I may be unfairly putting all of my concern and blame on the parents. After all, there are 3 physician-authors to this article and surgeons who performed this surgery. The article starts by talking about the dangers of obesity and epidemic of childhood obesity. The authors then talk about the success of bariatric surgery in children. They cite an article written by a in-country colleague reporting on a retrospective study of children ages 5 through 21 who were followed for up to 2 years. The cited article also calls for studies on long-term effects. The current authors state their purpose in writing as “probably the first case report of the successful management of a two and a half year old morbidly obese boy…” Reading this article, one gets the sense that the physicians may have been more interested in performing this surgery on a very young patient rather than providing best care for this particular patient.

From a Western perspective, this case is vulgar, an abuse of a child at the least, and perhaps inappropriate professional conduct by the surgeons. I find it disturbing that a physician would place a child at such risk for a surgery that poses a threat to the healthy growth and flourishing of a human being. But from a local perspective, it’s likely that Saudi Arabia has different philosophical traditions, rules, laws and oaths.

The journal itself also needs some scrutiny. According to its masthead, the International Journal of Surgery Case reports is “an author pays, peer-reviewed online journal publishing case reports only.” The authors paid the equivalent of $392.50 according to the author information portion of the journal’s website. And the journal only gets paid if the article is accepted. That just may set up a conflict of interest situation (see note above about sarcasm, it clearly is a conflict of interest).

The parents, the surgeons, and perhaps even the journal may have failed this child. And the saddest part is there is a little boy who has been surgically altered for life when other options clearly had not been diligently tried before this step was taken. The long-term affects on a growing child and a growing brain are unknown. The risks seem to outweigh the benefits in this case, especially as diet and exercise were apparently not serious attempted. This case is nothing short of outrageous.

This entry was posted in Conflict of Interest, Cultural, Featured Posts, Health Care, Pediatrics and tagged , . Posted by Craig Klugman. Bookmark the permalink.

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