An Interview with Kirk Reichard, MD
ASMBS Pediatric Surgery Committee Chair

Published in October 2013 Issue             

Recent headlines about children as young as two-years-old getting bariatric surgery have grabbed attention, but have not changed the position of the ASMBS and its Pediatric Surgery Committee. It issued Best Practice Guidelines in 2012 and nothing since then has changed the consensus on the risks and benefits of bariatric surgery in adolescents and the criteria for patient selection.

connect recently interviewed Kirk Reichard, MD, FACS, FAAP, ASMBS Pediatric Surgery Committee Chair, about the controversial use of bariatric surgery in children, before they reach adolescence.

How young is too young for bariatric surgery? Is there consensus in the bariatric and pediatric community regarding age?

The current consensus is that bariatric surgery should not be performed in children younger than adolescence -- that's too young. In adolescents, bariatric surgery is a safe and effective treatment for morbid obesity and co-morbid conditions, for whom other treatment options have failed. The Pediatric Committee of the ASMBS developed Best Practice Guidelines on surgery in adolescents, which were published in SOARD in January of 2012. This reflects the current view. There is no recent data that would compel the Committee to change that view.

We understand that there is no specific clinical age cut-off for adolescents, as it often varies between individuals, but from your clinical experience and that of your colleagues, what has been the youngest age of a patient that you have encountered that was considered an “adolescent”  based on Tanner stage ≥3 and 90-95% skeletal maturity?

Age 12-13 would be the youngest one would likely see skeletal and sexual maturity.

What is the ASMBS position on surgeries that have been performed on children as young as two-years old?

The ASMBS consensus guidelines are clear that bariatric surgery should not be performed on children before adolescence.

Some media outlets noted that the surgeons may have felt the operation was the only way to save the child's life – at two, he weighed more than 70 pounds and suffered from bowed legs and sleep apnea. Are there instances when surgery is appropriate for very young children? Or do you feel this was an inappropriate procedure to perform at this time?

It is clear that the obesity epidemic is affecting children at a younger age and to a more serious degree than ever before. While serious co-morbidities can be present in younger children, there are non-surgical ways to manage these. Bariatric surgery is generally not considered an emergency or acute life saving procedure, but rather should be approached as a treatment modality to manage and prevent the long-term co-morbidities of morbid obesity. In any situation, the risk of the procedure must be weighed against any of the potential co-morbid conditions being treated. Current consensus is that there is no evidence to support the use of bariatric surgery before adolescence, given the potential long-term risks to nutrition and growth.

What are the ethical concerns regarding performing surgery on children?

Children, by definition, cannot provide consent for surgical procedures. While the legal age of assent is younger, the ability to engage in abstract reasoning, that is the ability to integrate the risks and future consequences of a decision, start to develop during adolescence. In the situation of subjects who cannot provide consent, there is an imperative to provide the greatest benefit for the least harm. There is currently no definitive evidence to support the short term health benefits, or to define the long term nutritional risks, of bariatric surgery in younger children.

The ASMBS guidelines do not give specific age cutoffs, but doctors have noted that surgery should only be considered for adolescents who have completed their growth. Why is that advisable, and at what age do adolescents generally complete that growth?

Vitamin and mineral deficiency is a well described consequence of bariatric surgical procedures, and require long term supplements even in patients who are no longer growing. The metabolic needs of a growing child are greater, and there is significant concern about the nutritional effects of bariatric surgery on growth and development in this age group.

Adolescence is not defined by age, but rather by the onset of puberty, sexual maturity and skeletal maturity. It varies based upon sex, race, genetics and weight, among other parameters, and can therefore not be defined by a chronological age.

How is “physical maturity” defined?

Physical maturity is defined by the attainment of skeletal maturity, which can be estimated by attainment of 90-95% of expected height, and by radiographic evaluation of the growth plates. There is no set chronological age for these parameters. Sexual maturity is defined by reaching Tanner stage 3-4.

What age is a child or adolescent considered to be capable of
independent decision making?

Independent decision making typically develops during adolescence. However, there is significant variation, and each patient should be evaluated by a behavioral health specialist with expertise in adolescent development to help define this milestone.

What is the average age of children/adolescents in the U.S. having bariatric surgery?

There is currently no universal database of adolescents undergoing bariatric surgery, and so the true number and age are not known. In recent reports from discharge databases, most patients are 17 or older. We looked at BOLD data up to 2011. The average age was over 19, but the cutoff was 21, and most patients were in the older age range, similar to the discharge databases. In series that report patients under 18, the average age is generally around 16.

Is there concern that these headline-grabbing surgeries in very young children could change the public’s perception of adolescent surgery?

The development of new medical treatments should occur in the setting of rigorous prospective, controlled evaluation. The safety and efficacy of adolescent bariatric surgery has been verified using this process. Single case reports provide interesting reading. However, such reports, and the disproportionate attention they generate, undermine the scientific discipline needed to evaluate new surgical strategies for complex problems.

Is the committee working on anything specific, such as a position statement, to address the issue of surgery for very young children?

The committee has created evidence based Best Practice Guidelines that clearly define the indications for bariatric surgery. Patients younger than adolescence are not candidates, according to these criteria. We have found no evidence to compel us to change these recommendations, which were published in 2012. We do not support bariatric surgery in children before they enter adolescence, and this has not changed since our last consensus statement. No new statements are planned.