I was struggling to start an intravenous the other day on a 12 year-old girl when this question went through my mind: when does obesity in children become an issue of child abuse?
The girl was 77 kg, about 170 lbs, and she stood 150 cm or about 5 feet tall. She was obese. She had rolls of fat on her upper arms. She had a double chin. I felt an awful sort of sorrow for her being on the cusp of adolescence, knowing the capricious cruelties that teenagers inflict on each other. Her lot in life was about to get worse. And my immediate problem: she had some much adipose tissue that I couldn’t palpate a suitable vein to start the IV in her hands or arms, much less visualize one. Even the antecubital veins, the cephalic and basilic, the big monsters found on the inside of the elbows, were difficult to locate. Thank God, I thought to myself, we don’t need emergency venous access.
It may well be possible to construct a case that childhood obesity represents child abuse, in the form of parental neglect and negligence, of knowing the negative impact of obesity on your children and doing nothing about it in terms of changing diet and increasing physical activity. The sequellae of childhood obesity, as we know, are fairly dire. According to the American CDC:
Childhood obesity is associated with various health-related consequences. Obese children and adolescents may experience immediate health consequences and may be at risk for weight-related health problems in adulthood.
Some consequences of childhood and adolescent obesity are psychosocial. Obese children and adolescents are targets of early and systematic social discrimination. The psychological stress of social stigmatization can cause low self-esteem which, in turn, can hinder academic and social functioning, and persist into adulthood.
Cardiovascular Disease Risks
Obese children and teens have been found to have risk factors for cardiovascular disease (CVD), including high cholesterol levels, high blood pressure, and abnormal glucose tolerance. In a population-based sample of 5- to 17-year-olds, 70% of obese children had at least one CVD risk factor while 39% of obese children had two or more CVD risk factors.
Additional Health Risks
Asthma is a disease of the lungs in which the airways become blocked or narrowed causing breathing difficulty. Studies have identified an association between childhood obesity and asthma.
Hepatic steatosis is the fatty degeneration of the liver caused by a high concentration of liver enzymes. . .
Sleep apnea is a less common complication of obesity for children and adolescents. . .
Type 2 diabetes is increasingly being reported among children and adolescents who are obese.
So if starving a child represents neglect, which for obvious reasons puts a child at risk for serious harm, shouldn’t giving a child too much food be considered neglect and negligence as well? Both present a failure to provide adequate care to a child. And if this is true, is punishing the parents appropriate? Would education, rather than calling the authorities, more effectively help the child?
We’re a bit two-faced about this, culturally at least. A few years ago here in Toronto the case of Jeffrey Baldwin, a child who was starved to death by his grandparents, provoked a furious, outraged public response. We’re a more phelgmatic about the reverse situation. Fat children are a sort of societal meme, poor sots, stupid and inept. Think of the movies you’ve seen featuring obese children. Do you think of abused? Probably not.
For nurses and other health care professionals, the question is not just academic. We have a moral and ethical duty, not to mention a legal one, to report cases of abuse to child protective services, even if only abuse is suspected. At what point do we consider obesity in children to be abusive? Do we need guidelines on this point?