Sample Review

Childhood obesity and medical neglect. Todd Varness, David B Allen, Aaron L Carrel, Norman Fost. Pediatrics 2009;123:399-406. (from Madison, WI)

Review from Summer 2009 issue

In cases of obesity, does noncompliance with interventions constitute reportable child neglect and consideration of coercive state intervention? The authors argue that some cases of childhood obesity, primarily those with comorbid conditions, do constitute medical neglect. By coercive state intervention they are referring, ultimately, to removal from the home.

The authors discuss three criteria that may warrant a charge of medical neglect: 1) a high likelihood that serious imminent harm will occur; 2) a reasonable likelihood that coercive state intervention will result in effective treatment; 3) the absence of alternative options for addressing the problem. Removal from the home would require meeting all three criteria. Before declaring an absence of alternative options, the authors suggest pursuing nutrition, exercise, and behavior interventions and referring families to specialists in weight management. The state would be involved in mandating these interventions.

Regarding effective treatment, the authors argue that lifestyle interventions are the most likely to be acceptable as a mandated intervention. Instituting lifestyle interventions in the right setting with appropriate goals can have significant benefit for a child with comorbid conditions. An appropriate goal would not be resolution of obesity but alleviation of the comorbid condition(s). The right setting would likely involve initial hospitalization to address the comorbid condition(s) and the initiation of lifestyle interventions. This would be followed by placement in a group home or specialized foster home.

In terms of risk of harm, the authors point out that, although childhood obesity carries an increased risk for adult disease, that alone does not constitute serious imminent harm. No subcategory of obesity – being overweight, obese, or severely obese — automatically predicts serious imminent harm. The presence of comorbid conditions, however, does provide a means for assessing harm.

Four categories of childhood obesity are described: 1) obese children who have no comorbid conditions; 2) obese children who have comorbid conditions that predict serious harm but are reversible in adulthood; 3) obese children who have comorbid conditions that predict serious harm and are not reversible in adulthood; 4) obese children who have comorbid conditions that constitute serious imminent harm in childhood. The authors argue that, if alternative options have been exhausted, charges of medical neglect are justified in Category 4. They probably would be applicable in cases falling into Category 3 also but they would not be applicable in Categories 1 or 2.

The authors remind us that the majority of parents care deeply about their children. They say that their purpose in proposing these guidelines is not to make moral judgments regarding parents but to protect children from serious harm.

    Reviewed by Timothy J Kutz, M.D.