Perspectives for the Future

As this toolkit is incorporated into individual clinics to evaluate and treat pediatric obesity, clinicians should realize that for some children, the onset of obesity occurred years earlier. This section gives an overview of the possible factors that may have contributed to patients’ obesity in their early years. Also, some suggestions are offered to help prevent obesity in the early years, a critical step in the battle against childhood obesity.

Evidence suggests that some of the contributing factors may have started in utero (1,2). Several obstetrical researchers have demonstrated that the abnormal hyperglycemia in pregnant mothers with pregestational diabetes or gestational diabetes (GDM) will contribute to a fetal hyperglycemic state that appears to have long-lasting postnatal effects, including obesity, hypertension, and at times hyperglycemia in the later months of the affected fetus (1,2). Many of these youngsters manifest themselves as babies who are large for gestational age (LGA) at birth. Some of these babies may also have difficulties with neonatal hypoglycemia; many will also have increased risk for obesity and other features of the metabolic syndrome as they mature into adolescents and young adults (1). Catalano and his group have demonstrated that some of the high-risk babies born to mothers with gestational diabetes can manifest many of the features of LGA babies, including rounded facial appearance, increased waist size, increased size, and fullness of their extremities, but are of appropriate weight for gestational age (AGA). These babies exhibit a larger visceral adipose tissue component of their body composition (3). Many in the obstetrical field are making every effort to help pregnant mothers realize a more normal metabolic milieu, thereby minimizing the deleterious effects on their unborn children (4).

We also know that babies who are small for gestational age (SGA) will often have a period of rapid weight gain or so-called “catch-up growth” in the first few months of life and will have a high incidence of obesity in later life. Unfortunately, no consensus exists on the management of these SGA infants.(5, 6, 7, 8). The prudent suggestion at this time would be to follow the American Academy of Pediatrics (AAP) nutritional guidelines―not allowing an overabundance of calories in these infants and not starting complementary feedings, with their attendant caloric content, too early.

Of the many efforts to improve the outcome of the battle against obesity in children, one major weapon is breastfeeding. Several reports have demonstrated that childhood obesity is seen less often in infants who are breastfed for at least six months (9).

Special attention should be given to all toddlers' dietary intake to ensure a well-balanced and reasonable caloric intake following the American Academy of Pediatrics Committee on Nutrition's most recent guidelines. In the summer of 2008, the AAP Committee on Nutrition made new recommendations on the fat content of milk consumed by toddlers aged between 12 and 24 months and for those older than 24 months. Among the guidelines are the recommendations that children aged between 12 and 24 months consume 2% milk and that children older than 24 months consume fat-free milk (10).

Furthermore, there is a concern that toddlers are not getting enough exercise. These youngsters should be given the opportunity to have active free play that emphasizes the use of large muscle groups. The day care industry needs to be directed to provide ample opportunity for kids to be active, with a goal of one hour of physical activity a day.

It is critical to realize that obesity will follow a life cycle. Infants of obese/GDM mothers have a high chance of becoming obese youngsters who in turn become obese teenagers. Unfortunately, girls who are obese teenagers may become obese/GDM mothers, thereby closing the loop of the obesity life cycle (11). Health care providers are obligated to try to intervene at all possible points of the cycle to prevent obesity in their pediatric patients. Prevention seems to be more effective than treatment.

In closing, the pediatric health care provider should have a higher level of vigilance for this special group of at-risk infants in early life. "Red flags" should be raised when you encounter any infants who are SGA, LGA, or “obese AGA.” Additionally, if the infants' mothers are obese, have gained an excessive amount of weight during their pregnancy or have a history of diabetes mellitus or gestational diabetes, a prudent approach for these at-risk infants and their families would include the following measures:

1. Breastfeed exclusively for at least six months and preferably for 12 months.

2. Delay introduction of solids or complementary foods, with or without breastfeeding, for at least the first six months.

3. Encourage the intake of fruits and vegetables by infants older than 6 months, toddlers, and young children. In other words, encourage fruits and vegetables for EVERYBODY!

4. Let children determine the amount of food they eat, but let the parents ensure that the youngsters have a healthy variety of foods to eat. Psychologists call this the authoritative approach―it is very effective and is associated with the least amount of obesity in the children studied.

5. Monitor maximum portions. Children's caloric needs, as well as appropriate portion sizes, vary with age. Included are recommendations from the U.S. Department of Agriculture Center for Nutrition Policy and Promotion regarding recommended calorie intake and serving sizes.

6. Encourage patients’ families to set up safe and comfortable areas in their homes so that infants who are already crawling have the opportunity to crawl to their hearts' delight. Likewise, give toddlers and early preschoolers the opportunity to play and be active.



1. Boney CM, Verma A, Tucker R, Vohr BR. et al. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics. 2005;115(3):e290-e296.

2. Catalano PM, Ehrenberg H. The short- and long-term complications of maternal obesity on the mother and her offspring. Br J Obstet Gynaecol. 2006;113:1126-1133.

3. Catalano PM, Thomas A, Huston-Presley L, Amini SB. Phenotype of infants of mothers with gestational diabetes. Diabetes Care. 2007;30(suppl 2):S156-S160.

4. Conway DL. Obstetric management in gestational diabetes. Diabetes Care. 2007;30(suppl 2): S175-S179.

5. Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ. 2005;331(7522):929-932. 

6. Ong KK, Ahmed ML, Emmett PM, Preece MA, Dunger DB. Association between postnatal catch up growth and obesity in childhood: prospective cohort study. BMJ. 2000;320(7244):1244-1247.

7. Ong KK. Catch up growth in small for gestational age babies: good or bad. Curr Opin Endocrinol Diabetes Obes. 2007;14(1):30-34.

8. Stettler N, Zemel BS, Kumanyika S, Stallings VA. Infant weight gain and childhood over status in a multicenter, cohort study. Pediatrics. 2002;109(2):194-199.

9. Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol. 2005;162(5):397-403.

10. Daniels S, Greer FR; Committee on Nutrition.  Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122(1):198-208. 

11. Kral JG. Preventing and treating obesity in girls and young women to curb the epidemic. Obes Res. 2004;12:1539-1546.

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