5210 Pediatric Obesity Clinical Decision Support Chart

5210 Pediatric Obesity Clinical Decision Support Chart

by American Academy of Pediatrics (AAP)

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Overview

This convenient flip chart provides child health care professionals practical support and guidance to help improve care and outcomes for overweight youth.

 Bring your practice the latest ready-to-use tools including 

  • Step-by-step prevention, assessment, and treatment interventions for the overweight and obese child developed by the CDC
  • 15-minute obesity prevention protocol
  • Hypertension evaluation and management guidelines
  • Growth charts spanning birth to age 20 years -- including body mass index-for-age percentiles
  • Blood pressure levels for boys and girls
  • Coding information for obesity-related health services
  • Next Steps child weight reduction and management strategies

Product Details

ISBN-13: 9781581108941
Publisher: American Academy of Pediatrics
Publication date: 11/01/2014
Sold by: Barnes & Noble
Format: NOOK Book
Pages: 20
File size: 9 MB
Age Range: 18 Years

About the Author

The American Academy of Pediatrics is an organization of 66,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. The AAP is the largest pediatric publisher in the world, with a diverse list of resources that includes essential clinical and practice management titles and award-winning books for parents.
 

Read an Excerpt

Pediatric Obesity Clinical Decision Support Chart


By Jonathan Fanburg, Victoria W. Rogers, Michael Dedekian, Steven Feder, Sandra G. Hassink

American Academy of Pediatrics

Copyright © 2015 American Academy of Pediatrics
All rights reserved.
ISBN: 978-1-58110-894-1



CHAPTER 1

Overview of Treatment for the Overweight Child

Body mass index (BMI) calculation and classification of BMI percentage begin the process of evaluation.

1. Tailor interventions.

• Make age appropriate.

• Meet patient's and family's readiness to change.


2. Take key steps.

• Start early and aim for long-term behavioral/lifestyle change.

• Use small steps and gradual change.

• Solicit family support/praise.

• Create measurable goals ("if you can't count it, you can't change it").

• Focus on healthy behavior goals, not weight change.

• Keep it positive.

• Choose words carefully.

• Be aware of weight bias, stigma, and blame.


3. Use tested techniques.

• Emphasize successes, not failures.

• Help families recognize that making healthy changes can be difficult.

• Appreciate that adherence from patients will vary; support and return to the plan in a nonjudgmental way.

• Expect periods of relapse and be ready to troubleshoot with patient and family.

• Use motivational interviewing.

• Identify potentially high-risk nutrition and activity behaviors (eg, binging or hiding food).


4. Review mental health.

• Evaluate family stressors and comorbidities (eg, depression, anxiety, post-traumatic stress disorder).

• Assess need for mental health intervention (eg, family or individual counseling, medications).


5. Promote individualized concrete healthy changes.

• Encourage healthy habits at home starting at birth.

• Encourage breastfeeding.

• Consider focusing on one goal at a time with families over multiple clinic visits.

• Consider using Next Steps: A Practitioner's Guide of Themed Follow-up Visits to Help Patients Achieve a Healthy Weight. Any one of the Next Steps themes can be the focus of a follow-up visit for obesity. Guide families toward a goal within each theme in understandable terms. These themes are listed in greater detail on page 19 and in the Next Steps guide.

Understanding Health: Think about focusing on health, not a weight number.

Understanding Meaning of Healthy Foods: Foods in their natural state are usually best: fruits, vegetables, and whole grains.

Home Environment: Try keeping unhealthy food out of the house; add better choices instead.

Behaviors and Emotions Around Eating: Eating feels good, but if you're already full, do something else you enjoy instead.

Portion Sizes: Try U a plate for vegetables and fruit, % for carbohydrates/starches, and % for meat/protein.

Healthy Drinks: Drink more water. Think of other drinks as a special treat.

Parenting: Set kids up for success by setting limits, making reasonable rules, and giving praise.

Physical Activity: Moving is the best medicine; it improves all aspects of health.

Feeling Good About Yourself: There are many positives to your health. Protecting future health is the goal.

Label Reading: Use labels to help avoid excess carbohydrates and calories. Fewer ingredients are best.

Screen Time and Sleep: Two hours or less of screen time is best. Good sleep equals good health.

Meal Patterns and Snacks: Think about scheduling meals and snacks as a family.

Eating Out of the Home: Limit going out to eat and look for healthy choices when you do.

Holidays/Special Occasions: Limit celebrations to one day. Give away sweet leftovers.

Healthy Family: Food rules in the house should be the same for all. Working together is best.

Community Partners: Use your community. What's available nearby to keep your kids healthy?

Bullying and Teasing: Are other children at school treating your child well? Are there supportive friends?

Unintentional Disruptions: What are some things in the way of making your family healthier?

6. Refer complex comorbidities to a subspecialist.

• Immediately refer concerns of new-onset diabetes, pseudotumor cerebri, or slipped capital femoral epiphysis.

• Consider endocrinology referral for persisting metabolic syndrome or poor linear growth, gastroenterology for progressive alanine transaminase elevation, pulmonology or polysomnography for persistent sleep disorder/daytime fatigue, snoring/gasping for air, and psychiatry for persistent depression, anxiety, or low self-esteem.


7.In the office and beyond, create an environment that models good health.

• Advocate for schools to have appropriate physical activity and wellness programs.

– Use examination rooms and waiting rooms with photos of active kids.

• Use your own experiences and be a role model.


Tips for Busy Clinicians

Treatment Interventions

Communication

• Be empathetic.

• Deliver a set of consistent key messages — 5210.

• Keep a list of good Web sites to give to your patients. Have appropriate books and magazines available in your waiting room. Provide books, puzzles, and activity sheets — especially for children — that help promote healthy eating and active living.

• Display educational posters and create a bulletin board for community partners to update.

• Frame your discussions to expand the patient/family perception of what healthy lifestyle changes they can make. Keep goals small, simple, and concrete. Allow for personal choices. Selections a child enjoys will be more easily sustained.

• Have patients set specific behavior goals and action plans, and be sure to ask about these during the next visit or follow-up contact.

• Be aware of cultural norms of the patient, significance of meals/eating for the family/community, beliefs about special foods, and feelings about body size.


Team Approach

• Be a good role model; be physically active every day and work to make healthy food choices.

• Involve the clinical team in planning and implementing treatment intervention.

• Know your community resources and refer patients to them. These will help support families once they leave your office.

• Behavior change is a long-term process, and involving other qualified staff (eg, nurses, counselors, mid-level practicioners, and school nurses) will help ensure success.

Encourage involvement and change for the whole family and all caregivers.


ABCs of Counseling and Motivating Children Who Are Overweight and Their Families

ASK OPEN-ENDED QUESTIONS.

• How do you feel about us talking about your physical activity, TV watching, and eating today?

• How concerned are you about your child's weight? Why?

• What are some of the things you might like to change?


SET THE STAGE.

• Describe how responsibility for change is the patient's/family's.

• Put the patient at ease by explaining that obesity is a complex problem. Being healthy in today's society can be tough.

• Convey respect by acknowledging family history and weight issues. Address stigma of obesity.

• Honor patient choices regardless of clinician goals.


EXPRESS CARE AND EMPATHY.

• Do not criticize.

• Acknowledge the patient's feelings.

• Answer questions without sign of judgment.

• Listen more than tell. Elicit rather than instill.

• Use language that is nonjudgmental.

– "Healthier" food versus "bad" food

– "Healthier" weight versus "ideal" weight


For more information to see what this looks like in an office, go to Pediatric ePractice at the AAP: ihcw.aap.org/programs/pediatricepractice/pages/default.aspx.


Healthy Habits Questionnaire (Ages 2-9)

Many offices have successfully used a questionnaire to acquire basic healthy lifestyle information. Clinicians have also found that simply using and reviewing the questionnaire is a powerful tool for starting the discussion around healthy lifestyles.


Healthy Habits Questionnaire (Ages 10+)

Many offices have successfully used a questionnaire to acquire basic healthy lifestyle information. Clinicians have also found that simply using and reviewing the questionnaire is a powerful tool for starting the discussion around healthy lifestyles.


Medical Screening

Take a healthy lifestyle history.

Use the Healthy Habits Questionnaire (5210) (see pages 7 and 8).


Ask about family history.

First-degree relatives with obesity, type 2 diabetes, hypertension, lipids, or heart disease.


Ask about a review of systems.

See page 9, Obesity Assessment: Findings on Review of Systems.


Assess BMI percentile and classify.

Although classification by BMI percentile is currently being done, we should focus on healthy behaviors and avoid simply labelling kids.

• <5th = underweight

• 5th-84th = healthy weight

• 85th-94th = overweight

• >95th = obesity


Presently there is no label for children >99th percentile for BMI or definition of morbid obesity in children; however, experts are considering categorizing patients with BMI = >120% of the 95th percentile as having "severe obesity" (Circulation. 2013; 128:1689-1712).


Focus physical examination

See page 10, Obesity Assessment: Physical Examination Findings.

• Blood pressure (Correct cuff size is important.)

• Acanthosis nigricans, stretch marks

• Tonsils, goiter

• Tender abdomen, liver

• Bowing of legs, limp, limited hip range of motion Order laboratory tests.


Order laboratory tests.

Laboratory testing recommendations for childhood obesity are evolving. When deciding which tests to order, the patient's family history, review of systems, and comorbidities should be taken into consideration. If the patient is overweight (BMI 85-94th percentile for age), blood tests will less likely be abnormal but still can be used to discuss comorbidities, family illnesses, etc.

• Fasting lipid profile, hemoglobin A1c, fasting glucose, alanine transaminase

• Vitamin D (Level is commonly low in obesity.)

• Consider obtaining labs every 2 years or if there is lack of progress toward a healthy weight.

• The National Heart, Blood, and Lung Institute guidelines recommend fasting lipid profile for all children aged 9 to 11 and 17 to 21 years (Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. 2012).


Reference Values

Cholesterol

All children should undergo cholesterol screening once between ages 9 and 11 years and once between ages 17 to 21 years. Non-fasting total cholesterol and non-high density lipid (HDL) protein cholesterol (non-HDL cholesterol = total cholesterol - HDL) can be used for the initial lipid screening test. These cut points along with treatment guidelines were outlined by the National Heart, Lung, and Blood Institute in 2012 (Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents). Values provided are for children and adolescents. Parenthetical numbers — "( )" — are for young adults.


Liver Function Tests

Alanine aminotransferase (ALT) may be the most sensitive test for non-alcoholic steatohepatitis (NASH). Abnormal ALT can be interpreted when the ALT value is more than 2 times the reference value. A normal ALT may be seen in early stages of NASH. The reference value will vary from laboratory to laboratory.


Metabolic Syndrome

There is no consensus as to the definition for metabolic syndrome in children at time of this publication, and evidence is still developing. Per the National Heart, Blood, and Lung Institute guidelines, the group of risk factors within this chart may represent metabolic syndrome (Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report. 2012).


Metabolic Syndrome Component Levels for Evaluation of Children With Multiple Cardiovascular Risk Factors

Multiple risk factors with borderline values may have cardiovascular risk equivalent to an individual with extreme abnormality of a single major risk factor.


CODING FOR OBESITY AND RELATED COMORBIDITIES

While coding for the care of children with obesity and related comorbidities is relatively straightforward, ensuring that appropriate reimbursement is received for such services is a more complicated matter. Some payers may deny claims submitted with "obesity" codes (eg, 278.00), essentially carving out obesity-related care from the scope of benefits. Therefore, coding for obesity services is fundamentally a 2tiered system in which the first tier requires health care professionals to submit claims using appropriate codes and the second tier involves the practice-level issues of denial management and contract negotiation.

At time of publication, the Affordable Care Act (ACA) is being rolled out and is expected to include coverage for preventive health services including both obesity screening and counseling. However, how to fully apply these provisions is unclear at this time. Furthermore, grandfathered policies may not cover these services until they are renewed. Both interpretation of the ACA and grandfathered policies suggest that insurance coverage for obesity presently vary tremendously from state to state.

Generally, initial visits can be reimbursed at the 99215 level with follow up visits reimbursed at the 99214 level. Time based coding (requires documenting that 50% or more of the time was counseling as well as documentation of total time of visit and time spent counseling) can be used when indicated (99213 = 15 min, 99214 = 25 min, 99215 = 45 min).

The following is a partial guide to some of the most relevant codes for childhood obesity. A complete list can be found at Pediatric ePractice (www.pep.aap.org) in the section labeled Front Office and is much longer in length.


* * *


Diagnosis Codes (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] Codes)

On October 1, 2015, it is anticipated that these codes will be replaced by ICD10-CM codes.

278.0 Obesity


Symptoms, Signs, and Ill-Defined Conditions

783.1 Abnormal weight gain

783.21 Loss of weight


Other

The ICD-9-CM codes that follow (ie, V codes) are supplemental codes and should only be reported when the circumstance or condition is contributing to the encounter.

V85.51 BMI, pediatric, less than 5th percentile for age

V85.52 BMI, pediatric, 5th percentile to less than 85th percentile for age

V85.53 BMI, pediatric, 85th percentile to less than 95th percentile for age

V85.54 BMI, pediatric, greater than or equal to 95th percentile for age


ICD-10-CM Codes

ICD-10-CM codes will not be valid for reporting purposes until at least October 1, 2015. Do not report these codes until they are valid for use. Refer to the ICD-9-CM codes listed in the section prior to this.

E66.01 Morbid (severe) obesity due to excess calories

E66.8 Obesity, other

E66.09 Obesity , other due to excess calories

E66.9 Obesity, unspecified

E66.3 Overweight


Other

The ICD-10-CM codes that follow (ie, Z codes) are used to deal with occasions in which circumstances other than a disease or injury are recorded as diagnoses or problems. Many of these codes are supplemental codes and should only be reported when the circumstance or condition is contributing to the encounter.

Z68.51 BMI pediatric, less than 5th percentile for age

Z68.52 BMI pediatric, 5th percentile to less than 85th percentile for age

Z68.53 BMI pediatric, 85th percentile to less than 95th percentile for age

Z68.54 BMI pediatric, greater than or equal to 95th percentile for age

Z71.3 Counseling, dietary and surveillance

Z71.89 Counseling, other specified (exercise, parent-child problems)


Staged Intervention: Steps to Prevention and Treatment

As one progresses from stage 1 to 4, one will notice that the intensity of services increases and the number of resources used increases.


(Continues...)

Excerpted from Pediatric Obesity Clinical Decision Support Chart by Jonathan Fanburg, Victoria W. Rogers, Michael Dedekian, Steven Feder, Sandra G. Hassink. Copyright © 2015 American Academy of Pediatrics. Excerpted by permission of American Academy of Pediatrics.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Table of Contents

    Table of Contents
    Book Info

    Page 3
    Overview of Treatment for the Overweight Child
    Page 4
    Feeding Guide for Children
    Page 5
    Tips for Busy Clinicians
    Page 6
    Resources
    Page 7
    Healthy Habits Questionnaire (Ages 2–9)
    Page 8
    Healthy Habits Questionnaire (Ages 10+)
    Page 9
    Obesity Assessment: Findings on Review of Systems
    Page 10
    Obesity Assessment: Physical Examination Findings
    Page 11
    Medical Screening
    Page 12
    Reference Values
    Page 14
    Coding for Obesity and Related Comorbidities
    Page 15
    15-Minute Obesity Prevention Protocol
    Page 17
    Universal Assessment of Obesity Risk
    Page 18
    Staged Intervention
    Page 19
    Planned Follow-up Visits Using Next Steps
    Page 20
    Strategies for Teenagers
    Page 21
    Definition of Hypertension in Children
    Page 22
    Hypertension Management Algorithm
    Page 23
    Blood Pressure Levels of Boys
    Page 24
    Blood Pressure Levels of Girls
    Page 25
    Body Mass Index of Girls
    Page 26
    Body Mass Index of Boys
    Page 27
    Body Mass Index for 99th Percentile Cut Points








 

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