PEDIATRICS Vol. 122 No. 2 August 2008, pp. 267-272 (doi:10.1542/peds.2007-2867)
ARTICLE |
Morbidity of Overweight (
85th Percentile) in the First 2 Years of Life
a Department of Pediatrics, Bnai Zion Medical Center, Haifa, Israel
b Ministry of Health, Rappaport Faculty of Medicine, Technion, Haifa, Israel
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. Our hypothesis was that morbidity related to overweight/obesity is already evident in infants and young toddlers. The major objectives of this study were (1) to assess the prevalence of overweight in a sample of hospitalized infants and (2) to assess the prevalence of morbidity in overweight infants in a community-based sample.
METHODS. The hospital admission study population included 2139 infants, 
24 months of age, who were admitted for any reason to the pediatric department at the Bnai Zion Medical Center in 2004–2005. For the community-based sample, we identified overweight infants (
85th weight-for-height percentile in 2 measurements, 3 months apart), 24 months of age, in 8 mother and child health care facilities in the Haifa subdistrict of Israel. Parents of infants were interviewed by using a structured questionnaire.
RESULTS. We found that overweight infants (85th to 94th percentiles) had fewer admissions and fewer repeated admissions than expected. Infants of 95th percentile had more admissions than expected, as well as a larger number of repeated admissions. In the second part of the study, we found that rates of developmental delays (mainly delayed gross motor skills) and snoring were significantly higher in infants of 85th percentile. In addition, although the results were not statistically significant, infants with overweight suffered more frequently from breathing problems, such as asthma and stridor. When the mothers were asked to assess whether their child was overweight, only 31.6% of mothers of overweight children thought that the child was overweight.
CONCLUSIONS. The high admission rates for infants of 95th percentile and the high incidence rates of respiratory morbidity, snoring, and delayed gross motor skills in overweight infants support our hypothesis regarding early morbidity associated with overweight.
Key Words: obesity • morbidity • complications • infants • toddlers
Obesity, specifically childhood obesity, is one of the more-serious problems of modern society. Obesity has reached epidemic proportions and, according to a recent estimation, 
22 million children <5 years of age are overweight.1 This rising trend is continuing, and it is predicted that the next generation of children will be more obese and less physically active than the existing generation.1–3 This trend has also been observed in Israeli children.4
Increasing attention in the literature is devoted to childhood obesity and its related morbidity. The morbidity related to obesity, although observed more frequently in adults, may have significant implications in childhood.5,6 Childhood obesity-related medical complications depend on the degree of obesity, and some may be reversed with weight loss. Most of the articles that deal with this problem focus mainly on older children and adolescents. Morbidity in overweight infants and young children, as expressed in hospital admissions and illnesses, has not been studied.
Our hypothesis was that morbidity related to overweight/obesity is already evident in infants and young toddlers. The major objectives of this study were therefore (1) to assess the prevalence of overweight in a sample of hospitalized infants and (2) to assess the prevalence of morbidity in overweight infants in a community-based sample.
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METHODS |
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Definition of Overweight
There is no universally accepted definition of overweight in infants and children <2 years of age.7,8 Nutrition programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children have used weight-for-length values to determine overweight and thus program eligibility.9 Overweight in this age group is usually defined as
95th percentile of weight-for-length values. The Centers for Disease Control and Prevention 2000 growth charts10 have been used as a reference (through the Centers for Disease Control and Prevention EpiInfo 3.2.2). These charts have been validated for Jewish Israeli children 6 to 14 years of age.11
Hospital Admissions
The study population included children 24 months of age who were admitted for any reason to the pediatric department at the Bnai Zion Medical Center in 2004–2005. They were divided into 3 groups, that is, normal weight (5th to 84th percentiles), overweight (85th to 94th percentiles), or obese (95th percentile). Because length data were not available for all infants, we used only weight percentiles. We did not include infants born prematurely or those with congenital, genetic, or chronic illnesses.
Community-Based Sample
We identified overweight infants (age: 24 months; 85th weight-for-height percentile in 2 measurements, 3 months apart) in 8 mother and child health care facilities in the Haifa subdistrict of Israel. More than 95% of the population frequents these preventive care centers, which makes them ideal locations for recruitment for community- and population-based studies. Parents of infants were interviewed by using a structured questionnaire that assessed demographic details, type of nutrition, eating habits, and information about emergency department visits, admissions, and morbidity, including follow-up care for developmental delays, respiratory morbidity (asthma, stridor, recurrent pneumonia, and snoring during sleep), and gastroesophageal reflux symptoms. Randomly selected infants from the same health care facility with normal weight-for-height values served as a control group. Infants born prematurely or with congenital, genetic, or chronic illnesses were excluded.
The study was approved by the local ethics committee and the Ministry of Health. Informed consent was obtained from the community group.
Statistical Methods
Data analysis was performed by using SPSS 11.5 (SPSS, Chicago, IL). For part 1 of the study (hospital admissions), the 
2 test for goodness of fit was used to compare the observed and expected frequencies in each category. This test determines whether the observed frequencies differ significantly from the expected theoretical frequencies in the 3 categories. It aimed to test whether each category contains proportions according to the defined percentiles.
The observed group consisted of hospitalized children of 5th percentile; therefore, only 95% of children were considered. The theoretical expected proportion of children in the 5th to 84th percentiles is 80%/95%, the proportion of those between the 85th and 94th percentiles is 10%/95%, and the proportion of those of 95th percentile is 5%/95%. The expected number for each percentile category was calculated by multiplying the total number of children in the observed group by the theoretical percent expected.
For part 2 of the study (mother and child health care facilities), 2 groups were defined, that is, infants and young children with weight-for-height values of 85th percentile or <85th percentile. Comparison of continuous variables between the 2 groups was performed by using the t test or the Mann-Whitney test as appropriate. The 2 test was used for comparison of proportions between the groups. Because most of the differences noted were highly significant even after correction for multiple comparisons, we did not correct for multiple comparisons.
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RESULTS |
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Part 1: Hospital Admissions
A total of 2139 infants admitted in 2004–2005 met the inclusion criteria, and 25 were excluded. Of those, 1848 infants were between the 5th and 84th percentiles, 137 were between the 85th and 94th percentiles, and 154 were of
95th percentile.
Table 1 shows the admissions in 2004–2005 according to weight groups. There were significantly fewer admissions than expected for the 85th to 94th percentiles; however, there were significantly more admissions than expected for the 95th percentile group. When we examined recurrent admissions, we also noted significantly more recurrent admissions than expected in the 95th percentile group. We did not find any unique morbidity for the 95th percentile group.
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Table 2 shows the common morbidities according to weight percentiles among the hospitalized infants. As can be seen, the 85th to 94th percentiles group had fewer than expected upper respiratory infections, cases of asthma, bronchiolitis, and stridor, and cases of acute otitis media. Because a relatively small number of patients were admitted with gastroesophageal reflux or pneumonia, no clear conclusions can be drawn regarding those conditions.
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Part 2: Community-Based Sample
Eighty-five percent of the parents (223 of 262 parents) agreed to participate in the study. There were no differences between the overweight group and the control group regarding compliance.
We identified 89 children 6 to 24 months of age who had 2 measurements of 85th percentile in weight for height and 173 children 6 to 24 months of age who were between the 5th and 84th percentiles in 2 measurements (chosen as control subjects). Ten parents (11.2%) in the overweight group and 29 parents (16.7%) in the control group refused to participate in the study.
We had 79 infants in the 85th percentile (weight for height) group and 144 infants in the control group. Table 3 presents the demographic features of the participants. There were no significant differences between the groups regarding age, gender, or ethnicity. The overweight group had significantly higher birth weights and a borderline significant higher maternal BMI. No differences were observed for paternal BMI.
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Table 4 shows the nutritional characteristics of the groups. Although the control group had benefited from more exclusive breastfeeding, the difference was of only borderline significance (P = .06). No significant differences were noted for breastfeeding (with or without formula enrichment), length of breastfeeding, infant formula additions to breast milk, or use of thickeners in the first 6 months. Table 5 summarizes the main results of the study regarding the specific and generalized morbidity differences between the groups.
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As can be seen, overweight infants had significantly more gross motor developmental delay problems and more snoring. The overweight group had slightly more asthma and stridor (not statistically significant). No differences were noted for vomiting/regurgitation or for a history of pneumonia.
Although there were more emergency department visits in the overweight group (46.2% vs 36.1%), this difference was not statistically significant; they had no more admissions and no more specialist consultations. Interestingly, the overweight group had significantly fewer primary pediatrician visits per year, compared with the control group (3.87 and 4.47 visits per year, respectively; P = .026). The only noted difference in morbidity between the genders was a significantly higher rate of snoring for overweight girls, compared with overweight boys. When the mothers were asked to assess whether their child was overweight, only 31.6% of mothers of overweight children thought that the child was overweight (Table 6).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Obesity is a complex disease with genetic, metabolic, and behavioral determinants. Obesity results from an imbalance between energy intake and expenditure, and there are strong genetic influences on these components of energy balance.12,13 There are many studies demonstrating morbidity resulting from overweight and obesity in both adults and children. The young age group (<2 years of age) has been relatively neglected, however. This is the first study of which we are aware that examines this important issue in infancy and early childhood. In this study, we examined our hypothesis that morbidity from overweight starts earlier than recognized previously.
A significant number of obesity-related chronic illnesses are now manifesting in childhood rather than in adulthood. Childhood obesity is associated with orthopedic complications, pseudotumor cerebri and headaches, sleep apnea and hypoventilation syndrome, gall bladder disease, nonalcoholic steatohepatitis, polycystic ovary disease, insulin resistance and type 2 diabetes mellitus, hyperlipidemia, and hypertension.3,5,6,14–18
There were 3 main limitations to the study, as follows. (1) Because the hospital admission sample was studied retrospectively, we used only weight data, which were available for all infants, and not weight-for-height values, as recommended. (2) To assess prospectively the morbidity of the group of 95th percentile in the community, it would be essential to study many more patients than we did. Although we used case-control methods for this pilot study, the process of identifying sufficient numbers of children who were overweight made us adopt the 85th weight-for-height percentile as an initial cutoff point. Despite these limitations, we could have shown a significantly higher risk of admissions and readmissions in the hospitalized group of 95th weight percentile. In addition, only 3.6% of the infants in the community-based group were of 95th percentile for weight, and the relative risk might be even higher. We did not demonstrate specific morbidity, probably because of the relatively small group. The finding that the 85th to 94th weight percentile group had fewer admissions than expected and the community children of 85th weight-for-height percentile had fewer pediatrician and specialist visits is intriguing. These children may have greater reserves than others, which may be an advantage during sickness. Their appearance may be misleading, in that they may look healthier during illnesses, which may affect the decision to take them to their pediatrician or the emergency department or to admit them to the hospital. Among the community children, we did find specific morbidities, such as developmental delays, snoring, and respiratory problems such as asthma and stridor (although the latter was of only borderline significance), that were more common in the overweight group. (3) There is no reference for the relative proportions of Israeli infants who are of 85th or 95th percentile, because validation has been performed only for the 6- to 14-year age group.11 However, studies comparing children's populations have found less obesity in Israeli children, compared with the United States and several European countries.19
Developmental delays have been associated previously with overweight and obesity. Jaffe and Kosakov20 found gross motor delays in 30% of overweight and obese infants (according to Svegers index), compared with only 9% of normal-weight infants. They also showed that the degree of motor delay was more severe in the obese group, compared with the overweight group. Among older children, Graf et al21 studied the performance of overweight/obese first-grade children by using a gross motor development test for children and a 6-minute run. They showed that the overweight/obese group showed poorer results, compared with the normal/underweight group, even after adjustment for gender and age. Bandini et al22 found a higher prevalence of at-risk-for-overweight and overweight among children with limitations in physical activity and a higher prevalence of overweight in girls with learning disabilities, compared with children without these conditions, after adjustment for age and race/ethnicity.
von Mutius et al18 studied the relationships between asthma and atopy and BMI as part of the National Health and Nutrition Examination Study III. They showed that the prevalence of asthma increased significantly with increasing quartiles of BMI. After adjustment for confounders, a significant positive association between BMI and asthma remained. No relationship of BMI to atopy was noted.
A meta-analysis study by Flaherman and Rutherford23 summarized 4 studies that examined the effect of high body weight during middle childhood on the outcome of subsequent asthma and showed a 50% increase in relative risk. Although a relationship between gastroesophageal reflux and obesity has been shown,24,25 we had an insufficient sample size to assess this association.
Habitual or daily snoring is a symptom of sleep-disordered breathing in children, and it is reported in 10% of children.26 Obesity is a well-known risk factor for sleep-disordered breathing and is a predisposing factor for obstructive sleep apnea in children,26 because of the mass loading of upper airway and respiratory muscles and impaired ventilatory control. The prevalence of obstructive sleep apnea in obese children ranges from 13% to 36%, depending on the definition of obesity and obstructive sleep apnea.26 The severity of obstructive sleep apnea was positively related to the degree of obesity.26 High prevalence (30%) of sleep-disordered breathing in obese children was also shown in the study by Wing et al.16
Agras et al27 prospectively monitored 150 children from birth until 9.5 years of age. They found 5 independent risk factors for childhood overweight. The strongest was parental overweight, which was mediated by child temperament. The remaining risk factors were low parental concerns about their child's thinness, persistent child tantrums over food, and less sleep time in childhood. Reilly et al28 in their prospective cohort study found 8 risk factors for childhood obesity (BMI of 95th percentile) at 7 years. These factors included parental obesity (both parents), very early (by 43 months) BMI or adiposity rebound, >8 hours spent watching television per week at 3 years of age, catch-up growth, SD score for weight at 8 months and 18 months of age, weight gain in first year, birth weight, and short (<10.5-hour) sleep duration at 3 years of age. Higher birth weight also was shown by others to be positively associated with greater BMI in childhood and later life.29 Our overweight group did have significantly higher birth weights than the control group.
Growth and nutrition during infancy are being viewed with renewed interest because of the possibility that they may be linked to cardiovascular and metabolic health in later life.30 It is now known that metabolic programming (the phenomenon whereby a nutritional stress/stimulus applied during critical periods of early development permanently alters an organism's physiologic features and metabolism, the consequences of which are observed much later in life in the absence of the stress/stimulus that initiated them) is one of the critical factors contributing to the pathogenesis of obesity.31 Of particular interest are differences between breastfed and formula-fed infants with regard to nutrient intake and growth, because breastfeeding has been shown to be associated with reduced risk of obesity in later life.32–34 This trend was observed in our study, but the differences were of only borderline significance.
Maternal and parental obesity is known to increase significantly the risk of childhood obesity and the risk of maintenance of obesity into adulthood. This is likely the result of genetic and environmental factors.35–37 In our study, we found a relationship only between maternal BMI and the child's overweight.
Interestingly, only 31.6% of the mothers of overweight children thought that their infant was overweight. This is not unique to our society. Eckstein et al38 found that few parents of overweight and at-risk-for-overweight children recognized their child as being overweight or were concerned regarding their child's weight. In the study by Zehle et al,39 although mothers were aware of the need to provide their child with a nutritious diet and with opportunities to be active, this was not always reflected in their behaviors. For many mothers, obesity became a concern only if excessive weight gain occurred. Although an attempt to establish good eating habits early to prevent future obesity was considered, it was not always actively pursued. In another study, 89% of parents of overweight 5- to 6-year-old children and 63% of parents of overweight 10- to 12-year-old children were unaware that their child was overweight. Seventy-one percent of parents of overweight 5- to 6-year-old children and 43% of parents of overweight 10- to 12-year-old children were not concerned about their child's current weight. Only 31% of parents of 5- to 6-year-old children and 43% of parents of 10- to 12-year-old children were taking action to prevent unhealthy weight gain in their children.40 In a study from Argentina,41 76% and 98% of mothers of overweight and at-risk-for-overweight children, respectively, rated them as normal or thin. Mothers exhibited poor understanding regarding the eating habits of their at-risk-for-overweight and overweight children. This lack of awareness is critical, because children who were overweight (>85th percentile) 1 time during the preschool period were >5 times as likely to be overweight at 12 years of age than were those who were of <85th percentile for BMI at all preschool ages.42
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Although the consequences of infant and childhood excess body weight may seem to manifest in later years, this perception is inaccurate. The high admission rates for infants of
95th percentile and the high incidence of respiratory morbidity, snoring, and delayed gross motor skills among overweight infants support our hypothesis regarding early morbidity associated with overweight. Our findings indicate a need to intervene actively during these critical years by adopting proper eating habits and active lifestyles appropriate for this age and increasing parents’ awareness of the importance of adhering to normal weight even in this early age group. This is only a pilot study, and its results should be verified in larger studies.
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ACKNOWLEDGMENTS |
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We thank all of the nurses of the maternal and child health care centers for their help and cooperation. We also thank Prof Michael Jaffe and Prof Shmuel Rishpon for their helpful remarks and Dr Ada Tamir and Nili Stein for their help with the statistical analyses.
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FOOTNOTES |
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Accepted Oct 31, 2007.
Address correspondence to Ron Shaoul, MD, Department of Pediatrics, Bnai Zion Medical Center, 47 Golomb St, PO Box 4940, Haifa 31048, Israel. E-mail: shaoul_r{at}012.net.il
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Most of the articles that deal with childhood overweight and obesity focus mainly on older children and adolescents. Morbidity in overweight infants and young children, as expressed in hospital admissions and illnesses, has not been studied.
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| What This Study Adds This study shows for the first time that morbidity attributable to overweight may manifest much earlier than previously thought, even in infants and young children.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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