POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices Sarah C. Armstrong, MD, FAAP,a Christopher F. Bolling, MD, FAAP,b Marc P. Michalsky, MD, FACS, FAAP, FASMBS,c Kirk W. Reichard, MD, MBA, FAAP, FACS,d SECTION ON OBESITY, SECTION ON SURGERY

Severe obesity among youth is an “epidemic within an epidemic” and portends abstract a shortened life expectancy for today’s children compared with those of their parents’ generation. Severe obesity has outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents. Departments of aPediatrics and Population Health Sciences, Duke Center for Childhood Obesity Research, and Duke Clinical Research Emerging evidence has linked severe obesity to the development and Institute, Duke University, Durham, North Carolina; bDepartment of progression of multiple comorbid states, including increased cardiometabolic Pediatrics, College of Medicine, University of Cincinnati and Cincinnati c fi Children’s Hospital Medical Center, Cincinnati, Ohio; Department of risk resulting in end-organ damage in adulthood. Lifestyle modi cation Pediatric Surgery, College of Medicine, The Ohio State University and treatment has achieved moderate short-term success among young children Nationwide Children’s Hospital, Columbus, Ohio; and dDivision of Pediatric Surgery, Nemours/Alfred I. duPont Hospital for Children, and those with less severe forms of obesity, but no studies to date Wilmington, Delaware demonstrate significant and durable weight loss among youth with severe Policy statements from the American Academy of Pediatrics benefit obesity. Metabolic and bariatric surgery has emerged as an important from expertise and resources of liaisons and internal (AAP) and treatment for adults with severe obesity and, more recently, has been shown external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the to be a safe and effective strategy for groups of youth with severe obesity. organizations or government agencies that they represent.

However, current data suggest that youth with severe obesity may not have Dr Armstrong was responsible for the initial drafting of the adequate access to metabolic and bariatric surgery, especially among manuscript, conceptualized and contributed to the content of the initial manuscript, and contributed to the clinical perspective of the underserved populations. This report outlines the current evidence regarding recommendations; Dr Bolling contributed to the clinical perspective of adolescent bariatric surgery, provides recommendations for practitioners and the recommendations and conceptualized and contributed to the content of the initial manuscript; Drs Michalsky and Reichard policy makers, and serves as a companion to an accompanying technical conceptualized and contributed to the content of the initial manuscript and contributed to the surgical perspective and the enrollment report, “Metabolic and Bariatric Surgery for Pediatric Patients With Severe criteria table; and all authors contributed to revisions and critical Obesity,” which provides details and supporting evidence. edits of the entire manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This policy statement uses the term “pediatric” in reference to a person All policy statements from the American Academy of Pediatrics under 18 years of age. The term “adolescent” may be defined differently in automatically expire 5 years after publication unless reaffirmed, various studies and clinical settings on the basis of age or developmental revised, or retired at or before that time. stage. When making specific recommendations, this policy statement uses “adolescent” to refer to a person from age 13 years to age 18 years. To cite: Armstrong SC, Bolling CF, Michalsky MP, et al. AAP “Severe” obesity (class 2 obesity or higher) is defined as having a BMI $35 SECTION ON OBESITY, SECTION ON SURGERY. Pediatric or $120% of the 95th percentile for age and sex.1 Recent data from the Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices. Pediatrics. 2019;144(6):e20193223 NHANES (2014–2016) report the prevalence of severe obesity in youth at

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 144, number 6, December 2019:e20193223 FROM THE AMERICAN ACADEMY OF PEDIATRICS 7.9% overall, 9.7% in 12- to 15-year- EVIDENCE interventions challenging. In the olds, and 14% in 16- to 19-year-olds. Teen-LABS cohort, RYGB and VSG These numbers represent a near Data Quality groups experienced a mean weight doubling since 1999 and equate to Evidence regarding the safety and reduction of 27% and resolution of 4.5 million children in the United efficacy of metabolic and bariatric comorbidities at 3 years, including States affected by severe obesity.2 surgery is outlined in detail in the type 2 diabetes mellitus (95%), These children are at high risk for accompanying technical report.15 hypertension (74%), and developing chronic and progressive Data are derived from observational dyslipidemia (66%), with an diseases, including hypertension, cohort studies, case-control series, accompanying reduction overall in dyslipidemia, obstructive sleep apnea, retrospective case reports, and expert the prevalence of multiple concurrent polycystic ovarian syndrome, type 2 opinion. The relatively low cardiovascular disease risk factors diabetes mellitus, fatty liver disease, prevalence of bariatric surgery in (ie, 3 or more).17 Surgical treatment bone and joint dysfunction, adolescents and the practical and is more effective than medical depression, social isolation, and poor ethical barriers to randomization are therapy among adolescents with quality of life.3–7 known limitations. severe obesity for treatment of type 2 diabetes mellitus,25 and weight- Roux-en-Y gastric bypass (RYGB) is Data Sources related quality of life has also been often referred to as the gold standard The Teen-Longitudinal Assessment of shown to improve significantly.16 for surgical management of severe 1 8,9 7 Bariatric Surgery (Teen-LABS) study The FABS-5 study represents the obesity in adults and adolescents is the largest ongoing observational longest-term follow-up data in and is performed by using minimally cohort study of youth undergoing adolescents to date (5–12 years; invasive, laparoscopic surgical metabolic and bariatric surgery to mean of 8 years) with 78% subject techniques. RYGB results in date. There were 242 patients retention (n = 58 of 74). After fi signi cant weight loss as a result of (12–28 years of age) enrolled at 5 US RYGB, adolescents demonstrated its effects on appetite, satiety, and – 9 centers (2007 2011) undergoing a 29% reduction in BMI and regulation of energy balance. RYGB (n = 161), VSG (n = 67), or significant improvements in elevated LAGB (n = 14).16 Participants had blood pressure, dyslipidemia, and Vertical sleeve gastrectomy (VSG) 18 leadstoweightlossthroughsimilar a mean age of 17 years, were mostly type 2 diabetes mellitus at 8 years. effects on appetite, satiety, and female (75%) and white (72%), and Results from the AMOS cohort of regulation of energy balance and may had a mean preoperative BMI of 53 adolescents undergoing RYGB reduce appetite through delayed and 4 major comorbid conditions. demonstrated a mean weight loss gastric emptying and altered Although the study is still ongoing, of 36.8 kg at 5 years. By contrast, neurohormonal feedback recent publications have reported adolescents enrolled in lifestyle fi mechanisms.10 VSG is the most outcomes at 3 years, consisting of modi cation demonstrated a mean n 19,20 common bariatric procedure 99% ( = 225) of participants who increase in BMI of 3.3. A 16,17 performed in adults and is becoming have undergone RYGB or VSG. 2017 meta-analysis of 24 studies more common among adolescents.11,12 Other data sources include the reviewed outcomes for 1928 Follow-up of Adolescent Bariatric adolescent patients who received Laparoscopic adjustable gastric band Surgery at 5 Plus Years18 (FABS-51) LAGB, VSG, and RYGB. In this (LAGB), a reversible procedure that study (2001–2007), the Adolescent analysis, the mean absolute BMI accounted for approximately one- Morbid Obesity Surgery Study19,20 decrease at 6 months was 5.4% in third of all bariatric operations in the (AMOS) (2006–2009), and the patients who underwent LAGB, United States a decade ago,12 has Bariatric Outcomes Longitudinal 11.5% in patients who underwent experienced a significant decline in Database21 (2004–2010). Several VSG, and 18% in patients who use among adults because of limited smaller cohort studies provide underwent RYGB. At 36 months, long-term effectiveness and higher- additional data.22–24 The companion significant weight loss was than-expected complication rates.13,14 technical report further details the maintained with a mean BMI Disappointing outcomes in the strengths and limitations of these reduction of 10.3% in patients who context of few prospective studies in studies. underwent LAGB, 13% in patients the pediatric population have who underwent VSG, and 15% in resulted in a similar decline in use of Outcomes on Weight Loss and patients who underwent RYGB.26,27 LAGB among adolescents.11 At Comorbidity Resolution More recently, an analysis of present, LAGB is limited by the US Until recently, weight-loss studies electronic health record data Food and Drug Administration to have reported weight loss in different compared the effectiveness of people 18 years or older. ways, making comparison between bariatric procedures among pediatric

Downloaded from www.aappublications.org/news by guest on September 30, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS patients and demonstrated a similar in adolescents, and the American a disability is a relevant factor but is BMI reduction among patients who Society for Metabolic and Bariatric not an automatic contraindication, received VSG or RYGB, and a lower Surgery best practice and each case warrants additional BMI reduction in patients who recommendations32 all contribute to consideration.35 received LAGB.28 16 existing sets of recommendations for bariatric surgery in pediatric Eligibility Complications 33 patients. Key considerations include Determination of eligibility for Surgical complications are infrequent, BMI, comorbid health conditions, and bariatric surgery involves fi with the majority being de ned as quality of life. As metabolic and a thoughtful, shared decision-making minor (15%) and occurring in the bariatric surgery have become more process between the patient, early postoperative period (eg, widespread, outcomes have parent(s) or guardian(s), and medical postoperative nausea and supported indications for bariatric and surgical providers. In addition to dehydration).11,16,27 Major surgery that more closely mirror 24,33 BMI and comorbidity status, criteria perioperative complications (30 days) adult recommendations. Best include physiologic, psychological, were reported in 8% of Teen-LABS practice guidelines (Table 1), as and developmental maturity; the participants. In addition, 2.7% developed in 2018 by the American ability to understand risks and required reoperation before hospital Society for Metabolic and Bariatric benefits and adhere to lifestyle discharge, which was similar to Surgery, recommend that bariatric modifications; decision-making 29 fi adults. Micronutrient de ciencies surgery be considered for youth with capacity; and robust family and social $ are common after both RYGB (iron BMI 35 with concurrent severe supports leading up to and after 66%, vitamin B12 8%, and folate 6%) comorbid disease or for those with 2 surgery. Current longitudinal studies and VSG (iron 32% and folate BMI $40 kg/m (where comorbid fi 16 evaluating safety and ef cacy 10%). Vitamin D deficiency is disease is commonly encountered but fi 32,34 endpoints do not apply speci c age common preoperatively among not mandatory). Generally limits for the timing of surgery; thus, teenagers with obesity and does not accepted contraindications include there is no evidence to support the fi 16 change signi cantly after surgery. a medically correctable cause of application of age-based eligibility fi Folate de ciency is a concern for obesity, untreated or poorly limits.11,20 females of childbearing age.16 Long- controlled substance abuse, term implications of nutrient concurrent or planned pregnancy, deficiency are unknown because most current eating disorder, or inability to BARRIERS longitudinal studies of pediatric adhere to postoperative metabolic and bariatric surgery do recommendations and mandatory Access not manage patients through lifestyle changes. Gaps in Although nearly 4.5 million US subsequent pregnancy to assess for recommendations include a thorough adolescents have severe obesity, related complications.27 Among discussion of patient and/or family current estimates suggest that only adolescents who are more severely goals and expectations; procedural a small faction undergo metabolic and affected by anxiety or depression at preferences; detailed bariatric surgery.12,17,18,20,36,37 Recent baseline, limited data suggest that recommendations for perioperative estimates show a tripling of they may have a higher risk for care, particularly in females of procedural prevalence in the early postoperative anxiety and childbearing age; and defined 2000s (0.8–2.3 per 100 000 between depression.30 Although no expectations and optimal timing for 2000 and 2003) with current perioperative deaths were reported in transition of long-term care to adult estimates of between 1000 and 1600 the Teen-LABS, AMOS, or FABS-51 medical and/or surgical obesity care cases each year.1,38,39 Although cohorts, 3 deaths (0.3%) occurred— providers.33 The presence of limitations to access are at 9 months (related to infectious colitis),18 3.3 years (related to TABLE 1 Indications and Contraindications for Adolescent Metabolic and Bariatric Surgery hypoglycemic complications in an individual with type 1 diabetes),16 Wt Criteria Comorbid Conditions and 6 years (unrelated), respectively, Class 2 obesity, BMI $35, or 120% of the 95th Clinically significant disease, including obstructive collectively representing a recently percentile for age and sex, whichever is sleep apnea (AHI .5), T2DM, IIH, NASH, Blount reported 0.3% mortality rate.27 lower disease, SCFE, GERD, and hypertension Class 3 obesity, BMI $40, or 140% of the 95th Not required but commonly present Indications percentile for age and sex, whichever is lower Published adult indications for AHI, Apnea-Hypopnea Index; GERD, gastroesophageal reflux disease; IIH, idiopathic intracranial hypertension; NASH, non- 31 bariatric surgery, longitudinal data alcoholic steatohepatitis; SCFE, slipped capital femoral epiphysis; T2DM, type 2 diabetes mellitus.

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 144, number 6, December 2019 3 multifactorial, race and surgery as an option48; concern for Cost-effectiveness socioeconomic status have emerged altered growth or development; and Bariatric surgery is more costly in the as striking disparities in insurance provider weight bias manifested as short-term than other treatment authorization for metabolic and a belief that weight is a personal 40 options, although this varies by the bariatric surgery. A recent review responsibility rather than a medical 60 49,50 number and type of comorbidities. from the Teen-LABS research problem. Existing evidence However, long-term bariatric surgery consortium reports that less than half suggests that bariatric surgery does cost-effectiveness data related to the (47%) of qualifying surgical not lead to growth impairment, and pediatric population are limited but candidates received insurance among older adolescents, several include several studies that suggest coverage after an initial request for studies have demonstrated that linear 18,20,21 that surgery may become cost- authorization. Age under 18 years growth continues after surgery. effective around 5 years was cited as the most common reason Recent data from a single site outside postoperation.60–62 Despite economic for coverage denial. In contrast, 85% the United States routinely assertions related to the use of of adults who met surgical criteria performing RYGB and VSG for bariatric surgery in the pediatric obtained initial insurance coverage patients with a mean age of population, ongoing efforts to prevent authorization. Eleven percent of 11.5 years have shown no adverse obesity at the population level, adolescents never obtained impact on linear growth when including robust public health authorization despite multiple compared with age-matched peers 40 strategies, should continue to be appeals. Children and adolescents receiving medical management for improved and widely disseminated.61 from racial minority groups are more obesity,51,52 although more evidence likely to experience severe is needed to confirm this finding. obesity1,41 and related comorbid BEST PRACTICES health conditions.5 Recent data show Lifestyle Counseling that outcomes after adolescent Many providers prefer a “watchful Multidisciplinary Care bariatric surgery do not differ by waiting” approach, or long-term The evidence for safe and efficacious race or ethnicity21;however, lifestyle management.50 However, metabolic and bariatric surgery in adolescents of minority groups are current evidence suggests that pediatric patients is based on less likely to undergo a bariatric pediatric patients with severe obesity comprehensive care in surgery.42 This disparity appears are unlikely to achieve a clinically multidisciplinary clinics involving most related to socioeconomic status significant and sustained weight pediatric experts on obesity, as opposed to racial or ethnic reduction in lifestyle-based weight adolescent medicine, mental health, status.43–46 This disparity may be management programs53 and that nutrition, and exercise science in explained in part by inconsistent watchful waiting may lead to higher addition to surgeons. The eligibility criteria for related BMI and more comorbid multidisciplinary care model coverage among various conditions.54–58 This concern is maximizes pediatric and adolescent- government-sponsored insurance illustrated in a recent comparison of specific health care resources programs even in the instance of adolescents initially participating in designed to deliver optimal care.60 medical necessity. Medical necessity a comprehensive lifestyle program These comprehensive programs is defined as “health care before surgery (ie, delayed surgical follow a set of principles or best interventions that are evidence- treatment group) that showed higher practices for pediatric metabolic and based, evidence-informed, or based starting BMI at the time of surgery bariatric surgery. The American on consensus advisory opinion…to when compared with adolescents Society for Metabolic and Bariatric promote optimal growth and who did not participate in the Surgery,61 the American Heart development in a child and to… lifestyle program (ie, nondelayed Association,7 and several other diagnose, treat, ameliorate or palliate surgical treatment group).20 In medical society- and institution- the effects of physical conditions.”47 addition, comparative data examining issued guidelines support the postoperative outcomes along the multidisciplinary model.61 Although Provider Concerns severely obese BMI spectrum (low, national accreditation for adolescent National survey data suggest that middle, and high) suggest that metabolic and bariatric surgery is providers are reluctant to refer adolescents within a lower BMI range recent (2014), the Metabolic and pediatric patients with obesity for (BMI ,55) at the time of bariatric Bariatric Surgery Association Quality bariatric surgery. Concerns include surgery have a higher probability of Improvement Program provides a lack of knowledge about the biology achieving nonobese status when a resource for primary care providers of obesity, surgical procedures, risks, compared with individuals with to locate high-quality comprehensive and follow-up; a lack of awareness of a higher starting BMI (BMI $55).59 adult bariatric programs with

Downloaded from www.aappublications.org/news by guest on September 30, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS additional accreditation and and bariatric surgery begins with focused metabolic and bariatric pediatric-specific programs. a realistic discussion of these values surgery programs. and preferences, available treatment Adolescent-Oriented Care 5. Coordinate pre- and postoperative options, likely anticipated outcomes care with the patient, family, and Although, as described, no data exist for weight loss, improvement in multidisciplinary, anesthesia, and fi to de ne an age limitation for weight- comorbid conditions, and a realistic surgical teams. loss surgery in youth, the majority of understanding about the lifetime 6. Monitor patients postoperatively those who undergo surgery are need for healthy lifestyle changes. for micronutrient deficiencies and adolescents. The unique Effective communication strategies, consider providing iron, folate, and developmental, physiologic, and such as the teach-back method, vitamin B supplementation as emotional needs of adolescents with should be used to ensure clear 12 needed. respect to selection of appropriate understanding of risks and benefits. patients for surgery, the optimal It is important to establish the 7. Monitor patients postoperatively timing of surgery, and long-term expectation for long-term for risk-taking behavior and follow-up are distinct from those psychological follow-up with patients mental health problems. same needs in adults. In and families early in the process. particular, adolescent girls are more SYSTEM-LEVEL RECOMMENDATIONS likely than adolescent boys to PRACTICE-LEVEL RECOMMENDATIONS The AAP recommends that undergo bariatric surgery.16,20,21,27 pediatricians do the following. Some studies have noted increased The AAP recommends that pregnancy rates in adolescents after pediatricians do the following. 1. Advocate for increased access for 62 pediatric patients of all racial, metabolic and bariatric surgery and 1. Recognize that severe obesity ethnic, and socioeconomic a higher risk of small-for-gestational- (BMI $35 or $120% of the backgrounds to multidisciplinary age births among mothers who have 95th percentile for age and sex, programs that provide high- previously had metabolic and whichever is lower) places the 63 quality pediatric metabolic and bariatric surgery. As with other adolescent at higher risk for bariatric surgery. aspects of adolescent health, the liver disease, type 2 diabetes provider should appropriately mellitus, dyslipidemias, sleep The AAP recommends that engage the adolescent in the decision- apnea, orthopedic complications, government, health, and academic making process out of respect for his and mental health conditions medical centers do the following. or her developing autonomy and even when compared with milder 1. Use best practice guidelines ensure that the teenager has degrees of obesity. outlined in this policy statement to appropriate expectations for 2. Seek high-quality multidisciplinary support safe and effective surgical outcomes. Consultation with centers that are experienced in multidisciplinary, pediatric- an ethics professional may be assessing risks and benefits of focused metabolic and bariatric warranted in challenging situations. various treatments for youth with surgery programs. This guidance Values and Preferences severe obesity, including bariatric is considered best practice surgery, and provide referrals because it is based on consensus Eligibility for metabolic and bariatric to where such programs are expert opinion after reviewing surgery should be determined available. numerous practices in various through a thoughtful process that fi settings. considers the values of the patient 3. Understand the ef cacy, risks, fi and family and preference for the bene ts, and long-term health 2. Consider best practice guidelines, type of bariatric surgical procedure. implications of the common including avoidance of These decisions may only occur metabolic and bariatric surgery unsubstantiated lower age limits, after a thorough review of the effect procedures so that pediatricians in the context of potential health fi of obesity on the adolescent’s can effectively help in family care bene ts and individualized physical and emotional health and medical decision-making patient-centered care. an understanding of the risks, concerning surgical options to 3. Increase the number of and access benefits, and long-term implications manage severe obesity. to multidisciplinary, pediatric- of each procedure type. The 4. Identify pediatric patients with focused metabolic and bariatric relationship among the physician, severe obesity who meet criteria surgery centers, ensuring equal patient, family, and surgical team for surgery (Table 1), and provide access to adolescents who meet is paramount to success. Preparing timely referrals to comprehensive, criteria regardless of income, race, an adolescent patient for metabolic multidisciplinary, pediatric- or ethnicity.

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 144, number 6, December 2019 5 The AAP recommends that public and • an ongoing substance abuse problem STAFF private insurers do the following. (within the preceding 1 year); Mala Thapar, MPH 1. Provide payment for • a medical, psychiatric, psychosocial, multidisciplinary preoperative or cognitive condition that prevents SECTION ON SURGERY EXECUTIVE care to ensure appropriate adherence to postoperative dietary COMMITTEE, 2017–2018 selection of surgical candidates and medication regimens; and Kurt F. Heiss, MD, FAAP, and for multidisciplinary • current or planned pregnancy within Chairperson postoperative care and required 12 to 18 months of the procedure. Gail Ellen Besner, MD, FAAP medications and supplements to Cynthia D. Downard, MD, FAAP improve surgical outcomes. Mary Elizabeth Fallat, MD, FAAP LEAD AUTHORS Kenneth William Gow, MD FACS, FAAP 2. Provide payment for bariatric Sarah C. Armstrong, MD, FAAP surgery from evaluation through Christopher F. Bolling, MD, FAAP follow-up and ongoing care for Marc P. Michalsky, MD, FACS, FAAP, FASMBS STAFF pediatric patients who meet Kirk W. Reichard, MD, MBA, FAAP Vivian Baldassari Thorne standard criteria as set forth here. 3. Reduce barriers to pediatric SECTION ON OBESITY EXECUTIVE metabolic and bariatric surgery COMMITTEE, 2017–2018 ABBREVIATIONS (including inadequate payment, Christopher F. Bolling, MD, FAAP, AMOS: Adolescent Morbid Obesity limited access, unsubstantiated Chairperson Surgery Study Sarah C. Armstrong, MD, FAAP exclusion criteria, and bureaucratic FABS-51: Follow-up of Adolescent delays in approval requiring Matthew Allen Haemer, MD, MPH, FAAP Natalie Digate Muth, MD, MPH, RD, FAAP Bariatric Surgery at 5 unnecessary and often numerous John Conrad Rausch, MD, MPH, FAAP Plus Years appeals) for patients who meet Victoria Weeks Rogers, MD, FAAP LAGB: laparoscopic adjustable careful selection criteria. gastricband LIAISON RYGB: Roux-en-Y gastric bypass Teen-LABS: Teen-Longitudinal As- CONTRAINDICATIONS Marc Michalsky, MD, FACS, FAAP sessment of Bariatric The following are contraindications: Surgery • a medically correctable cause of CONSULTANT VSG: vertical sleeve gastrectomy obesity; Stephanie Walsh, MD, FAAP

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. DOI: https://doi.org/10.1542/peds.2019-3223 Address correspondence to Sarah C. Armstrong, MD, FAAP. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: Dr Armstrong disclosed that she has a research relationship with AstraZeneca; Drs Bolling, Michalsky, and Reichard have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 30, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices Sarah C. Armstrong, Christopher F. Bolling, Marc P. Michalsky, Kirk W. Reichard and SECTION ON OBESITY, SECTION ON SURGERY Pediatrics originally published online October 27, 2019;

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Downloaded from www.aappublications.org/news by guest on September 30, 2021 Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices Sarah C. Armstrong, Christopher F. Bolling, Marc P. Michalsky, Kirk W. Reichard and SECTION ON OBESITY, SECTION ON SURGERY Pediatrics originally published online October 27, 2019;

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