Pediatric Cushing’s

Pathologic Obesity

Pediatric providers evaluate obese children in many different venues.  What conditions warrant a more in-depth evaluation to allow for prompt treatment of a severe medical concern?

Children with exogenous obesity are on a much higher weight percentile for stature.  Thyroid function and fasting lipid panel may need monitoring.  Many obese school-children can be tall for stated age due to the growth-enhancing effects of insulin( a cousin of growth hormone): the tall stature is often missed until height is plotted on the growth chart.  When a history of polydipsia, polyuria, nocturia, and acute weight loss is obtained with signs of acanthosis nigricans, evaluation for insulin resistance, glucose intolerance and diabetes is in order.

Obese children are also at high risk for sleep apnea.  Typically the family admits when queried that the child snores loudly at night and falls asleep often at school or naps daily after school.  A sleep study is required if the child has a history of breath-holding or AM headaches that suggest brain oxygen deprivation at night.

Cortisol excess is a rare but vitally significant etiology for obesity.  Children with this disease gain weight quickly over weeks or a few months, with markedly rapid change in appearance to morbidly obese, rounded, and plethoric facies.  Hypertension, hursutism, adolescent-like acne inappropriate for the child’s age (open and closed comedones), and wide, erythematous striae are the hallmarks of Cushing’s syndrome.  When associated with stunted growth and premature adrenarche without gonadarche, pituitary and abdominal imaging is indicated to rule out central versus adrenal etiology.  The most common cause is an adrenal adenoma or carcinoma, with Cushing’s disease (ACTH excess) an extremely rare finding.  Surgical excision may completely resolve all signs and symptoms.

Keep an open mind when evaluating each child with obesity: things may be more serious than you first surmise.

Stephen W. Anderson, M.D.

Pediatric Endocrinology

Atlanta

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