BMI-based Evaluation and Management in Children — Labs for Obesity Management — Clinical Pathway: Outpatient Specialty Care and Primary Care

BMI-based Evaluation and Management in Children Clinical Pathway — Outpatient Specialty Care and Primary Care

Laboratory Studies

Category Age Recommended Screening Frequency
≥ 85th Percentile 2-9 No BMI based screening recommended
  • Every 2 yrs if normal
  • Every 6 mos if abnormal or sooner
    if appropriate:
    • As indicated by health
      risks/co-morbidities
10-20
  • Consider lipid screening, ALT and diabetes evaluation (FPG, OGTT or HgA1c)
≥ 95th Percentile 2-9 Consider fasting lipids
10-20
  • Lipid screening, ALT and diabetes evaluation (FPG, OGTT or HgA1c)

Reference – Diagnostic Interpretations

Pre-diabetes and Diabetes

Pre-diabetes Diagnostics Diabetes Diagnostics
Fasting glucose from 100 to 125 mg/dL Fasting glucose ≥ 126 mg/dL
HbA1c from 5.7% to 6.4% Random glucose ≥ 200 mg/dL
  HbA1c ≥ 6.5%

Management of HbA1c and Fasting Glucose Results

  • If fasting glucose and HbA1c < 5.7 % are within normal limits, then repeat glucose and HbA1c in 2 years or sooner if clinical concerns arise
  • If HbA1c is 5.7% to 5.9%, repeat HbA1c in 3-4 months
    • If stable trend in mild elevation in HbA1c, repeat every 6 months while following clinically. High risk for progression in rising BMI, strong family history, ethnicity
  • If fasting glucose > 99 mg/dL and/or HbA1c is ≥ 6%, refer to Endocrinology or Endocrine provider within Healthy Weight Program.

Urgent Referral to Endocrinology

Lab values are consistent with diabetes diagnosis: HbA1c > 6.4%; fasting blood sugar > 125 mg/dL; random blood sugar > 200 mg/dL with symptoms of diabetes

Referral to ED for Urgent Evaluation

HbA1c Gt; 8.5% or greater than 5% unintentional weight loss

Dyslipidemia and Lipid Heart Clinic Referral

Lipid Category Optimal Borderline Abnormal
Total Cholesterol < 170 170-199 ≥ 200
LDL-C < 110 110-129 ≥ 130
Non-HDL-C < 120 120-144 ≥ 145
Triglycerides, 0-9 yrs < 75 75-99 ≥ 100
Triglycerides, 10-19 yrs < 90 90-129 ≥ 130
HDL-C > 45 40-44 < 40

Management of Lipid Panel Results

  • If non-fasting lipids are abnormal, obtain a fasting lipid panel
  • If fasting non-HDL-C, triglycerides, or LDL are borderline, provide counseling and repeat labs in 3 months. If labs remain borderline, consider Lipid Heart Clinic referral
  • If fasting values are abnormal, refer to Lipid Heart Clinic

Urgent Referral to Lipid Heart Clinic

  • LDL-C > 190 mg/dL
  • Triglycerides > 400 mg/dL
  • Fasting values are abnormal and diagnosed with Type 1 or 2 Diabetes Mellitus or family history of Coronary Artery Disease < 60 y/o

NAFLD/NASH

Management of ALT results

  • If negative screen and risk factors remain unchanged, consider repeat ALT in 2 years
  • If ALT is elevated but ≤ 80 U/L, repeat a hepatic function panel within 3 months
  • If ALT ≥ 80 U/L on initial screen, consider NAFLD Clinic/GI referral
  • If persistently elevated > 2x ULN (22 U/L females or 26 U/L males), consider NAFLD Clinic/GI referral

Vitamin D Management

Monitoring Vitamin D

The concentration of circulating serum 25-hydroxyvitamin D, [25(OH)D] is the accepted measure of vitamin D status. To avoid clinical errors in interpretation, the total circulating 25(OH)D (i.e., 25(OH)D2 plus 25(OH)D3) should be reported. Status and levels are affected by many factors, including: weight, skin pigmentation, geographical areas, the season of the year, amount of sun exposure, and use of sunscreen or clothing that covers most of the skin.

Vitamin D Diagnostics

Deficiency < 20 ng/mL
Insufficiency 20-30 ng/mL
Sufficiency > 30-50 ng/mL
Toxic > 50 ng/mL

Note: CHOP guidelines are based on EPGC’s; AAP & IOM desire level > 20 ng/mL

Management of Vitamin D results

  • If negative screen, repeat Vitamin D 25-OH in 1 year
  • If positive screen, start Vitamin D3 2,000 Units/day and recheck levels in 2-3 months for resolution