Extreme obesity in children are mostly due to the endocrine or genetic causes or due to syndromes (cohen and carpenter). This two and half year old child weighed 30 Kg. One of the complication of this extreme obesity is pickwickian syndrome. In this syndrome there severe cardiorespiratory distress with alveolar hypoventilation, which is manifiested by polycythemia, somnolence and features of congestive cardiac failure.