IDIOPATHIC SCOLIOSIS

• Idiopathic scoliosis is lateral curvature of the spine

• Diagnosis is clinical and includes spinal x-rays
• Treatment depends on the severity of the curvature
STATISTICS

• Idiopathic scoliosis is the most common form of scoliosis

and is present in 2 to 4% of children aged 10 to 16 years
• Boys and girls are equally affected; however, it is 10 times
more likely to progress and require treatment in girls
• Genetic factors contribute about one third of the risk of
disease development
• Mutations in the CHD7 and MATN1 genes have been
implicated in some cases
SIGNS AND SYMPTOMS

• Scoliosis may first be suspected when one shoulder seems

higher than the other or when clothes do not hang straight,
but it is often detected during routine physical examination
• Other findings include apparent leg-length discrepancy and
asymmetry of the chest wall
• Patients may initially report fatigue in the lumbar region after
prolonged sitting or standing
• Muscular backaches in areas of strain (eg, in the lumbosacral
angle) may follow
SIGNS AND SYMPTOMS

• Scoliosis may first be suspected when one shoulder seems

higher than the other or when clothes do not hang straight,
but it is often detected during routine physical examination
• Other findings include apparent leg-length discrepancy and
asymmetry of the chest wall
• Patients may initially report fatigue in the lumbar region after
prolonged sitting or standing
• Muscular backaches in areas of strain (eg, in the lumbosacral
angle) may follow
DIAGNOSIS

• X-ray of the spine

• The curve is most pronounced when patients bend
forward
• Most curves are convex to the right in the thoracic area
and to the left in the lumbar area, so that the right
shoulder is higher than the left
• X-ray examination should include standing
anteroposterior and lateral views of the spine
DIAGNOSIS

• The amount of curvature is quantified in degrees based

on x-ray findings (the Cobb method)
• In this method, two lines are drawn on a posterior-anterior
x-ray of the spine, one extending from the top of the most
tilted upper vertebra and the other from the bottom of
the most tilted lower vertebra
• The angle formed by these lines is the Cobb angle.
DIAGNOSIS
PROGNOSIS

• The greater the curve, the greater the likelihood that it will
progress after the skeleton matures
• Curves > 10° are considered significant
• Prognosis depends on site and severity of the curve and
age at symptom onset
• Significant intervention is required in < 10% of patients
TREATMENT

• Physical therapy and bracing

• Sometimes surgery
• Prompt referral to an orthopedist is indicated when
progression is of concern or the curve is significant
• Likelihood of progression is greatest around puberty
• Moderate curves (20 to 40°) are treated conservatively
(eg, physical therapy and bracing) to prevent further
deformity
TREATMENT

• Severe curves (> 40°) may be ameliorated surgically (eg,

spinal fusion with rod placement)
• Scoliosis and its treatment often interfere with an
adolescent’s self-image and self-esteem
• Counseling or psychotherapy may be needed
OBESITY
STATISTICS

• Obesity is now twice as common among adolescents

than it was 30 years ago and is one of the most common
reasons for visits to adolescent clinics
• Although fewer than one third of adults with obesity were
obese as adolescents, most adolescents with obesity
remain obese in adulthood
• Despite many therapeutic approaches, obesity is one of
the most difficult problems to treat, and long-term success
rates remain low
STATISTICS

• Although most of the complications of obesity occur in

adulthood, adolescents with obesity are more likely than
their peers to have high blood pressure
• Type 2 diabetes mellitus is occurring with increasing
frequency in adolescents due to insulin resistance related
to obesity
• Because of society’s stigma against obesity, many
adolescents with obesity have a poor self-image and
become increasingly sedentary and socially isolated
ETIOLOGY

• he factors that influence obesity among adolescents are

the same as those among adults. Most cases are external
(eg, consuming too many calories and/or a low-quality
diet), often in conjunction with a sedentary lifestyle.
Genetic influences are common, and responsible genes
are now being identified ( see also Obesity and the
Metabolic Syndrome).
ETIOLOGY

• Parents may be concerned that obesity is the result of

some type of endocrine disease, such
as hypothyroidism or hyperadrenocorticism, but such
disorders are rarely the cause
• Adolescents with weight gain caused by endocrine
disorders are usually of small stature and have other signs
of the underlying disorder
DIAGNOSIS

BODY MASS INDEX

• Determination of the body mass index (BMI) is an
important aspect of physical assessment. Adolescents
whose BMI is ≥ the 95th percentile for their age and sex
are considered to have obesity
Metric BMI Formula
BMI = weight (kg) / [height (m)]2
• Primary endocrine or metabolic causes are uncommon
but should be ruled out if height growth slows significantly
DIAGNOSIS

• If the child is short and has

hypertension, Cushing
syndrome should be considered
TREATMENT

• All children and adolescents with obesity should be given

intensive health and lifestyle change strategies that
address nutrition, physical activity, and health behavior
• Adolescents 12 years old and older with obesity (BMI ≥ the
95th percentile for age and sex) may be given
medications for weight loss
• Adolescents 13 years old and older with severe obesity
(BMI ≥ 120% of the 95th percentile for age and sex) may
be referred for evaluation for metabolic and bariatric
surgery
TREATMENT

BARIATRIC SURGERY
ANOREXIA NERVOSA
• Characterized by a relentless pursuit of thinness, a morbid
fear of obesity, a distorted body image, and restriction of
intake relative to requirements, leading to a significantly
low body weight
• Diagnosis is clinical
• Most treatment is with some form of psychologic and
behavioral therapy
• Involvement of the family is crucial to the care of younger
patients
• Olanzapine may help with weight gain
• Anorexia nervosa occurs predominantly in girls and young
women
• Onset is usually during adolescence and rarely after age
40
Two types of anorexia nervosa are recognized:
• Restricting type: Patients restrict food intake but do not
regularly engage in binge eating or purging behavior;
some patients exercise excessively
• Binge eating/purging type: Patients regularly binge eat
and/or induce vomiting and/or misuse laxatives, diuretics,
or enemas
ETIOLOGY

• The etiology of anorexia nervosa is unknown.

• Other than being female, few risk factors have been
identified
• In some cultures, obesity is considered unattractive and
unhealthy, and the desire to be thin is pervasive, even
among children
• More than 50% of prepubertal girls in the US diet or take
other measures to control their weight
ETIOLOGY

• Excessive concern about weight or a history of dieting

appears to indicate increased risk, and there is a genetic
predisposition
• Family and social factors probably play a role
• Many patients belong to middle or upper socioeconomic
classes, are meticulous and compulsive, have average
intelligence, and have very high standards for
achievement and success
PATHOPHYSIOLOGY

Endocrine abnormalities are common in anorexia nervosa;

they include
• Low levels of gonadal hormones
• Mildly reduced levels of thyroxine (T4) and triiodothyronine
(T3)
• Increased cortisol secretion
PATHOPHYSIOLOGY

• Menses usually cease, but cessation of menses is no

longer a criterion for diagnosis
• Bone density declines
• In severely undernourished patients, virtually every major
organ system may be affected
• However, susceptibility to infections is typically not
increased
PATHOPHYSIOLOGY

• Dehydration and metabolic alkalosis may occur, and

serum potassium and/or sodium may be low; all are
aggravated by induced vomiting and laxative or diuretic
use
• Cardiac muscle mass, chamber size, and output
decrease; mitral valve prolapse is commonly detected
PATHOPHYSIOLOGY

• Some patients have prolonged QT intervals (even when

corrected for heart rate), which, with the risks imposed by
electrolyte disturbances, may predispose to
tachyarrhythmias.
• Sudden death, most likely due to ventricular
tachyarrhythmias, may occur
SIGNS AND SYMPTOMS

• Anorexia nervosa may be mild and transient or severe

and persistent.
• Even though underweight, most patients are concerned
that they weigh too much or that specific body areas (eg,
thighs, buttocks) are too fat
• They persist in efforts to lose weight despite reassurances
and warnings from friends and family members that they
are thin or even significantly underweight, and they view
any weight gain as an unacceptable failure of self-control
SIGNS AND SYMPTOMS

• Patients often exaggerate their food intake and conceal

behavior, such as induced vomiting
• Binge eating/purging occurs in 30 to 50% of patients. The
others simply restrict their food intake
• Many patients with anorexia nervosa also exercise
excessively to control weight
SIGNS AND SYMPTOMS

• Reports of bloating, abdominal distress, and constipation

are common
• Most women with anorexia nervosa stop having menstrual
periods
• Patients usually lose interest in sex
• Depression occurs frequently
SIGNS AND SYMPTOMS

• Common physical findings include bradycardia, low

blood pressure, hypothermia, lanugo hair (soft, fine hair
usually found only on neonates) or slight hirsutism, and
edema
• Body fat is greatly reduced
• Patients who vomit frequently may have eroded dental
enamel, painless salivary gland enlargement, and/or an
inflamed esophagus
DIAGNOSIS

Clinical criteria
• Not recognizing the seriousness of the low body weight
and restrictive eating are prominent features of anorexia
nervosa. Patients resist evaluation and treatment; they are
usually brought to the physician’s attention by family
members or by intercurrent illness.
DIAGNOSIS

Clinical criteria for diagnosis of anorexia nervosa include

the following:
• Restriction of food intake resulting in a significantly low
body weight
• Fear of excessive weight gain or obesity (stated
specifically by the patient or manifested as behavior that
interferes with weight gain)
• Body image disturbance (misperception of body weight
and/or appearance) or denial of the seriousness of illness
DIAGNOSIS

• Patients may otherwise appear well and have few, if any,

abnormalities in blood tests
• The key to diagnosis is identifying persistent active efforts
to avoid weight gain and an intense fear of fatness that is
not diminished by weight loss
DIAGNOSIS

• Patients may otherwise appear well and have few, if any,

abnormalities in blood tests
• The key to diagnosis is identifying persistent active efforts
to avoid weight gain and an intense fear of fatness that is
not diminished by weight loss
PROGNOSIS

• Mortality rates are high, approaching 10% per decade

among affected people who come to clinical attention;
unrecognized mild disease probably rarely leads to death
With treatment, prognosis is as follows:
• Half of patients regain most or all of lost weight, and any
endocrine and other complications are reversed
• About one fourth have intermediate outcomes and may
relapse
PROGNOSIS

• The remaining one fourth have a poor outcome,

including relapses and persistent physical and mental
complications
• Children and adolescents treated for anorexia nervosa
have better outcomes than adults
TREATMENT

• Nutrition supplementation
• Psychotherapy (eg, cognitive behavioral therapy)
• For children and adolescents, family-based treatment
• Sometimes 2nd-generation antipsychotics
TREATMENT

• May require life-saving short-term intervention to restore

body weight
• When weight loss has been severe or rapid or when
weight has fallen below about 75% of recommended
weight, prompt restoration of weight becomes critical,
and hospitalization should be considered
• Outpatient treatments may include varying degrees of
support and supervision and commonly involve a team of
practitioners
TREATMENT
• Nutritional supplementation is often used with behavioral
therapy that has clear weight-restoration goals
• Nutritional supplementation begins by providing about 30
to 40 kcal/kg/day; it can produce weight gains of up to
1.5 kg/week during inpatient care and 0.5 kg/week
during outpatient care
• Oral feedings using solid foods are best; many weight
restoration plans also use liquid supplements
• Very resistant, undernourished patients occasionally
require nasogastric tube feedings
TREATMENT
• Elemental calcium 1200 to 1500 mg/day and vitamin
D 600 to 800 IU/day are commonly prescribed for bone
loss
• Once nutritional, fluid, and electrolyte status has been
stabilized, long-term treatment begins
• Treatments should emphasize behavioral outcomes such
as normalized eating and weight
• Treatment should continue for a full year after weight is
restored. Results are best in adolescents who have had
the disorder < 6 months.
TREATMENT

Family therapy, particularly using the Maudsley model (also

called family-based treatment), is useful for adolescents.
This model has 3 phases:
• Family members are taught how to refeed the adolescent
(eg, through a supervised family meal) and thus restore
the adolescent’s weight (in contrast to earlier
approaches, this model does not assign blame for the
development of the disorder to the family or the
adolescent)
TREATMENT

• Control over eating is gradually returned to the

adolescent
• After the adolescent is able to maintain the restored
weight, therapy focuses on engendering a healthy
adolescent identity
TREATMENT

• Treatment of anorexia nervosa is complicated by patients'

abhorrence of weight gain and denial of illness. The
physician should attempt to provide a calm, concerned,
stable relationship while firmly encouraging a reasonable
caloric intake
TREATMENT

• Treatment also involves regular follow-up monitoring and

often a team of health care practitioners, including a
nutritionist, who may provide specific meal plans or
information about the calories needed to restore weight
to a normal level
• Although psychotherapy is primary, drugs are sometimes
helpful. Olanzapine up to 10 mg orally once daily may aid
weight gain