Obesity and Neglect: It's about the Child

Abstract

All rights reserved. 10.1016/j.jpeds.2012.02.035 R ecently, controversy has arisen when a proposal for (and subsequent report of) state intervention to protect a child from life-threatening consequences of obesity was countered by assertions that removal of a child from his or her home was never justified by obesity alone. The predominantly negative reaction to considering such an intervention reflects a failure to address two issues: (1) persistent misunderstanding of the purpose of, and the criteria needed for, state action related to child neglect of any cause; and (2) doubt that consequences of obesity alone could ever meet this threshold. In this discussion, we apply principles that guide determination of child medical neglect in general to lifethreatening childhood obesity, and specify the required conditions for state intervention that preserve both the possibility for and rarity of its necessity. The key concept is that extreme obesity alone does not constitute imminent harm, but in rare cases its health consequences do. In these rare cases, pediatricians are obligated, as in any situation of child abuse or neglect, to take necessary actions to protect the child. To paraphrase Bela Schick, a pediatrician has 3 important clients: first the child, second the child, and third the child. The primary mission of a pediatrician or other health provider initiating coercive state action is to protect a child from serious irreversible harm; it is not to blame or to punish parents. The terms “abuse” and “neglect” are unfortunate and misleading in our view, because most cases involve loving, caring parents who, for various reasons, are unable to protect their child from serious imminent harm. State action to remove a child from a home as a last resort to save the child’s life has been authorized by US courts for 130 years, and healthcare providers have had a duty to report such cases for 60 years. Reasons for such an action include physical abuse, sexual abuse, and medical or nutritional neglect. Obesity leading to an imminent life-threatening comorbid condition, such as respiratory failure, liver damage with likely liver failure, or severe diabetes, should be viewed as just one of dozens of examples in which state action might be necessary to save a life. Classifying such a situation as neglect might be appropriate when the family of the affected child fails to seek or provide medical care, or fails to control their child’s behavior to a degree that places the child at risk of serious harm, including death. Criteria justifying coercive state intervention should be stringent, so that removal of a child from the home for any reason is justified and indicated only when the following 3 conditions are present.