The 20th Congress of RSCANP,

Băile Felix, 18-21.09.2019

Details on the
20th RSCANP Congress
: news, information, program, registration, fees, abstracts, accommodation, sponsors, contact

The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


Managing Obesity and Neurological Complications in a Child

Autor: Mang Niculina Mărginean Otilia Corcheș Axinia Vasilescu Raluca Nicoleta
Distribuie pe:

SUMMARY
Introduction. Obesity is a complex condition that is an important risk factor for cardiovascular disease, hypertension, diabetes and sleep apnea. The risk is frequent, the prognosis being all the more unfavorable as the onset of onset is earlier and the overweight is bigger. Material and method. The case of the Z.A patient, aged 12 and 11 months, coming from the urban environment is presented. From the personal physiological history, we note that he is born by caesarean, 40 weeks weighing 5000 g, G II P II. Upon admission Vcr = 12 years and 11 months / Gr = 163 kg / Tr = 176 cm; Vt = 16 years and 9 months / Gt = 66 kg / Tv = 155.90 +/- 8.02. / BMI = 52.75 kg / m 2 (> 97% percentile) that falls into morbid obesity. SDS = + 2.50. Historically, we note that the patient is presented in the UPU for diffuse headache, subjective visual impairment, vomiting and diplopia suddenly installed for which an ophthalmic examination was performed indicating papillary edema. Progressively, visual disturbances are increased, suspicion of cranial VI paresis is raised, therefore angio-CT-normal limits and MRI examinations result in a diagnosis of reversible posterior encephalopathy. Paraclinic and biological investigations reveal hyperinsulinemia, insulin resistance (HOMA = 4.97), bilateral papillary edema and hepatocitolysis. Cardiological consultation reveals a borderline arterial hypertension in the context of obesity and Nebilet, Prestarium and Diurex are administered. Corroborating clinical, biological and imaging data, the diagnosis of morbid obesity was made by hyperphagia with increased cardiovascular risk. Results. Childhood obesity is not perceived as a disease. To a large extent, obesity and related conditions respond to treatment if it is early instituted and is properly conducted. The immediate development of the treated child’s obesity is favorable, but the remote evolution is reserved due to the difficulty of maintaining the weight achieved after the weakness. Unless urgent action is taken, with all advances in the pharmaceutical industry and modern medicine, it will increase the number of victims of neglected childhood obesity, reduced quality of life and reduced life expectancy. Conclusions. Obesity is a multifactorial disease and a public health problem and requires a close population screening to identify overweight children and include them in a cognitive behavioral therapy.
Keywords: Obesity, neurological complications, management
INTRODUCTION
Obesity is a complex condition that is an important risk factor for cardiovascular disease, hypertension, diabetes and sleep apnea. The risk is frequent, the prognosis being all the more unfavorable as the onset of onset is earlier and the overweight is bigger.
The case of the Z.A patient, aged 12 and 11 months, coming from the urban environment is presented. We note that the patient is presented for diffuse headache, subjective visual impairment, vomiting and diplopia suddenly installed.
CASE PRESENTATION
Z.A, aged 12 and 11 months, coming from urban area. Reasons for hospitalization are: diffuse headache, subjective visual disturbances (diplopia), convergent strabismus.
INTRODUCTION
Obesity is a complex condition that is an important risk factor for cardiovascular disease, hypertension, diabetes and sleep apnea. The risk is frequent, the prognosis being all the more unfavorable as the onset of onset is earlier and the overweight is bigger.
The case of the Z.A patient, aged 12 and 11 months, coming from the urban environment is presented. We note that the patient is presented for diffuse headache, subjective visual impairment, vomiting and diplopia suddenly installed.
CASE PRESENTATION
Z.A, aged 12 and 11 months, coming from urban area. Reasons for hospitalization are: diffuse headache, subjective visual disturbances (diplopia), convergent strabismus.
himself at the UPU Deva where he is referred to the Pediatric Neurology Clinic in Timisoara.
During the admission at the Neurology Clinic he was evaluated neurological and took laboratory tests. Data from hereditary-collateral antecedents: mother with obesity gr. III, he also has a normoponderal brother, father, affirmative, in good
health, deny contact with people with TB.
Data from physiological antecedents: the second child, born at ca. 40 weeks, GN = 5000 g, the mother can not tell the length at birth and the APGAR score, naturally fed up to 6 months, diversified 6 months (apple, vegetable soup). Prophylaxis of rickets with Vigantol oil 2 pic / day, 1 year. Vaccinated according to the national vaccination scheme.
Data from personal pathological history: repeated IACRS, he denied smoking and alcohol.
INPATIENT STATUS
Patient with chronological age 12 years and 11 months, weight = 163 kg, height = 176 cm, on the percentiles he has the height age = 16 years and 9 months, weight = 66 kg, age height = 155.90 with standard deviation +/- 8.02.Based on the antopometrics data the BMI = 52.7575 kg / m2 (> 97%) and standard deviation for height with value of + 2.50.
Overall relatively good status. Excessive appetite. Normal colored skin and mucous membranes, elastic skin folds, preserved turgor. Diffuse headache. Subjective vision disorders, congenital convergent strabismus. Excessively subcutaneous cellular deficiency represented. Normally conformed torace, present vesicular murmur, symmetrically bilaterally, without disseminated rallies on both fields. Precordial area of normal appearance, rhythmic, noisy heart beat, no overloaded breath TA = 140 / 90mmHg.
The soft, supple, breathable mobile abdomen allows superficial and deep palpation, loosened by the fatty panicle. The intestinal transit present, the normal stool. Free renal beds, present diuresis. Giordano negativ bilateral. Puberty stage 1.
Without signs of irritation meningeana. Temporospatial orientation, live ROT, bilateral symmetry.
Easy walking and orthostatism on short distances with bilateral support. Without extrapyramidal phenomena.
Paraclinic: hepatocytolysis (TGP: 33 u / l-vn: <26 u / l), leucocytosis (19.36 10 3 / ul vn 4.8- 10.8 10 3 / ul), hypercholesterolaemia (5.25 mmol / l in <5 mmol / l), hypertriglyceridemia (2.07 mmol / l in <1.7 mmol / l), hyperinsulinemia (28.99 μg / ml in 2.6- 24.9 μg / ml), insulin resistance (HOMA = 4.97). In the neurology department were taken: EEG: A theatrical background treadmill, underground, with motion artifacts, unmodified by hyperpnea MRI: Since brain engineering was not possible for technical reasons, on October 30, 2017, the transfer to Sibiu Clinical Pediatric Hospital was decided to continue imaging investigations (cerebral MRI) where reversible posterior encephalopathy syndrome PRES). He took an interdisciplinary cardiological consultation with the following results: BP = 140/90 mmHg. Cardiac ecography: cord, as normal as possible. Border HBP in the context of obesity. Weight reduction and hypocaloric regimen are recommended. It is decided to take a HOLTER BP which shows secondary obesity hypertension. Antihypertensive treatment with Nebilet, Prestarium and Diurex is recommended. POSITIVE DIAGNOSIS All the clinical, paraclinical and heteroanamnestics data are corelated and we formulated the following positive diagnostics: 1. Reversible posterior encephalopathy syndrome (PRES) 2. Visual acuity discharging 3. Double papillary edema 4. Strabism convergent both eyes 5. Hypertrophic hyperplasia, hyperplasia by hyper- phagia with increased cardiovascular risk 6. HBP secondary obesity 7. Hepatocytolysis 8. Leukocytosis 9. Hypercholesterolemia 10. Hypertriglyceridemia 11. Hyperinsulinemia 12. Insulin Resistance (HOMA = 4.97) 13. Food mistakes 14. Eating disorder DIFFERENTIAL DIAGNOSIS The differential diagnosis can be made with the following disorders: 1. Glicogenosis von Gierke: normal neuro- psychic development, excess fat on the hips, thighs and pubic region, hepatomegaly with hepatocitolysis, hyperlipaemia, hypercholesterolemia, hyperuricemia, hypoglycemia 2. Laurence-Moon-Biedl Bardet syndrome: normal / delayed waist, hypogonality, delayed neuro- psychic development, generalized mood disorder sometimes monstrous, cranial abnormalities, polydactylia, syndactia, pigment retinitis, optic atrophy, nystagmus. 3. Prader Willi syndrome: nanism, hypogonadism, morbid obesity, neuro-psychic delay, exaggerated appetite. 4. Metabolic syndrome: abdominal circumference> 94 cm, triglycerides> 150 mg / dl, HDL-cholesterol
<40 mg / dl, blood glucose> 100 mg / dL TA> 130/85 mmHg.
5. Craniofaringioma: delayed puberty, hypo- staphy, dry skin, obesity, headache, visual disturbance
6. Primary hyperaldosteronism: headache, subjective visual disturbances, HTA, muscle cramps, asthenia, polydipsia, signs of transient paralysis, paraesthesia, hypopotasemia, hypernatraemia, increased aldosterone.
TREATMENT
The treatment is hygienic-dietary: hypocaloric, hypolipidic, hypoglucidic, normoproteic nutrition with 3000 kcal / day, where max. 12% lipids divided into 5 meals per day (3 main and 2 snacks) and the medical treatment is:
Nebilet tb. 5 mg 1-0-0 tb / day Diurex tb. after 1 tb to 2 days Prestarium tb. 5 mg ½-0-0 tb / day
Metformin cpr. 500 mg for 3×1 cpr / day Liv 52 cpr. 2×1 cpr / day

EVOLUTION
Without adequate treatment, high blood pressure in children can be maintained as they age.
Favorable evolution under the hygienic-dietary regimen:
– decrease of tension values in parallel with the disappearance of symptomatology (especially persistent or recurrent headache)
– improving cardiac function by improving left ventricular filling and ejection fraction
– reducing the number of apnea / hour
– minimization of basal and postprandial

hyperinsulinemia, reduction of insulin resistance
– an improvement in osteo-articular symptoms The possible complications can be: bone
deformities in lower limbs, aseptic necrosis of the femoral head, dislipidemia, hyperinsulinemia, insulin resistance, type II diabetes mellitus, hyperuricemia, hypoventilation syndrome (Pick Wick sd), obstructive sleep apnea, asthma, reactive hyperchortitis, micropenia, HBP, right ventricular hypertrophy, stroke, hepatic steatosis, biliary lithiasis, albuminuria, early glomerular dysfunction and renal tubular dysfunction, neuro-cognitive deficits, feeling of inferiority, family conflicts, social isolation, school difficulties, absenteeism, emotional and psychological immaturity, mycotic and bacterial skin infections, trophic disorders of the lower limbs, nail dysplasia.
PROGNOSIS
In the long run, the prognosis is a reserved one, given that weight overweight has the ability to negatively influence various body functions that can shorten the life of patients. The higher the weight, the better the prognosis.
Prognosis is closely related to the age and degree of obesity. At the beginning of the illness, both functional and vital prognosis may be somewhat favorable, but as time goes on as complications occur, the prognosis will depend on their severity and less on the affliction in themselves.
Hospitalization:
By family doctor, neurologist and endocrinologist. To prevent childhood obesity and possible complications, it is recommended that family physicians and school health professionals incorporate BMI calculation into the usual child
health surveillance activity.
CONCLUSIONS:
1. Obesity has a plurifactorial etiology, the weight surplus being the result of the action of genetic and environmental factors, considered as determinants, acting individually or in combination with certain risk factors.
2. Childhood is a public health issue, both with increased prevalence, with a continuing upward trend and with the often serious complications it carries
3. Particular attention is now being paid to monitoring the population’s nutritional status

in identifying overweight and obese children, considering that early intervention can improve outcomes in the medium and long term, particularly in preventing complications.
4. It is recommended to include in the therapy of the obese child the cognitive behavioral psychological intervention. This is accomplished by daily enrollment of the child’s or family’sdiet in the conditions of the hygienic-dietary regimen prescribed by the physician. In this way, the child and the family have control over the affected person’s eating habits, easily identify the discrepancies between the prescribed regimen and the one previously followed, and can successfully succeed in correcting food mistakes.

REFERENCES:
1. Popa I, Brega D, Alexa A, Drågan M, Raica M – Obezitatea copi- lului și țesutul adipos, Ed. Mirton Timișoara, 2001.
2. Thompson DR, Obarzanek E, Franko DL, Barton BA, Morrison J, Biro FM, et al – Childhood overweight and cardiovascular disease risk factors: the National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatrics 2007;150(1):18-25.
3. Ciofu C – Obezitatea. În: Ciofu EP, Ciofu (ed.): Tratat de Pediarie pag 126-130, Ed. Medicală, București, 2001.
4. Ciofu C – Patologia endocrină a copilului. În: Ciofu EP, Ciofu C (ed.), Tratat de Pediatrie, pag 1249-1254, Ed. Medicală, București, 2001.