The short answer: which problems deserve a check?
The problems linked to a child's weight that deserve a check are: pauses in breathing during sleep, fatty liver, high blood pressure, insulin resistance and prediabetes, joint pain, early puberty, and effects on mood and bullying [1, 11]. The basic checks are simple: height, weight and BMI plotted on a growth chart, a blood pressure reading with a cuff that fits the arm, and specific blood tests chosen by age and risk factors [1, 3, 4]. Referral to another specialty happens when a warning sign or an abnormal result appears, not because of a number on the scale, and all of it is done without blaming the child or the parents and without a strict diet.
One important point: having one of these problems does not mean the others are present, and having no symptoms does not mean nothing is there. Fatty liver, high blood pressure and insulin resistance are often silent and must be looked for with a measurement or a blood test [3, 4]. The reverse is also true: when a problem is found early, it is much easier to manage.
Read also: Book an appointment
When is weight 'above range', and who needs a closer look?
The definition depends on age and a growth chart, not on one fixed number. For ages 5 to 19, the WHO defines overweight as more than 1 standard deviation above the WHO Growth Reference median and obesity as more than 2 standard deviations [11]. The US CDC defines obesity as a BMI at or above the 95th percentile for age and sex [12]. A clinician plots your child on the chart and follows the direction over several visits, which is more reliable than one number on one day.
The problem is common, which helps parents see that it is nobody's fault: in 2024 about 20% of children and adolescents aged 5 to 19 had overweight including obesity, up from 8% in 1990 [11]. In the United States, 19.7% of children aged 2 to 19 had obesity between 2017 and March 2020 [12].
Severe obesity is the group in which complications are more frequent and appear earlier. The American Heart Association statement reported that it affects 4 to 6% of American children and adolescents and that cardiometabolic risk rises with it [6]. In an older study of 439 children and adolescents with obesity, the metabolic syndrome reached 50% among the severely obese [5].
Breathing pauses in sleep and snoring
Obstructive sleep apnoea is one of the most commonly missed complications. The American Academy of Pediatrics technical report gives a prevalence in children of 0 to 5.7% and notes that obesity is an independent risk factor [2]. So even when the tonsils are not large, weight alone can cause the problem.
Common signs to notice: loud snoring most nights, pauses in breathing that you see, restless sleep and night sweating, mouth breathing, bedwetting after a dry period, morning headache, and daytime sleepiness, irritability or poor concentration. Some children look overactive rather than sleepy.
What is done: the clinician takes a history, examines the tonsils and nose, and in some cases requests a sleep study. First-line treatment is usually removal of the tonsils and adenoids when they are the blockage, but residual apnoea afterwards is more frequent with obesity: 13 to 29% in low-risk groups, and 73% when obese children were included with stricter criteria [2]. This is why follow-up after any treatment is important.
Referral here is to an ear, nose and throat doctor or a paediatric sleep service. If snoring is constant and you see breathing pauses, do not wait.
Fatty liver
Non-alcoholic fatty liver is one of the most common complications of obesity in children, usually without any symptoms. The NASPGHAN guideline reports a prevalence of 29 to 38% among children with obesity and that about 15% of affected children already have stage 3 fibrosis or higher at diagnosis [4].
The basic screen is a blood test for the liver enzyme ALT. The guideline suggests considering screening from age 9 to 11 for a BMI at or above the 95th percentile, and for the 85th to 94th percentile when risk factors are present (central fat, insulin resistance, prediabetes, abnormal blood fats, sleep apnoea, family history), and earlier for severe obesity or a family history [4]. The upper limit of normal for ALT is lower than many laboratories print: 22 U/L for girls and 26 U/L for boys [4].
If the result is normal and the risk factors are unchanged, the test is repeated every 2 to 3 years [4]. If ALT stays above twice the upper limit for more than 3 months, or is above 80 U/L, a wider evaluation is needed, because fatty liver is a diagnosis of exclusion and other causes such as viral hepatitis and thyroid disease must be ruled out [4]. Ultrasound is not recommended as a screening test, and a normal ultrasound does not rule out fatty liver [4].
Referral to a paediatric gastroenterologist is for persistently raised enzymes, enzymes raised for more than 2 years, or signs of fibrosis.
Read also: Fatty liver symptoms and diagnosis
Blood pressure
High blood pressure in children usually has no obvious symptoms, which is why measurement is how it is found. The AAP guideline recommends measuring blood pressure at preventive care visits, and at every health care encounter from age 3 for children with obesity, and contains 30 Key Action Statements, including a wider role for ambulatory (24-hour) monitoring [3]. From age 13 a simplified classification is used [3].
A practical point: the cuff must fit the child's arm. A cuff that is too small gives a falsely high number and frightens you for no reason. The child should be seated, relaxed and quiet before the measurement. One high reading is not a diagnosis; it is repeated at other visits, and the diagnosis needs high readings at 3 different visits.
What happens next: if readings stay high, the clinician looks for other causes (kidney, hormonal, medicines) and may request 24-hour monitoring, and when needed refers to a paediatric kidney, heart or hormone specialist outside the clinic. Any blood pressure medicine is decided only by the treating doctor, and we do not change or stop any medicine.
Parents can help by keeping earlier readings from past visits and mentioning any family history of high blood pressure.
Insulin resistance, prediabetes and the metabolic syndrome
Insulin resistance means the body needs more insulin to control blood sugar. Signs you may see: darker, thicker skin around the neck or under the arms (acanthosis nigricans), extra fat around the belly, and in girls irregular periods and extra facial hair. It can also be present with no sign at all.
The well-known New England Journal of Medicine study in children and adolescents found that each half-unit increase in BMI z score was associated with higher odds of the metabolic syndrome (odds ratio 1.55, confidence interval 1.16 to 2.08), and each unit increase in insulin resistance with an odds ratio of 1.12 [5]. The trend is gradual: a child does not have to be at the extreme for risk to begin.
Tests a clinician may request depending on the case: fasting glucose or HbA1c, blood fats (cholesterol and triglycerides), and sometimes fasting insulin. The AAP guideline asks for assessment of related conditions when a child is evaluated for obesity [1]. Referral to a paediatric endocrinologist outside the clinic is for a glucose or HbA1c in the diabetes or prediabetes range, or a suspected other type of diabetes.
We do not tell you to ban a food or put the child on a diet; the steps are whole-family habits, explained in our articles below.
Read also: Family habits without dieting
Joints and bones
Extra weight puts load on the knee, ankle and hip. A study in Pediatrics found knee pain in 21.4% of children and adolescents with overweight versus 16.7% of those without, and more fractures, discomfort and lower-limb malalignment among them [9]. When it should be seen by a doctor: a limp that persists, hip or knee pain that wakes the child or makes them avoid movement, a swollen or red joint, or hip pain with a limp in early adolescence. These need a paediatric orthopaedic doctor, a specialty outside the clinic, and should not be put off on the assumption that the cause is 'only weight'.
Assessment starts with a physical examination of walking and the joint, and sometimes imaging. Physiotherapy, when needed, is outside the clinic.
Movement the family enjoys matters most. If there is pain, the doctor guides the type of activity; we do not stop movement altogether.
Read also: The child nutrition and growth visit
Early puberty and hormone-related signs
The link between weight and puberty has been studied most in girls. A study of 354 girls found that a higher BMI z score from age 36 months was associated with earlier onset of puberty [7]. This does not mean every girl with extra weight will start early, but the likelihood is higher.
Signs worth showing a doctor: breast development in a girl earlier than expected for her age, pubic hair or body odour earlier than expected, or a very early first period. In boys, signs of puberty earlier than peers.
In teenage girls: irregular or absent periods, extra facial hair or severe acne together with extra weight may point to polycystic ovary syndrome and insulin resistance, and are assessed with an examination and hormone tests.
Assessment starts with height and weight on the chart and staging of puberty. Referral to a paediatric endocrinologist or a gynaecologist, outside the clinic, is for these signs. Having a sign does not mean the girl did anything wrong.
Mood, bullying and weight stigma
The psychological effect can be harder than the physical one. A meta-analysis of 18 studies with 51,272 participants found that obesity in children and adolescents was associated with higher odds of depression (odds ratio 1.34, confidence interval 1.1 to 1.64), while overweight alone showed no clear association (1.16, confidence interval 0.93 to 1.44) [10].
Bullying is a real part of the picture. A study of 821 children from third to sixth grade found that children with obesity were more likely to be bullied (odds ratio 1.63, confidence interval 1.18 to 2.25) [8]. The WHO links stigma, discrimination and bullying to childhood overweight and obesity [11].
Signs to take seriously: school refusal, withdrawal from friends, new sadness or irritability, sudden change in sleep or eating, negative talk about the body, or hiding food. Secret eating or severe restriction after comments from others can lead into an eating disorder.
Our advice: say the word 'weight' carefully, focus on health and habits rather than looks, do not compare the child with siblings, and do not comment on their food in front of others. For persistent sadness, severe bullying or thoughts of self-harm, refer to a child psychiatrist or psychologist outside the clinic.
Read also: A teen restricting food from fear of weight · Teen weight follow-up
The testing menu: what may be ordered and when
There is no single set of tests for every child; the clinician chooses by age and risk factors. The general menu:
• Every visit: height, weight and BMI on the growth chart, sometimes waist circumference, and a check of the skin, joints and pubertal stage [1]. • Blood pressure: at preventive care visits, and at every visit for a child with obesity from age 3, with a correctly sized cuff [3]. • Liver enzyme: from age 9 to 11 if BMI is at or above the 95th percentile, or between the 85th and 94th with risk factors, repeated every 2 to 3 years if normal and the risk factors are unchanged [4]. • Blood glucose or HbA1c and blood fats: by age and risk factors, at the clinician's judgement [1]. • Sleep questions: snoring, breathing pauses, sleepiness; a sleep study when suspicion is strong [2]. • A simple emotional check: questions about mood, bullying and eating [8, 10].
What does not need to be done as a routine: liver ultrasound alone to look for fatty liver [4], or many tests with no clear clinical question. If you have earlier results, send them before the visit so they are not repeated.
Also, no special device is needed to assess a child. Accurate height and weight and their interpretation on the chart is what matters.
When to refer to another specialty
Referral is for a specific sign, not just extra weight. The practical list:
• Constant snoring with breathing pauses, daytime sleepiness or new bedwetting: ear, nose and throat doctor or a sleep service [2]. • Liver enzyme raised for more than 3 months, above twice the upper limit, above 80 U/L, or raised for more than 2 years: paediatric gastroenterology [4]. • Repeatedly high blood pressure: paediatric kidney or heart specialist [3]. • Glucose or HbA1c in the diabetes or prediabetes range, or extreme thirst with frequent urination: paediatric endocrinology, urgently if thirst and urination are marked [1]. • Persistent joint pain or limp: paediatric orthopaedics [9]. • Signs of early puberty or marked menstrual disturbance: paediatric endocrinology or gynaecology [7]. • Persistent sadness, severe bullying or thoughts of self-harm: child psychiatry [8, 10]. • Severe obesity at a young age or many related conditions: a multidisciplinary programme [1, 6].
All the specialties above are outside the clinic. Our role at the Maadi clinic is children's nutrition, growth follow-up and coordinating steps with the child's treating paediatrician. We give no medicine advice; any treatment or change to a medicine is decided only by the treating doctor.
If you are not sure whether your child needs a referral, book a visit and we will look at the whole picture.
What to bring to the visit
The visit is more useful with a little preparation, and none of it is a judgement of you as a parent [1]:
• Earlier blood tests, ultrasound reports and any blood pressure readings. • The growth chart or vaccination card with height and weight over the years. • The names and doses of any medicines the child takes, and change nothing before the visit; the treating doctor decides. • Your notes on sleep: snoring, breathing pauses, bedwetting, sleepiness. • Family history: diabetes, blood pressure, fatty liver, cholesterol, polycystic ovaries, early puberty. • Notes on mood, school, friends and any comments the child faces. • An ordinary day of eating, movement and screens, without tidying it up.
At the visit, weight is discussed politely, and in front of the child with care; part of the time can be with the parents alone. The plan that comes out is habits for the whole family, not a diet for the child, not a food ban and not a weight-loss medicine.
